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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

The

seroprevalence

of

hepatitis

B,

hepatitis

C,

and

human

immunodeficiency

virus

in

patients

undergoing

septoplasty

Ozlem

Onerci

Celebi

,

Ela

Araz

Server,

Bahtiyar

Hamit,

Özgür

Yi˘

git

IstanbulEducationandResearchHospital,DepartmentofOtolaryngology,Istanbul,Turkey

Received28August2016;accepted26October2016 Availableonline17November2016

KEYWORDS Septoplasty; HBV; HCV; HIV; Seroprevalance Abstract

Introduction:Worldwide,hepatitis B virus, hepatitis Cvirus,and human immunodeficiency virusaremajorhealthproblems.Healthcareworkersareatriskoftransmittingblood---borne viruses,andsurgeonshaveahigherriskofexposuretobloodandhigherratesofpercutaneous injurythanotherhealthcareworkers.Septoplastyisamongthe3mostcommonlyperformed otolaryngologicalsurgeriesworldwide.

Objective:TodeterminetheseroprevalenceofHepatitisBsurfaceantigen,HepatitisCvirus antibody,andHumanImmunodeficiencyVirusantibodyinpatientsundergoingseptoplastywith and withoutturbinate surgeryunder generalanesthesia, and to determine if preoperative testingshouldbeperformedinsuchpatients.

Methods:Thisretrospectivecross-sectionalstudyincluded3731patientsthatunderwent septo-plastywithandwithoutturbinatesurgerybetweenJanuary2005andJuly2015.HBsAg,anti-HCV, andanti-HIVseropositivityinthepatientswasevaluatedretrospectively.

Results:Meanageofthepatientswas36years(range:11---81years).Inall,117(3.6%)patients werepositiveforHBsAg,12(0.3%)werepositiveforanti-HCV,and7(0.2%)werepositivefor anti-HIV.

Conclusions:Educationofhealthcareworkerscombinedwithroutinepreoperativeserological testinginpatients undergoingseptoplastyundergeneralandlocalanesthesiaareneededto increase awareness ofhepatitis B and C, andHIV infection among healthcare workersand patientsinordertodecreasethetransmissionrate.

© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Pleasecitethisarticleas:OnerciCelebiO,ArazServerE,HamitB,Yi˘gitÖ.TheseroprevalenceofhepatitisB,hepatitisC,andhuman immunodeficiencyvirusinpatientsundergoingseptoplasty.BrazJOtorhinolaryngol.2018;84:34---9.

Correspondingauthor.

E-mail:oonerci@yahoo.com(O.OnerciCelebi).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2016.10.008

1808-8694/©2016Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

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PALAVRAS-CHAVE Septoplastia; HBV; HCV; HIV; Soroprevalência

SoroprevalênciadehepatiteB,hepatiteCevírusdaimunodeficiênciahumanaem

pacientessubmetidosaseptoplastia

Resumo

Introduc¸ão: Nomundotodo,ovírusdahepatiteB(VHB),ovírusdahepatiteC(VHC)eovírus da imunodeficiênciahumana(HIV)sãoproblemasde saúdeimportantes. Osprofissionaisde saúdecorremoriscodetransmitirvírustransmitidospelosangue,eoscirurgiõestêmummaior riscodeexposic¸ãoao sangueetaxasmaiselevadasdelesõespercutâneasdoqueosoutros profissionais desaúde.Aseptoplastiaestáentreastrêscirurgiasotorrinolaringológicasmais comumenterealizadasemtodoomundo.

Objetivo: DeterminarasoroprevalênciadeanticorposHBsAg,anti-HCVeanti-HIVempacientes submetidosaseptoplastiacomesemcirurgiadeconchanasalsobanestesiageraledeterminar sedeveserrealizadotestepré-operatórionessespacientes.

Método: Esteestudotransversal retrospectivoincluiu3731pacientesqueforamsubmetidos àseptoplastiacomesemcirurgiadeconchanasalentrejaneirode2005ejulhode2015.A soropositividadeparaHBsAg,anti-HCVeanti-HIVnospacientesfoiavaliadaretrospectivamente.

Resultados: Aidademédiadospacientesfoide36anos(intervalo:11-81anos).Aotodo,117 (3,6%)pacientesforampositivosparaHBsAg,12(0,3%)forampositivosparaanti-HCVe7(0,2%) positivosparaanti-HIV.

