Other paediatric problems

Here are some of the other problems you may meet, and which do not require complete sections to themselves. Intussusception (10.8), and Ascaris obstruction (10.6) are described elsewhere.

OTHER PROBLEMS PROBLEMS IN NEONATES If a neonate or an infant has RETENTION OF URINE with overflow, the neck of his bladder is probably obstructed, by the contraction of his internal meatus, or more commonly by URETHRAL VALVES. These usually present in the first six months of life, but they can occur at any age, and even into adult life. They can present as retention, urinary tract infection, dribbling incontinence or renal failure. You may feel that an infant's bladder is distended, and you may be able to feel his kidneys. His distended bladder may simulate a rhabdomyosarcoma of the bladder, but will disappear on catheterization. Pass a urethral catheter (a 6[nd]8 Ch feeding tube is suitable) under ketamine or general anaesthesia. Alternatively insert a suprapubic catheter. Treat any infection and refer him. A urethral catheter is unsatisfactory, because its bore is so narrow that it soon blocks. A suprapubic tube is better, but even this does not drain his ureters or kidneys well.

If a neonate is born with a LARGE SOLID MASS BELOW HIS SACRUM, it is probably a coccygeal teratoma or hamartoma (benign or malignant). Refer him for surgery soon .

PROBLEMS [s7]IN OLDER CHILDREN If a child DISCHARGES URINE FROM HIS UMBILICUS and his urethra, he has a persistent urachus (rare). Sometimes urine discharges in a small spurt during micturition. He may not present until he is a year old or later. Excising the track is not difficult. See Section 28.5.

If he has a dirty UMBILICUS WHICH DISCHARGES, smells, and occasionally bleeds, he has a GRANULOMA OF THE UMBILICUS (very common), caused by an infected remnant of his cord (28.5). Clean it with spirit daily, apply alum powder (Paediatric Alum and Zinc Dusting-powder BPC), and keep it dry. Alum powder is also preventive, because it quickly dries the stump of the cord.

If a boy's URETHRA OPENS ON THE VENTRAL SURFACE OF HIS PENIS, he has hypospadias. Refer him at 3 years, so that the necessary plastic surgery can be completed by the age of 6.

If a child has RECURRENT ATTACKS OF CHOLANGITIS which may lead to JAUNDICE, suspect cystic dilatation, usually of his common bile-duct (CHOLEDOCAL CYST). An expert should be able to anastomose the fundus of his gall-bladder to his jejunum, and excise the cyst. If this is impossible, anastomosis alone is of some value.

28a Surgery, AIDS, and hepatitis B

''One night after I had been doing some blood tests in a rural area with some local medical colleagues, they went off with some girls from the town. They slept with them, and only one of them used a condom. In the morning I asked them how they could possibly have taken such a risk, since we all knew that the prevalence of HIV was quite high in the region. They laughed, saying that you couldn't give up living just because you might get a disease''.

A research worker in Central Africa reported in the March 1987 PANOS Dossier. 28a.1 Introduction While this system of surgery was being written, a disease appeared which seems likely to change the face of the developing world, and perhaps the entire world[md]AIDS, the acquired immunodeficiency syndrome, caused by the human immunodeficiency virus (HIV). Not the least of its consequences are those for surgery. Some of these are shared by HBV, the virus of hepatitis B, which provides some illuminating parallels and contrasts in what promises to be a pivotal chapter in these manuals.

Although AIDS overshadows hepatitis B, it is significant that during the production of this book, two of its contributors became infected with HBV, and one of them died of fulminant viral hepatitis. Both almost certainly acquired their infections in the theatre. This chapter is based on the experience of Central Africa, particularly Zambia, and applies less to more fortunate countries.

Fig. 28a-1 HIV, THE AIDS VIRUS. The outer lipid membrane is pierced by a glycoprotein (gp41) to which another larger glycoprotein (gp120) is attached. Inside are the core proteins (p18 and p24). When the virus enters a host cell, the enzyme reverse transcriptase makes a DNA copy of the viral RNA, which is permanently integrated into the host's DNA. 28a.2 AIDS Where HIV came from is a mystery. It is a retrovirus (RNA virus), and it is also a lentivirus (slow virus), which progressively destroys the immune system and infects the brain. It is one of the most genetically variable of all human viruses, and is spreading as a virgin-soil pandemic. In some studies, up to 50% of seropositive subjects have developed AIDS, but it is possible that some infected people may remain symptom-free for the whole of their natural lives. WHO considers that AIDS is likely to become a pandemic of such severity that it may cause more deaths than any previous pandemic in recorded history.

Although HIV has been isolated from blood, semen, saliva, vaginal secretions, tears, breast milk, and urine, only blood and blood products, semen, and vaginal secretions seem to be important sources for transmission.

The simple rule is that HIV is spread by: (1) Heterosexual intercourse[md]the dominant method in sub-Saharan Africa. (2) Homosexual intercourse[md]the dominant method in some communities in the developed world. (3) Blood transfusion and blood and tissue products. (4) Vertical transmission from a mother to her baby. (5) The shared needles and syringes of drug abusers, in which the blood that is drawn into a needle by one addict infects another. (6) Inadequately sterilized needles and equipment in hospitals and health centres, and by traditional practices, such as scarification, which pierce the skin.

The simple rule also is that HIV is not spread by: (1) Social and family contact, including sharing the same eating utensils or toilet facilities. (2) Nursing patients with AIDS. (3) The medical treatment of patients with AIDS. (4) Mosquitoes or bed bugs.

These simple rules require qualification, because the routes by which HIV spreads vary greatly in their efficiency. Worldwide, the vast majority of cases of AIDS (probably more than 90%) are the result of penetrative vaginal or anal intercourse. The only other routes of public health importance are the transmission of HIV from a mother to her child, and by the administration of blood and blood products.

