Correspondence
Transmission of Hepatitis Viruses by Surgeons
N Engl J Med 1996; 335:284-287July 25, 1996
- Article
To the Editor:
Harpaz et al. (Feb. 29 issue)1 provide a well-documented description of the transmission of hepatitis B virus (HBV) from a surgeon to at least 19 patients. The surgeon received the diagnosis of hepatitis B in February 1992, after the development of fatigue and jaundice; serum assays for hepatitis B surface antigen (HBsAg) and IgM antibody to hepatitis B core antigen were positive. The surgeon returned to practice in March 1992, when his symptoms abated, without further serologic evaluation to determine potential HBV infectivity. In July 1992, the surgeon was still positive for both HBsAg and hepatitis B e antigen (HBeAg), and his serum contained high levels of HBV DNA, indicating that he continued to be highly infectious.
Harpaz et al. and Gerberding, in an accompanying editorial,2 point to the precautions, outlined in guidelines issued by the Centers for Disease Control and Prevention (CDC),3 that the surgeon followed in performing his duties, in order to prevent the transmission of hepatitis to patients.
Why was the surgeon allowed to resume practice without a serologic evaluation of his potential infectivity? The CDC guidelines state, “Health care workers who are infected with HIV [the human immunodeficiency virus] or HBV (and are HBeAg positive) should not perform exposure-prone procedures unless they have sought counsel from an expert panel and been advised under what circumstances, if any, they may continue to perform these procedures.” Certainly, an expert panel would have required a return to a negative HBsAg and HbeAg and an acceptable reduction in the HBV DNA titer before allowing the surgeon to resume the performance of surgery. Could adherence to the CDC guidelines have prevented some of these cases of hepatitis B?
3 ReferencesDavid B.P. Goodman, M.D., Ph.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 191041
Harpaz R ,Von Seidlein L ,Averhoff FM , 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
Full Text | Web of Science | Medline2
Gerberding JL . The infected health care provider. N Engl J Med 1996;334:594-595
Full Text | Web of Science | Medline3
Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-proneinvasive proceduresMMWR Morb Mortal Wkly Rep 1991;40:1-9
Medline
To the Editor:
Although both Harpaz et al. and Esteban et al.1 documented a clear relation between specific surgeons and cases of hepatitis in patients, there was no physical evidence of direct contamination during the surgical procedures. Therefore, the inoculation may have occurred before or after surgery, while the surgeons changed intravenous lines, tubes, or dressings — procedures often carried out without gloves.
However, the point of these reports is also ethical. Once a needle or wire has penetrated the surgeon's skin, it will invariably touch tissues or fluids in the patient, resulting in inoculation. A surgeon who harbors such viruses can become a danger to his or her patients. Since it is our duty to protect patients at all costs, surgeons should be tested for communicable diseases, and those with positive results should not be permitted to perform invasive procedures. This policy would also increase awareness of the dangers of injuries related to the performance of surgery and might reduce their incidence.
1 ReferencesMaximo Deysine, M.D.
State University of New York at Stony Brook, Stony Brook, NY 117941
Esteban JI ,Gomez J ,Martell M , et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;334:555-560
Full Text | Web of Science | Medline
To the Editor:
The main lesson to be learned from the episode described by Harpaz et al. is that we are failing to use the tools we have. Immunization against hepatitis B must be mandatory for health care workers — particularly those involved in such an exposure-prone practice as thoracic surgery. It is hard to imagine why a thoracic-surgery program would not require immunization for the safety of its residents. Moreover, it is incomprehensible that serologic follow-up was not required of the resident after hepatitis B had been documented. Viral transmission has been demonstrated after essentially casual contact with persons who are positive for HBeAg. Determining the resident's serologic status before permitting a return to the operating room would have been prudent, to say the least.
In the broadest sense, this case demonstrates the hubris of our profession. A stunningly high percentage of practicing physicians remain susceptible to hepatitis B despite the availability of a safe and effective vaccine. Unless we in the medical profession run a tighter ship, we are inviting control by government regulators or — worse — business managers.
Geoffrey Wittig, M.D.
22 Red Jacket St., Dansville, NY 14437To the Editor:
. . . It is unfortunate that efforts to minimize the risk of occupational transmission of viral diseases have been impeded by the political sensitivity of issues surrounding HIV. I agree with Dr. Gerberding that mandatory testing for HIV, HBV, and hepatitis C virus (HCV) is an impractical solution. The need for mandatory vaccination against hepatitis B, however, is urgent and should be discussed separately. My colleagues and I have recently reported susceptibility to HBV in up to 25 percent of surgeons who have been in practice for more than 10 years.1 Susceptibility equals potential future infectivity.
