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Hepatitis C Sporadic Transmission

Sporadic transmission, when the source of infection is unknown, occurs in about 10 percent of acute hepatitis C cases and in 30 percent of chronic hepatitis C cases. These cases are also referred to as sporadic  or community-acquired infections. These infections may have come from  exposure to the virus from cuts, wounds, or medical injections or  procedures. Also known as nosocomial transmission.

Hepatitis C Risk Not Limited to Injection Drug Users

A study in New York City has found a higher than expected prevalence of hepatitis C infection among non-injecting drug users. In this study, as many as 17 percent of the subjects who denied a history of injection drug use were found to be infected, compared to a 2 percent infection rate in the general population. Among women from one of the study sites in East Harlem who reported use of non-injection heroin, the rate of infection was as high as 26 percent.

The findings, published in the May 1 issue of Substance Use & Misuse, may indicate that use of needles and syringes is not the only drug-related risk factor for HCV.
Currently, about 60 percent of all new cases of HCV infection in the U.S. are attributable to syringe and needle-sharing with an infected individual. Dr. Alan I. Leshner, NIDA Director, says this study demonstrates that "We need to look closer for other routes of HCV transmission among non-injecting drug-users. If hepatitis C can be transmitted through the sharing of non-injecting drug paraphernalia such as straws or pipes, we need to include this information in public health messages targeted to this population."
Dr. Stephanie Tortu, from the Tulane University School of Public Health and Tropical Medicine, in collaboration with Dr. Alan Neaigus of the National Development and Research Institutes, Inc. in New York City, conducted two separate studies with self-reported non-injecting drug users recruited from two NYC neighborhoods. The study participants either denied ever injecting drugs or reported that they had not injected drugs within the past six months prior to participating in the study.

Of 107 women and 251 men from the Lower East Side of Manhattan who reported never injecting, 14 percent of the women and 18 percent of the men were found to be infected with hepatitis C. Of the 171 women in the East Harlem sample who reported no history of injection drug use, 17 percent were found to be infected.

These rates, while lower than for those who had reported histories of injection drug use, were higher than those found in the general population. Of those who had reported past injection drug use, more than half of the men and women in the sample from the Lower East Side, and 62 percent of the women from East Harlem, were infected.

"These studies indicate that the prevalence of HCV among drug users who report that they have never injected is substantially higher than for the general population in the U.S. and several other countries, and prevalence may vary according to population, gender, age, and drugs used," says Dr. Tortu. "Further research is needed to determine the risk factors for HCV transmission among those with no history of injecting drugs."
The National Institute on Drug Abuse is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports more than 85 percent of the world's research on the health aspects of drug abuse and addiction. The Institute carries out a large variety of programs to ensure the rapid dissemination of research information and its implementation in policy and practice. Fact sheets on the health effects of drugs of abuse and other topics can be ordered free of charge in English and Spanish through NIDA Infofax at 1-888-NIH-NIDA (644-6432) or 1-888-TTY-NIDA (889-6432) for the deaf. These fact sheets and further information on NIDA research and other activities can be found on the NIDA home page at http://www.drugabuse.gov

100 women at risk after GP blunder

by Camillo Fracassini and Sue Leonard
 
UP TO 100 women have been put at risk of contracting HIV and hepatitis after they were given cervical smear tests using unsterilised equipment.
Over a period of 18 months Dr Carol Stewart, a GP at the Newland medical practice in Bathgate, West Lothian, mixed sterilised and unsterilised stainless steel speculums. The devices were then used by Stewart and her colleagues to carry out dozens of gynaecological examinations. The doctor is understood to have realised her mistake and contacted her superiors last month.

Health officials have now launched an investigation to identify all the patients Stewart and her colleagues treated during that period who, they believe, might have been exposed to HIV, hepatitis, the human papilloma virus — the main cause of cervical cancer — and chlamydia, which can cause infertility.

Documents obtained by The Sunday Times reveal the problem was identified 11 days ago, on October 30, and none of the women has yet been contacted. Last night Lothian Health Board was insisting it had not been picked up until this month.

Letters are to be sent out to the patients in the next week warning them that they could be at risk, but they will be offered tests only if they specifically request them. There is also a dispute among health officials within Lothian NHS Board over whether the women should be offered counselling.

Dr Brian Montgomery, medical director at West Lothian Healthcare NHS Trust, is understood to have expressed concern at the level of demand and expectation that such an offer might create.

Documents indicate that Stewart and her colleagues used the unsterilised equipment from March 2002. It is understood that containers for sterilised and unsterilised speculums were not clearly marked and Stewart mistakenly put the used devices in the wrong container.

A memo written by Dr Emma Williamson, a microbiologist at St John’s hospital in Livingston, West Lothian was circulated to health officials on October 31, the day after the alarm was raised. Officials at the Scottish executive were also alerted.

