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Addressing Hepatitis Risks in Surgery: An Occupational Health Perspective

This lecture by Dr. Paul Froom explores the risks and prevention of infectious diseases, such as HIV, HBV, and HCV, among healthcare workers, particularly surgeons. A case study of a 30-year-old asymptomatic surgeon raises critical questions about his ability to operate safely. The discussion includes various factors, such as infectivity, occupational disease classification, and the importance of preventive measures like vaccination and protective equipment. The talk emphasizes the need for healthcare institutions to manage occupational risks effectively and protect both staff and patients.

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Addressing Hepatitis Risks in Surgery: An Occupational Health Perspective

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  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.

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