Bloodborne HIV: Don't Get Stuck!

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Tag Archives: circumcision

Cock-ups happen. Parental Advisory: Read this first – your baby can’t

Comments Off on Cock-ups happen. Parental Advisory: Read this first – your baby can’t Posted by on June 13, 2013

This is a guest blog by Jim Thornton, re-posted from Ripe-Tomato.org. This reposting does not include the disturbing pictures of mutilated baby’s penises. To see the complete posting with pictures, go to: http://ripe-tomato.org/2013/02/16/cock-ups-happen/

The World Health Organisation Manual for Infant Circumcision’s (available at: http://www.who.int/hiv/pub/malecircumcision/manual_infant/en/) sample information sheet for parents (p. 110) is not adequate. Here is the bit on surgical harms:

Complications during male circumcision are rare, being estimated to occur in 1 of every 500 procedures. These complications, which can be severe, include poor cosmetic outcome, bleeding, infection, injury to the penis and the removal of too much or too little skin.

Using “rare” for a 1 in 500 risk, when earlier the benefit of “avoiding the need for circumcision later in life” (about 1 in 2,000) is mentioned without qualification, is biased. The figure also applies to the best series. Less well organised services report rates up to 20%, e.g. Nigeria, available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560152/?tool=pubmed). Since the manual is for use in developing countries the possibility of higher complication rates should be mentioned. Finally, Complications, which can be severe, include poor cosmetic outcome… is clearly designed to play down severity.

But more importantly, catastrophic complications are omitted altogether. Fully informed consent means telling people everything, however rare, which might alter the decision of a reasonable patient/parent. In gynaecology we mention the 1 in 10,000 risk of temporary colostomy after laparoscopic surgery for example. Unless we have a double standard for Africa, the complications below, which all appear elsewhere in the guide, should be mentioned. Italic text and pictures are all taken from the guide.

HIV, and other blood borne infections.

In male circumcision programmes a major concern is the potential transmission of bloodborne […] HIV and hepatitis B virus, to […] patients. The risk of acquiring HIV from an HIV-infected person through a needle-stick injury is estimated at 0.3% […] . The risk of acquiring hepatitis B virus infection, after being stuck with a needle that has been used on a person with hepatitis B infection, ranges from 6% to 37%, […] Most instances of transmission of infection in health-care facilities can be prevented through the application of standard precautions. If “it is a major concern” and only “most […] can be prevented”, it should be mentioned.

Amputation of the penis [picture available at ripe-tomato.org]

This extremely rare complication can be minimized by using good surgical technique but is unlikely to be eliminated. Unfortunately, even under ideal circumstances and with experienced surgeons [it] continues to occur.

Destruction of the penis by electro cautery.

One should NEVER use an electric current [..] with a metal Gomco clamp. […] The use of electrocautery […] has resulted in total ablation of the penis during male circumcision. To avoid this devastating complication, surgeons must be educated that electrocautery has to be strictly avoided when using a Gomco clamp.

Urinary retention from retained Plastibell rings.

Some of the most serious complications ever seen [retention and bladder rupture] […] have resulted from retained Plastibells. Educating the family to closely monitor the wound and the infant’s urine output is paramount with the use of this device.

Penile necrosis following the Plastibell technique [pictures available at ripe-tomato.org]

These two poor fellows aren’t going to be great in the sack.

Degloving – removal of the skin of the shaft [picture available at ripe-tomato.org]

None of these complications are common, but they all occur. If infant circumcision programmes get rolled out widely in developing countries, it is inconceivable that everyone will read all 140 pages of the WHO manual In the real world sterilisation goes wrong, mismatched Yellen clamps get packed together, and diathermy and wrong sized Plastibells get used. Even if they don’t, infants wriggle. Parents should be told.

AIDS, blood, HIV, iatrogenic, nosocomial , , , , , , ,

Circumcision: a Case of Retributive Healthcare?

13 Comments Posted by on January 1, 2013

[Cross-posted from the HIV in Kenya site.]

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because “there is no guarantee of the proper sterilization of such materials.” UN employees are also reassured that “We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment.”

The US Centers for Disease Control (CDC) states that “Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States.”

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

  • 230,000 HIV Infections
  • 1,000,000 Hepatitis C Infections
  • 21,000,000 Hepatitis B Infections
  • The above resulting in 1,300,000 deaths each year (WHO figures)
  • Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
  • At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force ‘healthcare’ in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of ‘retributive healthcare’.

AIDS, blood, HIV, iatrogenic, nosocomial , , , , , , , ,

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