THE SPREAD OF AIDS Evidence for the efficiency of some routes is still incomplete.

VERY EFFICIENT ROUTES. Although blood transfusion is the most efficient route, it is not the most common one.

Blood transfusion is at least 90% efficient.

Needles shared by drug abusers especially if there is much blood in the shared needle or syringe.

Penetrative sexual intercourse. The efficiency of particular methods varies. The male is a more efficient transmitter than the female; the rectum is more vulnerable than the vagina. The transmission rate per single contact is estimated to vary from 1/100 to 1/1000. The presence of GUD (genital ulcer disease) caused by another STD (syphilis, chancroid, or donovanosis) strongly promotes the heterosexual transmission of HIV, and so does traumatic bleeding, classically caused by the first intercourse (defloration). GUD is one reason why vaginal intercourse seems to be a more efficient route in sub-Saharan Africa than it is elsewhere. Another appears to be the greater frequency of intercourse with multiple partners. Risk is graded here from high to less high:

Receptive anal intercourse.

Receptive vaginal intercourse.

Insertive vaginal intercourse.

Insertive anal intercourse.

Oral intercourse (penile, vaginal, or anal).

From mother to child in utero or perinatally. 25[nd]50% of the children of HIV positive mothers become infected.

THE FAIRLY EFFICIENT ROUTES. Evidence is incomplete.

Improperly sterilized surgical equipment, needles and cannulae, etc., may also be fairly efficient vehicles of infection, so also may some traditional methods of scarification.

Breast-feeding during, but probably [f10]only [f41]during the post-infection peak of infectivity where HIV was acquired after delivery, especially if it was acquired by blood transfusion (see below).

Sex of any kind with a condom. A condom reduces the risk of HIV transmission, but does not eliminate it (some contributors would put this among the inefficient routes).

THE INEFFICIENT ROUTES. It is fortunate for health workers that the needlestick route is as inefficient as it is.

Needlestick injuries to health workers. About 0.5% per episode (the corresponding rate for hepatitis B is 20%).

Breast-feeding when a mother was infected before or during pregnancy. The added risk of breast feeding is likely to be small (see below).

ROUTES WHICH HAVE NEVER BEEN IMPLICATED IN TRANSMITTING HIV, BUT ARE PROBABLY NOT ENTIRELY SAFE. ''Wet kissing'; deep or vigorous tongue-kissing probably carries some risk.

RISK EXTREMELY LOW OR NON-EXISTENT. Shared bedding, toothbrushes, or eating utensils, etc. ''Ordinary family contact', and ''ordinary nursing care'. ''Dry kissing'.

NO RISK. Ordinary contact at school, in the community, and at work. Shaking hands, hugging. Swimming pools, toilets, telephones, door handles, food and cups. Insects or insect bites, including mosquito bites. Water. Droplet infection by coughing and sneezing (so far). Routine immunizations in childhood, or at any other time, with effectively sterilized needles and syringes.

CAUTION ! Beware of false positives and false negatives in diagnosing AIDS in babies. (1) HIV antibodies are transmitted passively from mother to child in utero, so beware of diagnosing infection in a seropositive child. Maternal antibody may persist for at least 6 months. (2) An infected child may not seroconvert for 18 months or more (rare). As a result a neonate may be positive, and then become negative as his mother's antibodies wane, only to become positive again as he makes his own antibodies.

Fortunately, in transmitting HIV, each of the above methods is orders of magnitude less efficient than it is in transmitting HBV.[+15]

''Ordinary family contact' and ''ordinary nursing care' are general terms which include a wide variety of possible routes of infection, some of which are not absolutely safe, despite the simple rule above. The risk is merely very small, rather than zero. A mother has been infected by her infant son, a woman has been infected while providing home nursing care for a sick neighbour, a nurse has been infected by contaminated blood on her hands and face. But these cases are exceptional and very rare. For those who are unaccustomed to weighing up risks (which is most people anywhere in the world), you are probably justified in using the ''simple rule'.

MR PRINTER insert the ''not in series figure' ''Remember Gonorrhoea'' here with the following attribution and delete this line[[ [f10][s8][d8]Drawn by Cath Jackson, with the kind permission of the Terence Higgins Trust.[[[+10] [em]Fortunately for health workers, and especially for surgeons, the routes through which we are exposed in our work are very inefficient. The difficulty is that, although these routes are inefficient, we are exposed to them repeatedly over a long period. Needlestick injuries and infected body fluids, especially blood on our skin, are our main risks. They are not easy to avoid because surgeons commonly injure themselves as well as their patients; they puncture their gloves in up to 30% of operations and injure themselves with needles or knives in 15[nd]20%. So take care where you put the point of your needle, and keep infected body fluids away from your skin. Gloves will keep body fluids away from your hands, but they are little protection against needlestick injuries. They can also put up a psychological barrier between a health worker and his patient, so don't use them unnecessarily.

