In the decade following hepatitis B vaccine’s 1981 approval, U.S. health officials issued evolving guidelines on who should receive the vaccine: first, gay men, injection drug users, and healthcare workers; later, hepatitis B-positive women’s children; and later still, all newborns. States laws that mandated the vaccine for all children were quietly accepted in the 1990s; in the 2000s, however, popular anti-vaccine sentiment targeted the shot as an emblem of immunization policy excesses. Shifting attitudes toward the vaccine in this (...) period were informed by hepatitis B’s changing popular image, legible in textual and visual representations of the infection from the 1980s through the 1990s. Notably, the outbreak of AIDS, the advent of genetically engineered pharmaceuticals, and a Democratic push for health reform shaped and reshaped hepatitis B’s public image. Hepatitis B thus became, in turn, an AIDS-like scourge; proof of a new era of pharmaceuticals; a threat from which all American children had a right to be protected; and a cancer-causing infection spread by teenage lifestyles. The metamorphosis of the infection’s image was reflected in evolving policy recommendations regarding who should receive the vaccine in the 1980s, and was key to securing broad uptake of the vaccine in the 1990s. (shrink)

Hepatitis B virus infects about 200 million people worldwide yearly. The consequences of the infection range from mild, self‐limiting hepatitis with full recovery and immunity to chronic infection with liver disease of varying severity, including fulminant hepatitis and death. Alternatively, individuals may become healthy carriers of the virus and thus serve as a reservoir of infection. In addition, all chronic carriers of the virus are also at risk for development of primary hepatocellular carcinoma later in life. Efforts (...) to combat this disease on a global scale require an inexpensive vaccine. Studies of the hepatitis B viral coat protein (HBsAg) have permitted the development of two generations of vaccine to date, and detailed structural studies of its antigenic sites may eventually allow the development of a completely synthetic (and therefore inexpensive) vaccine in the future. (shrink)

A simplified model using kinetic logic is proposed to approach the problem after Hepatitis B viral (HBV) infection. It accounts for several stable regimes or attractors corresponding to the essential dynamic behaviour of the replication of the Hepatitis B virus. Infection with the virus can result in viral clearance, fulminant hepatic failure and death, or chronic transmissible infection, that is multistationarity corresponding to the existence of the positive feedback circuit in our modelling. Another implication of this model is (...) the existence of oscillations or homeostatic mechanisms, sometimes observed in the viral cycle, consistent with the existence of the negative feedback circuit. Thus, this report shows how a simple model of kinetic logic may be used to account for the variety of manifestations of HBV infection. This model implies the presence of the Hepatitis B e antigen, whose conservation suggests that it plays an important role in the life cycle of hepadnaviruses. Its function in the viral cycle is still unknown, but our model suggests that this antigen could explain the passage from one state of the viral infection (acute or latent) to another, as well as the oscillatory behavior which may account for the intermittent symptoms of hepatitis observed in some patients. Furthermore, this model shows a virgin state. This state is also reached after recovery. The model proposed demonstrates that starting from a viral acute infection, the host's immune response, depending on the immunological status of the patient, can lead to viral clearance, or to periodic spontaneous reactivation. (shrink)

Background The potential for transmission of blood-borne pathogens such as hepatitis B virus from infected healthcare workers to patients is an important and difficult issue facing healthcare policymakers internationally. Law and policy on the subject is still in its infancy, and subject to a great degree of uncertainty and controversy. Policymakers have made few recommendations regarding the specifics of practice restriction for health care workers who are hepatitis B seropositive. Generally, they have deferred this work to vaguely defined (...) "expert panels" which will have the power to dictate the conditions under which infected health care workers may continue to practice. Discussion In this paper we use recent Canadian policy statements as a critical departure point to propose more specific recommendations regarding disclosure of transmission risks in a way that minimizes practice restriction of hepatitis B seropositive health care workers without compromising patient safety. The range of arguments proposed in the literature are critically examined from the perspective of ethical analysis. Summary A process for considering the ethical implications of the disclosure of the sero-status of health care workers is advanced that considers the varied perspectives of different stakeholders. (shrink)

