How can you stop hepatitis B and C?
How can you stop hepatitis B and C?
Risk of transmission is higher than HIV
A growing concern about the spread of hepatitis B and C in the OR has spurred debate about infected surgeons who continue to practice. While same-day surgery managers cannot legally require immunization and antibody testing due to the Americans with Disabilities Act, they should review their infection control policies, including monitoring the effectiveness of protective gear and precautions to stem the risk of transmission of the disease, surgery experts say.
Hepatitis B presents a greater risk of transmission in the OR than HIV, surgery experts say. No known cases of HIV have been transmitted from surgeons to patients, but since 1972, 24 clusters of hepatitis B transmissions from surgeon to patient have been identified. In one case, 13% of a surgeon's patients became infected.1 Surgeons, nurses, and other OR personnel are also at significant risk of contracting hepatitis B from an infected patient.
"Two hundred and fifty health care workers die every year because of complications of hepatitis infection, and I expect that to increase," says Edward J. Quebbeman, MD, PhD, professor of surgery at the Medical College of Wisconsin in Milwaukee. "That's a significant problem. That doesn't mean they all got it in the operating room, but some did."
According to estimates, some 8,700 health care workers contract hepatitis B each year from their work environment, including outpatient ORs.1 The Chicago-based American College of Surgeons recently issued recommendations that urge surgeons to become immunized and tested for antibody status. (See recommendations, below.)
Some 25% of practicing surgeons have had a hepatitis B infection, with an estimated 5% of those developing chronic hepatitis that remains infectious, as indicated by the presence of the "e" antigen (HBeAg).2 Infectious surgeons should "seek counsel from an unbiased expert review panel" to determine if they should continue their practice, the American College of Surgeons recommendations state.
"I believe we need to have some serious dialogue about whether those [infected] individuals can continue to practice surgery or not," says Donald E. Fry, MD, professor and chairman of the department of surgery at the University of New Mexico School of Medicine in Albuquerque. "I think the current evidence is compelling concerning their infectious potential."
Fry estimates that there are 100 "e" antigen positive" surgeons in the United States, or surgeons who have chronic hepatitis and are considered to be infectious. Among surgeons who have been in practice for less than 10 years, more than 90% have been vaccinated against hepatitis B; however, that percentage drops to 65% among those practicing for more than 14 years.3
Hepatitis C, a virus identified in 1989, is even more problematic for same-day surgery managers because no vaccine is available. A higher percentage of hepatitis C patients develop a chronic version of the disease, but it isn't known whether they remain infectious, Fry says. That means the focus of prevention is slightly different for hepatitis B and C, infection control experts say.
"For hepatitis B, immunization is the key. It will be far more effective than any policy or protective equipment," says Robert Rhodes, MD, chairman of the American College of Surgeons Committee on Bloodborne Pathogens and medical director of University Hospitals at the University of Mississippi Medical Center in Jackson.
"For hepatitis C, we have to rely on universal precautions, a series of recommendations about how to protect yourself in the OR."
Surgery experts recommend the following four steps to protect against hepatitis transmission:
1. Encourage physicians, nurses, and other perioperative personnel to be vaccinated and tested for hepatitis B antibody status.
The Washington, DC-based Occupational Safety and Health Administration requires employers to offer free hepatitis B vaccines to OR personnel. Although surgeons typically are not salaried employees, they should be included.
Hepatitis B vaccination requires a three-dose regimen and may require a booster shot after seven or 10 years, say infection control experts.
The risk of hepatitis transmission to patients from surgeons is greater than from other OR workers, notes Quebbeman. That presents a potential liability for same-day surgery managers. Yet surgeons or other health care workers legally cannot be required to accept vaccines or testing to determine antibody status, Quebbeman says.
"The chairman of our department encourages us to get tested periodically for HIV and hepatitis B," he says. "It is not a requirement. It's a suggestion."
The Denver-based Association of Operating Room Nurses recommends that employees who refuse to be vaccinated sign a statement that they were offered, but declined the vaccine.4
2. Check with your state health department to determine requirements related to surgeons who are "e" antigen positive for hepatitis B.
