Hepatitis B from doctors

Hepatitis B in healthcare workers: Transmission events and guidance for management

Hepatitis B virus (HBV) is the most efficiently transmissible of the bloodborne viruses that are important in healthcare settings. Healthcare workers (HCWs) are at risk for exposure to HBV from infected patients and, if infected, are similarly at risk of transmitting HBV to patients. Published cases of HBV transmission from HCW to patient are relatively rare, having decreased in frequency following the introduction of standard (universal) precautions, adoption of enhanced percutaneous injury precautions such as double-gloving in surgery, and routine HBV vaccination of HCWs. Here we review published cases of HCW-to-patient transmission of HBV, details of which have helped to guide the creation of formal guidelines for the management of HBV-infected HCWs. We also compare the published guidelines for the management of HBV-infected HCWs from various governing bodies, focusing on their differences with regard to vaccination requirements, viral load limits, frequency of monitoring, and restrictions on practice. Importantly, while there are differences among the recommendations from governing bodies, no guidelines uniformly restrict HBV-infected HCWs from performing invasive or exposure-prone procedures.

Healthcare providers as sources of vaccine-preventable diseases

Vaccine-preventable infectious diseases may be introduced into the healthcare setting and pose a serious risk to vulnerable populations including immunocompromised patients. Healthcare providers (HCPs) are exposed to these pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. The primary method of protection from work-related infection risk is vaccination that protects not only an individual HCP from disease, but also subsequent patients in contact with that HCP. Individual HCPs and healthcare institutions must balance the ethical and professional responsibility to protect their patients from nosocomial transmission of preventable infections with HCP autonomy. This article reviews known cases of HCP-to-patient transmission of the most common vaccine-preventable infections encountered in the healthcare setting including hepatitis B virus, influenza virus, Bordetella pertussis, varicella-zoster virus, measles, mumps and rubella virus. The impact of HCP vaccination on patient care and current recommendations for HCP vaccination against vaccine-preventable infectious diseases are also reviewed.

Health care workers as source of hepatitis B and C virus transmission

Transmission of hepatitis B and C from health care workers to patients remains rare in developed medical care systems but may be more common in systems that are still developing. Since the 1970s, at least 69 health care workers infected with hepatitis B or C have been implicated in transmission of their infection. This likely underestimates the magnitude of the problem. In this article, risk factors associated with transmission are reviewed and infection prevention and control practices outlined. Management of infected providers is also discussed. National guidelines are compared, highlighting different countries' approaches to this complex challenge.

Risk of HIV and other blood-borne infections in the cardiac setting: patient-to-provider and provider-to-patient transmission

Health care workers (HCWs) face a well-recognized risk of acquiring blood-borne pathogens in their workplace, in particular hepatitis B and C viruses (HBV/HBC) and human immunodeficiency virus (HIV). Additionally, infected HCWs performing invasive exposure-prone procedures, including in the cardiac setting, represent a potential risk for patients. An increasing number of infected persons could need specific cardiac diagnostic procedures and surgical treatment in the future, regardless of their sex or age. The risk of acquiring HIV, HCV, HBV infection after a single at-risk exposure averages 0.5%, and 1-2%, and 4-30%, respectively. The frequency of percutaneous exposure ranges from 1 to 15 per 100 surgical interventions, with cardiothoracic surgery reporting the highest rates of exposures; mucocutaneous contamination by blood-splash occurs in 50% of cardiothoracic operations. In the Italian Surveillance (SIROH), a total of 987 percutaneous and 255 mucocutaneous exposures were reported in the cardiac setting; most occurred in cardiology units (46%), and in cardiovascular surgery (44%). Overall, 257 source patients were anti-HCV+, 54 HBsAg+, and 14 HIV+. No seroconversions were observed. In the literature, 14 outbreaks were reported documenting transmission of HBV from 12 infected HCWs to 107 patients, and 2 cases of HCV to 6 patients, during cardiothoracic surgery, especially related to sternotomy and its suturing. The transmission rate was estimated to be 5% to 13% for HBV, and 0.36% to 2.25% for HCV. Strategies in risk reduction include adequate surveillance, education, effective sharps disposal, personal protective equipment, safety devices, and innovative technology-based intraoperative procedures.

Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control

BACKGROUND

Although about 1 percent of surgeons are infected with hepatitis B virus (HBV), transmission from surgeons to patients is thought to be uncommon. In July 1992, a 47-year-old woman became ill with acute hepatitis B after undergoing a thymectomy in which a thoracic-surgery resident who had had acute hepatitis B six months earlier assisted.

METHODS

To determine whether the surgeon transmitted HBV to this patient and others, we conducted chart reviews, interviews, and serologic testing of thoracic-surgery patients at the two hospitals where the surgeon worked from July 1991 to July 1992. Hepatitis B surface antigen (HBsAg) subtypes and DNA sequences from the surgeon and from infected patients were determined.

RESULTS

Of 144 susceptible patients in whose surgery the infected surgeon participated, 19 had evidence of recent HBV infection (13 percent). One of the hospitals was selected for additional study, and none of the 124 susceptible patients of the other thoracic surgeons at this hospital had evidence of recent HBV infection (relative risk, infinity; 95 percent confidence interval, 4.7 to infinity). No evidence was found for any common source of HBV other than the infected surgeon. The HBsAg subtype and the partial HBV DNA sequences from the surgeon were identical to those in the infected patients. Transmission of the infection was associated with cardiac transplantation (relative risk, 4.9; 95 percent confidence interval, 1.5 to 15.5) but not with other surgical procedures. The surgeon was positive for hepatitis B e antigen and had a high serum HBV DNA concentration (15 ng per milliliter). Our investigations identified no deficiencies in the surgeon's infection-control practices.

CONCLUSIONS

In this outbreak there was surgeon-to-patient HBV transmission despite apparent compliance with recommended infection-control practices. We could not identify any specific events that led to transmission.

Preventing bloodborne pathogen transmission from health-care workers to patients. The CDC perspective

The development of recommendations to manage the risk of bloodborne pathogen transmission from health-care workers to patients during invasive procedures has been difficult, primarily because of the limitations of available scientific data. Ultimately, both health-care workers and patients will be protected best by compliance with infection control precautions and by development of new instruments, protective equipment, and techniques that reduce the likelihood of intraoperative blood exposure without adversely affecting patient care.

Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures

This document has been developed by the Centers for Disease Control (CDC) to update recommendations for prevention of transmission of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in the health-care setting. Current data suggest that the risk for such transmission from a health-care worker (HCW) to a patient during an invasive procedure is small; a precise assessment of the risk is not yet available. This document contains recommendations to provide guidance for prevention of HIV and HBV transmission during those invasive procedures that are considered exposure-prone.

[Viral hepatitis B. Risk for the anesthetist]

The risk of hepatitis B, previously reported in other countries, has never been investigated in French anaesthetic medical staff. The prevalence of hepatitis B viral markers has been calculated among the medical staff of the Department of Anaesthesiology, the hospital health care personnel, patients before surgical procedure and renal transplantation patients. The frequency in anaesthesiologists (18.75%; 12 out of 64) was significantly greater (p less than 0.05) than in health care personnel (10.5%; 91 out of 863). Prevalence increased with the length of practice in anaesthesiology. Prevalence of markers is 8.7% (27 out of 196) in patients undergoing surgery and 82% (27 out of 33) in patients operated on for renal transplantation in 1981. Frequency of carriers of the hepatitis B surface antigen is 0% in medical staff, 0.2% in health care personnel and 0.5% in patients before surgery. Among the health care staff, anaesthesiologists belong to a high risk population for hepatitis B. Prevention by administration of hepatitis B vaccine is recommended to protect the anaesthesiologist, his relatives and his patients.