Conclusões: Aeducac¸ãodeprofissionaisdesaúdecombinadacomtestessorológicosrotineiros pré-operatórios em pacientes submetidos a septoplastia sob anestesia geral e local são necessáriospara aumentar aconscientizac¸ão sobreahepatite B eCe ainfecc¸ão peloHIV entreprofissionaisdesaúdeepacientesparadiminuirataxadetransmissão.

© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Worldwide,hepatitisBvirus(HBV),hepatitisCvirus(HCV), andhumanimmunodeficiencyvirus (HIV)aremajorhealth problems. Among the 2billion people infected with HBV worldwide,morethan350million sufferfromchronicHBV infection.1,2 The prevalence of HCV infection is reported to be 2.3%---3% (130---170million people), of which 80% develop chronic infection.3,4 Additionally, WHO reported that2millionpeoplewereinfectedwithHIVandthatthere were1.2milliondeathsrelatedtoAIDSin2014.5

Healthcare workers (HCWs) are at risk of transmitting blood---borne viruses, and surgeons have a higher risk of exposuretobloodandhigherratesofpercutaneousinjury thanotherhealthcareworkers.6---8Itisestimatedthat16,000 HCV; 66,000 HBV and 1000 HIV infections have occurred worldwide in healthcare workers in 2000 as a result of occupationalexposuretopercutaneousinjury.8Transmission ofblood---bornepathogenscanoccurvia percutaneousand mucocutaneousroutes,andsometimesviaexposuretoother bodyfluids.8,9

Septoplasty is amongthe 3 most commonly performed otolaryngological surgeries worldwide.10,11 It can be per-formed under general or local anesthesia.12---14 The nose --- and in particular the septum --- is a vascular organ and surgeonscommonlyencounterbleedingatsomepoint dur-ingseptoplasty.Moreover,surgeonsgenerallyusesuturesto stabilizetheseptum,tostabilizetheperichondrium(using transfixionsutures)sothatnasalpackingisunnecessary,to preventsuchcomplicationsashematomaandbleeding,and

toclose any septal mucosa tears.15,16 Turbinates arealso vascularorgansandturbinatesurgeryperformedwith sep-talsurgeryfurtherincreasesbleeding.17,18Thesefactorsare associatedwithsurgeonexposuretopatientblood and/or secretions,whichconsequentlyincreasestherisk ofblood bornevirustransmission,especiallyHBV,HCV,andHIV.19,20

AtourclinicpreoperativeserologicaltestingforHBV,HCV andHIVisperformed ineveryadultpatientinwhich elec-tivesurgeryundergeneralanesthesiaisindicated,butnot inpatientsundergoingelectivesurgeryunderlocal anesthe-sia,includingseptoplasty.Theaimofthepresentstudywas todetermine the seroprevalenceof HBsAg, anti-HCV, and anti-HIVinpatientsundergoingseptoplastywithandwithout turbinatesurgery,andtodetermineifpreoperativetesting forHBV,HCV,andHIVshouldalsobeperformedinpatients undergoingseptoplastywithandwithoutturbinatesurgery underlocalanesthesiaasanadditionalprecautiontoavoid exposuretopatientbloodandsecretionsduringsurgery.

Methods

This study included 3731 patients that underwent septo-plastywithandwithoutturbinatesurgerybetweenJanuary 2005andJuly2015.HBsAg,anti-HCV,andanti-HIV seropos-itivityinpatientsadmittedtotheOtolaryngologyClinicfor septoplasty with and without turbinate surgery was ret-rospectively analyzed. Preoperative blood samples were analyzedbyourhospital’smicrobiologydepartment.Patient age, gender, type of surgery, and serological data and hematologicalcountswererecorded.Thepatientswhohad

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additionalsinonasalsymptomsandwhoseCTscanrevealed sinonasaldiseasehadendoscopicsinus surgeryin addition toseptoplastyandthuswereexcludedfromthestudy.

The study protocol was approved by the local Ethics Committee(18/12/2015-742),andwasconductedin accor-dancewiththeDeclarationofHelsinki.Datafrequencyand mean±SDwereanalyzed.

