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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 Primary purpose of the lecture

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Hepatitis in a surgeon- problem oriented learning: Part I

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Hepatitis in a surgeon problem oriented learning part i l.jpg
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


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Primary purpose of the lecture I

  • 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,


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Case Study I

  • 30 year-old asymptomatic surgeon

  • After his residency, applied for a job in a teaching hospital

  • Pre-employment testing

  • HbsAg


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Case Study (2) I

  • e antigen negative- predicts low infectivity

  • mild elevations of liver enzymes


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Questions I

  • 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?


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What do we need to know? I

  • 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


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Risk of a penetrating injury during surgery I

  • 173 of 202 surgeons over 1 year

  • 32 of 97 students stuck or cut

  • Often the surgeon is unaware of the puncture


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Risk of an infection after a penetrating injury I

  • 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


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Risk of infection to unvaccinated surgeon I

  • Estimated in the US- 5% per year

  • Life time risk- 43%

  • Over twice that of the general population

  • Occupational disease


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Risk of infecting the patient I

  • 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


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Natural history of hepatitis B I

  • 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


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Natural history of hepatitis B (2) I

  • Pathogenicity = clinical disease after exposure

  • = infection rate x virulence

  • Chronic carriers- 1-10%

  • Increased risk of liver cancer (hepatoma)


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Deaths from viral chronic liver disease in the USA I

  • 16,000 deaths per year

  • 70% hepatitis C

  • 20% hepatitis B

  • 10% dual infection


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Acceptable risk to the patient I

  • Courts not sympathetic

  • CDC- recommended in 1991 against

  • Since- the CDC back tracked

  • determined by each state and hospital


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Case study I

  • 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


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Acceptable risk to the surgeon I

  • 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


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Employer’s obligation I

  • Provide all protective equipment

  • provide vaccinations

  • explain to the employees the risks involved


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Preventive measures- vaccination I

  • Three doses

  • protective serum titers (> 10 milliU anti-HBs)

  • 95-99% effective in young adults

  • less effective in those over 40 years


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Other preventive measures I

  • Gloves

  • Goggles

  • Blunt tipped needles


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Gloves I

  • 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


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Other protective equipment I

  • Visors: splash to face very common

  • resheathing method

  • 50% medical students needle-sticks during ward experience

  • hepatitis immune globulin


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Our case of the surgeon-further history I

  • injured blood contaminated needle during medical school and during residency on several occasions

  • Operated on HBV positive patients

  • Medical school-no organized program


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Further history (2) I

  • 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


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Summary I

  • Any risk to the patient is unacceptable.

  • He should be recognized as having an occupational disease

  • He should receive compensation.


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