We investigate and analyze the dynamics of hepatitis B with various infection phases and multiple routes of transmission. We formulate the model and then fractionalize it using the concept of fractional calculus. For the purpose of fractionalizing, we use the Caputo–Fabrizio operator. Once we develop the model under consideration, existence and uniqueness analysis will be discussed. We use fixed point theory for the existence and uniqueness analysis. We also prove that the model under consideration possesses a bounded and positive (...) solution. We then find the basic reproductive number to perform the steady-state analysis and to show that the fractional-order epidemiological model is locally and globally asymptotically stable under certain conditions. For the local and global analysis, we use linearization, mean value theorem, and fractional Barbalat’s lemma, respectively. Finally, we perform some numerical findings to support the analytical work with the help of graphical representations. (shrink)

Aim: To evaluate health-related quality of life of chronic hepatitis B and hepatitis B virus related cirrhosis patients and analyzed specific differences in all dimensions of HRQoL.Methods: A total of 349 patients met selection criteria were enrolled. The 36-Item Short-Form Health Survey was adopted.Results: Results showed that the physiological HRQoL of the cirrhotic group was significantly lower than that of the non-cirrhotic group, the psychological HRQoL was also lower. HRQoL was significantly negatively correlated with liver stiffness. We further (...) evaluated the risk factors associated with poor HRQoL in HBV-related cirrhosis patients. Results showed that positive HBV DNA viral load and HCC family history were independent factors associated with HRQoL in HBV-related cirrhosis. For better risk stratification of patients, multivariable analyses were conducted to explore the independent factors that affected specific physiological and psychological HRQoL. In specific physiological HRQoL, results show that marital status, positive HBV DNA viral load and antiviral drugs were independent factors associated with physiological HRQoL in cirrhosis patients. In psychological HRQoL, only HCC family history was independent risk factors associated with psychological HRQoL.Conclusion: We found that the impaired HRQoL dimensions of HBV related cirrhosis patients differ between the various subpopulations. According to our results, risk stratification, medical decision making and personalizing interventions could be made. (shrink)

This paper examines the ethical issues faced by health workers managing a fictional case of a female sex worker who is hepatitis B positive with a high level of virus but is asymptomatic. According to guidelines she does not require treatment herself, but is potentially highly infectious to others. Recent legal cases in the UK show it can be criminal to pass on HIV or hepatitis B infection sexually if the risk is known and the partner has not (...) been informed. However, there is no statute or case law showing that health workers are required to intervene to prevent such a potential ‘crime’, particularly when the partners are unknown, as in this case. The health workers could respond in various ways. They could do nothing, thus making further infection probable. They could advise the sex worker to use condoms and to inform her clients. They could treat the sex worker to reduce her level of infectivity, although there is no benefit to her. They could disclose the sex worker's status, although breaking confidentiality is a serious matter ethically and may be of no benefit to the unknown client group. Regulating prostitution might help; but sex workers with infection may work off licence. This paper discusses the clinical, moral and ethical issues associated with such a scenario and concludes that the most beneficial course is to target clients, through health education, to recognise the potential risks of infection from a sex worker and to take suitable precautions including immunisation against hepatitis B. (shrink)

Brock Macdonald1, Evi Vakiani2, Rhonda K Yantiss3, Jun Lee4, Robert S Brown Jr5, Samuel H Sigal61Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, CA, 2Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY, 3Department of Pathology and Laboratory Medicine, New York Weill Cornell Medical College, New York, NY, 4Division of Nephrology, Department of Medicine, Weill Cornell Medical College, New York, NY, 5Division of Gastroenterology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, (...) NY, 6Division of Gastroenterology and Hepatology, Department of Medicine, New York University, New York, NY, USA: The use of sirolimus as an alternative to calcineurin inhibitors for posttransplant immunosuppression is associated with a variety of inflammatory conditions. In this report, we describe the case of a 34-year-old man who developed abnormal liver tests 6 years after live-donor kidney transplantation and 5 years after initiation of sirolimus-based immunosuppression. Elevated aminotransferase levels persisted after withdrawal of potentially hepatotoxic medications, and serologic evaluation for viral hepatitis, autoimmune disease, and genetic disorders was unrevealing. Liver biopsy revealed prominent hepatocellular injury associated with a mixed inflammatory infiltrate and liver tests normalized within 2 weeks of discontinuation of sirolimus. In this report, we review previous reports of sirolimus hepatotoxicity and propose a unifying hypothesis for the various inflammatory conditions that have been attributed to sirolimus.Keywords: sirolimus, immunosuppression, transplant, inflammatory conditions, hepatotoxicity. (shrink)