Statisticalanalysis

StatisticalanalysiswasperformedusingSPSSv.16.0for Win-dows(SPSS,Inc.,ChicagoIL).Descriptivestatisticsaregiven with each value’s Standard Deviation (SD). The normal-ity of the distribution of data was determined using the Kolmogorov---Smirnovtest.Noneofthedatawerenormally distributed. Gender differences in age, and HBsAg, anti-HCV, and anti-HIV seropositivity were analyzed using the Mann---WhitneyUtest. The level of statistical significance wassetatp<0.05.

Results

In total,3731 patients underwent septoplasty in the oto-laryngology department between 1 January 2005 and 31 December 2015. Among the patients, 3241 underwent surgerywithgeneralanesthesia,versus490withlocal anes-thesia.Preoperativeserologicaldatawereavailableonlyfor patientsthatreceivedgeneralanesthesia; thusly,all anal-yseswereperformedwiththese3241patients’data.Mean ageof the patientswas36 years(range:11---81 years).In total,117(3.6%)patientswerepositiveforHBsAg,12(0.3%) werepositivefor anti-HCV,and 7(0.2%)werepositive for anti-HIV. All 7 patients that were anti-HIV positive were referredfor furtherconfirmation. Among the patients,11 wereaged<18years,allofwhichwerenegativeforHBsAg, anti-HCV,anti-HIV.

Among the patients, 941 were female and 2300 were male.Inall,2%ofthefemalepatients(23/941)werepositive forHBsAg,versus4%ofthemales(94/2300).TheHBsAg pos-itivityratewassignificantlyhigherinmales(Mann---Whitney U test, p=0.023). In total, 0.31% of the female patients (3/941)and0.39%ofthemalepatients(9/2300)were pos-itive for anti-HCV. All 7 patients that were positive for anti-HIVweremale. The anti-HIV positivityratewas0.3% consideringonlythemalepatients.Theanti-HCVand anti-HIV positivity rates did not differ significantly between genders.SerologicalfindingsaresummarizedintheTable1.

No alteration or correlation was found between the hematologicalcounting(CompleteBloodCount)andthe pos-itivepatients.

Discussion

HBV,HCV,andHIVareimportanthealthcareproblems world-wide.Surgeonshaveahigherriskofexposuretobloodand higherratesofpercutaneousinjurythantheother health-careworkers.6---8 andthesignificant ratesofmorbidityand mortalityduetothesevirusessuggestsurgeonsshoulduseall precautionspossibletoavoidexposuretopatientbloodand secretionsduringsurgery.Percutaneousinjuryoccursduring manysurgicalprocedures,varyinginfrequencywithsurgical specialty, andthe 75% ofblood---borne pathogen exposure occurs during surgery.20,21 It was reported that 5.5% of percutaneousinjuriesoccurinotolaryngologicalpractice.21 The suture needle was reported to be the instrument mostassociatedwithpercutaneousinjuryandexposureto blood---borne pathogens,accountingfor 50% ofall surgical injuries,followedbysharpinstruments(34%)---primarilythe scalpel blade (6.9%);the suture needleand scalpelblade are the 2 most commonly used surgical instruments dur-ingseptoplasty.20,21 Incision, suturing,woundclosure, and increasedbleedingareallassociatedwithsurgeonexposure tobloodandsecretions.20,21

ItwasreportedthatvaccinationagainstHBV,useof pro-tectiveglassesandgloves,doublegloving,andbluntsuture needles are the precautions necessary to protect against blood and body fluid exposure.7,21---24 Whether or not pre-operative testing of patients for HBV, HCV, and HIV can furtherdecreasetherisk oftransmissionremains unclear; incountrieswithlowinfectionrates,preoperativetestingis notcommonbecauseitisnotthoughttobecost-effective, whereasincountrieswithhighinfectionratesitisstrongly recommend that preoperative testing be performed.23,25 Transmissionofinfectionsviabloodoccursatahigherrate in developing countries than in developed countries, and occupational blood exposureis of greatconcernin devel-opingcountries.19 Turkey isa developingcountryin which the seropositivity rates were reportedto be0.52%---4.19% forHBsAg,0.1%---1%foranti-HCV,and0%---0.1%foranti-HIV, andthepresentseroprevalencefindingsofthecurrentstudy aresimilartothosereportedearlierforTurkey.26---28Turkeyis anintermediate-endemicregionforHBVandalow-endemic region for HCV.4,29---32 Moreover,HIV/AIDS is currently con-sideredtobean emergingdiseaseinTurkey.33 As such,at oursurgical department we request preoperative serolog-icaltesting includingHBsAg, anti-HCV, andanti-HIV,in all patientsundergoingsurgeryundergeneralanesthesia.