The document, headed “Potential transmission of STDs and blood-borne viruses in West Lothian primary care”, stated: “A GP working at Bathgate has realised that she has been using non-sterile vaginal speculums . . . The infection control team and WLT (West Lothian Trust) medical director were made aware of this incident on Thursday October 30.”

The document recommends “at risk women” should be offered screening for HIV, hepatitis B, hepatitis C and STDs. It also suggests offering hepatitis B vaccinations. However, a decision was allegedly taken at a crisis meeting held at Bathgate Health Centre on Thursday not to offer the tests unless they are specifically requested.

The speculums involved are duck-bill shaped instruments used to carry out cervical examinations. In addition to smears, the equipment is used by GPs for examinations relating to early pregnancy, contraception and period pain. Although the practice also runs a family planning clinic, only disposable speculums are used there.

Doctors and patient groups have expressed alarm at what has happened in Bathgate despite clear NHS guidelines and the publicity surrounding similar incidents where patients have become cross-infected.

Margaret Davidson, of the Scotland Patients’ Association, said: “This is horrific. Surely the containers for sterilised and unsterilised speculums should be clearly marked to ensure this does not happen? I feel awful for the women involved. I would be devastated.”

A spokeswoman for Lothian NHS Board said no action had been taken against Stewart. “The moment this error was identified practice changed. As of Friday, the Newland practice has been using only disposable speculums,” she said.

In a statement, Lothian NHS Board said: “Public health and infection control experts at Lothian NHS Board and West Lothian Healthcare NHS Trust are investigating an incident concerning medical equipment sterilisation at the Newland medical practice in Bathgate, West Lothian.

“All women who may be affected will be contacted by letter in the next few days. They will be offered advice and screening, as appropriate.

“This applies only to female patients within the Newland practice who had an internal vaginal examination using a metal speculum between March 25, 2002 and November 3, 2003. Anyone who believes they may be affected should call the helpline on 01506 422816.”

Volume 343 Number 25
·
1851
Brief Report

TRANSMISSION OF HEPATITIS C VIRUS FROM A PATIENT TO AN ANESTHESIOLOGY ASSISTANT TO FIVE PATIENTS

R. S TEFANROSS, M.D., SER GEIVIAZOV, PH.D., TANJA GROSS, FRIEDRICH HOFMANN, M.D., PH.D., HANS-MARTINSEIPP, M.D.,AND MICHAEL ROGGENDORF, M.D.

From the Institute of Virology, National Reference Center for Hepatitis C, University of Essen, Essen (R.S.R., S.V., T.G., M.R.); the Department of Occupational Health, University of Wuppertal, Wuppertal (F.H.); and the Institute of Hygiene, Dr.-Horst-Schmidt-Kliniken, Wiesbaden (H.-M.S.)  — all in Germany. Address reprint requests to Dr. Ross at the Institute of
Virology, National Reference Center for Hepatitis C, University of Essen, Hufelandstr. 55, D-45122 Essen, Germany, or at stefan. ross@uni-essen.de. ©2000, Massachusetts Medical Society.

PREVENTION and treatment of infections with hepatitis C virus (HCV) remain a major challenge.

The main source of HCV infection in developed countries was formerly transfusion of contaminated blood and blood products but is now injection-drug use.

In general, a potential risk factor can be established for about 90 percent of all cases of HCV infection.
One way of contracting HCV may be transmission from infected medical personnel to susceptible patients during medical care. Provider-to-patient transmission of HCV is rare, and in most cases HCV-positive surgeons are the probable source.
We studied an outbreak of HCV in a municipal hospital. Our findings suggest that an anesthesiology assistant contracted HCV from a chronically infected patient and subsequently transmitted the virus to five other patients.

METHODS
Patients The municipal hospital in which the HCV outbreak occurred provides general as well as specialty medical and surgical services. Between July 1 and October 13, 1998, HCV infection was diagnosed in four patients (Patients 2, 3, 4, and 6 in this report) on the basis of clinical symptoms, a rise in the serum alanine aminotransferase concentration, or detection of serum HCV antibodies and HCV RNA. All of these patients had undergone orthopedic or general surgery in the same hospital 6 to 18 weeks earlier.

A comprehensive investigation was initiated by the public health authorities, and we were asked to determine the circumstances of the suspected nosocomial HCV infections. An institutional review board of Essen University Hospital approved the study protocol, and the patients provided written informed consent.