Alzheimer's disease is characterized by formation of neuritic plaque primarily composed of a small filamentous protein called amyloid-beta peptide . The rate-limiting step in the production of Abeta is the processing of Abeta precursor protein by beta-site APP-cleaving enzyme . Hence, BACE1 activity plausibly plays a rate-limiting role in the generation of potentially toxic Abeta within brain and the development of AD, thereby making it an interesting drug target. A phase II trial of the promising LY2886721 inhibitor of BACE1 was (...) suspended in June 2013 by Eli Lilly and Co., due to possible liver toxicity. This outcome was apparently a surprise to the study's team, particularly since BACE1 knockout mice and mice treated with the drug did not show such liver toxicity. Lilly proposed that the problem was not due to LY2886721 anti-BACE1 activity. We offer an alternative hypothesis, whereby anti-BACE1 activity may induce apparent hepatotoxicity through inhibiting BACE1's processing of beta-galactoside alpha-2,6-sialyltransferase I . In knockout mice, paralogues, such as BACE2 or cathepsin D, could partially compensate. Furthermore, the short duration of animal studies and short lifespan of study animals could mask effects that would require several decades to accumulate in humans. Inhibition of hepatic BACE1 activity in middle-aged humans would produce effects not detectable in mice. We present a testable model to explain the off-target effects of LY2886721 and highlight more broadly that so-called off-target drug effects might actually represent off-site effects that are not necessarily off-target. Consideration of this concept in forthcoming drug design, screening, and testing programs may prevent such failures in the future. (shrink)

The numerous researches devoted to 'jaundice' during the Second World War have brought to light the existence of an infectious type of hepatic jaundice or 'homologous serum jaundice' following parenteral injection of vaccines containing human serum and blood transfusions, which were carried out on a large scale at the time. This type of serum jaundice was then gradually differentiated from 'catarrhal', contagious or epidemic jaundice by clinical trials along with large series of animal studies. Finally, the epidemiological, clinical and biological (...) data obtained made it possible to establish, between 1944 and 1954, the viral etiology of these two types of jaundice: the A virus, present in the patients' blood and stools, was considered to be the agent responsible for epidemic hepatitis; the B virus, present primarily in the blood, was held to be responsible for serum hepatitis. (shrink)

On the 50th anniversary of the Willowbrook experiment's inception, in which Dr. Saul Krugman intentionally infected cognitively disabled children with hepatitis, it is worth reflecting on how our attitude toward research ethics of the past informs our current practices. In examining ethical violations in postwar medicine, we frequently turn to examples that shock and appall, thereby offering concomitant comfort as we measure their safe distance from our own medical context. And yet, which modern medical student has not heard a (...) variation of the phrase "This study would never have passed an ethics committee today" in reference to a classic experiment or a professor's very own work? Even with Nuremburg fresh in the .. (shrink)

Few, if any, scientific inquiries are conducted against a background of complete knowledge, a background in which inquirers are in possession of the ‘full facts’ that relate to a particular question or issue. More often than not, scientists are compelled to conduct their deliberations in contexts of epistemic uncertainty, in which partial knowledge or even a total absence of knowledge characterise inquiry. Nowhere is this epistemic uncertainty more evident, or indeed more successfully controlled, than in the branch of scientific inquiry (...) called epidemiology. In this paper, I examine how epidemiologists overcome the unique challenges to inquiry that are posed by epistemic uncertainty. In specific terms, I contend that epidemiologists employ analogical reasoning strategies in an attempt to advance their inquiries in situations that are epistemically uncertain. The context for my claims will be the early inquiries that were conducted into the emergence of HIV/AIDS in the United States. I argue that early scientific work in relation to HIV/AIDS was directly premised upon epidemiological investigations in which analogical reasoning with hepatitis B had featured significantly. I conclude that epidemiological investigations of AIDS exemplify the capacity of analogical reasoning to advance inquiry under conditions of epistemic uncertainty. To this extent, analogical reasoning should be a concern both to those who address practical problems of uncertainty management and to those who pursue theoretical debates within argumentation studies and epistemology. (shrink)

