Occupational transmission of viral infections to surgeons from blood exposure in the operating room has been appreciated for nearly 60 years (13). While “serum hepatitis” was a known risk, it wasn’t until the recognition of the human immunodeficiency virus, HIV, as the putative agent of the acquired immunodeficiency syndrome in the 1980s (11) that surgeons became truly concerned about occupational infection from blood exposure. In 1989 hepatitis C was identified and yet another viral pathogen became a source of concern.
The intense focus of surgeons on blood-borne infection reached a crescendo during the mid-1990s. With epidemiological evidence that clearly identified occupational transmission of HIV infection as an infrequent event, and with the development of effective antiretroviral chemotherapy for the treatment of patients with known infection, the intensity of attention to this subject of viral transmission in the operating room has waned. Percutaneous injury in the conduct of invasive neurosurgical and other operative procedures continues to be a risk for infection, and vigilance in the avoidance of operating room injury needs to be a continued objective for all surgeons.
Potential Blood-Borne Pathogens
A total of six hepatitis viruses now have been identified (Table 1) (10).
Only hepatitis B, HBV, and hepatitis C, HCV, are significant blood-borne pathogens.
Hepatitis A and E are fecally-orally transmitted pathogens that do not have
chronic infection. Hepatitis D is an incomplete RNA virus that requires coexistent
HBV infection and is not considered an occupational risk. Hepatitis G has considerable
homology to HCV but is not recognized as having transmission risks in the operating
room.
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HBV is a DNA virus that is easily transmitted with exposure. A single hollow needlestick exposure from an infected patient has a 25 percent to 30 percent risk of transmission to a naive host. Solid needle transmissions are likely to be less frequent but are well documented to occur. With acute HBV infection, about 95 percent of cases will completely resolve, but 5 percent develop a chronic infection that lasts for a lifetime (19). Acute infection is clinically occult in 75 percent of cases, which means that the acutely infected individual likely will not be aware that infection exists. Among those with chronic HBV infection, many will have a chronically progressive illness that leads to end-stage liver disease or hepatocellular carcinoma. Some will have a chronic state of antigenemia where transmission can occur from them to others after exposure to blood and body -fluids, but the disease may not advance significantly for the original host. Over one million people in the U.S. currently have chronic HBV infection (14).
A highly effective HBV vaccine derived from recombinant technology is available for all healthcare personnel who have potential exposures to patient blood (21). Three doses of the vaccine are given over a six-month period, and documentation of seroconversion with the anti-HBV surface antibody means that the host will be protected against future exposures. There is no reason for any neurosurgeon not to be vaccinated. As many as 5 percent of vaccinated individuals do not seroconvert and should be revaccinated (10). Some are revaccinated with double the vaccine antigen. Failure to seroconvert means that the individual must rely upon strategies to avoid blood exposure as the principal preventive strategy against HBV infection.
HCV is an RNA virus with six different serotypes. Transmission occurs in about 2 percent of needlestick exposures (5). While transmission is less frequent than for HBV exposure, chronic infection results in 60 percent to 80 percent of patients following acute infection (1). Acute HCV infection is clinically occult in 70 percent of cases. Progression to hepatocellular carcinoma or end-stage liver disease occurs for many patients, while others have a chronic antigenemia with minimal clinical disease. An interesting feature of HCV infection is that prior acute infection does not confer permanent immunity to the host against future reinfection. A vaccine against HCV infection is not available. HCV infection is the leading cause for hepatic transplantation in the U.S. About three to four million people in the U.S. have chronic HCV infection (20).
HIV is an RNA virus of the retroviral group. -Hollow needlestick injury is associated with a 0.3 pecent risk of transmission (6). To date, transmission from a solid needle in the operating room environment has not been reported. Documented occupational transmissions of HIV infection in the healthcare setting have been with percutaneous and mucous membrane exposures (Table 2) (6). Epidemiological evidence from the Centers for Disease Control indicates that six surgeons likely have contracted HIV infection during surgical care, although the exact nature of the transmission events was not known. No documented case of HIV transmission of infection to surgeons in the operating room has been identified in the United States. Acute infection results in chronic infection. The evolution of highly effective, antiretroviral therapy is resulting in long-term survivors of a disease that while not cured was previously considered uniformly fatal (2). A vaccine against HIV infection continues to be elusive at this point. About 750,000 people living with HIV infection are currently estimated in the U.S. (7).
Prevention of Operating Room Exposure
The prevention of viral transmission in the operating room begins with the
avoidance of any blood contact. Studies at the University of New Mexico demonstrated
that 28 percent of operations had one or more members of the operating room
team who were contaminated with blood from the patient during the operative
procedure (17). Other studies demonstrated even higher rates of blood exposure
(18). Most blood exposure events occurred from breaks in the gloves and violations
in the surgical gown from the level of the elbow to the cuff of the glove.
Selected procedures tended to have higher exposure rates than others. For neurosurgeons,
major back operations and craniotomy for intracranial bleeding following trauma
likely will be high-risk circumstances. However, every procedure with surgical
needles and sharp instrumentation poses a potential risk.