Epidemiologic Studies
The charts of all patients with HCV infection were reviewed in detail. Interviews were conducted to obtain further information
about prior medical interventions, prior hepatitis infections, and P risk factors for the acquisition of HCV. To search for other potential cases of HCV transmission, we performed a retrospective seroepidemiologic study of all patients who had undergone surgery in the hospital between January and July 1998. Fifty-eight of these patients had died, and 904 were still alive; serum was obtained for antibody testing from 833 of these 904 patients. Hospital personnel were interviewed with special attention to compliance with infection-control practices and were tested for HCV antibodies. The hospital — in particular, the surgical facilities — was inspected by experts in hygiene and occupational health. Virologic and Molecular Studies

The presence of HCV antibodies was determined by enzymelinked immunosorbent assay (ELISA; Sanofi Diagnostics Pasteur,
Freiburg, Germany). Reactivity was confirmed by immunoblot assay (Mikrogen, Munich, Germany). HCV RNA was detected qualitatively and was also quantified with polymerase-chain-reaction (PCR) kits (Roche Diagnostics, Mannheim, Germany). HCV isolates were identified by genotyping, and HCV hypervariable region 1 (nucleotides 1491 to 1572, numbered as reported by Choo et al.) was amplified as described elsewhere.

Products of the second PCR were purified from the agarose gel (QIAquick, Hilden, Germany) and cloned into a plasmid vector (TOPO TA cloning kit, Invitrogen, Groningen, the Netherlands). Four to six clones from each subject were sequenced in both directions (with the Dye Terminator  DNA sequencing kit, Perkin–Elmer, Norwalk, Conn.). As area controls, the PCR products of HCV isolates that were obtained from chronically infected patients (located within a radius of approximately 200 km from the hospital) were subjected to direct sequencing.

To prevent possible cross-contamination of the samples, stringent procedures were used for nucleic acid extraction and amplification, and the analyses were performed several weeks apart. Sequences of HCV hypervariable region 1 that were obtained from the samples have been submitted to GenBank (accession numbers AF227763 through AF227786).
Statistical Analysis A matrix of nucleotide distances was calculated by Kimura’s two-parameter method.
The statistical significance of the differences was assessed by a two-sided Wilcoxon rank-sum test with the use of SPSS statistical software (SPSS, Chicago). Phylogenetic trees were constructed with use of the neighbor-joining algorithm on
the previous sets of pairwise distances (PHYLIP, version 3.5 ).
The significance of the grouping was evaluated by the bootstrap method (1000 replicates).

RESULTS
Epidemiologic Findings Six patients were found to have hepatitis C viremia. They are listed according to the dates of surgery in
Table 1. The HCV infection of Patient 1 was first diagnosed in 1996; she probably contracted the virus through the transfusion of contaminated blood or clotting-factor concentrates at the time of surgery for heart-valve replacement in 1980. Patients 2, 3, and had acute icteric hepatitis C 6 to 18 weeks after orthopedic or general surgery, whereas Patients and were asymptomatic after surgery. Only Patient 1 had ever received blood or blood products. None of the other patients had a history of hepatitis, nor were they aware of any history of hepatitis in their families. All reported no other risk factors for HCV infection,
including tattooing or body piercing, intravenous drug use, or high-risk sexual behavior. The operations were performed in two rooms. There was no known contact between the patients either before or during their hospitalizations, which were in different parts of the hospital.

Testing of staff members revealed the presence of HCV antibodies in one anesthesiology assistant. He had taken part in all six operations. At the end of February 1998, the assistant was HCV-negative, but he had acute icteric hepatitis C in June 1998. Besides occupational exposure, the anesthesiology assistant had no known risk factors for HCV infection. Intravenous
drug abuse was ruled out by extensive drug screening and numerous interviews. The assistant was almost entirely responsible for the administration of general anesthesia, including the preparation of narcotic drugs, the placement of venous and arterial catheters, the intubation of the patients, and the subsequent artificial respiration. He usually did not wear gloves, because he claimed that they diminished his sense of touch and therefore impaired his work. On questioning, he reported that during the time under investigation he had a wound on the medial side of the third finger of his right hand, sustained in the middle of April 1998 when he opened a box containing infusion solutions. The wound was initially the size of a thumbnail and bled repeatedly. He used a bandage for three or four days but not thereafter, although the wound was still weeping.

The assistant admitted that this was negligent behavior, but at the time he already considered the open wound to be an old injury and was not aware that such an attitude might be risky for him as well as for his patients. Between April 28, 1998, the day of surgery in Patient 1, and June 9, 1998, the day of surgery in Patient 6, the assistant participated in 39 operations. Between the time he went on sick leave because of acute hepatitis C and July 1998, another 118 operations were performed in the hospital, and no further HCV infections occurred
.

Hygiene and occupational health inspections as well as interviews with staff members indicated that numerous breaches of general infection-control practices had taken place. For instance, needles were frequently recapped after use, and gloves were not always worn in settings in which exposure was likely. Multidose vials for flushing solutions, saline, local anesthetic
drugs, and heparin were often used in the operating rooms, although the solutions were changed every second day. As a disinfectant for surfaces, the hospital used a product based on a peroxide compound (Dismozon pur, Bode Chemie, Hamburg, Germany) that is not recommended for areas grossly contaminated with blood. The central sterilization facility worked properly, as indicated by the relevant technical protocols.