Most states restrict practices of surgeons who are "e" antigen positive. In some cases, they have implemented review panels to determine whether the surgeons may continue to perform invasive procedures.
If no local or state review panel exists, the surgery center or hospital should develop one, including surgeons and infection control experts in the development, Fry says. In the United Kingdom, surgeons are required by the government to have a hepatitis B vaccine and to provide a documented antibody response to the vaccine, he notes. Practicing privileges are suspended there for surgeons who test positive for the "e" antigen.
"Even if there's no legal requirement [in the United States], there's a moral requirement that "e" antigen positive doctors limit their practice in some appropriate way to less invasive procedures," says Quebbeman. "That probably means no surgery unless they clear the antigen [indicating that they are no longer infectious]."
3. Monitor blood strike-throughs on gowns and gloves.
Circulating nurses should inspect members of the operating team when they are removing gowns and gloves to detect any blood that penetrated the barrier, says Quebbeman. The results of this inspection could be noted as a part of a quality assurance program, he says.
Quality should override cost concerns when choosing gowns and gloves, Quebbeman says. "Unfortunately, very often the products are chosen because of money or some individual likes the color, or style, or company," he says. "This is an ideal opportunity for an organization to do good quality assurance. You ought to have a solid, data-driven choice of protective gear."
Quebbeman also favors double-gloving for invasive surgical procedures. One study found that double-gloving reduced blood contamination of surgeons and first assistants from 51% to 7%.5
4. Provide inservice training to OR personnel that reminds them about the importance of universal precautions.
The emergence of hepatitis C makes universal precautions even more vital, says Fry. "It is, in fact, a critically necessary strategy to pursue so the hospital or health care facility can say it enforced every reasonable strategy to avoid nurses and physicians getting occupational exposure," he says.
For example, sharp instruments should be placed on an intermediate table rather than passed directly from the scrub to the physician, Quebbeman notes. Other specific recommendations have been outlined by the Centers for Disease Control and Prevention in Atlanta.6 (See source box, this page, for ordering information from the National AIDS Information Clearinghouse.)
Same-day surgery managers should monitor compliance with OR policies and procedures because an air of complacency can develop, says Rhodes.
"It's important . . . to create an atmosphere in which the health care workers feel confident about their working place and the patient feels confident about the health care environment," he says.
References
1. Statement on the surgeon and hepatitis B infection. Bulletin of the American College of Surgeons 1995; 80:33-35.
2. Fry DE. "Occupational Risks for Surgeons: Hepatitis." In: Fry DE, ed. Surgical Infections. Boston: Little Brown; 1995.
3. Panlilio AL et al. Serosurvey of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infections among hospital-based surgeons. Journal of the American College of Surgeons 1995; 180:16-24.
4. Association of Operating Room Nurses. Recommended practices for universal precautions in the perioperative practice setting. Standards and Recommended Practices. Denver: 1995.
5. Quebbeman EJ et al. Double gloving: Protecting surgeons from blood contamination in the operating room. Arch Surg 1992; 127:213-217.
6. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40:1-9. *
For more information on hepatitis B and C in the OR, contact:
* Donald Fry, chairman, Department of Surgery, University of New Mexico, Health Sciences Center, 915 Camino de Salud, Albuquerque, NM 87131. Telephone: (505) 272-4151. Fax: (505) 272-6493.
To receive a copy of recommendations regarding universal precautions against the spread of hepatitis B ("Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures," Morbidity and Mortality Weekly Report, July 12, 1991, volume 40, RR-8), contact:
* National AIDS Information Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003. Telephone: (800) 458-5231. Fax: (301) 738-6616. Copies cost 10 cents each, with a minimum order of 50 copies. Ask for doc- ument no. D693. Orders must be prepaid.
* Massachusetts Medical Society, P.O. Box 9120, Waltham, MA 02254-9120. Telephone: (800) 843- 6356. Fax: (617) 893-7368. Copies cost $3, which includes shipping and handling, and must be prepaid. Indicate date and article title with orders.