More Should Be Done to Protect Surgical Patients From Intraoperative Hepatitis B Infection

When do we, as a society, have the right or the duty to deny a person’s right to work in a chosen profession? The article by Spijkerman et al.1 in this issue of Infection Control and Hospital Epidemiology once again raises this question. The article reports that a surgeon was unresponsive to repeated attempts at hepatitis B vaccination, and then was infected with hepatitis B at least a decade before discovery through public health department investigations of symptomatic infections among some of his most recent patients. During the course of 4 years, the surgeon, unknowingly infected with hepatitis B virus (HBV), appears to have transmitted HBV to 28 patients. Since 1970, more than 375 patients worldwide have been infected with hepatitis B from their surgeon. In the United States, 19 patients were infected from a cardiothoracic surgeon who tested positive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg). 2 In 1996, in the United Kingdom, 20 patients were infected from a cardiovascular surgeon who tested positive for HBeAg.3 In 1994, following hip replacement surgery, a Welsh woman was infected and died of acute hepatitis B that was shown to be genetically identical to her surgeon’s hepatitis B; the surgeon tested positive for HBsAg and antibody to hepatitis B e antigen (anti-HBe) and negative for HBeAg.4 In Canada, an orthopedic surgeon who tested positive for HBeAg infected 4 patients.5 Now, in this issue, we read that a surgeon from The Netherlands who tested positive for HBsAg and HBeAg infected 28 patients during 4 years.1 There was transmission to 28 patients during both high-risk and exposure-prone procedures, and also unexpectedly during low-risk procedures. Spijkerman et al. found that the surgeon’s infection control practices were adequate; transmission occurred even when no break in infection control procedure or surgical technique occurred. How do surgeons and other healthcare workers (HCWs) get infected in the first place? Until the early 1980s, hepatitis B was a major occupational risk for HCWs. In 1989, the Center for Disease Control reported an annual rate of 4.89 cases per 1,000 exposed HCWs.6 In the United States, this translated to more than 12,000 HCWs each year newly acquiring hepatitis B, of whom 25% had clinical illness and 5% to 10% became long-term carriers. There is little to suggest that these rates were different anywhere in the Western world. Other studies have shown that infection rates and subsequent mortality rates were highest among those with the most blood contact (ie, surgeons, pathologists, emergency department staff, and technicians handling blood). Rates increased as a function of age and years of practice.7,8 Obviously, our first and foremost line of defense to prevent transmission of HBV from surgeon to patient is to prevent the infection in the surgeon in the first place. The hepatitis B vaccine is both safe and efficacious. It provides immunity for 92% of individuals following a first series, with 5% to 8% remaining poor responders even after additional vaccine.9 The mere suggestion of mandatory immunization raises many cries. In 1998, when Health Canada proposed mandatory hepatitis B immunization for all HCWs performing exposure-prone procedures, the Canadian Medical Association and the Canadian Dental Association opposed this recommendation.10 Voluntary, frequently free vaccination has failed miserably in Canada; national surveys suggest that anywhere from 10% to 60% of surgeons and other HCWs who perform invasive procedures are not immunized.