Should surgeons be tested for bloodborne pathogens?

Make it mandatory, HBV-infected surgeon urges

Citing concerns about patient safety and the "arrogance" of his professional colleagues, a retired surgeon is urging that those practicing surgery should undergo mandatory testing for bloodborne infections.

In sporadic episodes over the years, surgical patients worldwide have been infected with hepatitis B virus, hepatitis C virus, and rarely, HIV. Though the United Kingdom has adopted restrictive policies — particularly regarding the highly transmissible HBV — a "permissive" U.S. medical system allows infected surgeons to continue practice with complete autonomy, said John Wickenden, MD, a retired orthopedic surgeon living in Camden, ME.

"I believe we will need to develop mandatory requirements," he said recently in San Antonio at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). "Admissions to [surgical] training programs will need to be contingent upon testing of bloodborne pathogens and acceptance of vaccination when it is available. Periodic renewal of licensure and hospital privileges will need to be contingent upon mandatory serologic testing and vaccination. Established surgeons who test positive must be required to withdraw from procedural practices. I think I am in a small minority in believing this, but I do if we are going to take patient safety seriously."

Others speaking at panel session on the issue disagreed, arguing that confidential voluntary testing and treatment are more reasonable approaches.

"Health care worker-to-patient transmission requires an infected worker with virus circulating in the bloodstream," said Tammy Lundstrom, MD, an epidemiologist and HIV clinician at Detroit Medical Center. "There are many, many things that we can do these days to get the viral loads for HIV, hep C, and hep B undetectable, and thus reduce the very, very small risk of transmission even further. High viral load is an area I think we can make a huge impact on getting people tested and treated — if they know they are not going to lose their job or suffer breaches of confidentiality."

The current 1991 Centers for Disease Control and Prevention (CDC) guidelines on the issue were forged in the national heat of the 1990 Florida HIV dental case, which involved six patients apparently infected by their HIV-positive dentist.1 Erring on the side of caution in a debate that became heavily politicized, the CDC concluded that providers who have HIV or hepatitis B virus e antigen should go before confidential expert review panels to determine whether they should continue practicing and under what conditions. Most troublesome, infected providers who perform "exposure-prone procedures" (i.e., surgeons) are to inform patients of their status if they continue practice. To put it bluntly, that has not happened. Wickenden conceded that there must be an array of legal and cultural changes before any mandated testing could work.

"To tell [your serostatus] is to invite the possibility, perhaps the probability, that the surgeon will lose the ability to do surgery, be financially devastated, face gross disruption of his or her professional life, and be required to defend a flood of legal and liability issues," he said. "These are very real issues. If surgeons are going to buy into candid disclosures, these issues must be dealt with. There must be protection in the realm of professional liability. Adequate disability insurance must be available for the surgeon who cannot do surgery but can still practice nonsurgical medicine."

Don’t ask, don’t tell’

A practicing orthopedic surgeon from 1972 to 1999, Wickenden, has been HBV-positive for more than 30 years. He theorizes the infection occurred following a needlestick in 1966 when he was a medical student.

"I was never then or since clinically ill," he said. "My colleagues knew about my HBV status because I talked about it very openly. Nobody ever expressed any concerns about the possibility that I might transmit HBV. To my knowledge, I never transmitted hepatitis B to anyone, but the question has never been examined. I think given the statistics [today] that it’s likely that I did. I did many thousands of operations over the years. When I was practicing there wasn’t a don’t ask, don’t tell’ policy. There was essentially no policy. Today, in many hospitals for an array of reasons, the don’t ask, don’t tell’ policy prevails."

The CDC has tried to revisit and update its guidelines in recent years; but the issue is extremely controversial and polarizing, particularly in an era of patient safety. Some have argued that the current guidelines are driving HIV-positive workers out of medicine even though the risk of transmitting that virus during surgery is almost unquantifiable.2 (See HIC December 2000, under archives at www.HIConline.com.)

"Looking at the all of the information that we have available, not just from the United States but from other countries that have very good surveillance systems, we can say that the risk of transmission of a bloodborne pathogen to a patient is extremely low," said Denise Cardo, MD, a medical epidemiologist in the CDC division of healthcare quality promotion. "It is even lower for hepatitis C, and much lower for HIV. Most patient care activities do not provide an opportunity for patient exposure to [the worker’s] blood. This is something we should really keep in mind, especially if we are going to discuss whether we should test health care providers."