HIV attacks helper T cells. This reduces the body's ability to resist both the recognized pathogens and the normally harmless commensal organisms, which are thus able to cause opportunistic infections. The result is that a patient with AIDS may suffer, either simultaneously or in sequence, from a wide variety of infections which vary geographically. In Africa, he presents with: (1) Continuing severe loss of weight (hence the Ugandan name ]]''slim disease'). (2) Intractable diarrhoea due to Cryptosporidium, Microsporidium, and Isospora belli. (3) Oral and oesophageal candidiasis (thrush)[md]which is almost invariable. (4) Generalized mild enlargement of his lymph nodes, which are firm enough to be seen under his skin, particularly in his occipital and lateral cervical regions. (5) Mild pyrexia. (6) Anaemia. (7) Recurrent multidermatomal attacks of herpes zoster. (8) Tuberculosis, which is often extrapulmonary, and may fail to respond to treatment (very common). (9) Neurological problems, such as encephalitis and bizarre forms of peripheral neuritis. (10) Septic infections: recurrent boils and abscesses (common), perianal sepsis (5.13) and PID (both of which are made worse by HIV, 6.6), and periostitis (rare, 7.6D). (11) Increased sensitivity to drugs. (12) Bleeding due to thrombocytopenia. (13) ''AAKS', or atypical African Kaposi's sarcoma (fairly common, 32.21). (14) Cryptococcal meningitis (common in Zaire, but not elsewhere). (15) Pneumocystis carinii pneumonia (rare in East and Central Africa, but occurring in Zimbabwe). (16) Toxoplasmosis. (17) Cytomegalovirus (probably). (18) Children present with multiple septic infections and failure to thrive (common).

A few weeks after infection with HIV, seroconversion is occasionally accompanied by a self-limiting mononucleosis-like illness (and rarely by encephalitis). A patient then remains relatively well, although he may have fluctuating minimally painful lymph node enlargement, tiredness, malaise, and a little fever and weight loss. After several months he recovers symptomatically (although his enlarged nodes may persist), often for years, before he develops further symptoms.

Although AIDS can usually be diagnosed clinically, all hospitals should be able to test for HIV antibodies. Unfortunately, both the equipment and the reagents are expensive; but there are aid agencies which are prepared to assist with their purchase. The standard method is an ELISA technique, which is not completely reliable, because the virus can be present for up to 3 months (sometimes 6 months) before the ELISA test becomes positive, and even after this it may occasionally give false negatives (depending on the assay method; it also gives a significant number of false positives). The competitive immunoassay (''Welcozyme') test gives almost no false positives, but may give some false negatives. A few AIDS cases also give false negatives, either because no antibody is present at the time of presentation, or because the antibody is to a virus which is not detected by the test being used (there are two types of virus, HIV[,1],,, common in East and Central Africa, and HIV[,2],,, common in West Africa).

There is presently no vaccine, and the prospects that there will ever be one are uncertain. So the only methods of control are: (1) No sex before marriage. (2) No sex outside marriage. In default of this a single partner, or a reduction in the number of partners, reduces the risk. Multiple partners greatly increase it. Unfortunately, no sex outside marriage does not help if your partner is already positive. (3) Condoms, which reduce the risk, but do not eliminate it; they are frequently used improperly, and do not completely prevent infected body fluids coming into contact with skin. The message that sex with a condom is therefore ''safe sex' is thus dangerously misleading: it is only ''safer' sex. Sex with a condom is less risky, but it is still risky. (4) Restricting the use of blood and blood products, and where possible testing the blood you give. (5) The effective sterilization of needles and syringes, and anything which may be used on another patient, such ]]as any instrument, cannula, or intravenous fluid set. If the sterilization practices of a hospital are imperfect, and HIV is common, the infection of one patient by another is a major potential risk. This is iatrogenic infection (infection as the result of the activities of health workers) and must be prevented. (6) Care in preventing needlestick injuries.

IATROGENIC INFECTION MUST BE PREVENTED The fact that HIV enters the human genome makes the prospect of a radical cure even less likely than that of a vaccine. Azidothymidine (AZT) can produce remissions for up to a year at a cost of about $5000 and numerous blood transfusions. Unlike a patient dying of cancer, an AIDS patient is usually young, and may sometimes live for several years, so he may need more than merely ''terminal' care. You can do much to help him and his relatives: (1) Prevent and treat all infections early and efficiently. Warn him that STDs are dangerous, and treat AAKS. It has been said that, in Africa, the effective and early treatment of tuberculosis would do more good than AZT. (2) Encourage good nutrition. (3) Advise a woman that pregnancy may accelerate the disease, and will probably produce an infected child; provide her with contraception. (4) Discourage potentially harmful traditional practices, such as scarification, emesis, and purgation, but be neutral towards harmless ones. (5) Provide a patient with good nursing care. Understand and counsel him sympathetically, and encourage your staff and the hospital chaplain to do so too; shake hands with him. (6) Support his relatives and advise them how to care for him. (7) Set up outreach services to help him and them. Emphasize the simple rule that spread does not occur by social contact, or through nursing care.

HIV is potentially present, in greater or lesser concentration, in all a patient's body fluids. Outside the body, it may survive for a variable period if it is wet. It is however an enveloped virus,, and is highly sensitive to drying, detergents, heat, alcohol, formalin, and hypochlorite (bleach). The ordinary methods of disinfection in Section 2.5 will kill HIV on instruments and dressings. The most practical disinfectant to use on clothes, bed linen, and blood spills, etc. is hypochlorite, either as common bleach, or as tablets of sodium dichloroisocyanurate (NaDCC); or you can use Virkon (see below).

Breast-feeding. The vertical transmission of HIV is responsible for most paediatric AIDS. 25[nd]50% of the children of HIV positive mothers become infected in utero or during birth; but how much infection occurs in utero and how much during birth is not known. Only the remaining children are at potential risk of HIV in breast milk, but the added risk of breast-feeding is likely to be small. If however a mother is infected after delivery as the result of an infected post-partum blood transfusion, the risk may be greater. It may also be greater if she acquired her infection while she was breast- feeding (usually from her husband). There is a period of viraemia soon after infection, and it has been suggested that breast- feeding during this phase may be more dangerous than at other times.

