How significant is the risk of transmission?

Since 1970, more than 375 patients around the world have been infected with hepatitis B virus (HBV) from their surgeons.1

"The risk is significant," John W. Wickenden, MD, said at the most recent meeting of the Washington, DC-based Association for Professionals in Infection Control and Epidemiology. Wickenden, a retired surgeon in Camden, ME, has been infected with HBV for more than 30 years.

Concerning the hepatitis C virus (HCV) — in addition, some 1.8% of the population is infected, and the figure is believed to be higher among health care workers.2

Cases of transmission may be difficult to determine. Only a small number of surgical patients infected with HCV become symptomatic, and even fewer do so early enough to recognize the possible relationship with their prior surgery, according to William P. Fiser Jr., MD, assistant professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.2 Fiser voluntarily left his position as a cardiac surgeon when he tested positive for HCV and was diagnosed with advanced liver disease.3

Poor infection control practices aren’t always to be blamed for transmission, infection control experts say.

A study of 1,564 patients in the Netherlands found that a surgeon who tested positive for hepatitis B surface antigen and hepatitis B e antigen definitely transmitted the virus to eight patients, probably transmitted the virus to two more, and possible transmitted it to 18 others. The surgeon’s infection control practices were adequate, and transmission occurred even when there was no break in infection control procedures or proper surgical techniques.4

In a study of HCV transmission from surgeons and anesthesiology staff to patients, researchers reviewed seven cases of surgeons or anesthesiology staff infected with HCV transmitting the disease to their patients.5 In most cases, patients were infected through inadvertent exposure to the workers; in fact, only two incidents were caused by clear breaches of infection control practices. In the same study, HCV transmission rates in various retrospective investigations varied from 0.04% to 2.7%.5

In the Netherlands’ study, although the risk of HBV infection during high-risk procedures was seven times higher than that during low-risk procedures, at least eight (28.6%) of the 28 patients were infected during low-risk procedures.6 "Policies allowing HBV-infected surgeons to perform presumably low-risk procedures should be reconsidered," the researchers concluded. An editorial accompanying the article stated that "even the simplest procedures may not be risk-free."7

References

1. Paton S, Zou S, Giulivi A. More should be done to protect surgical patients from intraoperative hepatitis B infection. Infect Control Hosp Epidemiol 2002; 22:303-305.

2. Rabin R. Deciding to step away. Newsday, Dec. 27, 2002:A03.

3. Fiser WP. Should surgeons be tested for blood-borne pathogens? Infect Control Hosp Epidemiol 2002; 23:296-297.

4. Paton S, Zou S, Antonio Giulivi A. More should be done to protect surgical patients from intraoperative hepatitis B infection. Infect Control Hosp Epidemiol 2002; 23:303-305.

5. Ross RS, Viazov S, Thormählen M, et al. Risk of hepatitis C virus transmission from an infected gynecologist to patients: Results of a 7-year retrospective study. Arch Intern Med 2002; 162:805-810.

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

7. Chiarello LA, Cardo DM. Preventing transmission of hepatitis B virus from surgeons to patients. Infect Control Hosp Epidemiol 2002; 23:301-302.