Should HBV or HCV positive surgeons refrain from operating.

J Pak Med Assoc Viruses like hepatitis B, C and HIV spread by blood and blood fluids. Health care professionals including surgeons and all those who perform exposure-prone procedures are at risk of contracting these blood-borne viruses, but they generally do not recognize or report these potential exposures due to reluctance to report sharps injuries, or to present for testing for blood-borne virus transmission, for fear of being barred from surgical practice. Although surgeons may fear transmission of HIV in particular, it is hepatitis C that poses the greatest risk.1,2 Doctors are at a high risk for needle stick injuries, while surgeons often cut or nick themselves while operating inside the patient's body cavity. Reporting of such injuries is a critical step in initiating an early prophylaxis or treatment. A survey reported that surgeons-in-training suffer an average of eight needle sticks in their first five years of training3 and virtually all surgical residents (99%) had had a needlestick injury by their final year of training. Furthermore, many injuries (51% of those assessed overall, including 16% of those involving high-risk patients) were not reported to an employee health service.3 Despite the risk, however, there is no mandatory testing of surgeons for blood-borne viruses, and infected health care workers are not prohibited from practicing medicine or invasive surgery.4 Local expert panels are convened to review cases if they come up, but many surgeons simply refrain from being tested.4 The first few incidents of doctor to patient transmission occurred in Spain5 and UK.6 In the Spanish incident five out of 222 patients exposed between 1988 and 1994 to a surgeon with chronic HCV infection became infected with hepatitis C genotype 3, which matched the surgeon's infection when subjected to nucleotide sequencing.5 In the UK incident a patient developed acute hepatitis C after cardiothoracic surgery.6 None of the 277 patients who underwent testing at least six months after exposure had evidence of infection, making the transmission rate 0.36% (1/278). 6 In UK the infected surgeons who have a high chance of transmitting intra-operative HCV to their patients are recommended not to perform further exposure prone procedures.6 In another report, HCV was transmitted from a surgeon to a female patient who underwent a gynaecological surgery in UK in 1997. The woman had no other risk factor for infection apart from this surgery and further investigations showed that the surgeon was unaware of this infection and serotyping and genotyping of the virus showed that both surgeon and patient carried genotype 4, which is rare in UK.7 Over 1600 women operated upon by this surgeon have been contacted and offered tests.7 According to a report by the Senate of Surgery of UK and Ireland, which represents the royal college of surgeon and other specialties, gynaecology is one of the highest risk specialty for surgeon injury, with sharps injuries occurring in 10% of all procedures and up to 21% from vaginal hysterectomies.7 The risk of hepatitis C virus (HCV) transmission to surgeons is related to the HCV prevalence in the surgical patient population.8 However, the risk of an individual surgeon acquiring HCV through occupational exposure is low, even in an areas where there is extremely high prevalence of HCV like injecting drug using population.8 Surgeons however should be encouraged to observe universal precautions and present for assessment after needlestick injuries to protect themselves and their patients from this insidious infection.8 Another study reported a low risk of HCV transmission to liver transplant surgeons despite their being operating on HCV infected patients.9 The study estimated the prevalence of HCV infection in 117 liver transplant surgeons attending the 9th Congress of the International Liver Transplantation Society using unlinked anonymous rapid testing for HCV by finger prick. Two (1.7%) surgeons had antibodies to HCV and one (0.8%) had detectable HCV RNA (genotype 1a). Assuming that both infections were acquired during surgery, the estimated maximum rate of HCV transmission was 1 per 743 to 1,045 years of surgical practice (0.96 to 1.35 HCV transmissions per 1,000 years of general surgery) and 449 to 683 years of liver transplant practice (1.46 to 2.23 HCV transmissions per 1,000 years of liver transplantation practice). 9 Cross-sectional studies show the actual seroprevalences of hepatitis C in surgeons to be equivalent to, or slightly higher than, those of the general population.10,11 Therefore, the risk seems to be considerably higher than might be predicted, and can be estimated by this formula.12 A surgeon who performs 300 procedures per year and is at the end of a 35-year surgical career has a risk of 4.9% of being HCV antibody-positive, with a 3.8% risk of being RNApositive on polymerase chain reaction testing (people are not Editorial