You will have to balance the benefits and risks of breast and artificial feeding, and follow the guidelines below. Advice suitable for the industrial world where laboratory services are good, and a safe artificial feed is practical, differs from that for the developing world, where neither of these things obtain. The critical priority is that the potential risk of HIV infection should not halt the present global drive for the return of breast-feeding, and the avoidance of artificial feeding.

Melbye M, Njelesani EK, Bayley Anne, Mukelebai K, et al., ''Evidence for heterosexual transmission and clinical manifestations of human immunodeficiency virus infection and related conditions in Lusaka, Zambia. Lancet. 1986;ii:1113[nd]1115. MR PRINTER insert the ''Not in series figure' ''HIV [+]'' here without a heading but with the following attribution and delete this line[[ [f10][s8][d8]Drawn by Nick May, with the kind permission of The Independent.[[[+10]

AIDS PREVENTING SPREAD [s7]BY BLOOD TRANSFUSION INDICATIONS FOR TRANSFUSION. In areas where HIV is highly endemic there is only one indication for blood transfusion[md]when the patient's life is in danger. Any transfusion which is not indicated is contraindicated!

METHOD. Try to establish HIV testing in your hospital. Minimize the risk of infection by: (1) Screening all donor blood. Unfortunately, this is not completely effective (see above). (2) Question all donors, and don't take blood from anyone who has had an STD in the previous 5 years (not easy to verify). (3) Don't take blood from high-risk groups, such as prisoners, drivers, or the army. (4) Try to establish a tested donor panel from social groups at low risk (and prepare for its rapid shrinkage). In an ''anti-AIDS club', or church group, the desire to remain publicly a ''safe donor' may encourage saying ''No' to extramarital or premarital sex. (5) Reduce the need for transfusion by treating anaemia medically, particularly the anaemia of pregnancy, and by the efficient care of patients with sickle cell anaemia.

Instead of using blood to treat hypovolaemia use: (1) Saline, which stays in the circulation for about 2 hours. (2) Gelatin (''Haemaccel'), which is expensive but does not interfere with cross-matching. (3) Dextran (''Dextraven'); which is cheaper, but makes cross-matching more difficult. (3) The patient's own blood by autotransfusion (16.10), as with an ectopic pregnancy (16.6), or rupture of his spleen (66.6) or liver (66.7). Avoid blood transfusion, unless it is life-saving. Major paediatric surgery is an exception, because a child has such a small blood volume. Where possible, take blood from a close relative, a spouse, or a parent, who is likely to have the same HIV status as he has. In one African country the only relative who can be almost guaranteed to be HIV negative is the patient's grandmother.

If you need blood for elective surgery, take a unit from him 1 week and 2 weeks preoperatively, store them and give him iron. If necessary, 3 or 4 units can be obtained this way.

CAUTION ! Never give a single unit of blood to an adult patient who can do without one, unless it was his own, donated previously. If it happens to contain HIV, it may be fatal. He is likely to need at least 2 units or none.

MIDWIFERY. If a mother is HIV positive, her blood will contain HIV, so will the placenta. Wear gloves and an apron, and don't let her blood get into an open cut or wound. If possible, don't let it get on your skin. So, wash your hands and cover open cuts. Make sure that your staff also follow these rules!

BREAST-FEEDING. Advise people like this:

If a woman is HIV-positive, persuade her strongly not to become pregnant because this encourages the progression of the disease. Unfortunately, her husband may want more children and she may have little choice.

If a mother is HIV-positive before birth, the added risk from breast-feeding, if any, is small:

If a safe artificial feed is impractical (most likely), she must breast-feed her baby. The immuological, nutritional, psychological and child-spacing benefits of breast-feeding outweigh the small added risks of infection.

If a safe artificial feed is practical (unlikely under the conditions for which we write), opinions are divided. Some would advise breast-feeding and others not.

If a mother becomes infected during or after delivery, the problem is largely theoretical, because you are unlikely to diagnose infection, until it is too late to alter her management. The manner in which she became infected may however determine the risk of transmission:

If she was infected by a blood transfusion during delivery, her infectivity may be greater, and an artificial feed is advisable.

If she was infected in some other way while breast feeding (usually by her husband), she may be infective during the early viraemic phase of her infection. The risk of infection may however be less than if she is infected by blood transfusion.

If a mother is at high risk of HIV, but you don't know if she is HIV-positive or not, advise her to breast-feed.

If she and her baby are both infected, advise her to breast-feed.

If you run a milk-bank in an area of HIV prevalence, be on the safe side and pasteurize the milk intended for another baby at 60[de]C for half an hour, or boil it. This will impair some of its immunological activity, but it will still be better than formula.

BLOOD PRODUCTS include plasma and human immune globulin, and factors for the treatment of clotting defects. If they are derived from the pooled plasma of many donors, they are particularly likely to be contaminated by HIV. Unless these products are certified as being HIV-free, avoid them.

IN THE LABORATORY treat all blood as potentially contaminated, and kill HIV in serum by heat-treating it (56[de]C for 30 minutes) before you test it, making sure that this will not upset the test first. Improve laboratory hygiene, and especially avoid pipetting by mouth.

Fig. 28a-1a DISINFECTANTS FOR HIV. WHO AIDS Series (2), ''Guidelines on Sterilization and High-Level Disinfection Methods Effective Against the Human Immunodeficiency Virus (HIV). Geneva 1988.

DISINFECTION [s7]FOR HIV AND HBV CAUTION ! Clean all instruments thoroughly before you disinfect them. If HIV prevalence is high, try to give them a preliminary soaking in a chemical disinfectant first, before they are cleaned, so as to reduce the risk to the staff who clean them.