To avoid blood contact with the skin of the operating team members, universal precautions have been recommended by the Centers for Disease Control (8). The philosophy is simply that all patients should be considered risks for blood-borne infection, and a standard regimen of preventive strategies should be adopted. Face shields (required by the Occupational Safety and Health Administration) and double-gloving are the most common methods used to enhance personal protection against exposure. Because surgeons and other professionals in the operating room do not have completely intact skin of the hands, the objective of complete avoidance of blood contact with the skin is desirable. Unfortunately, universal precautions have not been universally applied and do not significantly avoid needlestick or percutaneous injury from other sharp edges encountered in the operating room.
An increased awareness for needles, scalpels, other sharp instruments, and bony spurs is very important in avoiding percutaneous injury. Reloading and repositioning of the needle in the holder must be undertaken with care. Swaged needles should be removed before tying the suture material. Needles should not be left in the operative field. Needle tips should not be palpated in difficult exposure circumstances. Passage of the loaded needle holder to the surgeon is a common source of injury to the technician or surgeon. The surgical “way station” with a Mayo stand that permits delivery and removal of the loaded needle holder becomes an effective method for avoiding injury with instrument exchange. Used needles should be discarded into an appropriate container or temporarily embedded into a Styrofoam block. Hollow needles for injection are particular sources for injury and should be removed from the operative field as soon as the infiltration or aspiration of tissues has been completed. Hollow needles should not be recapped.
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Management of the Exposure Event
While progress has been made in the reduction of needlestick and other sharp
injuries in the operating room, these incidents continue to happen. The immediate
response to a sharp injury is local treatment of the site. Ideally, rescrubbing
of the hands including the injury site has the greatest likelihood for reduction
of any viral contaminants. This is commonly not practical, and more often the
site of the injury is irrigated with a viricidal agent (for example, isopropyl
alcohol or povidone iodine) and the surgeon regloves and continues the procedure.
Antiviral irrigation of the wounded area has not been shown to impact transmission
but it is of value theoretically.
The postprocedural response of the surgeon should be indexed to knowledge of the patient’s serological status for viral pathogens (9). If the patient is known to have HBV, and the surgeon is a known responder to the HBV vaccine, then nothing more needs to be done. Remote HBV vaccination of the surgeon without current knowledge of antibody status requires that an anti-HBV surface antibody test be done, and if the test is negative the surgeon should get a booster dose of the vaccine. If the test is positive, the surgeon is protected. If the surgeon is not vaccinated, then a dose of the HBV immunoglobulin should be administered and the initial dose of the HBV vaccine should be given.
If the patient is infected with HCV at the time of the injury to the surgeon, no vaccine is available. The HCV immunoglobulin is not established as having any value to the prevention of HCV infection after an exposure event. The surgeon is followed with either a reverse transcriptase polymerase chain reaction study to identify HCV RNA, or sequential antibody tests are done to identify seroconversion. The exposed surgeon is then begun on anti-HCV, antiviral chemotherapy as soon as infection is identified. Prophylactic antiviral treatment is not recommended without evidence of seroconversion.
If the patient is known to have HIV infection, then triple-drug, antiretroviral treatment is begun immediately. A full course is administered and the surgeon is followed for seroconversion.
The more common scenario is that a percutaneous injury occurs and the status of the patient to the various viral pathogens is unknown. Correct practice would be to request a viral screen of the patient following the procedure. Commonly the request for screening of the patient is done based upon the severity of the injuring event and the surgeon’s perception of the infectious risk that the patient may pose. All significant needlestick and sharp injuries should trigger updating the surgeon’s status with respect to HBV vaccination and the initiation of antiretroviral chemotherapy until the patient’s status is defined. Follow-up for HCV and HIV infection is essential if the infectious status of the patient remains unknown.
New Horizons in Occupational Infection in the OR
It is unlikely that all blood-borne pathogens have been identified. Not all
patients with the so-called non-A, non-B hepatitis of the 1970s and 1980s have
been confirmed to have HCV, and there is considerable speculation that at least
one additional hepatitis virus remains undefined. The TT virus is a new blood-borne
hepatitis agent identified in Japan that is of uncertain risk as an occupational
pathogen (16). The West Nile virus and other episodic viral infections pose
a potential risk for occupational infection in the operating room. For neurosurgeons
in particular, the recognition of transmission of new-variant Creutzfeldt-Jakob
disease, vCJD, from contaminated neurosurgical instruments means that even
prions pose a potential and unrecognized risk in the operating room (4). Some
experimental (12) and clinical (15) reports have now suggested that vCJD can
be transmitted by transfusion, and this too becomes a potential risk for blood
contamination.
The spectrum of potential risks is likely to increase rather than decline. The blood of patients will potentially harbor occupational infections for neurosurgeons and all clinicians in the care of patients. These risks are not to be a source of fear but rather are to be understood. Appropriate measures for prevention, and prompt action once a needlestick or other sharp injury has occurred is strongly recommended. Blood is a toxic substance and should be treated accordingly.
Donald E. Fry, MD, is emeritus professor of the Department of Surgery, University of New Mexico School of Medicine, Albuquerque, N.M., and executive vice-president of clinical outcomes management with Michael Pine and Associates, Chicago, Ill. The author reported no conflicts for disclosure.
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