CDC launches study of HCV transmission

How many are linked to health care?

Like most cardiac surgeons, William Fiser, MD, of Little Rock, AR, occasionally cut or nicked his hand during delicate procedures. He did not use blunt suture needles or double gloves. He did not routinely order blood tests on himself or his patients after blood exposures.

But his life changed in 1999 when he discovered, almost by accident, that he had hepatitis C. So did one of his recent patients, who was his receptionist.

Fiser’s experience made him an advocate for safer practices in the operating room and for addressing the issue of hepatitis C transmission during exposure-prone procedures. Although his case was never conclusively linked to his patient’s — the RNA mapping showed one difference in the HCV viruses — it, once again, has raised the issue of provider-to-patient transmission of hepatitis C.

More information about such transmissions soon may be forthcoming. The Centers for Disease Control and Prevention (CDC) has enhanced its surveillance of health care-related transmission of hepatitis C. The search for new cases stems from recent reports that involved surgeon-to-patient transmission in New York and reuse of contaminated needles during medical procedures in other states.

"We have implemented a broader look at all of the cases reported nationwide in older individuals — persons unlikely to have traditional risk factors — for hepatitis B and acute hepatitis C," says Miriam Alter, PhD, associate director for epidemiologic science in the CDC’s division of viral hepatitis. In these elderly patients, public health authorities will look for past medical procedures "to determine if there’s a reason to believe there might be transmission occurring in the health care setting," she says.

The CDC also is conducting extensive interviews in its surveillance in sentinel counties that help track HCV and other diseases. "Every patient who did not have a known risk factor for infection is asked in detail about all of their potential health care-related exposures," Alter explains.

So far, the evidence indicates that the health care-related transmission of hepatitis C is sporadic, she says. For example, in 2001, North Shore University Hospital in Manhasset, NY, tested patients who had surgery with a well-known cardiac surgeon over a 10-year period. Three were positively connected; four were considered a probable link.

"Usually one would expect [cases] to occur in clusters," Alter notes. "If they’re not appearing in clusters, we may be missing the single cases."

She acknowledges that even the enhanced surveillance may miss cases. Most people are asymptomatic when they acquire hepatitis C and may not know they have the disease for many years. "This is a way to evaluate it to some extent. If there are asymptomatic cases, there are likely to be symptomatic ones as well."

Jane Perry, MA, director of communications for the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville, applauds CDC’s enhanced surveillance. The center advocates more research into the risk of provider-to-patient transmission. "It can be a Catch-22. If you don’t look for the cases, you might assume they’re not there," she says. "And patients don’t always make the connection with their health care provider if they are infected with HCV."

Fiser rarely thought about the occupational risks of surgery until he discovered he was HCV-positive during a life insurance exam. He had been feeling fatigued and achy. He had even mentioned the symptoms to his internist. But he didn’t imagine that he could have a serious liver disease.

Like other surgeons, he didn’t think about the hazards of bloodborne pathogen exposure that he lived with every day.

"Surgeons by nature are risk takers. You’re calculating the odds on everything," says Fiser, who is medical director of the Arkansas regional organ recovery agency and heads a cardiac research program at Arkansas Children’s Hospital.

"What are your odds of dying from the surgery? What are the odds of a bad result? They just don’t perceive this as enough of a risk to change their behavior," he says. "We need to raise the level of awareness to try to cause people to change their behaviors and adopt safer techniques."

In fact, the rate of HCV transmission appears to be very low. Hepatitis C has a transmission rate of about 0.5% from occupational exposures — slightly greater than that of HIV and less than that of hepatitis B, according to a review of literature by needle safety expert Janine Jagger, PhD, MPH.1 The CDC estimates the HCV transmission rate at 1.8%.

Yet hepatitis C is problematic, because about 80% of those infected are asymptomatic and may not know they harbor the virus. CDC estimates that about 2.7 million Americans have chronic HCV infection.

There have been sporadic reports of provider-to-patient or patient-to-patient transmission of HCV, most of them involving reuse of needles. An outbreak in 2001 occurred in a private endoscopy practice when an anesthesiologist reinserted used needles into multidose vials of fentanyl to provide additional anesthetic during surgery. In that case, 12 patients contracted HCV from one chronically infected patient within a three-day period.2

Reuse of needles was linked to HCV transmission to 69 patients in an Oklahoma pain clinic and 99 patients at a Nebraska chemotherapy clinic.2 In a German case, an anesthesiology assistant transmitted HCV to five patients from a wound on the finger when he performed procedures without wearing gloves.3

For HIV and hepatitis B, CDC guidelines call for expert review panels to identify exposure-prone procedures and consider applying restrictions in individual cases. As years have gone by with only one subsequent documented case of provider-to-patient transmission of HIV, occupational health experts have concluded that no procedures are exposure-prone for HIV.4

The CDC has never updated its guidelines to include HCV, and it states simply: "Currently, no recommendations exist to restrict professional activities of health care workers with HCV infection. As recommended for all health care workers, those who are HCV-positive should follow 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.5

That’s not enough guidance, according to Fiser. He worked with the Arkansas medical board to develop a policy on surgeons with HIV, hepatitis B, and hepatitis C.

The medical board will now consider cases on an individual basis, taking into account the nature of the procedures and the safety measures that can be used to prevent exposure.

Was I the source?’

By coincidence, Fiser and his former patient found out about their hepatitis C at around the same time. He suspected a connection and asked the Arkansas Department of Health to investigate. But when the state epidemiologist contacted the CDC, the agency declined because there was no cluster of cases, Fiser continues.

He eventually submitted samples to a private lab and paid for the testing himself. His receptionist’s blood was drawn before she began treatment; his sample was drawn a year later, after treatment. "I just wanted to know the truth," Fiser says. "Did this happen? Was I the source?

"It took over a year for me to ever get a report. Basically, they said there was one difference," he says. The lab concluded the virus didn’t match, but Fiser doesn’t consider that finding conclusive.

Before his patient’s surgery, her liver enzymes were normal. Her problems began after surgery. "The circumstantial evidence was extremely strong," he says. None of Fiser’s other patients have been tested for hepatitis C.

His patient responded favorably to treatment, but Fiser was not as fortunate. He suffered from severe side effects to eight months of treatment with ribavirin and interferon. His viral load remains high — more than 2 million viral particles per cc of blood. He has liver fibrosis.

"It’s a life-changing experience. After I was diagnosed, I had a liver biopsy, which showed advanced liver disease, which was news to me. Your whole plan of life changes drastically. You have to deal with your mortality sooner than you want to," Fiser notes.

Despite his fatigue, he has been able to maintain his nonclinical work. "As long as I get adequate rest, I do pretty well," he says.

Fiser never intended to become an advocate for sharps safety, HCV testing of health care providers, or anything else. But he firmly believes there needs to be more information about HCV transmission in the health care setting — and stronger recommendations to govern exposure-prone procedures.

He says he hopes surgeons will become more aware of the risks and adopt sharps safety practices in the OR.

"I really believe that if we had some objective data on this, it would make a huge difference in terms of surgeons being willing to change the way they practice," he says.

References

1. Jagger J, Puro V, De Carli G. Occupational transmission of hepatitis C virus (letter). JAMA 2002; 288:1,469; author reply 1,469-1,471.

2. Balter S, Layton M, Bornschlegel K, et al. Transmission of hepatitis B and C viruses in outpatient settings — New York, Oklahoma, and Nebraska, 2000-2002. MMWR 2003; 52:901-906.

3. 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.

4. 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.

5. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47(RR19):1-39.