HIV and HBV are both destroyed by: (1) The standard methods of autoclaving at 121[de]C (1 kg cm['2]) for 20 minutes. This is the method of choice for reusable instruments. There is a special WHO/UNICEF portable steam sterilizer for this purpose. (2) A hot-air oven (including a domestic oven) at 170[de]C for 2 hours. This temperature will destroy reusable plastic syringes. (3) Boiling for 20 minutes; HBV is destroyed by a few minutes' boiling, and HIV probably is too. WHO recommends 20 minutes to be sure.

CAUTION ! In practice, chemical disinfectants are not reliable, because: (1) They may be inactivated by blood or other organic matter. (2) They must be prepared carefully. (3) Some of them rapidly lose their strength when stored in a warm place. Chemical disinfection must not be used for needles and syringes, and should only be used for skin-cutting and invasive instruments as a last resort, and then only after the instruments have been properly cleaned, and disinfected in solutions that are correctly used.

Both viruses are also destroyed by the following solutions applied for not less than 10 minutes and preferably for longer: (1) Chlorine-releasing solutions, see below. (2) Ethanol 70% (higher and lower concentrations are less effective). (3) 2- propanol (isopropyl alcohol) 70%. (4) Povidone iodine 2.5% for 15 minutes. (5) Formaldehyde 4% (40% solution diluted 1:10) for 30 minutes); this is corrosive, so rinse equipment thoroughly. (6) Glutaraldehyde 2% activated (made alkaline) with a powder supplied with the solution. (7) Hydrogen peroxide 6% (30% solution diluted 1:4). See also Sections 2.4 and 2.5, and make sure that all instruments are thoroughly washed before being immersed in disinfectant.

CAUTION ! The following methods are NOT recommended: (1) Solutions of spirit less than 70%, and especially less than 50%. (2) Cetrimide (''Cetavlon') and chlorhexidine (''Hibitane') are not effective, although the 70% spirit in which they are usually made up is effective. (3) 0.1% formalin (stronger concentrations are effective). (4) ''Dettol', ''Roxenol', flavine, etc.

SPECIAL CAUTION ! Washing instruments and then immersing them in 1% cetrimide for 3 minutes between cases is NOT safe!

CHLORINE releasing compounds are excellent disinfectants. Their power is expressed as ''available chlorine': % for solid compounds, and % or parts per million (ppm) for solutions. 0.0001% = 1 mg/litre = 1 ppm. 1% = 10 g/litre = 10, 000 ppm. Chlorometric degrees ([de] chlorom) are sometimes used, 1[de]chlorom = 0.3% available chlorine.

Chlorine corrodes iron and stainless steel, so don't store these disinfectants in stainless steel containers, or use them repeatedly for disinfecting good quality stainless steel equipment. Immerse such equipment for less than 30 minutes and rinse it well.

Sodium hypochlorite solutions (liquid bleach, ''eau de Javel' etc.) are unstable. Neat disinfectant solutions (''Domestos', ''Chloros', ''Sterite') contain about 100,000 ppm. Strong hypochlorite solution BP contains not less than 80,000 ppm. Most supermarket brands contain about 50,000 ppm; ''Milton' contains about 10,000 ppm. Hypochlorite is readily inactivated by blood and organic matter, which need increased concentrations to disinfect them.

5000 ppm will inactivate HIV in 1 minute, 50 ppm take 10 minutes. Hypochlorite is very unstable at this dilution, so make up the solution freshly and then discard it.

Calcium hypochlorite (70% available chlorine) and bleaching powder (35% available chlorine) are sold as granules, tablets, or powder, and decompose gradually if they are not protected from heat and light.

Sodium dichlorisocyanurate (NaDCC, 60% available chlorine) is comparatively stable.

Chloramine T, tosylchloramide sodium (25% available chlorine) as powder or tablets is also comparatively stable.

Use chlorine solutions like this:

For general disinfection for wards, theatres, and laboratory benches, use solutions of 1000 ppm.

For disinfecting blood, body fluids, excreta, etc., on surfaces flood the area to be disinfected with a solution of hypochlorite diluted to not less than 5000 ppm, and leave it on for half an hour before rinsing. Finally, wipe the area with more hypochlorite.

CAUTION ! (1) When cleaning spills wear gloves. (2) Dilution of the virus by washing is simple and important. (2) If you use alcohol, wipe the surface several times, because alcohol evaporates. (3) Establish the rule ''You spill it, you clean it''. (4) ]]Make sure your hospital disposes of its contaminated materials safely, and does not put them on a rubbish tip where they may be ''reclaimed' by scavengers.

VIRKON (ANT, also from ECHO), a proprietary antiseptic, is a balanced stable blend of peroxygen compounds (mainly inorganic salts), surfactant, and organic acids in an inorganic buffer system at pH 2.6. It is a stable pink/grey powder in sachets of 50 g or in buckets, and is non-corrosive, non- bleaching, and non-toxic, and is not a transport hazard. For disinfecting needles and syringes, use it as a fresh 1% solution for at least 10 minutes; 30 minutes is better.

PREVENTING AIDS AND HEPATITIS B [s7]DURING SURGERY Wear gloves whenever you deal with body fluids, and an apron, and a gown when you operate. Double gloves are little extra protection. Avoid getting blood on your skin, and especially into cuts or wounds. Full glasses will protect your eyes, if an artery spurts blood into them; aerosol and splash injury to the conjunctiva has not been recorded as transmitting either virus. If you do get blood or body fluids on yourself, wash immediately.

SYRINGES, NEEDLES, AND NEEDLESTICK INJURIES. Shortage of needles is going to compel you to reuse them.

