First Hand: The Surgeon and Hepatitis C

Journal of Hand Surgery
Volume 37, Issue 8 , Pages 1693-1694, August 2012

 

Veterans Administration Medical Center, Richmond, VA

Received 1 February 2012; accepted 23 April 2012. published online 25 June 2012.

First Hand: The Surgeon and Hepatitis C

Severe malaise, nausea, headache, and a look in the mirror showing that jaundice had colored my skin confirmed beyond denial that the tiny glove and skin puncture sustained about 2 weeks prior had, truly, been a notable happening. I was finished performing surgery on a hepatitis C–positive patient with a drug addiction when the inadvertent puncture occurred. I had been distracted while applying the dressing.

Fortunately, hospital rules require that all puncture wounds in the operating room must be reported. That report to the employee health department was the most positive action I took that day.

Consider the probability that a surgeon will acquire acute or chronic hepatitis C. As the old saw goes, with validity, if you are one of those surgeons who acquire the disease, for you it is 100%. So long as you do not contract hepatitis C, you can continue to deny that you are at risk and reassure yourself that you are careful and “it will not happen to me.” Centers for Disease Control and Prevention data from surveillance hospitals estimate that more than 380,000 exposures to blood occur annually to health care workers.¹

A mistaken assumption that the incidence of hepatitis C in the general population is low might give surgeons a sense of invulnerability. Avoiding contact with patients who are drug addicted or hepatitis C–positive can help, but it is not ethical behavior.

Sadly, the distribution of hepatitis C is wide. (The most recent assessment by the Centers for Disease Control and Prevention is that 3.2 million people in the United States have the virus.²) The disease is commonly undiagnosed because it is chronic and indolent in most patients; therefore, the percentage who present with acute disease cannot be derived.

How do persons with chronic disease learn that they are afflicted? If one is fortunate, the clues will present during routine blood tests, at insurance physicals, and hospital admissions. It is late for others who learn the truth when they develop cirrhosis or primary liver cancer.

Despite the low chance of exposure to a patient with active hepatitis C and despite my vigilance and care, I acquired the hepatitis C genotype 1 virus, the most common of 6 genotypes in the United States, as well as the most difficult type to treat.

You, if so afflicted, are a patient, a supplicant looking to your favored hepatologist for advice and help. The obvious question is “should one treat or accept a symptom-free but active virus until cirrhosis or liver cancer intervenes?”

If you choose no treatment, you become a pariah to those to whom you can transmit the virus, such as patients, family, friends, and medical personnel who might be treating you. Inadvertent sharing of a toothbrush, for example, can transmit the virus. In addition, you cannot consume any alcoholic beverages or drugs that are metabolized in the liver.

End-stage cirrhosis and possible primary liver cancer often result from chronic hepatitis C, the leading cause of cirrhosis and primary liver cancer in the United States. The prospect of arriving at this state is often enough to cause one to consult a favorite hepatologist and choose drug treatment to try to eradicate the virus. That was the choice I made.

Treatment protocols do not vary much. They use 2 drugs. Neither of them attacks the virus directly. The hope is that Interferon alpha will stimulate the immune system to clear the virus, which has been crippled by ribavirin. Anyone who has prescribed these drugs or has been treated with them will describe the myriad unpleasant and often dangerous side effects. The standard treatment protocol continues for 48 weeks. The medications leave the patient in a weak, uncomfortable state for a year. That, in itself, is depressing. However, the drugs often cause dangerous, chemically induced depression. Careful monitoring of the psyche is essential if one is to avoid loss of life to suicide.
The weakened state during treatment is due to substantial depression of red blood cells, white blood cells, platelets, and other systemic effects. Growth hormones such as epoetin alfa (Procrit; Janssen Biotech, Horsham, PA) and filgrastim (Neupogen Amgen, Neuburg Park, CA) and, perhaps, transfusions are likely to be required to be able to continue treatment and have the patient survive.
The treatment protocol has been modified recently.³ A third drug is being added to the regimen. One of the new drugs has increased the chances of successfully eliminating the virus from 4 in 10 to 6 in 10, and it often makes it possible to reduce the treatment time from 48 weeks to 24 weeks.
One should not be reassured by the new treatment protocol. Twenty-four weeks on the drug regimen is still long, arduous, and dangerous.

