Patients and healthcare workers have concerns about potential transmission of blood-borne pathogens, either from healthcare worker to patient, or from patient to healthcare worker. Much of this concern was prompted by the epidemic of human immunodeficiency virus (HIV), but knowledge of the hepatitis viruses (B and C), which are transmitted by blood contact, has increased over the last two decades.
Hepatitis B virus (HBV) and hepatitis C virus (HCV) are more efficiently transmitted blood-borne pathogens than HIV in the healthcare setting. In the United States, it is estimated that between 880,000 and 1.89 million people are chronically infected with HBV, and between 2.4 million and 4 million people are infected with HCV.
Hepatitis B
Hepatitis B is a liver infection caused by HBV. HBV infection leads to inflammation of the liver and ultimately cirrhosis. Hepatitis B can be transmitted via blood, semen, or another body fluid from a person infected with HBV. In the non-healthcare setting this most frequently happens through sexual contact, sharing needles, syringes, or other drug-injection equipment, or from mother to baby at birth. In the healthcare setting, healthcare workers are at increased risk of HBV infection because of their frequent exposure to blood and other body fluids.
For some, HBV infection is an acute, or short-term, illness and for others, it can become a long-term, chronic infection. Risk of chronic infection is related to age at infection: approximately 90% of infected infants become chronically infected, compared with 2%–6% of adults.
HBV infection is detected by serologic testing for HBV antibodies. Chronic, or persistent, infection is documented by the continued presence in serum of the HBV surface antigen. In some cases of persistent infection, the hepatitis "e"-antigen, which indicates the presence of very high viral concentrations in the patient's blood, is present and is indicative of high risk of disease transmission through blood exposure. In many centers, detection of the e-antigen has been replaced by actual counts of the number of viral units in the infected patient's blood. High viral concentrations indicate increased risks for transmission The incidence of transmission via needlestick injury in one study was approximately 2% with hepatitis B e-antigen (HBeAg)-negative blood and 19% with HBeAg-positive blood.
The Centers for Disease Control and Prevention (CDC) recommends that all healthcare workers (including surgeons), with reasonably anticipated risk for exposure receive the complete hepatitis B vaccine series and have their immunity documented through postvaccination testing. The hepatitis B vaccine is safe and effective with a rate of 94%–98% in protecting from chronic HBV infection for at least 20 years.
Cases of transmission of HBV from surgeons to patients are rare and likely occur because of contact with the surgeon's blood. Blood exposure from the surgeon to the patient could occur when the surgeon sustains an intraoperative injury (for example, a needlestick or cut), which allows the surgeon's blood to directly touch the patient's open tissues. Surgeons should know their HBV immune status and be vaccinated if not already immune. Surgeons who have contracted HBV infection and are at risk of being e-antigen positive should obtain expert medical advice for their own care and take appropriate measures to prevent disease transmission to patients.
Hepatitis C
Chronic hepatitis C is an increasingly common bloodborne pathogen encountered by surgeons. Exposure may happen from blood or other body fluids, via a needlestick or from a splash of blood or body fluids into the eye or mouth, while caring for a patient. The rate of transmission of HCV to healthcare workers is unknown, but overall thought to be low. In a study including 885 healthcare workers with a percutaneous exposure to anti-HCV–positive blood the estimated risk for HCV infection was reported as approximately 0.2%.
Unlike hepatitis B, no vaccine exists to prevent the transmission of the HCV. Surgeons should adhere to strict infection control practices, including universal precautions and prompt management of exposures to mitigate risk. These precautions include consistent hand hygiene, using appropriate personal protective equipment, and ensuring proper handling and disposal of sharps and contaminated materials.
The CDC has developed guidelines for healthcare workers potentially exposed to HCV. The preferred pathway recommends testing the source patient as soon as possible (preferably within 48 hours) after exposure using a Nucleic Acid Test (NAT) for HCV Ribonucleic Acid (RNA) and testing the healthcare provider with an HCV antibody test with reflex to NAT for HCV RNA if positive. The CDC does not recommend prophylactically treating healthcare workers with direct-acting antiviral therapy for all potential exposures.
Effective treatment for HCV now exists and is recommended by the CDC for healthcare workers with serologic proof of an acute HCV infection. After the initial diagnosis of acute HCV (defined as quantifiable RNA), the Infectious Disease Society of America recommends HCV treatment should be initiated without awaiting spontaneous resolution.
The risk of transmission of HCV virus from surgeon to patient is low, but there have been reported cases. Because of this, it is prudent for surgeons to follow the above recommendations after potential exposures to mitigate the risk of developing an unknown chronic infection. Effective treatment for HCV now exists, and surgeons known to be infected with HCV can reduce or eliminate the risk of transmission to patients by seeking treatment.
Recommendations
Based upon current data and recommendations issued by the CDC, the ACS supports the following:
- Relevant to all blood-borne pathogens: Surgeons should continue to use the highest standards of infection control, involving the most effective known sterile barriers, universal precautions, and scientifically accepted measures to prevent blood exposure. This practice should extend to all sites where surgical care is rendered and should include safe handling practices for needles and sharp instruments. During every operation, maximum effort should be exerted to prevent patients' exposure to the blood of members of the surgical team and to protect the surgical team from exposure to the blood of patients.
- Relevant to all potentially infected patients: Surgeons have the same ethical obligation to render care to hepatitis-infected patients as they have in rendering care to other patients.
- Relevant to hepatitis B (HBV): Surgeons who have not been immunized and have not had previous infection with HBV (i.e., have no antibodies to HBV), should be immunized for HBV. Documentation of seroconversion to a positive antibody test for the surface antibody for HBV should be obtained one month after completion of the immunization process. Failure to seroconvert should result in a second attempt at immunization.
- Relevant to HBV immunization and antibody status: Surgeons should know their HBV immunization and antibody status. Surgeons with acquired antibodies from successful immunization are protected from future infections and are not infectious to their patients. Surgeons with natural antibodies to HBV have had previous infection and should know whether they are positive for the antigen of HBV. If they are negative for the HBV-surface antigen, then they do not have chronic infection, and they cannot transmit the infection to patients. If they are positive for the HBV-surface antigen, they should be tested for the e-antigen of HBV. If they are positive for the HBV-surface antigen but are negative for the e-antigen, then they can continue medical practice but should consult expert medical advice for their own personal health. If the chronically infected HBV surgeon is positive for e-antigen or has high viral counts in their blood then treatment should be considered in coordination with a liver specialist. Effective treatments now exist for chronic hepatitis B and successful treatment may improve the health of the surgeon and mitigate the risk of transmission to the patient.
- Relevant to hepatitis C (HCV): Surgeons should know their antibody status for HCV infection. The National Institute of Health recommends testing for:
- All adults 18 years and older at least once in their lifetime, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is under 0.1%
- Healthcare, emergency medical, and public safety personnel after needle sticks, sharps, or mucosal exposures to HCV-positive blood
Surgeons who are negative for HCV antibodies are at risk for HCV infection and should employ all strategies to prevent blood exposure for the future. Surgeons who have chronic HCV infection should consider treatment in coordination with a liver specialist.
Summary
The cornerstone to prevent exposure to all bloodborne pathogens remains proper use of personal protective equipment, implementation of universal precautions, and attention to detail when dealing with blood and potentially blood-contaminated items. Immunization against HBV infection appears to be the most effective method of preventing transmission of HBV to members of the surgical team.
