HBV transmission to surgical patients raises testing issues

Jagger: Asking HCWs to know HBV status a ‘head-in-the-sand policy’

A recent case of hepatitis B transmission from a surgeon to as many as eight patients highlights the potential risk of health care workers who perform exposure-prone procedures but do not know their bloodborne pathogen status. Yet public health authorities say such transmissions are too rare to justify a testing mandate.

Hospitals should implement policies about the “identification and management” of HBV-infected health care workers, but the ultimate responsibility lies with the providers, according to updated hepatitis B guidelines from the Centers for Disease Control and Prevention.1 “[P]roviders have an ethical and professional obligation to know their HBV status and to act on such knowledge accordingly,” a CDC ethics committee concluded.

Those 2012 guidelines strengthen recommendations for HBV-infected health care providers and students, calling for pre-vaccination serologic testing for those at higher risk for HBV, “such as those born to mothers in or from endemic countries and sexually active men who have sex with men,” and for those performing exposure-prone procedures. However, CDC does not recommend any routine testing of health care workers for HCV or HIV.

Relying on health care workers to request testing can lead to a willful ignorance, cautions Janine Jagger, PhD, MPH, director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville, in emailed comments to HEH. And it is even less defensible in an era of improved treatment for HIV, chronic HBV and HCV infection, she says.

“Rapid detection and treatment of an HCV infection in a surgeon is in everyone’s interest, both the surgeon’s and future patients,” she says. “To conclude that early detection of a treatable infection is in any way discriminatory to healthcare workers is head-in-the-sand policy at its worst.”

Other occupational health professionals say that the current voluntary system is working. HBV-positive health care workers are typically detected during the process of HBV vaccination on hire, and health care workers come forward and report their status in a system that is confidential and non-punitive, says Mark Russi, MD, director of occupational health at Yale-New Haven Hospital and chair of the Medical Center Occupational Health section of the American College of Occupational and Environmental Medicine.

Yale-New Haven offers HCV testing to all new employees. “Just about everybody takes us up on that,” he says. “It’s an opportunity for intervention in disease where you can make a real difference if you treat early rather than late.”

High viral load raises risk

In the recently reported case, an orthopedic surgeon had a needlestick and discovered in the post-exposure follow up that he had asymptomatic chronic hepatitis B with a very high viral load (>17.9 million IU/mL). He was also positive for hepatitis B surface antigen e, which also indicates a higher risk of transmission.

The surgeon had immigrated to the United States from a country where HBV is endemic and entered an orthopedic residency. Upon hire at an unnamed hospital, the surgeon had two series of HBV vaccination but failed to develop a protective level of HBV antibody. The surgeon had no additional follow-up after the non-response.2

That is where the scenario departs from what many occupational medicine physicians consider best practice. CDC guidelines advise that repeated non-responders should be tested to determine their HBV infection status.

“If they had the proper policies in place, he would have been identified much earlier,” says William Buchta, MD, MPH, an occupational health consultant with the Mayo Clinic in Rochester, MN, who was not involved in this case report.

In a follow-up investigation, of the 328 patients who had procedures in the nine months since the surgeon had been hired, 232 (70.7%) agreed to testing. Two patients had active disease with HBV that was genetically identical to the surgeon. Six other patients with no other known risk factors had evidence of past HBV infection – and HBV specimens that were genetically similar to the surgeon’s.

Transmission despite good technique

Perhaps the most troubling aspect of the case of the HBV-infected surgeon is that transmission occurred despite good technique and precautions, including double-gloving. An investigation found no previous exposures, glove tears, or problems with technique.

“He was known by his peers and supervising surgeons to have excellent surgical technique and reported double-gloving for 100% of surgical procedures, standard practice for all orthopedic procedures at Facility A,” the authors stated.

They speculate that micro-perforations in the glove, combined with the high viral load, led to the transmission.

Guidelines from the Society for Healthcare Epidemiology of America (SHEA)3 and the 2012 CDC guidelines recommend using viral load rather than e antigen status as a marker of the need for monitoring of HBV-positive health care workers who perform exposure-prone procedures. (See exposure-prone procedures, below.) The SHEA cutoff is 10,000 GE (genomic equivalents) per milliliter, while the CDC cutoff is 1,000 IU/ml (or 5,000 GE/ml).