Remember, I said that having followed the mandatory reporting requirement was a useful thing to have done. Of course, getting statistical data recorded is the obvious rationale, but because my incident was recorded, it was relatively easy to confirm that my disease was an acquired on-the-job injury. This meant that I received medical care and medications from the insurance program. At the end of the treatment, I added up the costs of the Interferon, ribavirin, epoetin alfa (Procrit), filgrastim (Neupogen), the antidepressant, and drugs used to treat the skin manifestations and other symptoms.

The cost approached US$70,000. Of course, this is not the whole cost story. There were charges for expensive viral tests and other blood tests. There were costs for travel, parking, and doctor's visits. My estimate for the total approaches US$100,000. Add that to lost time from a productive occupation, and the economic losses stagger. Providentially, I was among the 40% cured by treatment.

Upon having read this, you will properly infer that the best outcome is to avoid acquiring the virus.

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Hepatitis C and the Hand Surgeon: What You Should Know
Journal of Hand Surgery
Volume 37, Issue 8 , Pages 1711-1713, August 2012

Chronic hepatitis C has recently become the number one cause of liver-related mortality in the United States.¹ A blood-borne infection, it is most commonly spread by intravenous drug use. However, health care workers such as hand surgeons can be exposed through “sharp” injuries (eg, accidental needle sticks) both in clinic and in the operating room. If one acquires hepatitis C, there is approximately an 80% chance that it will develop into a chronic infection.² Hepatitis C infection is deemed chronic if detectable hepatitis C virus (HCV) ribonucleic acid (RNA) is present for at least 6 months. After hepatitis C has developed into a chronic infection, there is roughly a 30% chance that cirrhosis will manifest within the next 20 years.³ Cirrhosis develops because the HCV targets hepatocytes, causing damage to them through a mechanism not completely understood.⁴ There is no vaccine for the prevention of hepatitis C infection. In this article, we review the transmission, diagnosis, treatment, and prevention of hepatitis C as it pertains to practicing hand surgeons.

Transmission
The prevalence of hepatitis C in the United States is estimated⁵ to be around 1% to 1.6%. Unfortunately, sharp injuries are relatively common in hand surgery, perhaps owing to the confined working area of the hand.⁶, ⁷, ⁸ Studies have shown that up to 19% of all gloves used during hand procedures sustain a perforation, which is often undetected.⁷ It is estimated that 97% of hand surgeons in practice for more than 10 years have sustained a sharp injury, most frequently from a suture needle.⁶, ⁷ Hollow-bore needles (eg, syringes) are believed to be more likely to successfully transmit disease than their solid-bore counterparts (eg, suture needles) because the former often contain blood in their lumens, which can result in greater inoculation after a needle stick.⁹ Historically, the transmission rate for a needle stick injury involving an infected hepatitis C patient has been quoted¹⁰ as 3% to 5%. However, more recent studies¹¹ have shown that the actual rate of transmission might be much lower, about 0.3%.