Table1 SerologicaldataforHBsAg,anti-HCV,andanti-HIV.

Total Females(n=941) Males(n=2300) p

n % n % n %

HBsAg 117 3.6 23 2 94 4 0.023a

Anti-HCV 12 0.3 3 0.31 9 0.39 0.758

Anti-HIV 7 0.2 0 0 7 0.3 0.09

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The preoperative prevalence of HBV in the present study’sseptoplastypatientswassignificantlyhigherinmales (4%) than in females (2%), as previously reported, which we think could be due greater social mobility and free-domamongmalesindevelopingcountries,especiallyinrural areas,makingthemalepopulationmoreproneto contract-ingtheinfection34,35;however,thereareotherstudiesfrom developing countries showing higher rates of infection in females.36

Our department frequentlyperforms septoplasty;3731 patients underwent the procedure with and without turbinate surgery between 2005 and 2015, of which 3241 receivedgeneralanesthesiaand490receivedlocal anesthe-sia.Localanesthesiaisasafeandcost-effectivetechnique forsinonasalsurgeryinselectedpatientswhenpaincanbe preventedand/ortreatedduringsurgery.12,37,38Our depart-mentgenerallyusesgeneralanesthesiaduringseptoplasty (3241 of 3731 patients) and all patients undergoing sep-toplasty under general anesthesia undergo preoperative serologicaltesting,includingHBsAg,anti-HCV,andanti-HIV; however,serologicaltestingisnotperformedinourpatients undergoingseptoplastyunderlocalanesthesia.Local anes-thesia is associated with less bleeding during septoplasty thangeneralanesthesia37,38;however,bleedingcanstillbe a problem for some patients under local anesthesia. Our patientsthatreceivelocalanesthesiagenerallyhaveahigh riskforgeneralanesthesia,includinghypertensivepatients andpatientsthatuseblood-thinnersforcardiacdisorders. These patients have a tendency for bleeding even under local anesthesia, putting the surgeon at risk of exposure toblood.Additionally,althoughlocalanestheticagentsare effectivepainrelievers,itisreportedthatnotallpatients aresatisfiedwiththepainmedication theyget fromlocal anesthesia.12Patientsthataresensitivetopaintendtomake sharpmovementsinresponsetopainduringsurgery, jeop-ardizing positioning of the scalpel blade and sutures.14,39 Moreoverexperiencingpainincreasesbloodpressure, mak-ingpatientsmorepronetobleeding.Turbinatesurgeryalso increasestheriskofbleeding.Allofthesefactorsalsoare significant risk factors for surgeon exposure toblood and percutaneousinjuryduringseptoplastyunderlocal anesthe-sia,whichsuggeststhatpreoperativeserologicaltestingin patientsreceivinglocalanesthesiacouldberoutine.

Weobtain theCTscanifthepatientreportsany symp-toms related to sinus disorders. Of the patients who we obtainedCTscan,thepatientswhohadsinusdiseasewere excludedfromthestudyandhadendoscopicsinus surgery performedinadditiontoseptoplasty.Wewantedtoexclude thesebecausewe onlywantedtoincludethemostwidely performedprocedure(septoplasty)andmakethesurgeons awarethatalthough itiscommonlyperformedanda rela-tivelyeasyandstraightforwardsurgery,itshouldbekeptin mindthateventhemostcommonandbasicsurgical proce-dureputsthesurgeonunderriskoftransmittingblood---borne pathogens.When thinkingabout thecomplicationsof sep-toplastyoranysurgery,transmissionoftheinfectionshould alwaysbekeptinmind.