“These guidelines seek to ensure maximum patient safety, without compromising the privacy rights of the provider and potentially limiting patient and community access to quality medical care,” Scott Holmberg, MD, chief of epidemiology and surveillance at the CDC’s viral hepatitis branch, said in an emailed response to HEH.

Since 1994, there have been only two reports of provider-to-patient transmission of HBV, although there were 42 identified instances before 1994.2 Public health authorities point to this as evidence that the current system of HBV vaccination, post-vaccination testing and self-reporting of HBV infection is working.

“The risk of hepatitis B transmission from providers to patients is extremely low, even during exposure prone procedures,” says Holmberg. “Standard precautions, like double-gloving during invasive surgical procedures, have nearly eliminated the already very low risk of hepatitis B transmission.”

But Jagger contends that the lack of evidence about transmission may reflect a lack of identification.

“Surgeon-to-patient transmission of HBV and HCV continues to occur today,” she says. “Their apparent rarity can, in part, be explained by the persistence and official sanctioning of a national policy that encourages non-reporting.

“Unfortunately, the consequences of the “don’t ask, don’t tell” mentality, which was never in the interest of patients, and now is not even in the interest of surgeons, still linger on,” she says.

References

1. Holmberg SD, Suryaprasad A, Ward JW. Updated CDC recommendations for the management of hepatitis B virus–infected health-care providers and students. MMWR 2012;61(RR-3):1–12.

2. Enfield KB, Sharapov U, Hall KK, et al. Transmission of hepatitis B virus from an orthopedic surgeon with a high viral load. Clin Infect Dis 2012; 56:218–224.

3. Henderson DK, Dembry L, Fishman NO, et al. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infect Control Hosp Epidemiol 2010; 31:203-232.

Exposure-prone procedures increase transmission risk

Centers for Disease Control and Prevention recommendations on exposure-prone surgical procedures include the following key points:

Category I. Procedures known or likely to pose an increased risk of percutaneous injury to a health-care provider that have resulted in provider-to-patient transmission of hepatitis B virus (HBV)

These procedures are limited to major abdominal, cardiothoracic, and orthopedic surgery, repair of major traumatic injuries, abdominal and vaginal hysterectomy, caesarean section, vaginal deliveries, and major oral or maxillofacial surgery (e.g., fracture reductions). Techniques that have been demonstrated to increase the risk for health-care provider percutaneous injury and provider-to-patient blood exposure include:

• digital palpation of a needle tip in a body cavity and/or

• the simultaneous presence of a health care provider’s fingers and a needle or other sharp instrument or object (e.g., bone spicule) in a poorly visualized or highly confined anatomic site.

Category I procedures, especially those that have been implicated in HBV transmission, are not ordinarily performed by students fulfilling the essential functions of a medical or dental school education.

Category II. All other invasive and non-invasive procedures

These and similar procedures are not included in Category I as they pose low or no risk for percutaneous injury to a health-care provider or, if a percutaneous injury occurs, it usually happens outside a patient’s body and generally does not pose a risk for provider-to-patient blood exposure. These include:

• surgical and obstetrical/gynecologic procedures that do not involve the techniques listed for Category I;

• the use of needles or other sharp devices when the health-care provider’s hands are outside a body cavity (e.g., phlebotomy, placing and maintaining peripheral and central intravascular lines, administering medication by injection, performing needle biopsies, or lumbar puncture);

• dental procedures other than major oral or maxillofacial surgery;

• insertion of tubes (e.g., nasogastric, endotracheal, rectal, or urinary catheters);

• endoscopic or bronchoscopic procedures;

• internal examination with a gloved hand that does not involve the use of sharp devices (e.g., vaginal, oral, and rectal examination; and

• procedures that involve external physical touch (e.g., general physical or eye examinations or blood pressure checks).

Source: Holmberg SD, Suryaprasad A, Ward JW. Updated CDC recommendations for the management of hepatitis B virus–infected health-care providers and students. MMWR 2012;61(RR-3):1–12.