In practice, make sure that anyone who cleans and washes needles and syringes uses gloves, so that any HIV in them does not get into any cuts he may have on his skin. The best method of sterilization is heat, by boiling or autoclaving, or where practical in a hot-air oven (provided they have been well cleaned first). If you use a disinfectant such as ''Virkon' or hypochlorite, the criteria for killing HIV and HBV must be fulfilled (see above). Ask staff on the wards to squirt syringes and needles through with water, to immerse them in ''Virkon' or hypochlorite, and to send them for sterilizing.

Ideally, use a new needle for each patient and discard the old syringe, needle, and protective sheath into a safe puncture- and leak-proof container (a ''sharps bin': if necessary an old beer can, as the small hole makes a ''non-return' valve), without resheathing the needle. This is the occasion when you are most likely to puncture yourself accidentally.

BED LINEN, etc. It is impractical to destroy contaminated linen, or to ask AIDS patients to wash their own linen. You are unlikely to have enough disinfectant (hypochlorite or lysol) to disinfect it, or to be able to boil it. The only practical steps you may be able to take are to sluice it using gloves (the usual practice anyway), to launder it (preferably hot) as best you can with a detergent, and to hang it out in the sun; and to require that the laundry staff should wear gloves for general hygiene, and avoid frank blood and faeces. In practice, ordinary domestic or institutional laundery using heat and detergent in a washing machine is effective. If facilities are stretched, laundry from AIDS patients should have priority.

HEALTH EDUCATION. (1) Emphasize that healthy carriers, not AIDS patients are the main means of transmission. (2) Make sure that you and your staff do all you can to tell the community how HIV is spread, and how it is not spread. Organize lectures, seminars, and group discussions for community leaders, government leaders, church leaders, hospital and health centre staff, and student nurses and paramedicals. Secondary and primary schoolchildren are important target groups. Include AIDS in the health education talks you give to all inpatients and outpatients, and especially to all antenatal mothers. Make the most of drama groups. Place posters in public places. Discuss methods of spread with the relatives and contacts of AIDS patients, who should be screened.

SYMPTOMATIC TREATMENT [s7]FOR AIDS An AIDS patient has usually to be cared for at home. As with a terminal cancer patient (33.1), admit him to establish the diagnosis, and start what treatment is possible for his main problems. Base your decision to admit him subsequently on: (1) How ill he is at a given time, (2) how far away he lives from a hospital or health centre, and (3) his home circumstances.

Here are a few of the many conditions you may have to treat:

Diarrhoea. Rehydrate him with oral rehydration salts (ORS). Isospora belli responds to co-trimoxazole. Most AIDS-related diarrhoea (Cryptosporidium, etc) is incurable, but symptoms fluctuate, and loperamide (''Imodium') usually improves them.

Tuberculosis. Treat this. Suspect HIV if a patient with tuberculosis does not improve on treatment, or if he develops some new manifestation of it while he is being treated, or has an adverse drug reaction. Watch out for tuberculous lymph nodes (29.2).

Oral candidiasis. Nystatin is ineffective and ketoconazole may not be absorbed if he has achlorhydria (common).

Atypical African Kaposi's sarcoma (AAKS, 32.21) is well worth treating by chemotherapy.

Pneumocystis pneumonia. Suspect this if you see widespread fluffy opacities in his chest X-ray (in Zambia these are more likely to be due to AAKS); you will be unable to confirm it. Give him trimethoprim for 6 weeks, but expect only temporary improvement.

If an HIV-positive person in Africa develops pulmonary symptoms suspect: (1) bacterial or viral pneumonia (the former normally responding to antibiotics). (2) Tuberculosis, which may be radiologically atypical (29.1). (3) Pulmonary Kaposi's sarcoma (look for purple patches on his palate or gums). (3) Other infections, not yet identified.

If he has malaise and fever without clear symptoms or signs suggesting a cause (common), try erythromycin or trimethoprim empirically for 7[nd]10 days.

If he is paralysed and immobile, treat any bed sores he develops as in Section 33.2.

SUMMARY AIDS is a serious threat to mankind. Health workers in the developing world have a particular responsibility: (1) To

really care for AIDS patients. Get close to them, examine inpatients frequently; greet them, and be seen to shake hands with them. (2) Control the spread of HIV through blood and blood products. (3) Establish a means of testing for HIV. (4) Make sure that syringes, needles, and instruments don't spread it. (5) When you operate, try not to prick yourself or your assistants.

DIFFICULTIES [s7]WITH AIDS If you want to SCREEN a patient preoperatively for HIV, and have no means of testing him, the following signs will be some help: the multidermatome deep scars of herpes zoster (90% HIV-positive in Central Africa), symmetrical lymphadenopathy, oral thrush (patchy erythema on his palate, or small deposits in his gingivobuccal sulcus), and unexplained weight loss.

If you want a set of CLINICAL CRITERIA for the diagnosis of AIDS, use the BANGUI CRITERIA. The presence of at least two major symptoms and at least one minor symptom is sufficient to make a clinical diagnosis of AIDS:

Major symptoms. (1) Unexplained fever for longer than a month. (2) Unexplained diarrhoea for longer than a month. (3) More than 10% weight loss.

Minor symptoms. (1) A maculopapular rash. (2) Oral candidiasis. (3) Herpes zoster. (4) Aggressive or uncontrollable herpes simplex. (5) Unexplained cough for more than a month. (6) Large nodes in more than one extrainguinal site.

If DIAGNOSIS IS DIFFICULT, consider BIOPSY. Symmetrical nodes of modest size ([lt]2.0 cm) don't need it. For nodes which make you suspect Kaposi's sarcoma, see Section 32.21.

If a group of nodes is asymmetric (a group of nodes in one axilla or on one side of the neck), biopsy one. You may find tuberculosis or lymphoma, both treatable. Solitary enlarged nodes are rare.

