Literature Review
Patient-doctor-patient transmission a first in U.S.
Cody SH, Nainan OV, Garfein RS, et al. Hepatitis C virus transmission from an anesthesiologist to a patient. Arch Intern Med 2002; 162:345- 350.
In the first reported case of its kind in the United States, an anesthesiologist appears to have contracted hepatitis C from one patient and later transmitted it to another patient during a procedure.
The case investigation began in January 1996, when a 64-year-old man, identified by the authors as Patient A, became ill with acute hepatitis seven weeks after undergoing a thoracotomy at hospital X. He had no identified risk factors. Just a week before surgery, he and his wife donated blood and both tested negative for anti-HCV; 10 weeks before surgery, his liver enzyme levels were normal.
Meanwhile, the anesthesiologist who had provided care during the thoracotomy exhibited symptoms of acute hepatitis infection three days after the procedure. Subsequent testing showed that no other members of the surgical team were positive for anti-HCV.
In epidemiologic investigations, the authors contacted patients who had been treated by the anesthesiologist for the six months before the onset of his illness, all patients treated on the same day as Patient A under the care of other anesthesiologists, and all patients who underwent surgery in the same operating room during the week before or after the incident. Also, investigators contacted and tested patients who had been treated by the anesthesiologist at another hospital, where he worked for 18 months beginning six months after his acute illness.
In all, seven patients tested positive, but only two of them shared a genotype: Patient A and Patient B, a 42-year-old woman who had tested positive for anti-HCV when she made an autologous blood donation one week before her surgery. Her procedure occurred 8½ weeks before the surgery of Patient A.
Based on detailed testing, the investigators concluded that the anesthesiologist contracted HCV from one patient and transmitted it to another. "This scenario is supported by two findings," they state. "First, the time intervals between Patient B’s surgery and the anesthesiologist’s acute hepatitis C and between Patient A’s surgery and his anti-HCV seroconversion are consistent with the average six- to seven-week incubation period for hepatitis C. Second, the HVR1 quasi-species of the isolates of the anesthesiologist and patients A and B indicate that they are extremely closely related to each other. The close relationship of these quasi-species is in direct contrast to the high degree of variation observed among the quasi-species of unrelated HCV-infected persons in the general population studied in this investigation and among unrelated individual patients described by other investigators."
Yet despite repeated interviews with the anesthesiologist and a review of OR and medical records, the investigators could not identify a specific exposure incident.
"The transmission pattern involving the two patients and the anesthesiologist suggests that the anesthesiologist experienced at least two percutaneous exposures to his patients’ blood during a nine-week period, neither of which he could recall," the authors state. "During neither of these surgical procedures did the anesthesiologist perform procedures that would have placed him at high risk for incurring an injury or placed him in contact with the blood of the patient."
The authors note that there are only three other published reports of transmission of hepatitis C from a health care worker to a patient. One involved a cardiac surgeon with a chronic infection in Spain who transmitted HCV to five patients. Another cardiac surgeon with a chronic infection in the United Kingdom transmitted HCV to one patient, and an anesthesiology assistant in Germany contracted HCV from a patient with a chronic infection and then transmitted the HCV to five other patients.
The authors cite reports of two outbreaks of nosocomial transmission of HCV that were related to abuse of intravenous narcotics intended for the patients. "The anesthesiologist involved in our investigation repeatedly denied injection drug or other substance abuse," they state.
"Our investigation documented transmission of HCV from a health care worker to a patient that did not seem to occur during performance of his normal duties," they conclude. "Acute hepatitis C in a patient without commonly recognized risk factors and with a history of recent surgery or hospitalization should engender a thorough investigation into the potential nosocomial source(s) of transmission.
"Current guidelines for the prevention of transmission of bloodborne pathogens from health care workers to patients do not recommend restrictions of the professional activities of HCV-infected health care workers," they write.
"All health care workers should follow a strict aseptic technique and standard precautions, including appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments."
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