Virologic and Molecular Findings
All six patients and the anesthesiology assistant were positive for serum HCV antibodies and HCV RNA. At the time of the investigation, Patient 1 and the assistant had high plasma levels of HCV RNA (2.6¬107 copies of HCV RNA per milliliter and at least 1¬10 copies of HCV RNA per milliliter, respectively). Genotyping revealed HCV type 1a infection in all cases. The alignment of sequences of HCV hypervariable region 1 demonstrated a very high degree of homology between the isolates obtained from the patients and those obtained from the anesthesiology assistant.  Among the subjects nuclotide distances varied only from 0 to 0.05, whereas a comparison of the subjects’ sequences with those of the 10 area controls with type 1a HCV and the 13 genotype-1a sequences drawn from GenBank showed nucleotide distances that ranged from 0.25 to 0.59 (P<0.001) (data not shown).

Figure 1.Alignment of the Sequences of HCV Hypervariable Region 1 from the Patients, the Anesthesiology Assistant, and Selected Controls.The two most divergent clonal sequences from each person (designated a and b) have been included. C1 and D10749 denote the selected controls.
 

The relatedness of the sequences of hypervariable region 1 from all six patients and the anesthesiology assistant was further demonstrated by phylogenetic analysis. All sequences of HCV hypervariable region 1 from the patients and the anesthesiology assistant segregated into a cluster, which was clearly separated from all other sequences of HCV genotype 1a (data not shown).

These results indicate that all six patients and the assistant were infected with the same HCV isolate.
The available epidemiologic and molecular biologic evidence suggested that Patient 1, who had chronic HCV infection, was the index patient in the chain of transmission. The anesthesiology assistant contracted HCV from Patient 1 and subsequently transmitted the virus, during the incubation stage of his disease, to at least five patients.

DISCUSSION
Our findings provide evidence that a nonsurgical staff member infected with HCV transmitted the virus to at least five patients. To our knowledge, such events have been occasionally recorded only for nonsurgical personnel infected with hepatitis B virus
(HBV). 15-18

Our conclusion is supported by both epidemiologic and molecular evidence. The five patients had no known risk factors for HCV infection, and there were no evident contacts among them — a fact that excludes the possibility of patient-to-patient transmission.   On the other hand, the anesthesiology assistant was the only staff member infected with HCV and could be identified as the sole common denominator in all six cases. He tested negative for serum HCV antibodies approximately eight weeks before Patient 1 underwent surgery on April 28, 1998, and had symptoms of acute hepatitis C six weeks after this operation. Since viral RNA usually appears in the blood within the first week after the transfusion of contaminated blood, 19 HCV was probably present in the blood of the anesthesiology assistant and transmissible starting in the first week of May 1998. Furthermore, the incubation periods of HCV recorded in the patients, which ranged from 6 to 18 weeks after surgery, are in agreement with the incubation times reported for HCV after post-transfusional infection (2 to 26 weeks 20).

Our molecular investigations were based on sequence analyses of HCV hypervariable region 1, which mis commonly used to distinguish between related and unrelated isolates of the same subtype. 21
The evolutionary distances between the sequences of hypervariable region 1 obtained from our subjects were similar to those reported previously for epidemiologically linked strains of HCV in infections caused by needlestick injuries 22
or transmitted from mothers to their babies. 23,24

Phylogenetic analysis confirmed that the assistant and all six patients were infected with the same HCV isolate. We could identify an index case as well as the direction of the spread of HCV. However, we were not able to pinpoint the precise mechanisms leading to the infections. The only identifiable condition that might have caused the spread of the virus was the
wound on the assistant’s right hand. Given the high plasma levels of HCV RNA in both Patient 1 and the assistant, and given that the assistant usually did not wear gloves in the operating room, it is possible that a fraction of a microliter of blood or wound secretions might have transmitted HCV from Patient 1 to the assistant and subsequently from him to the five other patients. Wound secretions due to exudative dermatitis have previously been implicated in provider- to-patient transmission of HBV, 15
and the high prevalence of HCV in patients with chronic skin diseases like psoriasis is most likely attributable to infection through minute skin abrasions.25

In our study, patients could have been exposed to minimal and invisible amounts of the assistant’s blood or wound secretions directly through mucosal lesions caused by intubation or through indwelling venous and arterial cannulas. Other possible but less likely routes of transmission include inadvertent contamination of instruments or multidose vials with blood or wound secretions from the assistant. Multidose vials have been implicated previously in nosocomial HCV,26 HBV,27,28 and human immunodeficiency virus 29 infections.

