Will HBeAg-positive surgeons be barred from practice?
Public health debate to erupt over recent report, expert predicts
United States physicians who are hepatitis B e-antigen (HBeAg)-positive will no longer be permitted to perform surgery by the year 2000, says a prominent surgeon who made the controversial prediction at a recent series of educational symposia held across the country. The pronouncement sparked denial from the federal Centers for Disease Control and Prevention in Atlanta and concern from the 58,000-member American College of Surgeons (ACS) in Chicago.
The United Kingdom (UK) in 1993 issued regulations requiring all surgeons to be vaccinated against HBV, to provide a documented antibody response to the vaccine, and to be suspended from practice if they test positive for HBeAg.
Donald E. Fry, MD, professor and chairman of the department of surgery at the University of New Mexico in Albuquerque, predicts the United States soon will follow suit.
In a presentation at "The Surgeon and Bloodborne Viral Pathogens in the Operating Room," a series of clinical education conferences held in Los Angeles, San Francisco, New York City, and Chicago, Fry cited recent studies in this country and the UK documenting cluster cases of HBeAg-positive surgeons transmitting the virus to patients.1,2
The UK report identifies 10 clusters of hepatitis B infections in patients of HBeAg-positive general surgeons, OB/GYNs, and cardiothoracic surgeons. A total of 81 patients were identified as being infected by those surgeons between 1984 and 1993. Infectivity rates ranged from 0.3% to 9%.
Fry predicts the U.S. report will have a major impact on the medical community and the public when published in the near future. The article, presently under review by a major medical journal, documents HBV transmission from a single cardiothoracic surgeon to 18 patients, four of whom developed chronic hepatitis. Hepatitis B antigen was identified in the glove effusion fluid of the surgeon without evidence of blood in the glove. The surgeon had double-gloved, and no gloves were lacerated.
The surgeon, who had never received hepatitis B vaccine, had acute hepatitis B in January 1992 yet continued to operate. Records showed he performed surgery on 142 patients between September 1991 and July 1992, which represents a 13% HBV infectivity rate. Epidemiologic and laboratory evidence proved the surgeon to be the source of infection.
Debate to go public
"My guess is that when that article is released, there will be considerable debate and discussion about it," Fry tells Hospital Employee Health. "When I see how vigorously and inappropriately everyone reacted to the threat of [health care worker-to-patient transmission of] HIV, when there is public knowledge of the revelation that hepatitis B can in fact be transmitted [from HCW to patient], there will be significant public reaction to it. Up to this point, the debate has traveled only in professional circles."
Because hepatitis B screening is voluntary for U.S. surgeons, there is no way of knowing how many are HBeAg-positive. But Fry suggests a number can be estimated based on "probability calculations." For every 1,000 operating surgeons, approximately 20% to 25% have been infected with HBV. About 1% to 1.25% have chronically active disease. "This means that 10 to 12 of every 1,000 surgeons are potentially e-antigen-positive," he says.3
The evidence now exists that surgeons who are positive for the e-antigen of hepatitis B, which means that they have chronic infection and are particularly infectious, are a risk to their patients, Fry states. "My position is that if the evidence continues, the appropriate strategy has to be that they cannot practice surgery. How can anyone say that surgeons should continue to operate if they have an infectious disease that has been documented to infect patients?"
Nevertheless, the federal Centers for Disease Control and Prevention in Atlanta responded to Fry's comments by telling Hospital Employee Health that it does not recommend an across-the-board restriction of infected surgeons' practices, nor does it plan to in the foreseeable future.
Craig Shapiro, MD, medical epidemiologist in the CDC's hepatitis branch, says the agency recommends that surgeons be tested for hepatitis B infection, specifically for the e-antigen. If positive, their practice should be reviewed by an expert review panel to decide whether they need to be restricted. Vaccination also is recommended.4
Expert review panels vary from state to state, Shapiro notes. Some operate under the auspices of state health departments, while others may be established by local hospitals. Their function is to consider procedures infected surgeons perform, as well as surgical technique, skill, and possible medical impairment on a case-by-case basis.
Despite the recent UK and U.S. reports, Shapiro says the CDC's recommendations are adequate to prevent what the agency perceives as "a very low risk" of hepatitis B transmission from surgery.
"If I were going to have surgery, my concerns would be on other things than the risk of getting hepatitis B," he says. "These outbreaks are very rare when you look at the tens of thousands of surgical procedures that are done each year in the United States."
In addition, Shapiro notes that younger
surgeons and graduating medical students
are receiving hepatitis B vaccine in larger
numbers.
"As time goes on, eventually the whole surgical community will be vaccinated," he states.
But Fry says the CDC recommendations fall short of solving the problem. Use of an expert review panel is "not a bad first step, but if you have a surgeon who has transmitted hepatitis B to a patient, can the expert panel then say it is okay for that surgeon to continue to practice? I think not."
A recently issued ACS statement also recommends the use of expert review panels. In addition, the organization urges surgeons to use "the highest standards of infection control," to be vaccinated against HBV early in their careers, and to know their HBeAg status.5
Surgeons fear financial doom
Robert Rhodes, MD, medical director of the University of Mississippi Medical Center in Jackson and former chair of the ACS committee on bloodborne pathogens, says the issue is complicated by a number of factors.