Introduction Future HIV vaccine efficacy trials with adolescents will need to ensure that participants comprehend study concepts in order to confer true informed assent. A Hepatitis B vaccine trial with adolescents offers valuable opportunity to test youth understanding of vaccine trial requirements in general. Methods Youth reviewed a simplified assent form with study investigators and then completed a comprehension questionnaire. Once enrolled, all youth were tested for HIV and confirmed to be HIV-negative. Results 123 youth completed the questionnaire (mean (...) age=15 years; 63% male; 70% Hispanic). Overall, only 69 (56%) youth answered all six questions correctly. Conclusions Youth enrolled in a Hepatitis B vaccine trial demonstrated variable comprehension of the study design and various methodological concepts, such as treatment group masking. (shrink)

BACKGROUND: The availability of costly safety measures against transfusion-transmissible infections forces Western countries to confront difficult ethical questions. How to decide about implementing such measures? When are such decisions justified? As a preliminary to addressing these questions, we assessed which concerns shape actual donor blood safety policymaking in five Western countries. STUDY DESIGN AND METHODS: Our qualitative study involved determining which issues had been discussed in advisory committee meetings and capturing these issues in general categories. Appropriate documents were identified in (...) collaboration with local decision-making experts in Canada, Germany, the Netherlands, the United States, and the United Kingdom. The introduction of hepatitis B virus nucleic acid testing and selected measures against variant Creutzfeldt-Jakob disease, West Nile virus, and Q-fever were chosen as cases representing decision-making on safety measures with high costs and low or uncertain added safety. RESULTS: A broad inventory of concerns was established, including: 1) nine categories of advantages and disadvantages of candidate safety policies; 2) six kinds of difficulties in assessing risks and forecasting the effects of safety policies; 3) 13 decision-making principles; and 4) six kinds of practical barriers hampering the translation of candidate policies into decisions. CONCLUSION: Blood safety policymaking involves a wide variety of competing concerns, and approaches to reconcile these considerations are themselves contested. Developing a systematic decision-making approach requires ethical reflection on, among others, reasonable costs of safety and the value of transparency in public policy. (shrink)

BackgroundThe Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality.MethodsWe performed a single-center retrospective review of all-comers waitlisted for liver (...) transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors.ResultsCompared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors.ConclusionsThe findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important. (shrink)

In this article, I draw on my fieldwork creating protein models of hepatitis B at a biotech laboratory to think through how to approach the body and disease from ontological and phenomenological perspectives. I subsequently draw on Mariella Pandolfi’s work on how bodies can be made to suffer history and Paul Farmer’s work on global tuberculosis disparities to explore ways of analysing embodied activity as a means of identifying and clinically addressing enactments of social inequality and disease. I also (...) introduce Merleau-Ponty’s phenomenological concept of ‘flesh’ as a conceptual heuristic that allows us to understand the meaningful structuring of ontological worlds beyond our own. As I argue, bringing these perspectives together not only allows us to re-envision what an effective disease treatment should be in diverse medical contexts, but also how to better understand health disparities and the nature of disease itself. (shrink)