Whatever the precise mechanisms of HCV transmission in this outbreak, the spread of the virus could probably have been prevented if so-called universal precautions for infection control had been taken. 30

Breaches of infection control are therefore associated with a high risk of the transmission of blood-borne pathogens. Supported in part by a grant to the German National Reference Center for Hepatitis C.

We are indebted to the local authorities for their help in the epidemiologic investigations; to S. Hoffmann, L. Gallina, and S. Sarr for their excellent technical assistance; to P. Galle, M.D., for providing serum and extracted RNA; and to D. Danzglock, M.D., for helpful discussions concerning the mechanisms of viral-pathogen transmission.

REFERENCES
1.Cohen J. The scientific challenge of hepatitis C. Science 1999;285:26-30.
2.Alter MJ. Epidemiology of hepatitis C. Hepatology 1997;26:Suppl 1:62S-65S.
3.Recommendations for prevention and control of hepatitis C virus
(HCV) infection and HCV-related chronic disease. MMWR Morb Mortal
Wkly Rep 1998;47(RR-19):1-39.
4.Ross RS, Viazov S, Renzing-Köhler K, Roggendorf M. Changes in the
epidemiology of hepatitis C infection in Germany: shift in the predominance
of hepatitis C subtypes. J Med Virol 2000;60:122-5.
5.Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus
by a cardiac surgeon. N Engl J Med 1996;334:555-60.
6.Duckworth GJ, Heptonstall J, Aitken C. Transmission of hepatitis C virus
from a surgeon to a patient. Commun Dis Public Health 1999;2:188-92.
7.Brown P. Surgeon infects patient with hepatitis C. BMJ 1999;319:1219.
8.Choo Q-L, Richman KH, Han JH, et al. Genetic organization and diversity
of the hepatitis C virus. Proc Natl Acad Sci U S A 1991;88:2451-5.
9.Viazov S, Zibert A, Ramakrishnan K, et al. Typing of hepatitis C virus
isolates by DNA enzyme immunoassay. J Virol Methods 1994;48:81-91.
10.Allander T, Gruber A, Naghavi M, et al. Frequent patient-to-patient
transmission of hepatitis C virus in a haematology ward. Lancet 1995;345:603-7.
11.Ou C-Y, Ciesielski CA, Myers G, et al. Molecular epidemiology of
HIV transmission in a dental practice. Science 1992;256:1165-71.
12.Kwok S, Higuchi R. Avoiding false positives with PCR. Nature 1989;
339:237-8. [Erratum, Nature 1989;339:490.]
13.Mizokami M, Lau JY-N. Molecular evolutionary analysis: its application
in the study of hepatitis C virus. In: Lau JY-N, ed. Hepatitis C protocols.
Totowa, N.J.: Humana Press, 1998:147-58.
14.Felsenstein J. PHYLIP (phylogenetic inference package). Seattle: University
of Washington, 1993.
15.Snydman DR, Hindman SH, Wineland MD, Bryan JA, Maynard JE.
Nosocomial viral hepatitis B: a cluster among staff with subsequent transmission
to patients. Ann Intern Med 1976;85:573-7.
16.Coutinho RA, Albrecht-van Lent P, Stoutjesdijk L, et al. Hepatitis B
from doctors. Lancet 1982;1:345-6.
17.Polakoff S. Acute hepatitis B in patients in Britain related to previous
operations and dental treatment. BMJ 1986;293:33-6.
18.Prentice MB, Flower AJ, Morgan GM, et al. Infection with hepatitis
B virus after open heart surgery. BMJ 1992;304:761-4.
19. Farci P, Alter HJ, Wong D, et al. A long-term study of hepatitis C virus
replication in non-A, non-B hepatitis. N Engl J Med 1991;325:98-104.
20. Esteban JI, Cordoba J, Sauleda S. The clinical picture of acute and
chronic hepatitis C. Curr Stud Hematol Blood Transf 1998;62:102-18.
21. Major ME, Feinstone SM. The molecular virology of hepatitis C. Hepatology
1997;25:1527-38.
22. Suzuki K, Mizokami M, Lau JY, et al. Confirmation of hepatitis C virus
transmission through needlestick accidents by molecular evolutionary
analysis. J Infect Dis 1994;170:1575-8.
23. Weiner AJ, Thaler MM, Crawford K, et al. A unique, predominant
hepatitis C virus variant found in an infant born to a mother with multiple
variants. J Virol 1993;67:4365-8.
24. Ohto H, Terazawa S, Sasaki N, et al. Transmission of hepatitis C virus
from mothers to infants. N Engl J Med 1994;330:744-50.
25. Chouela E, Abeldano A, Panetta J, et al. Hepatitis C virus antibody
(anti-HCV): prevalence in psoriasis. Int J Dermatol 1996;35:797-9.
26. Widell A, Christensson B, Wiebe T, et al. Epidemiologic and molecular
investigation of outbreaks of hepatitis C virus infection on a pediatric
oncology service. Ann Intern Med 1999;130:130-4.
27. Alter MJ, Ahtone J, Maynard JE. Hepatitis B virus transmission associated
with a multiple-dose vial in a hemodialysis unit. Ann Intern Med 1983;99:330-3.
28. Oren I, Hershow RC, Ben-Porath E, et al. A common-source outbreak
of fulminant hepatitis B in a hospital. Ann Intern Med 1989;110:691-8.
29. Katzenstein TL, Jorgensen LB, Permin H, et al. Nosocomial HIVtransmission
in an outpatient clinic detected by epidemiological and phylogenetic
analyses. AIDS 1999;13:1737-44.
30. Update: universal precautions for prevention of transmission of human
immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens
in health-care settings. MMWR Morb Mortal Wkly Rep 1988;37:377-82, 387-8.

