1. Hepatitis in a surgeon- problem oriented learning: Part I Paul Froom MD, MOccH Chief of Epidemiology Israel- National Institute of Occupational and Environmental Health Associate Professor of Epidemiology Sackler School of Medicine, Tel Aviv University

2. Primary purpose of the lecture Learn about the risk and prevention of infectious diseases (HIV, HBV, HCV) in health care workers and in their patients Learn the following terms: infectivity, virulence, pathogenicity, host, reservoir,carrier, common source, propagated disease, colonization, epidemics,

3. Case Study 30 year-old asymptomatic surgeon After his residency, applied for a job in a teaching hospital Pre-employment testing HbsAg

4. Case Study (2) e antigen negative- predicts low infectivity mild elevations of liver enzymes

5. Questions Should this surgeon be accepted and allowed to operate on patients? Should the surgeon be recognized as having an occupational disease? Does he deserve compensation? Should he have a liver biopsy? What do we need to know?

6. Risk of injury during surgery Risk of infection after a penetrating injury Risk of infection to unvaccinated surgeon Risk of infecting the patient Treatment for chronic active hepatitis Concept of acceptable risk

7. Risk of a penetrating injury during surgery 173 of 202 surgeons over 1 year 32 of 97 students stuck or cut Often the surgeon is unaware of the puncture

8. Risk of an infection after a penetrating injury INFECTIVITY of common exposure to health care workers (HCW) HBV - e antigen positive- as high as 30% HBV - e antigen negative- probably around 5% Hepatitis C- 2-5% AIDS = 3/1000

9. Risk of infection to unvaccinated surgeon Estimated in the US- 5% per year Life time risk- 43% Over twice that of the general population Occupational disease

10. Risk of infecting the patient Exact risk? Gynecological surgeon- 9% infected High risk operations: C-section or hysterectomy Cases reported of e-antigen negative surgeons infecting patients One fatal case reported

11. Natural history of hepatitis B Incubation period- up to 180 days Infected patients: 1/3 asymptomatic, 1/3 flu-like symptoms, 1/3 jaundice Virulence- proportion of overt infections Rare patient -death from acute hepatitis

12. Natural history of hepatitis B (2) Pathogenicity = clinical disease after exposure = infection rate x virulence Chronic carriers- 1-10% Increased risk of liver cancer (hepatoma)

13. Deaths from viral chronic liver disease in the USA 16,000 deaths per year 70% hepatitis C 20% hepatitis B 10% dual infection

14. Acceptable risk to the patient Courts not sympathetic CDC- recommended in 1991 against Since- the CDC back tracked determined by each state and hospital

15. Case study Surgeon infected 5 patients over 4 months required to obtain written informed consent from the patients required to double-glove required to attempt to avoid self-injury 5 months later-infected women during C- section Excluded from further surgical operations

16. Acceptable risk to the surgeon Best not to operate on patients with HBV, HCV or HIV most agree if procedure has benefit to the patient obligation to operate despite the risk

17. Employer’s obligation Provide all protective equipment provide vaccinations explain to the employees the risks involved

18. Preventive measures- vaccination Three doses protective serum titers (> 10 milliU anti-HBs) 95-99% effective in young adults less effective in those over 40 years

19. Other preventive measures Gloves Goggles Blunt tipped needles

20. Gloves Reduce risk: dentists: 6/395 Vs 0/369 (patients) Double gloving: blood contact rate 25% to 10% Sharps injury fluid transmitted reduced by 75% Yet- 3.5% risk of blood contact per operation even after double gloving

21. Other protective equipment Visors: splash to face very common resheathing method 50% medical students needle-sticks during ward experience hepatitis immune globulin

22. Our case of the surgeon- further history injured blood contaminated needle during medical school and during residency on several occasions Operated on HBV positive patients Medical school-no organized program

23. Further history (2) Hospitals claimed that vaccination free of charge Letters sent to the MDs Used double gloving No lectures given Lawyers for the hospital claimed that the risks are common knowledge to MDs

24. Summary Any risk to the patient is unacceptable. He should be recognized as having an occupational disease He should receive compensation.