HEALTH EDUCATION IS THE WAY TO PREVENT AIDS MR PRINTER insert ''No, dear, he is one of us'' (28a-4) here without a heading and with the following attribution and delete this line[[ [f10][s8][d8]Drawn by Cath Jackson, with the kind permission of the Terence Higgins Trust.[[[+10] 28a.3 AIDS and surgery Although the complete surgical pathology of HIV is unknown, it is likely to alter the practice of surgery in several ways:

(1) HIV influences the surgical diseases that a patient presents with, because it alters his response to infections. If he is HIV-positive, infections which would normally be only a minor nuisance, may become serious abscesses (5.1). A minor genital infection may become PID (6.6). There is also a peculiar and unusual type of osteitis described in Section 7.6D. Surgical tuberculosis (29.1) is also more common.

(2) HIV may alter his response to surgery, and therefore the indications for major surgery, in a way which varies geographically. In London, HIV-positive patients and patients with frank AIDS disorders, such as pneumocystis or serious gastrointestinal infections, can heal their wounds and deal with bacterial sepsis much as a normal person would. In Central Africa, an HIV-positive patient is surgically normal and heals well unless: (a) He has chronic sepsis at the operation site, as with a perianal, or ischiorectal abscess, or a fistula, which is unlikely to heal normally when it is excised or laid open. If however the operation wound does not go through an area of chronic sepsis (as with an amputation), you can expect him to heal normally. (b) He is very ill with AIDS. If so, a surgical wound through normal tissue (as with an amputation), will heal badly; just as it would do if he was cachectic from a terminal cancer.

There appears to be an increased rate of infection in orthopaedic implants, and of the breakdown of reconstructive procedures (VVFs, 18.18, etc).

HIV-positivity is not necessarily therefore a contraindication to surgery. However, in Africa: (a) If he has chronic sepsis at the operation site, you will have to weigh up the effects of not operating, with those of a poor response if you do operate. (b) If he is seriously ''ill' with frank AIDS, you can expect that healing will be impaired. In general, if you expect him to live for years, months, or even some weeks, operate. If not, as with a terminal cancer patient, don't.

(3) HIV is a potential risk to the surgical team. Fortunately, this risk appears to be low, and to be much less than that of acquiring HBV. The most serious, but least likely event, is a needlestick injury that results in the actual injection of contaminated blood, or some other body fluid. This has only been recorded as having happened with certainty on four occasions, whereas several hundred health workers have pricked themselves without converting serologically, or developing AIDS.

Nevertheless, AIDS in a highly endemic area has added to the risks of surgery. When only an occasional patient is HIV- positive, the risk is negligible. Nobody knows how high it is when 20% of the ordinary surgical patients are HIV-positive, say one in every list, during a surgical career of 30 years. As we write, one and probably two doctors in sub-Saharan Africa are known to have contracted AIDS in the course of duty. Of the health workers presently suffering from AIDS worldwide, 95% have been found to have non-occupational exposures that have put them at high risk of acquiring it.

An infected person is thought to shed HIV for life, but he is probably most infectious soon after exposure, before antibodies have developed, and later about the time when the p24 antibodies decline, and clinical illness (''preAIDS') starts. Clinical disease, or markers of progression (falling T4 counts), do however increase the chance of infecting sexual partners or children, and the same may be true in the theatre.

Should you operate? You cannot screen all surgical patients before you do, although you can suspect HIV infection (28a.2D). We argue most strongly that, on the correct indications, you should operate. In addition to the general indications as to when and when not to operate, which are given in Section 1.8, you will need to consider a patient's response to surgery, as described above.

Several contributors work under conditions where the HIV rate is 5 to 30%, and believe that the risk to a careful surgeon is low. We advise you how to reduce this risk, although you cannot, alas, abolish it. Wear goggles, use two pairs of gloves, use scissor dissection where possible, and don't operate on an HIV-positive patient when you are tired at the end of a list and therefore less likely to be careful.

In common with many other callings, the care of the sick has often involved risk, and probably always will. Before the discovery of penicillin, streptococcal septicaemia from a finger prick not uncommonly killed surgeons (see the story of Hamilton Bailey, 2.10). For a period of about 40 years (1945 to 1985) antibiotics changed all that, and left only hepatitis B as an appreciable risk. With AIDS, we are back were we were. Surgery has risks and, whether we like it or not, is nobler by having them.

Life is dangerous, and is 100% fatal, in that we are all going to die some time. Much of the skill of living it depends on taking a proper view of the risks that might end it. The risks of dying from AIDS contracted in the theatre are likely to be much less than at least two others: (1) Dying on the roads, which continues to kill many doctors in the developing world. One contributor to this manual died in this way while it was being written, and the senior editor has himself had two very narrow escapes. So fasten your seat belt, and see Section 50.2. (2) Contracting AIDS promiscuously. The safety precaution here is clear.

Sim AJW and Dudley HAF, ''AIDS and the surgeon''. Br Med J 1988;296:80 Fig. 28a-2. HEPATITIS B. A, the structure of the virus. B, the clinical syndromes associated with acute and chronic HBV infection. C, antigen and antibody levels in acute hepatitis. D, antigen and antibody levels in chronic hepatitis. A, C, and D, Program of Appropriate Technology in Health (PATH), Vol 6, No. 3, Figs 1 and 2. B, from the Oxford Textbook of Medicine. Both with kind permission. 28a.4 Hepatitis B Although hepatitis in its various forms is an important cause of disease all over the developing world, its importance in district hospital surgery is mainly restricted to: (1) The need to distinguish hepatitis from surgical obstruction to the bile ducts (32.26). (2) The danger of hepatitis virus B (HBV) to you and your staff.