Indeed, the issue of mandatory testing has risen again after publication of an outbreak in the Netherlands involving an HBV-positive surgeon who infected 28 patients.3 The CDC has not advocated any mandatory testing, but Cardo said testing for treatment issues and lowering viral loads could be an extremely important issue.

"If the purpose [of testing] is for practice restrictions then we need to be careful," she told APIC attendees. "Who should be tested and how often? Being negative today does not mean being negative next year. Who should know the results? Discrimination is something that we really saw with HIV. We are very concerned that the next step is that we are going to test all of the patients."

If surgeons demand to know the serostatus of their patients, they only may take enhanced precautions with those infected, undermining the whole concept of standard precautions, Cardo warned. In an editorial on the issue written with a CDC colleague, she argued that, "A broad systems approach . . . will protect patients and health care workers more effectively than policies focused solely on infected health care providers."4

That comprehensive approach includes administering HBV vaccine to health care personnel, viewing all blood as potentially infectious, using measures to reduce blood exposure, and having a surgical team committed to promoting and maintaining a safe work environment. Health care providers who perform surgical and gynecologic procedures also have a responsibility to know their bloodborne virus serostatus and, if positive, seek advice from experts regarding patient safety, she noted.

But such measures may be easier to recommend than implement. An infection control advocate, Wickenden was rebuffed by his colleagues when he tried to make HBV vaccination and double gloving mandatory while serving as the chief of surgery at his former hospital.

Captains of the ship

"My efforts were overwhelmingly opposed," he said. "With that failure, we didn’t even come remotely close to mandating that surgeons be required to document there serologic status in relation to bloodborne pathogens, and our experience wasn’t unique. Voluntary programs of vaccination have failed miserably. Only a few countries, most notably the United Kingdom since 1993, have made HBV testing and vaccination mandatory."

The efforts to mandate infection control measures made Wickenden unpopular with his colleagues, and the surgical staff eventually asked that he be replaced as the chairman of the department of surgery, he said.

"Even in this era where physicians kneel at the altar of evidence-based medicine, many surgeons are not willing to accept mandates to yield their autonomy even when there lives or the lives of their patients may depend upon it," he said.

Though they have deep knowledge in surgery, surgeons are rather shallowly informed on the transmission of bloodborne pathogens, Wickenden charged. This lack of knowledge is compounded by an attitude of arrogance, an "insistence that they are captains of the ship and must not be saddled by systems requirements that inhibit their ability to respond to what they believe to be the unique circumstances."

That no-holds-barred assessment drew a strong wave of empathetic applause from the ICPs in attendance at the APIC session.

The surgical arena is far removed from the world of policies and recommendations, he reminded, noting that in his experience, infection control measures often were either sloppy or absent.

"Let me tell you from my experience that the real surgical world is often a more hostile, dangerous, and ignorant place than some theorists believe it to be," he said. "I believe that the performance of many surgeons, no doubt many of whom are carrying bloodborne pathogens, is frequently inept. And that is why I believe that is equally necessary that policies focus on the infected surgeon or other health care worker."

Frequently, orthopedic surgeons and other surgical specialists are working in a blood bath, he said. "Our hands are deep in bloody flesh; loose arteries squirt, high-speed drills splatter blood widely, drapes and the floor are often soaked with blood and bloody irrigation fluid, and so are our gowns, our masks, our caps, and shoes," Wickenden said. "Bone fragments are sharp and pointy; we often arrange them by manual palpitations without visual access. We use sharp drills, pins, screws, and other instruments."

Under such conditions — even though HIV has raised infection control awareness — frequent blood exchanges occur between surgeon and patient, he said. "It’s not enough that we define systems of value and promote their voluntary acceptance," he said. "If we are going to make rapid and substantive improvements in the safety of surgeons and patients in regard to the transmission of bloodborne pathogens, I believe that we must introduce an element of compulsion."

References

1. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40(RR-8):1-9.

2. Gostin LO. A proposed national policy on health care workers living with HIV/AIDS and other bloodborne pathogens. JAMA 2000; 284:1,965-1,970.

3. Spijkerman IJB, van Doorn L-J, Janssen MHW, et al. Transmission of hepatitis B virus from a surgeon to his patients during high-risk and low-risk surgical procedures during 4 years. Infect Control Hosp Epidemiol 2002; 23:306-312.

4. Chiarello LA, Cardo DM. Prevent transmission of hepatitis B virus from surgeons to patients. Infect Control Hosp Epidemiol 2002; 22:301-302.