As mentioned above, preoperative serological testing, includingHBsAg,anti-HCV,andanti-HIV,isperformedinall ofourpatientsundergoingsurgeryundergeneral anesthe-sia.Inadevelopingcountrywithahighprevalenceofthese viruses,suchtestingalertssurgeons,nurses,andtheentire

surgicalteamtotheneedforextracautionduringsurgery.In addition,preoperativeserologicaltestingfacilitates inform-ing our patients that are unaware of their seropositivity and early detection of infection in patients in which the associateddiseaseswouldotherwisegoundetected,which helps limit the spread of virus in the community. The presentstudy’sseropositivepatientswerereferredfor fur-therinvestigationandwereencouragedtotakeallnecessary precautions to prevent transmission to other individuals. Theseprecautions are especiallyimportant,as worldwide ahighproportionofoccupationallyacquiredHCV,HBV,and HIVinfectionsoccurindevelopingcountriessuchasTurkey, inwhichhealthcareworkersareexposedtoapatient popu-lationwithahigherprevalenceofblood---bornevirusesthan indevelopedcountries.19

None of the 7 patients who were positive for anti-HIV wereawareof theirdiseasebeforethesurgery. Ofthe12 patientsthatwereanti-HCVpositive,onlyonepatientwas awareofhisresultsbeforethesurgery.Ofthe117patients thatwereHbSAgpositive,32patientswereawareoftheir resultsbeforetheirsurgery.Thesenumbersmaybesomehow unreliable,as these diseases can be sexually transmitted andthepeoplewhoknowtheyhavethedisease(especially HIV)maybereluctanttoexpressthattheyhave an infec-tiousdisease. This is important especiallyin conservative countrieswherepeoplewhohavethesediseases(especially HIVandHCV)mightbeexcludedfromthesociety.Itisa sur-geon’smostimportantresponsibilitytorespectthepatient confidentialityandtoreassure the patientthathisor her resultswillbekeptconfidential.Otherthanthat,wehave hadpatientswhowere reluctanttoinformusabout their diseasebeforetheirbloodworkwaspositiveforinfection, whichwasmainlybecausetheythoughttheirdiseasewould resultincancelationoftheirsurgery.Thus,thesurgeonmust understandthepatientsconcernsandaddressanyquestions intheir mind accordingly.Also,we had patients withlow socioeconomicstatuswhoalreadywerediagnosedinother placesbeforeweobtainedbloodtestsfromthem.Theywere toldthattheyhadthediseaseintheplacetheywere diag-nosed,butfailedtounderstandordidnotpayattentionto it,thusdidnotinformusaboutthis.Thus,obtainingthese bloodworkscanbecrucialinincreasingpatientawareness, especiallyincountriesoflowsocioeconomicstatus.There maybemanyotherreasonsforthepatientstobereluctant totella surgeonthat theyhavetothedisease. Forthese reasonsweobtainthesebloodworkonaroutinebasisfrom allourpatientswhoweperformsurgery.

For patients undergoing septoplasty under local anes-thesia, it might also be useful to perform preoperative serologicaltesting, as septoplasty is also associated with the risk of contamination. It was reported that Turkish healthcareworkersinahospitalsettinghaveahighriskof percutaneousinjury/mucosalexposure,butoverall aware-nessofsuchriskislow.40Althoughtheoccupationalriskto healthcareworkers is lowerin Turkey than in some other developingcountries,40---42 studiesshowthatthereisahigh incidenceoftheexposuretobloodbornepathogensin Turk-ishHCWs,ascomparedtodevelopedcountries.40,42---45Some studiesindicatethatroutineserologicaltestingisnot neces-saryforallpreoperativepatients,butshouldbeperformed inpatientswithriskfactors.23Thisapproachcouldbe feasi-blein low prevalence countries,but not in Turkey,which

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has higher prevalences. Furthermore, overall awareness of percutaneous and mucocutaneous injury among Turk-ishhealthcare workers is low.40 Educationalprograms for increasingawareness of the risk in Turkish hospitals is of utmost importance and when combined with serological testing, such programs could be more effective and fur-therincreaseawareness.Tothebestofourknowledgethe presentstudy is thefirsttoassessthe prevalenceof HBV, HCV,andHIV infectioninpatientsundergoingseptoplasty. Also,ourstudyincludesalargepatientpopulation.

Conclusion

Septoplastywithandwithoutturbinatesurgeryisassociated withtheriskoftransmissionofblood---bornevirus transmis-siontosurgeons,whetherperformedunderlocalorgeneral anesthesia. The present findings indicate that education ofhealthcareworkerscombinedwithroutinepreoperative serologicaltestinginpatientsundergoingseptoplastyunder generalandlocalanesthesiacouldfurtherincreasepatient andhealthcareworkerawareness,anddecrease contamina-tionrates.

Funding

Theauthorsdisclosenofinancialrelationshiprelevanttothis publication.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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