Hepatitis C Virus Transmission From an
Anesthesiologist to a Patient

Sara H. Cody, MD; Omana V. Nainan, PhD; Richard S. Garfein, PhD, MPH; Hildy Meyers, MD, MPH; Beth P. Bell, MD, MPH; Craig N. Shapiro, MD; Emory L. Meeks, BS; Harriett Pitt, MS; Eric Mouzin, MD; Miriam J. Alter, PhD; Harold S. Margolis, MD; Duc J. Vugia, MD, MPH

Background

An anesthesiologist was diagnosed as having acute hepatitis C 3 days after providing anesthesia during the thoracotomy of a 64-year-old man (patient A). Eight weeks later, patient A was diagnosed as having acute hepatitis C.

Methods

We performed tests for antibody to hepatitis C virus (HCV) on serum
samples from the thoracotomy surgical team and from surgical patients at the 2 hospitals where the anesthesiologist worked before and after his illness. We determined the genetic relatedness of the HCV isolates by sequencing the quasispecies from hypervariable region 1.

Results

Of the surgical team members, only the anesthesiologist was positive for antibody to HCV. Of the 348 surgical patients treated by him and tested, 6 were positive for antibody to HCV. Of these 6 patients, isolates from 2 (patients A and B) were the same genotype (1a) as that of the anesthesiologist. The quasispecies sequences of these 3 isolates clustered with nucleotide identity of 97.8% to 100.0%. Patient B was positive for antibody to HCV before her surgery 9 weeks before the anesthesiologist's illness onset. The anesthesiologist did not perform any exposure-prone invasive procedures, and no breaks in technique or incidents were reported. He denied risk factors for HCV.

Conclusions

Our investigation suggests that the anesthesiologist acquired HCV
infection from patient B and transmitted HCV to patient A. No further
transmission was identified. Although we did not establish how
transmission occurred in this instance, the one previous report of
bloodborne pathogen transmission to patients from an  anesthesiologist
involved reuse of needles for self-injection (1).

(1) Brief Report: Transmission of Hepatitis C Virus from a Patient to
an Anesthesiology Assistant to Five Patients NEJM Volume 343(25), 21 December 2000, pp
1851-1854

Study blames technician for hepatitis in patients

The Associated Press

Cdn. Liver Foundation
   
NEW YORK -- A medical technician with a cut on his finger accidentally infected five hospital patients with the dangerous hepatitis C virus in the first documented case of its kind, German researchers say.

The researchers would not identify the hospital or say where it was located.

The vast majority of hepatitis C cases are contracted by drug abusers from dirty needles. But in rare cases, patients have been infected by their surgeons or anesthesiologists.

The case involving the technician is the first documented instance of hepatitis C being transmitted to patients by medical personnel who are not doctors, said Dr. R. Stefan Ross at the University of Essen.

He and colleagues reported the case in Thursday's issue of the New England Journal of Medicine.

The researchers blamed an anesthesiology technician, whose job was to assist the anesthesiologist, a doctor, administer anesthesia.

They said he probably passed along the virus from a cut on his finger. He normally did not wear gloves, saying they diminished the sense of touch he needed for his work.

Hepatitis C is a viral disease of the liver that can cause jaundice, fatigue, pain and vomiting. It can lead to serious liver damage and cancer.

In the German case, the technician apparently contracted the virus from a patient during surgery in 1998. Within six weeks, he helped administer anesthesia to five other patients, all of whom developed hepatitis C.

Genetic analysis confirmed the technician was the source of the virus.

Ross estimated the chances of such infection at 140 for every one million invasive procedures. He said patients "should not be afraid about having any medical treatments because these things are very rare."

Phlebotomy  Today 

Claiming that gloves diminished the sense of touch he needed for his work, an anesthesiology technician has been found to have infected five hospital patients with the deadly hepatitis C virus.  The revelation was published in the December, 2000 issue of the New England Journal of Medicine and reported by the Associated press. 

