Universal screening: To do or not to do.

Discussions on risks faced by health-care workers (HCWs) at the workplace do not feature in most forums in India, or even if they do, they are far removed from the mainstream events. That is why the study by Rewri et al.[1] on the seroprevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among patients undergoing cataract surgery published in this issue of the journal is a welcome change because it raises several issues related to preoperative universal screening and the risk of disease transmission from patient to patient and from patient to HCW.

This study reports that about 5.9% of patients undergoing cataract surgery at a teaching hospital in North India were serologically positive for HIV, HBV, or HCV.[1] The authors considered this to pose significant risk to HCWs and other patients. On similar lines, Rishi et al. recently reported that the average annual incidence of needle-stick injuries (NSIs) among HCWs at a tertiary eye care center over a 6-year period was 23/year (almost 2 per month).[2] Yet, another report from one of the nation's busy multispecialty hospitals presented more alarming data. About 80% of HCWs in this particular institute reported one or more NSIs in their career, of which 17.6% involved a patient with known history of HIV, HBV, or HCV or intravenous drug use.[3] About 27.3% of HCWs were not wearing gloves at the time of injury, and 62.1% of HCWs attributed feeling fatigued or rushed as causes for their injury. However, more disturbing is that 14.8% of the HCWs did nothing after incurring the NSI with only 7% taking postexposure prophylaxis. The World Health Organization estimates that globally more than 3 million HCWs are exposed to sharp objects contaminated with HCV, HBV, or HIV every year, which corresponds to 1 in 10.[4] Such exposures in workplace result in about 66,000 HBV, 16,000 HCV, and 200–5000 HIV infections among HCW worldwide!

Although the National AIDS Control Organization (NACO), India, estimates HIV infection to be on a decline, the prevalence is 0.26% (0.22%–0.32%). Nearly 12 states have a prevalence significantly higher than the national average.[5] Although accurate data of HBV and HBC infection in India are not available, estimated HBV prevalence is 2%–8%, with an estimated carrier population of 56.5 million,[6] while HCV is <2%.[7] However, both these entities have exceptionally high prevalence in certain regions of the Northeast, Central, and South India and in the Andaman and Nicobar Islands.

Despite a large known pool of HIV, HBV, and HCV infection and the risk of transmission to HCWs or other patients, routine universal serological screening for these infections is not recommended in India under the National Program for Control of Blindness or elsewhere by other professional bodies such as the American Academy of Ophthalmology or the National Institute for Clinical Excellence, UK. The lack of evidence of direct disease transmission from infected patients to other patients or HCWs during intraocular surgeries, along with the variable sensitivity and specificity of the screening tests, the presence of a window period before seroconversion, the narrow focus of only safeguarding the HCW interest and not case detection and treatment of hitherto undiagnosed patients, and the costs of conducting these tests in resource-scarce settings are some of the reasons why universal screening does not find universal acceptance.[8] In India, where more than 6 million cataract surgeries are performed annually, the extra cost incurred by universal screening acts as a strong deterrent.

Despite the lack of guidelines, many in eye care routinely conduct preoperative serological tests because of concerns of disease transmission. However, such testing raises some concerns, mainly related to the performances of the rapid screening tests which are not infallible. NACO mandates providing pre- and posttest counseling before testing for HIV,[9] and this is generally not available in stand-alone eye care facilities, raising ethical concerns and scope of discrimination.

On the other hand, patients operated under various programs do not get tested because no funds are separately allocated for conducting serological tests. Cataract surgeries in “mega cataract camps” are conducted in high numbers, and in a short period, with the HCW rushed or fatigued, circumstances reported as major causes of NSI.[3] These raises concern about the health of the eye care worker. The costs of testing both HCW and patient after a NSI, postexposure prophylaxis, and the emotional strain suffered by HCW during this period are estimated to be significant.[2] Sometimes, the surgeries in these camps are performed sequentially without changing phacoemulsification tips risking disease transmission to other patients. The main argument in favor of universal screening is that foreknowledge of the patient's serological status will make the HCW alert, and implement safe practices known as universal precautions. Surgeries in seropositive individuals can be conducted safely by following universal precautions.[10]

Universal screening remains a quandary. But then what about safeguarding the health interests of HCWs or patients in terms of disease transmission? Would I be more comfortable operating a patient knowing the serological status? The answer is an emphatic yes. Would it guarantee me foolproof protection? Based on the current level of evidence available, the answer is a no. Ahmed and Bhattacharya[8] worked out a solution by proposing a three-tier strategy: universal screening in resource-rich settings, selective screening based on history and examination in limited-resource settings, and no screening or screening under special circumstances in resource-scarce settings. The authors advise universal precautions as the shield against infection prevention.

While health care vacillates on this issue, eye care organizations and ophthalmic societies need to robustly create awareness about workplace safety among eye care workers. The eye care worker must heed safety practices at the workplace for safeguarding one's own health and that of his family and at the same time not discriminate against the seropositive individual. Universal screening of patients cannot replace universal precautions. Elements of universal precautions can be adopted without making major changes in existing protocol or significantly adding to the prevailing costs.