Introduction. Healthcare workers (HCWs) should theoretically have the necessary education and environment to adopt a healthy lifestyle, and they supposedly also should have a higher participation rate in WHP programmes. HCWs are, for several reasons, considered to be a key group in health promotion, especially due to the fact that the healthcare system reaches a substantial number of people in need of lifestyle changes such as increased physical activity (PA) [5]. Furthermore, healthcare professionals are considered to be the most credible (...) source of health information [6]. HCWs' lifestyles can play an important role in increasing awareness among patients regarding lifestyle changes, because HCWs' own lifestyle habits and interests in lifestyle behaviour have been shown to positively influence their counselling practices and attitudes [6–7]. The international movement 'Health Promoting Hospitals and Health Services', which was initiated by the World Health Organization (WHO), highlights the importance of also focusing on the health and lifestyle of the employees. Methods. We conducted survey based on a standardized and adapted questionnaire that included socio-demographic data and points related to healthy lifestyle. We adhered to the latest recommendations on designing and reporting survey studies. Before conducting the study, the questionnaire was pretested among 5 experts and revised twice. The survey was conducted in Kazakh / Russian for respondents who speak two languages fluently at the choice of participants. The filling of the questionnaire took on average 45 minutes. We reported absolute numbers and percentages. Chi-square tests were used to compare responses between groups. Results were considered significant at a P value of < 0.05. Statistical analyses were performed using the application SAS OnDemand for academia (version 3.81, Carry, North Carolina, USA). Results. Our data revealed that nurses were more likely to adhere to healthy eating principles and to have a regular diet at home. GPs were more likely to consume fast food and add salt when food is not salted enough. Nurses were more likely to eat greens regularly. GPs had a stronger belief in the impact of diet on health. More nurses rated their diet as healthy. Media promotion significantly influenced GPs for changing diet towards healthier options. Eating patterns vary according to the risk of stress. Research shows that chronic stress influences the amount and types of consumed food, contributing to both overeating and malnutrition, and that stress hormones can lead to the development of obesity. GPs are more likely to have used tobacco products compared to nurses. GPs are more likely to smoke more than 10 cigarettes per day. GPs have a slightly higher belief in the necessity of a healthy lifestyle compared to nurses. GPs and nurses have different testing frequencies for Hepatitis B and C, with nurses testing more frequently. GPs are more likely to have sexual activity after drinking alcohol. Conclusion. It is known that a healthy lifestyle of doctors affects the attitude of patients and their motivation to change their lifestyle. Thus, the lifestyle patterns of health workers, as well as the understanding of the motivation of these patterns, are more likely to affect public health. (shrink)

The risk of transmission of HIV or hepatitis B from infectious health care workers to patients is low. However, inadvertent exposure causes great concern amongst patients of an infected health care worker.The patients of a Scottish dentist diagnosed hepatitis B e antigen positive were informed by letter of their exposure. A sample of patients was sent a postal questionnaire. Most respondents reported feeling anxious on receiving the letter but almost all thought patients should always be informed following treatment (...) by an infectious health care worker, although the risk was very small.We discuss clinical and ethical factors relating to informing patients following exposure to an infectious health care worker. We suggest that a balance should be struck between patients' wishes to know of risks to which they have been exposed, however small, and the professional view that when risks are negligible, patients need not be informed. (shrink)

The National Blood Policy in India relies heavily on voluntary blood donors, as they are usually assumed to be associated with low levels of transfusion-transmitted infections . In India, it is mandatory to test every unit of blood collected for hepatitis B, hepatitis C, HIV/AIDS, syphilis and malaria. Donors come to the blood bank with altruistic intentions. If donors test positive to any of the five infections, their blood is discarded. Although the blood policy advocates disclosure of TTI (...) status, donors are not, in practice, informed about their results. The onus is on the donor to contact the blood bank. Out of approximately 16 000 donations in the past 2 years, 438 tested positive for TTI, including 107 for HIV. Only 20% of the donors contacted the blood bank; none of them were HIV positive. Disclosure by blood banks of TTI status by telephone or mail has resulted in serious consequences for some donors. Health providers face an ethical dilemma, in the absence of proper mechanisms in place for disclosure of test results, regarding notification to donors who may test positive but remain ignorant of their TTI status. Given the high cost of neglecting to notify infected donors, the authors strongly recommend the use of rapid tests before collecting blood, instead of the current practice, which takes 3 h to obtain results, and disclosure of results directly to the donor by a counsellor, to avoid dropouts and to ensure confidentiality. (shrink)

Currently, any dentist in the UK who is HIV-seropositive must stop treating patients. This is despite the fact that hepatitis B-infected dentists with a low viral load can continue to practise, and the fact that HIV is 100 times less infectious than hepatitis B. Dentists are obliged to treat HIV-positive patients, but are obliged not to treat any patients if they themselves are HIV-positive. Furthermore, prospective dental students are now screened for hepatitis B and C and HIV, (...) and are not allowed to enrol on Bachelor of Dental Surgery degrees if they are infectious carriers of these diseases. -/- This paper will argue that: (i) the current restriction on HIV-positive dentists is unethical, and unfair; (ii) dentists are more likely to contract HIV from patients than vice versa, and this is not reflected by the current system; (iii) the screening of dental students for HIV is also unethical; (iv) the fact that dentists can continue to practise despite hepatitis B infection, but infected prospective students are denied matriculation, is unethical; and (v) that the current Department of Health protocols, as well as being intrinsically unfair, have further unethical effects, such as the waste of valuable resources on ‘lookback’ exercises and the even more damaging loss of present and future dentists. Regulation in this area seems to have been driven by institutional fear of public fear of infection, rather than any scientific evidence or ethical reasoning. (shrink)

