APT:荟萃分析:医院侵入性手术感染丙型肝炎病毒的风险

2022-08-09 从医路漫漫 MedSci原创

在治愈慢性丙型肝炎病毒感染的患者中,HCC的残留风险仍然较高。

背景:丙型肝炎病毒(HCV)主要是一种血源性病毒,估计全球血清流行率为2.5%。但是,观察到国家之间存在很大差异,埃及和巴基斯坦的普通人群中抗HCV流行率较高。慢性HCV感染大多数情况下无症状,可能会导致严重的并发症,如肝硬化或肝细胞癌(HCC),约20%的患者会发展为HCC现在有高效且耐受性良好的直接抗病毒治疗(DAAs)可用,但这些治疗仍然昂贵。据估计,2019年全球79%的慢性HCV感染者仍不知道自己的状况,限制了DAAs的人口影响。

此外,在治愈慢性丙型肝炎病毒感染的患者中,HCC的残留风险仍然较高。此外,丙型肝炎病毒治疗不应是对抗新感染的唯一方式,因为越来越多的证据表明,即使在DAA治疗后,诱导的持续病毒学反应再感染也可能发生,特别是在注射毒品的人群中。因此, 限制丙型肝炎病毒污染风险的预防干预措施仍然是全球应对丙型肝炎病毒的关键。尽管注射吸毒已被确定为全球获得新的丙型肝炎病毒感染的最重要的风险因素,由于侵入性操作的高频率和住院患者中丙型肝炎病毒感染个体的过度表现,医疗保健机构可能在丙型肝炎病毒传播动态中发挥重要作用。 医疗程序与世界范围内的多次丙型肝炎爆发有关,例如在埃及、印度或美国。在感染控制干预措施依从性欠佳的医疗机构中,患者仍可能在输血或血液透析后受到感染。在许多国家,既往住院治疗已被确定为丙型肝炎病毒感染的主要风险因素。在丙型肝炎病毒流行率高的国家,感染控制干预措施可能未得到系统实施,并且缺乏有关丙型肝炎病毒感染风险的数据。

在这种情况下,更好地控制医院获得性感染将大大有助于对抗丙型肝炎流行。这需要清楚地了解医疗机构中不同高风险程序所扮演的角色。

目的:了解和量化以医院为基础的侵入性手术对丙型肝炎病毒(HCV)传播的作用。

方法:我们进行了系统的综述和荟萃分析,以确定最近报道的与医源性操作相关的丙型肝炎病毒感染风险测量的研究。根据专家的意见,侵入性手术被分成10组,并对其进行汇总测量。最后,用Meta回归方法评估合并措施与国家水平的丙型肝炎病毒流行率或医疗服务可获得性和质量(HAQ)指数之间的关系。

结果:我们纳入了71项研究。最常被评估的措施是输血(66项措施)和手术(43项措施)。合并的优势比(OR)差异很大,从牙科手术的1.46(95%可信区间:1.14-1.88)到移植的3.22(1.7-6.11)不等。1998年前输血的OR值(3.77,2.42~5.88)高于无日期输血的OR值(2.20,1.77~2.75)。在特定程序的分析中,丙型肝炎病毒感染风险与内窥镜检查的HAQ显著负相关,与内窥镜检查和手术的丙型肝炎病毒感染率正相关。

图1 研究特点。纳入研究的数量:(A)发表年份;(B)患者类型;(C)国家;(D)研究设计。研究总数,71项。

图2 森林图报告了与不同组医源性操作相关的HCV感染风险的汇总或估计。点对应于平均估计值,误差线对应于这些估计值的95%置信区间。实线代表OR = 1的极限,虚线代表总体估计值。用于每次汇总或计算的观察总数在第N列中指定,并表示为每个点估计值周围的灰色区域的大小;每个估计的异质性在列I2中描述。给定的研究可用于多个程序组的OR估计。根据相关的平均估计值对过程进行排序,从最高到最低。CI,置信区间;HCV,丙型肝炎病毒。

图3 不同国家的HCV感染风险图:(A)输血(B)手术。棕色点对应于用于计算给定集合OR的观察值(结果测量)的数量。每个国家/地区根据估计值或按照浅红色到暗红色的颜色梯度进行着色。报告了平均估计值及其95% CI。CI,置信区间;HCV,丙型肝炎病毒。

图5 森林图报告了HCV高流行国家(> 5%)和低流行国家(< 5%)与不同组医源性操作相关的HCV感染风险汇总或估计值。高流行率群体包括埃及、巴基斯坦和马里。点对应于平均估计值,误差线对应于这些估计值的95%置信区间。实线代表OR = 1的限值,虚线代表总体估计值的平均值。用于每次汇总或计算的观察总数在列N中指定,每次估计的异质性在列I2中描述。给定的研究可用于多个程序组的OR估计。根据相关的平均估计值对过程进行排序,从最高到最低。在丙型肝炎高流行国家没有移植措施的报道。*:发现高流行率国家和低流行率国家之间存在显著差异的程序;I2列中的空白对应于不存在异质性,因为程序组只计算一个观察值。高流行率国家和低流行率国家之间的总体差异:p值= 0.33。CI,置信区间;HCV,丙型肝炎病毒。

结论:各种侵入性操作与丙型肝炎病毒感染显著相关。我们的结果提供了关于丙型肝炎病毒风险的程序排名,可用于确定感染控制干预措施的优先顺序,特别是在丙型肝炎高流行率环境中。

原文出处:Henriot P,  Castry M,  Luong Nguyen LB,et al.Meta-analysis: risk of hepatitis C virus infection associated with hospital-based invasive procedures.Aliment Pharmacol Ther 2022 Aug;56(4)

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    2023-02-15 venlin
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