1. Hepatitis in a surgeon- problem oriented learning: Part I Paul Froom MD, MOccH Chief of Epidemiology Israel- National Institute of Occupational and Environmental Health Associate Professor of Epidemiology Sackler School of Medicine, Tel Aviv University

2. Primary purpose of the lecture • Learn about the risk and prevention of infectious diseases (HIV, HBV, HCV) in health care workers and in their patients • Learn the following terms: infectivity, virulence, pathogenicity, host, reservoir,carrier, common source, propagated disease, colonization, epidemics,

3. Case Study • 30 year-old asymptomatic surgeon • After his residency, applied for a job in a teaching hospital • Pre-employment testing • HbsAg

4. Case Study (2) • e antigen negative- predicts low infectivity • mild elevations of liver enzymes

5. Questions • Should this surgeon be accepted and allowed to operate on patients? • Should the surgeon be recognized as having an occupational disease? • Does he deserve compensation? • Should he have a liver biopsy? • What do we need to know?

6. What do we need to know? • Risk of injury during surgery • Risk of infection after a penetrating injury • Risk of infection to unvaccinated surgeon • Risk of infecting the patient • Treatment for chronic active hepatitis • Concept of acceptable risk

7. Risk of a penetrating injury during surgery • 173 of 202 surgeons over 1 year • 32 of 97 students stuck or cut • Often the surgeon is unaware of the puncture

8. Risk of an infection after a penetrating injury • INFECTIVITY of common exposure to health care workers (HCW) • HBV - e antigen positive- as high as 30% • HBV - e antigen negative- probably around 5% • Hepatitis C- 2-5% • AIDS = 3/1000

9. Risk of infection to unvaccinated surgeon • Estimated in the US- 5% per year • Life time risk- 43% • Over twice that of the general population • Occupational disease

10. Risk of infecting the patient • Exact risk? • Gynecological surgeon- 9% infected • High risk operations: C-section or hysterectomy • Cases reported of e-antigen negative surgeons infecting patients • One fatal case reported

11. Natural history of hepatitis B • Incubation period- up to 180 days • Infected patients: 1/3 asymptomatic, 1/3 flu-like symptoms, 1/3 jaundice • Virulence- proportion of overt infections • Rare patient -death from acute hepatitis

12. Natural history of hepatitis B (2) • Pathogenicity = clinical disease after exposure • = infection rate x virulence • Chronic carriers- 1-10% • Increased risk of liver cancer (hepatoma)

13. Deaths from viral chronic liver disease in the USA • 16,000 deaths per year • 70% hepatitis C • 20% hepatitis B • 10% dual infection

14. Acceptable risk to the patient • Courts not sympathetic • CDC- recommended in 1991 against • Since- the CDC back tracked • determined by each state and hospital

15. Case study • Surgeon infected 5 patients over 4 months • required to obtain written informed consent from the patients • required to double-glove • required to attempt to avoid self-injury • 5 months later-infected women during C-section • Excluded from further surgical operations

16. Acceptable risk to the surgeon • Best not to operate on patients with HBV, HCV or HIV • most agree if procedure has benefit to the patient • obligation to operate despite the risk

17. Employer’s obligation • Provide all protective equipment • provide vaccinations • explain to the employees the risks involved

18. Preventive measures- vaccination • Three doses • protective serum titers (> 10 milliU anti-HBs) • 95-99% effective in young adults • less effective in those over 40 years

19. Other preventive measures • Gloves • Goggles • Blunt tipped needles

20. Gloves • Reduce risk: dentists: 6/395 Vs 0/369 (patients) • Double gloving: blood contact rate 25% to 10% • Sharps injury fluid transmitted reduced by 75% • Yet- 3.5% risk of blood contact per operation even after double gloving

21. Other protective equipment • Visors: splash to face very common • resheathing method • 50% medical students needle-sticks during ward experience • hepatitis immune globulin

22. Our case of the surgeon-further history • injured blood contaminated needle during medical school and during residency on several occasions • Operated on HBV positive patients • Medical school-no organized program

23. Further history (2) • Hospitals claimed that vaccination free of charge • Letters sent to the MDs • Used double gloving • No lectures given • Lawyers for the hospital claimed that the risks are common knowledge to MDs

24. Summary • Any risk to the patient is unacceptable. • He should be recognized as having an occupational disease • He should receive compensation.