1 ReferencesUlrich P. Jorde, M.D.
Mount Sinai Medical Center, New York, NY 100291
Panlilio AL ,Shapiro CN ,Schable CA , et al. Serosurvey of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among hospital-based surgeons. J Am Coll Surg 1995;180:16-24
Web of Science | Medline
To the Editor:
Dr. Gerberding writes that the correct response to continued reports of the transmission of blood-borne pathogens from infected health care providers to patients during invasive procedures is to focus on injury prevention and vaccination against HBV. Although I agree, more action is needed. zero risk exists only in fantasy. As long as we expect surgeons and other health care providers to care for patients infected with blood-borne pathogens, we must also expect that, despite all precautions, some of these providers will become infected. Just as workers' compensation exists for other workers who are injured on the job, society should compensate infected health care workers. In the case of surgeons, it may be that those with viremia above designated threshold levels will no longer be able to operate. Such surgeons should be offered counseling, disability compensation, and help finding alternative work as part of an active policy, as opposed to the haphazard way in which these situations are currently handled in most institutions.
Amy Beth Kressel, M.D.
New York Medical College, Bronx, NY 10451To the Editor:
What remains enigmatic in the study by Harpaz et al. is the mode of viral transmission. We propose that the surgeon's sweat may have been the vehicle for the transmission of HBV.
HBsAg has been detected in almost all body fluids, yet only serum, semen, and saliva have been shown to be infectious in laboratory experiments.1 Two articles have reported the presence of HBsAg in eccrine sweat glands.2,3 The performance of cardiac surgery is demanding, prolonged, and stressful. There can be excessive sweating underneath the gloves and on the forehead, which may contaminate the operating field. Indeed, both HBsAg and HBV DNA were detected in washings (containing sweat? serum?) from the surgeon's hands. A serious effort should be made to determine the infectiousness of human sweat.
3 ReferencesIsrael Potasman, M.D.
Neora Pick, M.D.
Bnai Zion Medical Center, Haifa 31048, Israel1
Robinson WS. Hepatitis B virus and hepatitis D virus. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 4th ed. Vol. 2. New York: Churchill Livingstone, 1995:1406-39.
2
Telatar H ,Kayhan B ,Kes S ,Karacadag S . HB-Ag in sweat. Am J Gastroenterol 1977;68:492-493
Web of Science | Medline3
Brodersen M ,Wirth M . Detection of HBSAg and HBSAb in sweat. Acta Hepatogastroenterol (Stuttg) 1976;23:194-201
Medline
Author/Editor Response
The authors reply:
To the Editor: Drs. Potasman and Pick propose that sweat may have been the vehicle of HBV transmission. To our knowledge, sweat has never been epidemiologically linked with HBV transmission. Furthermore, the demonstration of HBsAg in sweat may not be related to infectivity, since HBsAg can be present as noninfectious, incomplete viral particles.1 We believe that the HBsAg and HBV DNA isolated from washings of the surgeon's hands after the simulation of suture tying were derived from serous exudates from cuts on his fingers. We are planning further studies to confirm our observations.
Dr. Deysine states that for the protection of patients, surgeons should be tested for communicable diseases. The CDC recommendations for the prevention of HBV transmission during invasive procedures state that surgeons should know their HBeAg status, and if they are positive, they should be evaluated by an expert review panel.2 Mandatory testing of surgeons for HBV is not recommended, in part because the current estimate of the risk of transmission does not warrant the resources needed to implement mandatory testing programs. The institutions involved followed these recommendations by restricting him from operating until a local expert committee had reviewed the situation. On the basis of the available information about HBV transmission and the surgeon's practices, the committee believed that the risk of transmission was low, even though he remained HBeAg-positive, and therefore decided that he could continue operating. When it was clear that HBV had been transmitted, he stopped operating.
We explored the possibility that viral transmission from the infected surgeon occurred before or after surgery. We thought this possibility was unlikely, because the surgeon had minimal contact with patients outside the operative setting, and the little contact he did have involved patients of other thoracic surgeons as well, but these patients did not become infected.