AbstractWe propose an emerging conceptualization of “intervention hesitancy” to address a broad spectrum of hesitancy to disease prevention interventions among healthcare personnel (HCP) beyond vaccine hesitancy. To demonstrate this concept and its analytical benefits, we used a qualitative case-study methodology, identifying a “spectrum” of disease prevention interventions based on (1) the intervention’s effectiveness, (2) how the intervention is regulated among HCP in the Israeli healthcare system, and (3) uptake among HCP in the Israeli healthcare system. Our cases ultimately contribute to (...) a more nuanced conceptualization of hesitancy that HCP express towards disease prevention interventions. Our case interventions included the seasonal influenza vaccine, the Mantoux test, and the hepatitis B (HBV) vaccine. Influenza and HBV are vaccine-preventable diseases, though their respective vaccines vary significantly in effectiveness and uptake among HCP. The Mantoux test is a tuberculin skin test which provides a prevention benchmark for tuberculosis (TB), a non-vaccine preventable disease. We conducted semi-structured interviews with relevant stakeholders and analyzed them within Israeli and international policy context between 2016 and 2019, a period just prior to the COVID-19 pandemic. We propose the conceptualization of “intervention hesitancy”—beyond “vaccine hesitancy”—as “hesitancy towards a wide range of public health interventions, including but not limited to vaccines”. Results suggested that intervention hesitancy among HCP is rooted in weak trust in their employer, poor employment conditions, as well as mixed institutional guidelines and culture. Conceptualizing intervention hesitancy expands the ability of healthcare systems to understand the root of hesitancy and foster a supportive institutional culture and trust, cognizant of diverse disease prevention interventions beyond vaccination. (shrink)

This paper examines the debate over the human immunodeficiency virus (HIV) as the cause of acquired immunodeficiency syndrome (AIDS) from an historical perspective. The changing criteria for proving the link between putative pathological agents and diseases are discussed, beginning with Robert Koch's research on anthrax in the late nineteenth century. Various versions of 'Koch's postulates' are analyzed in relation to the necessity and sufficiency arguments of logical reasoning. In addition, alterations to Koch's postulates are delineated, specifically those required by the (...) discovery of rickettsiae and viruses in the early twentieth century and by the immunological testing developed after midcentury to demonstrate the links between elusive viral agents and two diseases, hepatitis B and infectious mononucleosis. From this perspective, an examination of the AIDS debate is constructed. Molecular biologist Peter Duesberg's argument that HIV is not the cause of AIDS is analyzed in light of his contention that a version of Koch's postulates has not been satisfied. Additional research findings through 1990 relating to the etiology of AIDS are also noted. (shrink)