If practice restrictions were imposed on U.S. surgeons, they and their families would suffer financially, unlike their UK counterparts, Rhodes points out. The UK health system is structured so physicians are paid by a national health service. UK physicians who test HBeAg-positive receive a pension or disability payment from the government. There is no such protection for U.S. surgeons, who work under a predominantly fee-for-service payment system.
The ACS is exploring methods of providing disability insurance to U.S. surgeons who become carriers.
"That would close the loop of what is available to British surgeons but not to American surgeons," Rhodes says, "but clearly being immunized against hepatitis B is better than any insurance policy. The issue of hepatitis B is a simple one in the sense that there is a vaccine available, and all surgeons should be immunized," Rhodes says. "That will not only protect them from getting the disease, but then will subsequently prevent them from transmitting it back to patients."
Rhodes also notes the increase in vaccination rates among younger surgeons, estimating that "well over 90% of surgeons who are now in training or who have recently completed training are immunized against hepatitis B."
The problem lies in the group of surgeons who have been in practice for 15 years or more, before the advent of any vaccine. "About 35% of surgeons in this group are still susceptible to the disease by virtue of not having had the vaccine or not developing natural immunity," Rhodes says.
"If they acquired hepatitis B, only a small percentage of those surgeons would become carriers and subsequently transmit the disease to patients," he maintains.
Mandatory testing not well-received
"With time, as they retire from practice, they will be replaced by surgeons who have a very high immunization rate. To a certain extent, this is a problem that will go away if surgeons avail themselves of the opportunity to get immunized early in their careers. Therefore, it's not necessary to invoke regulations," Rhodes states.
Mandatory testing requirements would be
the first step toward regulation, and surgeons have responded to that proposal "very poorly," he says.
"Given that regulations would have a high penalty and restrict practices of surgeons, and particularly if there was not some safety net to provide economic security, in essence we'd be fostering a policy of don't tell, or don't be tested, or do anything you can not to be caught," Rhodes says. "That's not the goal of those policies, but people being people, unless the financial safety net is there, I would expect that regulations would create a tremendous bureaucracy; would not totally eliminate the problem because there still would be people who would try to work around it; and would reduce transmissions by only a very small amount."
Both Fry and Rhodes note the issue of hepatitis C transmission is even more problematic. HCV causes chronic infection in 50% to 80% of acute infections,6 as opposed to 25% of HBV carriers.7 About 1 million U.S. residents have chronic hepatitis B, while some 3.5 million now have chronic HCV, Fry says.8
"The occupational risks of becoming infected with hepatitis C may become a significant issue because of the seroprevalence of people being infected in society," he notes.
Surgeons might shun hepatitis C patients
Rhodes adds that surgeons cannot protect themselves or their patients from hepatitis C transmission because there is no vaccine against HCV.
"The result is that if the public wants to regulate surgeons through the political process, when in fact surgeons are at great risk and have no way of protecting themselves, there is concern that the one way surgeons could protect themselves is by simply not operating on patients who are infected with hepatitis C, for instance," Rhodes says. "Who wins in that situation? It might be easy to say you can invoke regulations, but there might be a lot of unintended consequences. If we get so concerned about the issue that we have to set regulations, we have to realize that they may set a precedent for other types of issues, the net result of which would be to reduce or jeopardize health care to the public without necessarily restricting a lot of surgeons."
Expert review panels are an effective control, he says, as long as infected surgeons can come forward without being identified, unless they have infected patients.
References
1. Heptonstall J, Collins M, Smith I, et al. Restricting practice of HBeAg positive surgeons: Lessons from hepatitis B outbreaks in England, Wales, and Northern Ireland 1984-93. Presented at Conference on Prevention of Transmission of Bloodborne Pathogens in Surgery and Obstetrics. Abstract No. A51. Atlanta; February 1994.
2. Harpaz R, Van Seidlein L, Averhoff F, et al. Hepatitis B virus transmission associated with cardiothoracic surgery. Presented at Conference on Prevention of Transmission of Bloodborne Pathogens in Surgery and Obstetrics. Abstract No. A50. Atlanta; February 1994.
3. Fry DE. The Infected Health Care Worker (Unpublished report). Albuquerque, NM: University of New Mexico School of Medicine, department of surgery; 1995.
4. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40 (No. RR-8):1-9.
5. American College of Surgeons. Statement on the surgeon and hepatitis B infection. Bull Am Coll Surg 1995; 80:33-35.
6. Alter MJ. Community acquired viral hepatitis B and C in the United States. Gut 1993; 34 (2 Suppl):S17-S19.
7. Centers for Disease Control and Prevention. Protection against viral hepatitis: Recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR 1990; 39
(No. RR-2):1-26.
8. Fry DE. Bloodborne Pathogens: Implications for the Surgical Environment in the Year 2000 (Unpublished report). Albuquerque, NM: University of New Mexico School of Medicine, department of surgery; 1995. *
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