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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

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
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,
case study
Case Study
  • 30 year-old asymptomatic surgeon
  • After his residency, applied for a job in a teaching hospital
  • Pre-employment testing
  • HbsAg
case study 2
Case Study (2)
  • e antigen negative- predicts low infectivity
  • mild elevations of liver enzymes
questions
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?
what do we need to know
What do we need to know?
  • 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
risk of a penetrating injury during surgery
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
risk of an infection after a penetrating injury
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
risk of infection to unvaccinated surgeon
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
risk of infecting the patient
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
natural history of hepatitis b
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
natural history of hepatitis b 2
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)
deaths from viral chronic liver disease in the usa
Deaths from viral chronic liver disease in the USA
  • 16,000 deaths per year
  • 70% hepatitis C
  • 20% hepatitis B
  • 10% dual infection
acceptable risk to the patient
Acceptable risk to the patient
  • Courts not sympathetic
  • CDC- recommended in 1991 against
  • Since- the CDC back tracked
  • determined by each state and hospital
case study15
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
acceptable risk to the surgeon
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
employer s obligation
Employer’s obligation
  • Provide all protective equipment
  • provide vaccinations
  • explain to the employees the risks involved
preventive measures vaccination
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
other preventive measures
Other preventive measures
  • Gloves
  • Goggles
  • Blunt tipped needles
gloves
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
other protective equipment
Other protective equipment
  • Visors: splash to face very common
  • resheathing method
  • 50% medical students needle-sticks during ward experience
  • hepatitis immune globulin
our case of the surgeon further history
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
further history 2
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
summary
Summary
  • Any risk to the patient is unacceptable.
  • He should be recognized as having an occupational disease
  • He should receive compensation.
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