In the report, researchers blamed the technician after DNA studies confirmed that the virus acquired by the five patients was identical to that carried by the technician.  It is thought that the technician had acquired the virus from a patient during surgery in 1998 and passed it on to the five patients over a six week period immediately following his exposure. The German researchers who prepared the report speculate that transmission occurred through a cut on the technician's ungloved finger.

The report does not name the technician, the hospital at which the exposures took place, or the city in which he worked. It is the first  documented case of hepatitis C being passed on to patients by medical personnel other than physicians.  
In the U.S., OSHA mandates the use of glove for all phlebotomy procedures except in volunteer blood donor collection centers

 .http://www.phlebotomy.com/Newsl101.htm

HCV Transmitted to Five Patients in Miami Hospital

By Harvey S. Bartnof, MD

Five persons became infected with HCV (* hepatitis C virus) in a Miami hospital, according to Dr. Gerald Krause, MD, from Miami, Florida. Dr. Krause reported the findings at the recent International Conference on Nosocomial (hospital-acquired) Infections sponsored by the Centers for Disease Control and Prevention (CDC). The only potential common source was saline (salt water) drawn from a multiple-dose vial that was shared by health professionals on the same ward. All five patients had had an intravenous line that was flushed with saline during their respective hospitalizations. Detailed molecular tests indicated that all five patients were infected with the same HCV "strain."

Three patients were diagnosed with acute hepatitis C within six weeks after having been admitted to the same ward in a Miami hospital. All patients that had been on the ward were tested for HCV infection; an additional two were found. Although no nurses could recall a specific breach in infection control practices, all five patients had intravenous (IV) lines that had been flushed with saline. The nurses had shared the same multi-dose vial of saline.

Dr. Krause said that hospitals should stop using multi-dose saline vials and consider using single-dose syringes or vials to avoid unwanted "nosocomial" infection. Dr. Krause is with the Florida Department of Health in Tallahassee. Transmission of HCV by this route in western countries is believed to be extremely uncommon.

5/29/00 Source  Clinical Capsules. HCV in Saline. Internal Medicine News. May 1, 2000; page 30.

Nosocomial HIV-transmission in an outpatient clinic detected by epidemiological and phylogenetic analyses.

Katzenstein TL, Jorgensen LB, Permin H, Hansen J, Nielsen C, Machuca R, Gerstoft J

Department of Infectious Diseases, Rigshopitalet, Copenhagen, Denmark. Terese@RH.DK

OBJECTIVE: To determine if a case of HIV-infection in a patient (GP) with common variable immunodeficiency, and with no known risk factors for HIV-infection, could be due to horizontal nosocomial transmission. METHODS: For determination of time of transmission stored serum-samples from GP were analysed for HIV RNA content. Patient records were used to identify patients, who had received intravenous therapy on the same day as GP. Samples from GP and these possible source patients were identified and phylogenetic analyses of the env, gag and RT-encoding region of pol were performed. Furthermore, routines in conjunction with intravenous therapy were examined. RESULTS: We identified a patient (FDL) harbouring virus almost indistinguishable from the virus isolated from GP. The pairwise nucleotide distance between the C2-V3-C3 region of the env and gag sequences from the two patients were 1.9 and 0.9% respectively. In addition, GP harboured HIV RNA with a foscarnet resistance mutation further lending support to virus from the foscarnet-treated FDL being the source of the infection. Interestingly, GP experienced increases in immunoglobulin production after contracting the HIV-infection, and decreases after antiretroviral-induced viral suppression. A clinical procedure which, under stressful conditions, could lead to breaches in infection control measures was identified. The source of the infection was most likely a contaminated multidose vial. CONCLUSION: Through epidemiological and phylogenetic analyses a case of horizontal nosocomial HIV-transmission was disclosed. Identification of multidose vials as possible vehicles for horizontal nosocomial transmission recently led to the recommendation of restriction of the use of multidose vials, a recommendation supported by the present study. The study underlies the importance of a constant survey of infection control precautions.

7 Patients Acquire HCV at US Hemodialysis Center

By Harvey S. Bartnof, MD

CDC reports that seven patients likely acquired HCV (hepatitis C virus) from a US hemodialysis (blood filtering) center. Suzanne Cotter, MD, from the CDC (Centers for Disease Control and Prevention) was the lead author. The cluster acquired HCV during the period from September 1997 and October 1998.

