HCV-infected surgeon advises testing his patients
300 patients contacted, but no exposures recalled
Some 300 patients of a surgeon who felt "a moral and ethical responsibility" to disclose his hepatitis C virus infection are being offered testing by Fletcher Allen Health Care in Burlington, VT.
In the absence of public health guidelines for such situations, the surgeon and health facility decided to undertake what appears to be the first publicly announced HCV "look-back" study in the United States to search for cases of provider-to-patient transmission. Researchers in Spain reported the first documented case of HCV transmission from a surgeon to patients last year.1
A plastic and reconstructive surgeon at Fletcher Allen Health Care, the physician disclosed his infection and wrote a letter March 15, 1997, encouraging patients to be tested.
"There has been no recollection of any incident where transmission could have happened and none has been documented," says Mike Noble, Fletcher Allen spokesman. "This is all just to be super-precautionary and try to take care of the patients."
In the letter to patients, the surgeon said he acquired HCV during the course of his surgical practice and discovered it during routine health care. He did not detail any incident of occupational exposure that could have resulted in his infection, nor did he say when he thought he was infected. Fletcher Allen released a statement saying the 300 patients were identified in a "preliminary search" that included all those treated since May 1996. In his letter, the surgeon assured patients they likely were not exposed and that he stopped practicing as soon as he learned of his infection.
"I am not aware of any incident in your surgery where infection could have occurred," the surgeon wrote. "I felt an immediate ethical and moral responsibility to inform all of my patients. . . . While this has obviously had a significant impact on my family and my career, my paramount concern at this time is for the well-being of my patients."
In additional information distributed by Fletcher Allen, patients were also urged to be tested to reduce the risks of further transmissions, review their treatment options, and help researchers better understand the risks of transmission in this setting. Those testing positive for HCV will have their viral strain matched against the surgeon’s by molecular epidemiology techniques to determine whether transmission occurred during a procedure.
While such efforts have been previously undertaken for patients treated by surgeons and dentists with HIV and hepatitis B virus, there are few guidelines regarding HCV-infected providers. Indeed, the Centers for Disease Control and Prevention has been questioned and criticized for not adding HCV to its guidelines for workers infected with bloodborne pathogens. (See related story in Hospital Infection Control, March 1997, pp. 33-36.) The current CDC guidelines call for workers who perform invasive procedures to know their HIV and HBV e antigen status and go before review boards if infected. In general, HCV is considered more infectious than HIV per exposure incident, but is not as infectious as HBV following a similar exposure, such as a needlestick.
In addition to plastic and reconstructive surgery, the surgeon lists his specialities as cosmetic surgery, microsurgery, and hand surgery. Though no definitive procedure lists have been developed with regard to provider-to-patient transmission of bloodborne pathogens, the CDC has cited the increased risk of such exposure-prone procedures as working in a body cavity or in a poorly visualized site. The recent case of HIV transmission in France involved prolonged orthopedic surgery, while both the aforementioned HCV case and an HBV provider-to-patient case involved cardiothoracic surgery.2
"Judging by his recollection of how the cases have gone in his work here, it seems like the probability for any transmission is extremely small to zero," Noble says.
References
1. Estaban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334:555-560.
2. Harpaz R, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549-554.
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