Surgeon-To-Patient HBV Transmission, CDC Update on Chronically Infected

Abstract & Commentary

By Stan Deresinski, MD, FACP, FIDSA, Clinical Professor of Medicine, Stanford University, Hospital Epidemiologist, Sequoia Hospital, Redwood City, CA

This article originally appeared in the February 2013 issue of Infectious Disease Alert. It was peer reviewed by Timothy Jenkins, MD. Dr. Deresinski is Clinical Professor of Medicine, Stanford University, and Dr. Jenkins is Assistant Professor of Medicine, University of Colorado, Denver Health Medical Center. Dr. Deresinski does research for the National Institutes of Health, and is an advisory board member and consultant for Merck, and Dr. Jenkins reports no financial relationships relevant to this field of study.

Source: Enfield KB, et al. Transmission of hepatitis B virus from an orthopedic surgeon with a high viral load. Clin Infect Dis 2013;56:218-24.

A surgeon reported having suffered a sharps injury while performing an orthopedic procedure. Baseline testing found no evidence of HBV infection in the source patient, but determined that the surgeon had preexisting HBV infection, with positive HBsAg, positive HBeAg, negative IgM anti-HBc, and normal serum hepatic transaminases. The surgeon had emigrated from a country with a high prevalence of HBV infection, had completed his residency training in the U.S., and had been employed at a different hospital prior to his current place of practice. He had previously received 2 complete courses of HBV vaccination without developing a protective level of anti-HBs. However, no additional testing of HBV markers had been performed at that time.

Because his serum HBV DNA concentration was >17.9 million IU/mL, he was removed from surgical practice. Former patients of the surgeon at his previous facility were evaluated for evidence of HBV infection. Of the 232 patients who consented to testing, 2 had acute HBV infection and their virus had >99.9% nucleotide identity with that of the surgeon. There were an additional 6 patients who had evidence of past HBV exposure without other identified risk factors, suggesting possible transmission from the surgeon. Two patients had evidence of past HBV exposure but had risk factors; transmission from the surgeon was considered indeterminate in these cases. The surgeon was considered to be technically proficient and no breaches in procedure were retrospectively identified.

Commentary

It is useful to examine the management of the surgeon described by Enfield and colleagues relative to current guidelines.1,2 The Centers for Disease Control and Prevention now recommends that providers and students at increased risk for HBV infection, such as, in this case, those born to mothers in or from endemic countries, should undergo prevaccination testing. Prevaccination testing for chronic HBV infection should also be performed on all providers performing exposure-prone procedures. Health-care providers who do not have a protective concentration of anti-HBs (>10 mIU/ml) after revaccination (i.e., after receiving a total of 6 doses) should be tested for HBsAg and anti-HBc to determine their infection status. This was not done with the surgeon described.

HBV infection in health-care providers and students who do not perform invasive exposure-prone procedures should be managed as a personal health issue and does not require special oversight. In contrast, chronically infected surgeons and others who perform exposure-prone Category I activities should undergo oversight by an Expert Panel. CDC has defined 2 categories of exposure-prone patient care procedures (confusingly, SHEA has 3 categories, with a reverse order of risk and with an intermediate Category II defined as one in which procedures for which transmission is theoretically possible but unlikely):

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 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 II. All other invasive and noninvasive procedures.

CDC recommends that HBV infection alone should not disqualify infected individuals from the study or practice of surgery, dentistry, medicine, or allied health fields, but strongly emphasizes the need for strict adherence to standard precautions. They also recommend against a variety of potentially onerous monitoring and management requirements as well as constraints on practice. Chronically infected surgeons and others who perform Category I activities may conduct such procedures if low or undetectable HBV viral load is documented at least every 6 months, or more frequently as indicated by such factors as a change in antiviral therapy. A threshold viral load level of 1000 IU/ml (5000 genome equivalents/ml) is recommended, as is an assay with a lower limit of detection of 10-30 IU/ml. Fluctuations above the threshold will necessitate that the provider abstain from performing exposure-prone procedures while subsequent retesting occurs, and if needed, modifications or additions to the health-care provider’s drug therapy and other reasonable steps are taken.

Finally, the Consult Subcommittee of CDC’s Public Health Ethics Committee has noted that providers have an ethical and professional obligation to know their HBV status and to act on such knowledge accordingly.

References

1. Holmberg SD, et al. Updated CDC recommendations for the management of hepatitis B virus-infected healthcare providers and students. MMWR 2012;61(RR-3):1-12.

2. Henderson DK, et al. Society for Healthcare Epidemiology of America. 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;31:203-32.