Diagnosis
Whenever a needle stick injury occurs with a contaminated needle, the individual sustaining the injury should report it immediately to occupational medicine, regardless of the index of suspicion for hepatitis C or human immunodeficiency virus (HIV) transmission. Studies show that only about a third of surgeons always report such injuries.¹² It is important to have the blood of both the individual who sustained the needle stick and the patient tested, to establish a baseline for the former and test for a disease such as hepatitis C in the latter (hepatitis B and HIV are also typically tested). Consent from the patient is required before testing. In determining hepatitis C status, a rapid enzyme-linked immunoassay (ELISA) test is often used as an initial screening tool. It is a sensitive test (> 95% sensitivity) and can detect antibodies to hepatitis C in the blood.¹³ If the ELISA test is positive, the result is usually confirmed with an HCV polymerase chain reaction (PCR) test, a slightly less sensitive but more specific test (> 95% specificity) that detects the presence of HCV RNA in blood.¹⁴, ¹⁵, ¹⁶ The HCV PCR test is considered the gold standard for confirming a diagnosis of HCV infection. A positive ELISA can also be confirmed with a recombinant immunoblot assay test, which is comparable in specificity to the HCV PCR test (Fig. 1). Of note, false-positive ELISA test results can occur; however, they are relatively rare and tend to happen in patients with autoimmune diseases.¹⁴, ¹⁵, ¹⁶ It generally takes from 3 to 7 days for each of these test results to come back, depending on how frequently the laboratory runs each test. The price of an ELISA test is approximately $60, whereas the recombinant immunoblot assay averages $140, and the HCV RNA test averages $170.¹⁴

Although it varies by institution, any individual who sustains a needle stick from a patient with known hepatitis C should not only be tested initially but again at 6 weeks, 3 months, and 6 months from the event. Repeat testing is necessary because even infected patients are frequently asymptomatic, and it can take months for the virus to become detectable in the blood. It is important to diagnose an hepatitis C infection in a timely fashion so that treatment can be initiated.²

Treatment
After a diagnosis of hepatitis C has been established, the next question is whether to begin treatment, with the goal being to prevent chronic hepatitis from developing. Some patients choose to forego treatment because of the numerous side effects of the drugs that must be administered. Treatment generally consists of interferon with or without ribavirin for 24 to 48 weeks. In a recent study involving 15 patients treated during the acute phase of hepatitis C with interferon with or without ribavirin for 24 weeks, all became HCV RNA negative within 4 to 8 weeks.¹⁷ Unfortunately, the side effects of the interferon therapy are numerous and often debilitating. Flu-like symptoms, fatigue, and depression are common throughout treatment. Ribavirin also has negative side effects, most notably hemolytic anemia. As part of the treatment for hepatitis C, patients are also encouraged to protect their livers from both alcohol and acetaminophen.

Prevention
All medical personnel should protect themselves from their patients' bodily fluids at each and every encounter. Operating room staff should always wear protective eyewear, because reports of transmission of blood-borne diseases such as hepatitis C exist in the literature.¹⁸ Safety needles should also be available, for several authors have reported a 70% to 100% reduction in needle stick injuries after switching to safety-engineered devices.⁸, ¹⁹ A recent study by Tosini et al analyzing different types of safety syringes showed that passive (ie, fully automatic) devices are associated with the lowest incidence of needle stick injury.²⁰ However, in a more recent study by Sibbit et al, some passive devices (eg, automatically retractable syringes) were shown to be ineffective in performing certain basic orthopedic procedures such as arthrocentesis, in which longer needles and larger syringe volumes might be required.⁸ The authors ultimately concluded that shielded safety needles and manually retractable syringes (as opposed to automatic) were most appropriate for orthopedic procedures.⁸

Double gloving for surgeons and scrub technicians can also decrease the chances of an accidental exposure. In a 2009 Cochrane Review, the authors concluded that double gloving was effective in preventing perforation of the innermost glove without interfering with surgeon performance.²¹ A study by Sebold et al has shown that wearing outer gloves that are cut-resistant (eg, those made of Kevlar or other similar materials) versus wearing outer gloves of either the thick “orthopedic” type or standard latex variety notably reduces the rate of inner glove perforation.²² A more recent study by Louis et al on the same subject found that cut-resistant gloves might not be as effective as the Sebold study suggests.²³ Louis showed that wearing cut-resistant outer gloves only slightly decreased the frequency of inner glove perforation.²³ Other basic measures to reduce the risk of intraoperative sharp injuries include announcing the transfer of all sharp instruments, transferring all sharp instruments in a basin, and avoiding having several surgeons close one wound at the same time.

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