Hepatitis in a surgeon- problem oriented learning: Part I

Paul Froom MD, MOccH

Chief of Epidemiology

Israel- National Institute of Occupational and Environmental Health

Associate Professor of Epidemiology

Sackler School of Medicine, Tel Aviv University

Primary purpose of the lecture

• Learn about the risk and prevention of infectious diseases (HIV, HBV, HCV) in health care workers and in their patients

• Learn the following terms: infectivity, virulence, pathogenicity, host, reservoir,carrier, common source, propagated disease, colonization, epidemics,

Case Study

• 30 year-old asymptomatic surgeon

• After his residency, applied for a job in a teaching hospital

• Pre-employment testing

• HbsAg

Case Study (2)

• e antigen negative- predicts low infectivity

• mild elevations of liver enzymes

Questions

• Should this surgeon be accepted and allowed to operate on patients?

• Should the surgeon be recognized as having an occupational disease?

• Does he deserve compensation?

• Should he have a liver biopsy?

• What do we need to know?

What do we need to know?

• Risk of injury during surgery

• Risk of infection after a penetrating injury

• Risk of infection to unvaccinated surgeon

• Risk of infecting the patient

• Treatment for chronic active hepatitis

• Concept of acceptable risk

Risk of a penetrating injury during surgery

• 173 of 202 surgeons over 1 year

• 32 of 97 students stuck or cut

• Often the surgeon is unaware of the puncture

Risk of an infection after a penetrating injury

• INFECTIVITY of common exposure to health care workers (HCW)

• HBV - e antigen positive- as high as 30%

• HBV - e antigen negative- probably around 5%

• Hepatitis C- 2-5%

• AIDS = 3/1000

Risk of infection to unvaccinated surgeon

• Estimated in the US- 5% per year

• Life time risk- 43%

• Over twice that of the general population

• Occupational disease

Risk of infecting the patient

• Exact risk?• Gynecological surgeon- 9% infected• High risk operations: C-section or

hysterectomy• Cases reported of e-antigen negative

surgeons infecting patients• One fatal case reported

Natural history of hepatitis B

• Incubation period- up to 180 days• Infected patients: 1/3 asymptomatic,

1/3 flu-like symptoms, 1/3 jaundice• Virulence- proportion of overt

infections• Rare patient -death from acute hepatitis

Natural history of hepatitis B (2)

• Pathogenicity = clinical disease after exposure

• = infection rate x virulence• Chronic carriers- 1-10%• Increased risk of liver cancer

(hepatoma)

Deaths from viral chronic liver disease in the USA

• 16,000 deaths per year• 70% hepatitis C• 20% hepatitis B• 10% dual infection

Acceptable risk to the patient

• Courts not sympathetic• CDC- recommended in 1991 against• Since- the CDC back tracked• determined by each state and hospital

Case study• Surgeon infected 5 patients over 4 months

• required to obtain written informed consent from the patients

• required to double-glove

• required to attempt to avoid self-injury

• 5 months later-infected women during C-section

• Excluded from further surgical operations

Acceptable risk to the surgeon

• Best not to operate on patients with HBV, HCV or HIV

• most agree if procedure has benefit to the patient

• obligation to operate despite the risk

Employer’s obligation

• Provide all protective equipment• provide vaccinations• explain to the employees the risks

involved

Preventive measures- vaccination

• Three doses• protective serum titers (> 10 milliU

anti-HBs)• 95-99% effective in young adults• less effective in those over 40 years

Other preventive measures

• Gloves• Goggles• Blunt tipped needles

Gloves

• Reduce risk: dentists: 6/395 Vs 0/369 (patients)

• Double gloving: blood contact rate 25% to 10%

• Sharps injury fluid transmitted reduced by 75%

• Yet- 3.5% risk of blood contact per operation even after double gloving

Other protective equipment

• Visors: splash to face very common• resheathing method• 50% medical students needle-sticks

during ward experience• hepatitis immune globulin

Our case of the surgeon-further history

• injured blood contaminated needle during medical school and during residency on several occasions

• Operated on HBV positive patients• Medical school-no organized program

Further history (2)

• Hospitals claimed that vaccination free of charge

• Letters sent to the MDs

• Used double gloving

• No lectures given

• Lawyers for the hospital claimed that the risks are common knowledge to MDs

Summary

• Any risk to the patient is unacceptable.• He should be recognized as having an

occupational disease• He should receive compensation.