Journal Reviews: HCV moves from patient to doctor to other patient; Make worker flu shots a patient safety issue

HCV moves from patient to doctor to other patient

First such case in the United States

Cody SH, Nainan OV, Garfein RS, et al. Hepatitis C virus transmission from an anesthesiologist to a patient. Arch Intern Med 2002; 162:345-350.

In the first reported case of its kind in the United States, an anesthesiologist appears to have contracted hepatitis C from one patient and later transmitted it to another patient during a procedure. The case investigation began in January 1996, when a 64-year-old man, identified by the authors as Patient A, became ill with acute hepatitis seven weeks after undergoing a thoracotomy at Hospital X. He had no identified risk factors. Just a week before surgery, he and his wife donated blood, and both tested negative for anti-HCV; 10 weeks before surgery, his liver enzyme levels were normal.

Meanwhile, the anesthesiologist who had provided care during the thoracotomy exhibited symptoms of acute hepatitis infection three days after the procedure. Subsequent testing showed that no other members of the surgical team were positive for anti-HCV.

In epidemiologic investigations, the authors contacted patients who had been treated by the anesthesiologist for the six months before the onset of his illness, all patients treated on the same day as Patient A under the care of other anesthesiologists, and all patients who underwent surgery in the same operating room during the week before or after the incident. Also, investigators contacted and tested patients who had been treated by the anesthesiologist at another hospital, where he worked for 18 months beginning six months after his acute illness.

In all, seven patients tested positive, but only two of them shared a genotype: Patient A and Patient B, a 42-year-old woman who had tested positive for anti-HCV when she made an autologous blood donation one week before her surgery. Her procedure occurred 8½ weeks before the surgery of Patient A. Based on detailed testing, the investigators concluded that the anesthesiologist contracted HCV from one patient and transmitted it to another.

"This scenario is supported by two findings," they stated. "First, the time intervals between Patient B’s surgery and the anesthesiologist’s acute hepatitis C and between Patient A’s surgery and his anti-HCV seroconversion are consistent with the average six- to seven-week incubation period for hepatitis C. Second, the HVR1 quasispecies of the isolates of the anesthesiologist and patients A and B indicate that they are extremely closely related to each other. The close relationship of these quasispecies is in direct contrast to the high degree of variation observed among the quasispecies of unrelated HCV-infected persons in the general population studied in this investigation and among unrelated individual patients described by other investigators."

Yet despite repeated interviews with the anesthesiologist and a review of OR and medical records, the investigators could not identify a specific exposure incident.

"The transmission pattern involving the two patients and the anesthesiologist suggests that the anesthesiologist experienced at least two percutaneous exposures to his patients’ blood during a nine-week period, neither of which he could recall," the authors wrote. "During neither of these surgical procedures did the anesthesiologist perform procedures that would have placed him at high risk for incurring an injury or placed him in contact with the blood of the patient."

The authors noted that there are only three other published reports of transmission of hepatitis C from a health care worker to a patient. One involved a cardiac surgeon with a chronic infection in Spain who transmitted HCV to five patients. Another cardiac surgeon with a chronic infection in the United Kingdom transmitted HCV to one patient, and an anesthesiology assistant in Germany contracted HCV from a patient with a chronic infection and then transmitted the HCV to five other patients.

The authors cited reports of two outbreaks of nosocomial transmission of HCV that were related to abuse of intravenous narcotics intended for the patients. "The anesthesiologist involved in our investigation repeatedly denied injection drug or other substance abuse. Our investigation documented transmission of HCV from a health care worker to a patient that did not seem to occur during performance of his normal duties."

"Acute hepatitis C in a patient without commonly recognized risk factors and with a history of recent surgery or hospitalization should engender a thorough investigation into the potential nosocomial source(s) of transmission. Current guidelines for the prevention of transmission of bloodborne pathogens from health care workers to patients do not recommend restrictions of the professional activities of HCV-infected health care workers. All health care workers should follow a strict aseptic technique and standard precautions, including appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments," they conclude.

Make worker flu shots a patient safety issue

Can case be made for protecting patients?

Salgado CD, Farr BM, Hall KK, et al. Influenza in the acute hospital setting. Lancet Infectious Diseases 2002; 2:145-55.

Why are health care workers notoriously lax in receiving influenza immunization? The authors of this review article listed the most commonly cited reasons as inconvenience, necessity of obtaining written informed consent, and concerns about vaccine effectiveness and side effects — including misconceptions that the vaccine may cause influenza. But perhaps most importantly is a "lack of understanding of the risks of acquiring infection and transmitting it to high-risk patients."

One study found that physicians were significantly more likely to accept the vaccine than other occupational groups. Advancing age, prior absenteeism (as surrogate marker for underlying illness), higher socioeconomic status (salary), and marriage also were associated with increased vaccine uptake in various target groups. Another study found that the predictors of acceptance were prior receipt of influenza vaccine, age of at least 50, and knowledge that vaccine does not cause influenza. "Convincing evidence that influenza immunization of health care workers would prevent nosocomial cross-infection would be a compelling argument in favor of health care worker immunization," the authors wrote.

They cited two studies conducted in Scottish geriatric hospitals, one retrospective and one prospective, that provided evidence that health care worker immunization was associated with reduced mortality during influenza season in the resident patients. "However, it was unclear whether the reduction in mortality was due to prevention of influenza, since no data were presented regarding specific rates of influenza-related illness or pneumonia in patients or workdays lost in health care providers," they stated.

Another study from the University of Virginia (UVA) in Charlottesville documented an association between a significant improvement in vaccine compliance among hospital employees and a significant decrease in nosocomial influenza among hospital patients for the same period. "Vaccine efforts need to be directed at all health care workers and other staff who deal directly with sick people," the authors said. They recommend targeting professional support staff with patient contact, younger workers, those recently employed, and lower-paid workers. At UVA, use of a chart showing updated health care worker compliance rates with influenza vaccine, posted in frequented areas of the hospital, was partly responsible for increasing vaccination acceptance rates to nearly 70%, they noted.