This thoughtful reflection on a valuable questionnaire survey of patients' attitudes regarding being told that their dentist had been infected with hepatitis B is of very direct relevance to HIV, as the authors show.1 The measured tone and analytical approach are a welcome change from the stridency that has characterised some of the debate elsewhere. I am very conscious that more time and effort has gone into drafting and redrafting, amending, revising and refining policy in this area than in (...) any other area of HIV control, with the probable exception of blood transfusion. Yet this is the setting that has the lowest risk among all established routes. Why has it been so hard to establish a satisfactory policy and practice to deal with this situation?Many factors, of course, apply. However, much seems to stem from a prevailing view, fostered by recent political administrations, that health care can be delivered in a risk-free way. This has also been linked with a “blame culture”, where adverse outcomes are seen as someone's fault, and where the professions are regarded with distrust. It has been fuelled by levels of concern about risk for HIV that have stemmed more from media “stories” about risk than careful risk assessment.Hence Blatchford et al comment that public anxiety about HIV relative to hepatitis B was a factor in assessing how the incident was handled, implying that HIV was of greater concern - even though the risk of transmission is some two orders of magnitude less. Interestingly, they also comment that, because the risk of death with HIV is higher than for hepatitis B, this balances the overall risk. I am not sure of the validity of this argument, …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vertical Transmission:The Patient, the Student, the TeacherMiguel PaniaguaHe did not ask for this fate, nor did he deserve it, particularly considering the tragic circumstances. Lì presented to the campus health provider one month prior with fatigue, abdominal pain, and jaundice. He and his parents immigrated to the United States from China when he was a child. He was well aware that he had hepatitis B from what is (...) termed "vertical transmission." His mom unknowingly passed on this virus to him during her pregnancy. In most countries with a high prevalence of the virus, prenatal screening is routinely undertaken, and prophylaxis administered. I am not certain this occurred in Lì's case and at this point it did not matter. Lì knew he would live with this for the duration of his life. In fact, he told me he had gone his whole life to this point without any symptoms whatsoever. What is known about chronic hepatitis B infection is that in most people affected, it can be considered a chronic disease where most live a long full life. The risk of advancing to liver cirrhosis or cancer in general is low. This unfortunately was not the case with Lì.What transpired was what they most feared. As he was studying for his final exams, Lì endured days of worsening fatigue, malaise, and nausea. He noticed his skin was a tinge of yellow and he was having some itching that was unusual. He noticed his clothes fitting more loosely and found he had unintentionally lost twenty pounds. He visited the campus health center and after a series of tests and imaging studies, Lì was diagnosed with advanced hepatocellular carcinoma, an unfortunate sequela of this chronic infection. It was then that he put school on hold and returned home to get further care.I first met Lì in the hospital as a consultant for the palliative medicine service. "He won't listen." "He is so difficult." "He is in denial." These were examples of some of the care team's exasperated assessments of his demeanor as a patient. What I did not realize prior to visiting him the first time was that Lì was a pre-clinical medical student. When I first met him, he did not want to talk very much; he was preoccupied and distant. In retrospect, I can see that he was suffering on so many levels. His appearance was gaunt and cachectic. The lights in the room cast shadows in the concave areas of his temples and his collarbones were the most prominent feature of his torso through his hospital gown. He glowed yellow from jaundice. When I examined him on this first visit, I noticed that his liver, a now grossly enlarged hard and nodular structure, occupied most of his abdomen. I found that speaking to him as a colleague, even calling him "doctor," helped him feel respected and enabled me to build rapport with him. At one point, I described to him the findings I felt in his abdomen. "I can palpate the edge of your liver here, what seems to be eight centimeters below your costal margin. There are many palpable nodularities on the ventral surface." It was at this point I invited him to palpate what I was feeling. I gently guided his own hand over his abdomen and noticed him studying the features as if they were not his own, like a skilled diagnostician.Over the course of three weeks, I visited with Lì when I was on service. The last time I saw him, he had declined rapidly, his disease progressing [End Page 17] cruelly, and he was very short of breath and becoming more somnolent. I noticed his mother in the room, standing by his bed, and crying inconsolably as he lay suffering. I felt deep anguish and remorse, wondering if she said these words to herself "It is all my fault," considering the source of his initial illness. I cannot even imagine.As I assisted the team in titrating his comfort medications, I sat with him. He shook my hand with all the strength left that he could muster and said, "you are a good doctor." I... (shrink)

This study investigated 204 doctors' and nurses' perceived knowledge of bloodborne pathogens and their attitudes towards bloodborne pathogen-infected health care workers. A structured questionnaire examined: (1) their perceived knowledge of bloodborne pathogens; (2) their attitudes towards bloodborne pathogen-infected personnel; and (3) their opinions on limitation of employment of bloodborne pathogen-infected personnel and restrictions on performing clinical procedures. The levels of HIV-related knowledge were significantly higher than for hepatitis C and B viruses. Although the participants demonstrated more positive attitudes towards (...) hepatitis C- and B-infected health care workers, 64% recommended restricting infected personnel from performing invasive procedures. Attitudes were negatively correlated with opinions on restricting infected personnel from health care work or limiting their involvement in clinical activities. This study highlights the need to formulate a policy to cope with the professional and moral dilemmas related to infected health care workers employed in hospitals, especially for those involved in invasive procedures. (shrink)