Literature Review
Hepatitis B transmission from surgeon to patients
• Spijkerman IJB, van Doorn LJ, Janssen MHW, et al. Transmission of hepatitis B virus from a surgeon to his patients during high-risk and low-risk surgical procedures during four years. Infect Control Hosp Epidemiol 2002; 23:306-312.
• Chiarello LA and Cardo DM. Preventing transmission of hepatitis B virus from surgeons to patients. Infect Control Hosp Epidemiol 2002; 23:301-302.
• More should be done to protect surgical patients from intraoperative hepatitis B infection. Infect Control Hosp Epidemiol 2002; 23:303-304.
Transmission of hepatitis B from a surgeon to patients can remain undetected for many years and may occur even in procedures that have not been considered exposure-prone, the authors concluded after a retrospective study of cases linked to an HBV-infected surgeon.
In the cases described, a general surgeon in The Netherlands was a known nonresponder to the HBV vaccine. He reported numerous percutaneous injuries over the years.
A test of stored serum indicated that he was infected with hepatitis B for at least 10 years without being aware of it. The infection came to light when three surgical patients in 1998 and 1999 reported acute HBV infections.
Those infections prompted a widespread testing of the surgeon’s patients. Of the 1,594 patients tested, 28 had HBV infections that may be linked to the surgeon. In eight cases, DNA sequence analysis confirmed that the surgeon was the source of infection. (In one case, the patient’s wife developed severe acute hepatitis B through secondary transmission; DNA sequencing was identical to that of the surgeon. The husband, who apparently resolved his infection, tested negative.)
Another two cases were considered probable because patients exhibited signs of acute hepatitis within six months of surgery but then tested negative for HBV antibody. Eighteen cases were considered possible because the patients had no other risk factors for HBV other than the procedure performed by the HBV-infected surgeon. The surgeries occurred between June 1995 and February 1999.
The transmission rate, based on confirmed, probable, and possible cases, was 1.8%.
An analysis of the surgeries raises several issues related to the potential for transmission of HBV from health care workers to patients. Past policies have focused on "exposure-prone" procedures as presenting a risk to patients.
Risk factors for HBV
The authors found that duration of surgery and complications during or after surgery were risk factors for HBV transmission. The risk of HBV infection was seven times greater during high-risk procedures compared with low- or medium-risk procedures, they found.
But eight of the 28 infected patients had undergone low-risk procedures, such as ligation and stripping of varicose veins. "In our study, the proportions infected for low-risk and medium-risk operations were similar, and transmission during these procedures contributed substantially to the total number of infected patients," the authors state.
Guidelines that differentiate between "exposure-prone" and "nonexposure-prone" procedures should be reconsidered, they assert. "Given the difficulty of classifying surgical procedures and the apparent risk associated with low-risk procedures, this policy should be seriously questioned, especially regarding surgeons who have already transmitted HBV to patients," they state.
The authors raise another question: What should be done about known nonresponders to the HBV vaccine?
They suggest that "a more stringent policy of vaccination and testing of surgeons could prevent similar outbreaks," including regular testing of nonresponders for HBV markers. Furthermore, they advocate better surveillance of acute HBV infections, which may have led to earlier identification of the transmission.
The testing and possible restriction of practice of health care workers infected with HIV, HBV, or hepatitis C remains controversial. Two editorials accompanying the article give contrary views of how to reduce the risk of transmission.
One by Linda Chiarello and Denise Cardo of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta emphasizes the use of safe work practices, such as hands-free passing of instruments in the operating room and double-gloving during invasive surgical and obstetric procedures.
"Healthcare providers who perform surgical and gynecologic procedures also have a responsibility to know their bloodborne virus serostatus and, if possible, to seek advice from an expert consultant regarding patient safety. The surgeon in this report was a nonresponder to hepatitis B vaccine and should have been tested for hepatitis B surface antigen following that determination," Chiarello and Cardo state.
Yet Shirley Paton, Shimian Zou, and Antonio Giulivi of the Health-Care Acquired Division of the Centre for Infectious Disease Prevention and Control in Ottawa, Canada, advocate more stringent measures, including more active surveillance, tracking of nonresponders, and possible practice restrictions.
"On the basis of Spijkerman et al. and previous work done in this area, invasive surgery or other procedures performed by HBeAg-positive HCWs may pose an unacceptable risk to patients that may not be reducible by minor practice changes or enhanced infection control activities," they state.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content