We agree with Drs. Wittig and Jorde that vaccination against hepatitis B is important in preventing infection among surgeons, thereby also reducing the risk of transmission to patients. Vaccination of health care workers has been recommended since 1982 by the Public Health Service's Advisory Committee on Immunization Practices, and the guidelines of the Occupational Safety and Health Administration require that employers offer vaccination to their employees. There is no precedent for federal laws requiring that persons receive vaccine. A recent report indicates that over 90 percent of younger surgeons have received HBV vaccine.3 Nevertheless, we agree that increased efforts must be made to ensure that all appropriate health care workers receive HBV vaccine.
3 ReferencesRafael Harpaz, M.D.
Craig N. Shapiro, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30306James D. Cherry, M.D.
University of California, Los Angeles, Los Angeles, CA 900241
Kim CY ,Tilles JG . Purification and biophysical characterization of hepatitis B antigen. J Clin Invest 1973;52:1176-1186
CrossRef | Web of Science | Medline2
Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-proneinvasive proceduresMMWR Morb Mortal Wkly Rep 1991;40:1-9
Medline3
Panlilio AL ,Shapiro CN ,Schable CA , et al. Serosurvey of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among hospital-based surgeons. J Am Coll Surg 1995;180:16-24
Web of Science | Medline
Author/Editor Response
To our knowledge, the case of surgeon-to-patient transmission of HCV that we describe is the only one reported so far. Hence, in the absence of information on the frequency of such transmission, guidelines cannot be established. Mandatory screening of surgeons for antibodies to HCV and subsequent restrictions on the practice of those found to be positive are measures that seem particularly disproportionate to the problem, and as Dr. Gerberding correctly points out in her editorial, such screening might lead to discrimination by surgeons against infected patients. We also agree with Dr. Gerberding that the goal of protecting patients would be better accomplished by reinforcing measures aimed at preventing accidental injuries to the surgeon, since this approach would prevent HCV transmission in both directions. The screening of surgeons for antibodies to HCV should be recommended only when an effective HCV vaccine is available. We will then be able to vaccinate susceptible health care workers and provide adequate treatment for those already infected.
Juan I. Esteban, M.D.
Rafael Esteban, M.D.
Jaime Guardia, M.D.
Hospital General Universitari Vall d'Hebron, 08035 Barcelona, SpainAuthor/Editor Response
Drs. Potasman and Pick suggest that infected sweat could serve as a source of intraoperative HBV transmission from infected surgeons to their patients. The plausibility of this hypothesis should be tested by measuring the quantity of HBV in sweat. However, epidemiologic data do not support sweat as a mode of transmission in this or any other setting. Viral transmission during invasive procedures is closely associated with blind surgical manipulations (i.e., those made by feel); such procedures increase the risk of percutaneous injuries and, hence, contact with blood. Dr. Deysine postulates that HBV might have been transmitted to patients during minor bedside procedures. Intravenous-line changes, tube placements, and dressing changes should not be performed without gloves, but these procedures have never been linked to outbreaks of infection with blood-borne pathogens transmitted from infected health care providers to patients.
In my view, it is not necessary to invoke new or unusual routes of viral transmission to account for the infections reported by Harpaz et al. The surgeon implicated in the outbreak performed procedures (e.g., suture tying) that were demonstrated to damage the skin with sufficient severity to allow the leakage of HBV into his gloves. The surgeon's hands were in direct contact with the patient's tissue. Even new sterile gloves are imperfect barriers, and cardiothoracic surgery is associated with a high risk of intraoperative perforation of gloves. Despite data demonstrating the efficacy of double gloves in preventing contact with blood during surgery,1 the surgeon did not wear double gloves. Thus, the conditions necessary for the transmission of hepatitis were met: an infectious source (the injured surgeon), a vehicle (contaminated gloves that were perforated), and a portal of entry (the surgical wound).
Periodic testing of surgeons for blood-borne pathogens is an expensive intervention that would have a minimal effect on the intraoperative risk of transmission. Moreover, implementing a testing program would be impractical. How often would such testing be conducted — after each procedure in an infected patient? Which blood-borne viruses would be included in the testing program? What is the threshold of acceptable titers? Who would pay for the testing program, and how would compliance be monitored and enforced? I agree with Drs. Jorde and Wittig that immunization of all susceptible health care providers is the best strategy to prevent nosocomial transmission of hepatitis B and should now be mandatory.
1 ReferencesJulie Louise Gerberding, M.D., M.P.H.
San Francisco General Hospital, San Francisco, CA 941101
Gerberding JL ,Quebbeman EJ ,Rhodes RS . Hand protection. Surg Clin North Am 1995;75:1133-1139
Web of Science | Medline