HBV invades the cells of the liver and releases a complex series of antigens. These and the antibodies to them can be detected in the blood. You will not be able to detect them, so no more will be said about them here, except that, in an acute attack which is successfully recovered from, the surface antigen (HBsAg) appears in the blood and is then replaced by the antibody (anti-HBs). In chronic hepatitis, when the patient becomes a carrier, HBsAg persists, and no anti-HBs appears. Highly infectious carriers (''super carriers') are also HBeAg-positive.

Hepatitis B has a low prevalence in the industrial world, but is highly endemic in China, South-East Asia, sub-Saharan Africa and in the Amazon basin. In these areas most people are infected at birth, or in early childhood; 5[nd]30% of the population become chronically infected with the virus or carriers of it, and most adults show serological evidence of having had it.

The virus persists in the liver of carriers (see below), and is present in the blood, semen, milk and other body fluids. Transmission is the result of the accidental inoculation of minute amounts of blood, or body fluids, which enables HBV to spread: (1) Vertically from a carrier mother to her infant; this usually occurs during delivery, and infection during pregnancy (i.e in utero) is rare. This is the common route of infection in China, South-East Asia, and Africa. (2) Horizontally among children through scratches and small sores. This is another common route in Africa. By the age of 25 years 75% of people in some endemic areas in the developing world have been infected by one or other of these routes. (3) Through blood transfusions and imperfectly sterilized needles. (5) By vaginal or anal intercourse. (6) Among the inmates of institutions, such as those for the mentally handicapped.

If an infant is infected, there is a greater than 90% chance that he will have a subclinical infection; and a small chance that he will have a clinical attack, which is usually mild. There is also a a significant chance that he will progress to chronic active hepatitis (CAH), or to chronic progressive hepatitis (CPH), as the result of becoming a carrier. Many cases of CAH progress to cirrhosis, and some of these to hepatoma, which is the commonest malignant tumour in the developing world (32.26).

If an adult is infected, there is a 90% chance that he will have an acute clinical attack of hepatitis, with or without jaundice (fulminating and commonly fatal in about 1%), and a 5% chance that he will become an asymptomatic carrier. If he becomes a carrier, he has a 4% chance of developing CPH or CAH, perhaps leading to cirrhosis and hepatoma.

If the surface antigen (HBsAg) persists for more than 6 months after an attack, the patient is a carrier. The earlier he is infected, the more likely he is to become one. At birth, the risk is 80 to 90% if a child's mother is a carrier (HBsAg and HBeAg positive, a ''super carrier'). The risk is about 50% during the first 5 years of life, and only about 5% if the infection occurs in adult life. The carrier state usually lasts for life.

Chronic hepatitis is hepatic inflammation which lasts longer than 6 months. It takes two forms, which may be associated with hepatitis B, or with other conditions: (1) Chronic persistent hepatitis (CPH), in which inflammatory cells are confined to the portal tracts; the patient is asymptomatic, with no physical signs of liver disease, and only minor biochemical abnormalities. His prognosis is good, and he seldom gets cirrhosis. (2) Chronic active hepatitis (CAH), in which inflammatory cells extend beyond his portal tracts, and he is unwell and jaundiced, with abnormal liver function tests; he is likely to become cirrhotic, and is at increased risk of hepatoma.

The risks of hospital-acquired infection differ in the industrial and the developing world. In the industrial world carriers are uncommon, but when they occur health workers are at risk, because they are unlikely to have met the virus before. In the developing world many chronic carriers come to surgery, but as most indigenous health workers will already have been infected, usually subclinically in infancy or childhood, subsequent reinfection in the theatre is unimportant. The risk is that, in caring for a carrier patient, a small quantity of blood or body fluid will enter the circulation of a non-immune health worker, and infect him with HBV, the commonest cause of infection being a needlestick injury. Unlike HIV, a very small quantity of blood may be infectious. The risk varies according to state of the infected patient, and the circumstance. High risks are: (1) Patients with acute hepatitis B. (2) HBsAg and HBeAg positive ''super carriers'. (3) HBsAg positive carriers, who do not at the same time have antiHBe.

HEPATITIS B For sterilization and prevention during surgery see Sections 2.5 and 28a.2.

If you grew up in the developing world, you are probably immune from reinfection. If however you come from the urban elite, and so may not have met the virus before, you may still acquire it.

If you grew up in the industrial world and work in the developing world, you are at particular risk, because you will probably not have met the virus before, and will treat many chronic carriers. If you become infected, your chances are those of any other adult, as described above[md] a 1% chance of fulminant hepatitis, a 4% chance of CAH, and a 5% chance of becoming a carrier. You would be wise to be immunized.

PASSIVE IMMUNIZATION. Hepatitis B immunoglobulin (HBIG, expensive) gives immediate protection which lasts about 6 months. A dose given early in the incubation period will either be protective, or modify the attack considerably.

ACTIVE IMMUNIZATION. Vaccine is expensive, but advances in genetic engineering promise to make it cheaper. It can withstand being out of the cold chain for 30 days. Give three doses at months 0, 1 and 6. Give infants and children under 12 5[nd]10 [gm]g, give adults 10[nd]20 [gm]g. It is 95% effective.

If a baby has a ''super carrier' mother (HBsAg and HBeAg positive), he is at risk of becoming a carrier. Unfortunately, you are unlikely to be able to test for the carrier state. Give him vaccine within the first 3 days of birth, preferably on the first day, accompanied by HBIG 0.5 ml into the other thigh. Repeat the vaccine only at 1 month and 6 months. It is 95% effective, if HBIG is also given, and only 80[nd]90% effective without it.