David Glasser

Characterization of patients accepting and refusing routine, voluntary HIV antibody testing in public sexually transmitted disease clinics.

BACKGROUND AND OBJECTIVES To determine the proportion of HIV-infected sexually transmitted disease (STD) clinic patients identified during routine, voluntary HIV counseling and testing and to characterize patients accepting and refusing counseling and testing, we linked data from a blinded HIV seroprevalence survey to data from the HIV counseling and testing program. GOAL OF THIS STUDY This study characterizes patients accepting and refusing routine HIV counseling and testing in two public STD clinics. STUDY DESIGN A cross-sectional, blinded HIV seroprevalence survey was conducted of 1,232 STD clinic patients offered HIV counseling and testing. RESULTS HIV seroprevalence was higher among patients who refused voluntary testing (7.8% versus 3.6%, P = 0.001). Patients who refused testing were more likely to report a prior HIV test (45.6% versus 27.2%; P < 0.001). Among patients reporting a prior HIV test, differences were noted between reported prior results, both positive and negative, and blinded results. CONCLUSIONS HIV-infected STD patients may not be detected by routine HIV testing, and self-reported HIV results should be confirmed.

Report of the eye bank association of America medical advisory board subcommittee on fungal infection after corneal transplantation

Purpose: To investigate the incidence of fungal infections after corneal transplantation to determine whether storage media supplementation with an antifungal should be considered. Methods: Adverse reactions reported to the Eye Bank Association of America through the online adverse reaction reporting system between January 1, 2007, and December 31, 2010, were reviewed to identify cases of recipient fungal infection. Data were collected regarding the donor, the donor cornea, recovery and processing, and mate culture and clinical course of the recipients. Results: Thirty-one cases of culture-proven fungal keratitis (n = 14) and endophthalmitis (n = 17) were reported out of 221,664 corneal transplants performed using corneal tissue distributed by domestic eye banks (1.4 cases per 10,000 transplants performed). Although the annual incidence of postkeratoplasty fungal infection has not increased significantly since 2005, a trend toward an increasing rate of fungal infection has been observed. Fungal infections were more commonly reported after endothelial keratoplasty procedures (0.022%) than penetrating keratoplasty procedures (0.012%), but the difference was not statistically significant (P = 0.076). Additionally, no association was found between fungal infection after endothelial keratoplasty and whether the lamellar tissue cut was performed by the surgeon or the eye bank technician. Seventy-three percent (16 of 22) of the fungal cultures performed on the mate corneas were positive, with infection developing in 67% (10 of 15) of recipient eyes (endophthalmitis in 6 eyes and keratitis in 4 eyes). Conclusions: Although a nonsignificant increasing trend in the rate of fungal infection has been observed over the past 6 years, it is not sufficiently compelling to pursue antifungal supplementation of donor storage media.

Serologic testing of cornea donors

PURPOSE To review the current requirements and rationale for serologic testing of cornea donors and to provide guidelines for dealing with results of nonrequired tests. METHODS Eye Bank Association of America (EBAA) and Food and Drug Administration (FDA) regulations are examined with respect to current knowledge of the risk of donor-to-host transmission of systemic infectious diseases via corneal transplantation. RESULTS Negative screening tests are required for human immunodeficiency virus (HIV) 1 and 2, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) before release of tissue for transplantation. Other tests reported by organ-procurement organizations commonly include hepatitis B core antibody (anti-HBc), syphilis, cytomegalovirus (CMV), and human T-lymphotropic virus (HTLV) I and II. No systemic infectious-disease transmission from donor corneas supplied by EBAA-member eye banks has occurred in the last 12 years, a period during which >400,000 corneas were provided for transplantation. CONCLUSION EBAA donor-screening requirements, including serologic testing, have resulted in an excellent safety record. Requirements for serologic testing should continue to be regularly reviewed as new information becomes available.

