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.