Transmission of HBV raises issues about staff
Transmission of HBV raises issues about staff
CDC updates guidelines for facilities
By Gary Evans, Executive Editor of Hospital Infection Control
A recently reported case of hepatitis B virus transmission from a chronically infected surgeon to as many as eight patients underscores the need for providers to know their HBV status and seek the counsel of an expert review panel if they perform invasive or so called “exposure-prone” procedures, public health officials emphasize.
“Hospitals can try, but the obligation really is on the healthcare providers who are doing the work,” says David Henderson, MD, hospital epidemiologist at the National Institutes of Health Clinical Center in Bethesda, MD. “This is one of those unfortunate circumstances where he may not have thought of [his HBV status], but he should have thought of it. It is the responsibility of the healthcare provider, especially those that are doing these kinds of procedures.”
A leading expert on the issue of provider-to-patient infections, Henderson wrote an accompanying editorial commentary to the case report, which does not disclose the location of incident or the identity of the surgeon.1,2 The case has several unusual features, including the fact that the surgeon had asymptomatic chronic HBV infection acquired at birth in a country with high endemic levels of HBV.
In light of the case and increasing reports of endemic HBV infections in foreign medical and dental students from Asia and other areas, the Centers for Disease Control and Prevention (CDC) has issued new guidelines on the issue.3 The CDC guidelines also emphasize that medical providers have a professional and ethical obligation to know their HBV status, to protect patients and because circulating HBV can be reduced dramatically by current therapies.
“Responsible medical professionals of any ilk should know their hepatitis B status, but you have a particular responsibility if you are a surgeon or an oral surgeon,” says Scott Holmberg, MD, chief of epidemiology and surveillance at the CDC’s viral hepatitis branch. “If they are infected and they have a high viral load, we think that should be managed and they can get treatment to get that viral load down.”
The surgeon in this case had an extremely high viral load, with an HBV DNA concentration of >17.9 million IU/mL. However, that was not known until a workup investigation began following a needlestick injury to the surgeon. The injury occurred when a needle, passed by an assisting surgeon during suturing, punctured the surgeon’s index finger. The surgeon immediately reported the incident to occupational health for evaluation as the assisting surgeon completed the operation. The occupational health evaluation concluded that there was no suggestion of surgeon-to-patient exposure during the event. However, as the subsequent investigation revealed the high titer of HBV in his blood, the surgeon was ordered to halt his orthopedic practice, which mainly consisted of knee and hip replacements. The surgeon was not aware of any risk factors for HBV infection and did not recall any prior instances of needlestick injury during his career, the investigators reported.
A retrospective cohort study of all patients who underwent surgery by the surgeon was conducted. A total of 232 (70.7%) of potentially exposed patients consented to testing. Of those, two were found to have acute infection, and six had “possible transmission — evidence of past exposure without risk factors,” investigators reported. Genome sequence analysis of HBV DNA from the infected surgeon and patients with acute infection revealed genetically related virus (>99.9% nucleotide identity). (For information on lack of follow-up to HBV vaccine status, see story, this page.)
Transmission route a mystery
Ultimately no clear method of transmission could be determined, which led investigators to theorize “that unknown or microperforation of the glove might have occurred.”
Glove microperforation has been shown to occur with a high frequency. Bacterial transmission through microperforations has been estimated to occur at a rate of 5%; however, the rate of viral transmission is unknown. In addition to microperforation, glove laceration during arthroscopic shoulder surgery occurs in 51% of outer gloves and 17% of inner gloves,” according to studies cited by the investigators.
The surgeon apparently has returned to practice after his viral titer was diminished through treatment. Improved HBV medications now make it possible to lower circulating virus to near undetectable levels, which makes it possible for infected providers to continue their medical practice with appropriate oversight.
Costi Sifri, MD, one of the authors of the report and an epidemiologist in the division of infectious diseases at the University of Virginia Health System in Charlottesville, says, “It is my understanding that the institution referred to a panel of experts in hepatitis and infectious diseases, and that is the process that was used to determine future work practices.”
The most recent CDC guidelines recommend using HBV DNA serum levels, rather than the hepatitis B e-antigen status, to monitor potential infectivity of a provider. For healthcare professionals requiring oversight, the serum HBV DNA considered “safe” for practice is <1,000 IU/ml. The Society for Healthcare Epidemiology of America (SHEA) has also issued guidelines allowing medical practice by an HBV-infected provider if viral load and other factors are monitored by an expert review panel.4
- Henderson, DK. Exceptions That Prove the Rule. Clin Infect Dis 2013; 56:225-227.
- 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; 56:218–24.
- 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. Accessed at http://1.usa.gov/N0zXmH.
- 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; 31:203–32
There was no follow-up on HBV vaccine failure
A critical element in the case of a surgeon infected with the hepatitis B virus (HBV) is that the surgeon had not previously responded to two series of HBV vaccinations, but it appears no further action was taken, say the authors of a case report on the incident.1-2
No additional evaluation of this non-responder status (i.e., testing for the presence of HbsAg, the surface antigen of the hepatitis B virus) was performed prior to the needlestick injury, the authors noted.
Costi Sifri, MD, one of the authors of the report and an epidemiologist in the division of infectious diseases at the University of Virginia Health System in Charlottesville, says, “The hospital in question doesn’t have a policy requiring people to know their [HBV] status. I know that in the state of Virginia and other states, it is something that is not a requirement, but there are some questions regarding state licensure that include whether one knows if they have a chronic viral infection.”
Failure to respond to HBV vaccine — not once but twice — should have raised a red flag, suggesting the possibility the surgeon had chronic HBV infection, says David Henderson, MD, hospital epidemiologist at the National Institutes of Health Clinical Center in Bethesda, MD. “That information should have been passed on to the director of the occupational medicine service, who should have called the surgeon up and said, ‘You are from an area where these kinds of HBV infections are endemic, and you did not respond to the vaccine twice. Is it possible that you are a chronic carrier and would you like for us to look into that for you?’”
Such an intervention might have prevented the infections, but the fact that the surgeon reported his needlestick injury suggests he was not trying to conceal his HBV status, Henderson says.
Transmission of bloodborne pathogens from providers to patients has become exceedingly rare, with this incident thought to be the first documented case of provider to patient HBV transmission since 1994. The case also reflects the trend of medical providers coming into the United States from areas in the world such as China where the prevalence of HBV infection is high. In such countries, many people acquire the virus at birth and go to become asymptomatic chronic carriers.
Interviews conducted with the surgeon’s coworkers attested to his excellent technique and use of barrier precautions during operations.
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