ROUTINE VOLUNTARY HIV SCREENING IN STD CLINIC CLIENTS : CHARACTERIZATION OF INFECTED CLIENTS

Since January 25, 1988, the Baltimore City Health Department has offered routine, confidential, human immunodeficiency virus (HIV) testing to clients of the citys two sexually transmitted disease (STD) clinics. During the first 11 months of the program, testing was offered at 20,843 patient visits and was accepted at 15,181 (73%) of these; 612 (4%) individual clients had results that were positive for HIV. Four hundred thirty-seven (71%) seropositive clients returned for test results, post-test counseling, and further evaluation. Most HIV-infected clients were single, and black men accounted for 75% of seropositive individuals. HIV-infected women tended to be younger than infected men (7% of the female clients were adolescents). Although homosexual activity, intravenous drug use, and sex with a partner at risk were common risk factors for seropositive clients, after two interviews 17% of men and 38% of infected women did not report traditional risk factors for HIV infection. Most clients were asymptomatic or had generalized lymphadenopathy at the time of HIV diagnosis. Health care resources for these individuals were limited; 62% of men and 85% of women either had no health insurance or received public assistance. Routine, voluntary, confidential HIV counseling and testing is a practical, effective means to identify HIV-infected individuals among clients being treated at STD clinics. Identification of these individuals early in the course of infection provides opportunities to implement early follow-up and therapy, to counsel clients to help prevent further spread of infection, and to obtain useful information for projecting future health care needs and policy.

Eye banking and corneal transplantation communicable adverse incidents: current status and project NOTIFY.

Purpose: Evidence of the transmission of disease via donor ocular tissue has been demonstrated for adenocarcincoma, rabies, hepatitis B virus, cytomegalovirus, herpes simplex virus, Creutzfeldt-Jakob disease, and a variety of bacterial and fungal infections. Methods: Although there is no evidence to date of disease transmission for HIV infection, syphilis, hepatitis C, hepatitis A, tuberculosis, HTLV-1 and -2 infection, active leprosy, active typhoid, smallpox, and active malaria, these entities remain contraindications for transplantation for all eye banks nationally and internationally. The potential sources of contamination include infected donors, during the process of removing tissue from cadaveric donors, the processing environment, and contaminated supplies and reagents used during processing. The transmissions of Herpes simplex virus and HSV via corneal graft have been shown to be responsible for primary graft failure. HSV-1 may also be an important cause of PFG. Results: The long latency period of some diseases, the emergence of new infectious disease, and the reemergence of others emphasize the need for long-term record maintenance and effective tracing capabilities. Conclusions: The standardization of definitions for adverse events and reactions will be necessary to support the prevention and transmission of disease. International classification of a unique identification system for donors will be increasingly important for vigilance and traceability in cross-national exportation of human cells, tissues, and cellular- and tissue-based products. Opportunities for continuous improvement exist as does the need for constant vigilance and surveillance.

Tissue complications during endothelial keratoplasty.

Purpose: To report 6 cases of apparently inseparable corneal lamellae during intraoperative preparation of tissue for Descemet stripping automated endothelial keratoplasty (DSAEK). Method: Collection of clinical case reports from an e-mail survey of The Cornea Society and endothelial keratoplasty discussion group participants and Eye Bank Association of America member eye banks. Results: Five cases involved eye bank precut tissue. Surgery was aborted in 4 of these cases. In the fifth case, a free anterior cap was identified and the posterior lamella was successfully transplanted. In 1 case, in which an incomplete lamellar cut was made in the operating room, the surgery was continued after manual completion of the lamellar dissection. Conclusions: The most likely causes of inability to separate the lamellae after punching a DSAEK donor cornea are a decentered or incomplete lamellar cut and unsuspected premature separation of the lamellae. Premature separation can occur with an anterior cap that detaches before the central trephination or a posterior lamella that is inadvertently removed from the field after the central trephination. Careful inspection of the donor cornea under the operating microscope can reduce the risk of a decentered cut and can identify the presence of both lamellae. DSAEK may be completed successfully with an intact posterior lamella.