Hepatitis in a surgeonproblem 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?
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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
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16,000 deaths per year
70% hepatitis C
20% hepatitis B
10% dual infection
Acceptable risk to the patient
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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 Csection
• 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 measuresvaccination
• 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 surgeonfurther 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.