Preventing Transmission of Hepatitis B Virus From Surgeons to Patients

Isolated episodes of transmission of hepatitis B virus (HBV), hepatitis C virus, and human immunodeficiency virus (HIV) from infected healthcare providers to patients in healthcare settings have been reported. Most HBV transmissions have occurred during invasive surgical or obstetric procedures. In general, three conditions are necessary for transmission of blood-borne viruses from healthcare personnel to patients: (1) the healthcare provider must be infected and have the virus circulating in the bloodstream; (2) the healthcare provider must be injured or have a condition that provides some other source of direct exposure to infected blood or body fluids; and (3) the injury mechanism or condition must present an opportunity for the healthcare provider’s blood to directly contact a patient’s mucous membranes, wound, or traumatized tissue (recontact). 1 The article by Spijkerman et al. in this issue of Infection Control and Hospital Epidemiology adds important information concerning the risk of transmission of HBV from infected surgeons to patients.2 The authors conducted a retrospective cohort study of 1,564 patients operated on by an HBV-infected surgeon and a case–control study to identify risk factors for transmission. Several findings from this investigation are similar to those of other reports of transmission, namely the episode involved a hepatitis B e antigen (HBeAg)–positive healthcare provider with a high viral load and risk factors for transmission included longer duration of surgery and more highly invasive procedures. However, this epidemiologic study suggests that even the simplest procedures may not be risk free. The authors raise questions concerning appropriate policies for infected healthcare providers that call for response and discussion. Certain aspects of this investigation are of particular interest. The outbreak involved a general surgeon who performed a variety of surgical procedures (eg, sigmoid and ileocecal resection, mastectomy, aorta bifurcation prosthesis, and ligation and stripping of varicose veins) that, in the United States, are usually performed by surgical specialists. This surgeon reportedly performed an average of 61 surgical procedures per month. By his own admission, he sustained frequent puncture injuries and noted suturerelated lesions on his hands. He wore double gloves during major trauma operations but apparently not during major elective surgical operations. No information is provided on surgical techniques that may have contributed to patient exposures (eg, the use of fingers as a backstop or to guide suture needles or the use of hands rather than instruments for wound retraction or exploration). However, surgical complications, including wound infection, were more common in cases than in controls. Whether they are indicative of poor quality of care in general cannot be determined based on the information provided. Much of the evidence presented in this study may have important implications for current policies regarding infected healthcare providers. In particular, it calls into question the use of procedure category as the sole criterion for determining whether an infected healthcare provider poses a risk of transmission to patients. In 1991, the Center for Disease Control (CDC) attempted to create a list of “exposure-prone procedures” based on evidence of previous HBV transmission during a given invasive procedure, observational studies, or both that showed an increased risk for injury of healthcare providers during the procedures. However, this and subsequent efforts to create a list of exposure-prone procedures were unsuccessful, due in part to a failure to consider other factors that may influence the risk of transmission, such as technical skill and use of preventive practices by the healthcare provider. The oppor-