Among the 51 hemodialysis patients tested from the same center, eleven were previously known to be HCV antibody positive. Of the remaining 40 patients, seven or 17% became HCV antibody positive during the observation period. No staff health providers were HCV positive. All seven patients who seroconverted had their dialysis done on the 2nd or 3rd shifts of the day, with seroconversion rates ("attack rates") of 36% and 29%, respectively, for the two shifts. The most significant evidence was the following. Those who seroconverted (case-patients) followed chronically-infected patients on the same dialysis machine significantly more frequently (median 31 sessions) than control (non-seroconverting) patients (median one session). Numerous examples of substandard infection control practices were recorded, mostly blood contamination of environmental surfaces. Genotype testing was performed on three of the seven HCV seroconverters and six of the eleven chronically-infected patients. All three case patients and three of six chronically-infected patients had genotype 1b. The other three chronically infected patients had genotype 1a.

The geographic location of the dialysis center was not stated in the abstract. However, the authors were from either the CDC or from Johns Hopkins School of Public Health in Baltimore, Maryland. The authors conclude that, "Multiple transmissions of HCV from patient-to-patient in a chronic hemodialysis center occurred, apparently because of blood contamination of supplies or equipment among patients."
12/1/99

Reference

Cotter S and others. Transmission of hepatitis C virus in a chronic hemodialysis center. Abstract and poster presentation 460 at the 37th Annual Meeting of the Infectious Diseases Society of America (IDSA). November 18-21, 1999; Philadelphia, Pennsylvania.

Copyright 2001 by HIV and Hepatitis.com. All Rights Reserved
 

Journal of Clinical Microbiology, October 1998, p. 2926-2931, Vol. 36, No. 10
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.

Genetic and Serological Evidence for Multiple Instances of Unrecognized Transmission of Hepatitis C Virus in Hemodialysis Units

First Department of Pathology1 and Second Department of Internal Medicine,2 Nihon University School of Medicine, Tokyo, Japan

Received 13 November 1997/Returned for modification 22 December 1997/Accepted 29 June 1998

* Corresponding author. Mailing address: Department of Pathology, Nihon University School of Medicine, 30-1, Ooyaguchikami-machi, Itabashi-ku, Tokyo 173, Japan. Phone: 81-3-3972-8111. Fax: 81-3-3972-8830. E-mail: mesumi@med.nihon-u.ac.jp.

Journal of Clinical Microbiology, October 1998, p. 2926-2931, Vol. 36, No. 10
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.

Contamination of doctors' and nurses' pens with nosocomial pathogens.

Lancet. 1998 Jan 17;351(9097):213. No abstract available. PMID: 9449890; UI: 98111543.

What he didn't expect - nor did his doctors - was that he would contract HIV, the virus that causes AIDS.

How he caught HIV is shrouded in mystery. But a coroner's report this year obtained by The Gazette suggests that Marcil might have been exposed to a contaminated medical instrument following his transplant.

An internal investigation by the hospital revealed that staff were reusing disposable instruments inside patients' bodies for diagnostic purposes.

Marcil might have come into contact with HIV from such a procedure.

Marcil, once a strapping man of 220 pounds who enjoyed boating and picking apples, died at home on June 18, 2001, surrounded by his wife and friends.

He was rail-thin and 55 years old.

His case illustrates the growing public concern about the improper cleaning and reuse of medical instruments across Canada.

This week, the Ontario government ordered every hospital in that province to review its disinfection and sterilization procedures after a Toronto hospital admitted that 861 men could have been exposed to HIV and hepatitis viruses during prostate biopsies.

In Quebec, no such review is being considered by the provincial government.

What's more, there are no uniform guidelines on the reuse of disposable medical instruments.

Adding to the concern is this dirty secret: some Montreal-area hospitals continue to recycle high-risk, disposable instruments to cut costs, but they will never admit it publicly, say hospital insiders who are familiar with the practice.

The result is that patients' lives potentially are being placed in jeopardy every day, says Dr. Mark Miller, chief of infection control at the Jewish General Hospital.

"It's a patient danger issue," Miller said.

"Many of these instruments get soiled inside and outside with blood and body fluids. The single-use instruments are not meant to be reused. The impact can be the transmission of any number of infections, some of which can be minor, and many of which can be lethal."

Meanwhile, Marcil's death has left his widow bitter and saddened, wondering how a hospital could reuse instruments that should be thrown away after a single use.

"I'm very angry about the whole thing," said Lucie Lamarche, who is suing St. Luc for $230,000.

"It has not been easy for me."

---

Marcil was already a very sick man when he was put on a waiting list for a liver transplant in March 1998. He was suffering from cirrhosis of the liver, a disease of irreversible scarring of the organ that filters out waste products in the blood.

Years earlier, he had contracted the hepatitis C virus - possibly through a tainted blood transfusion in British Columbia. That virus had probably caused the cirrhosis.

Marcil, who had worked as a cook at St. Charles Borromée Hospital, underwent the liver transplant on May 6, 1999. Lamarche said that her husband recovered quickly, and she was happy to see the colour return to his cheeks.

Two months later, however, Marcil's health took a turn for the worse. Doctors ran a series of tests on him and discovered he was HIV-positive. When a doctor broke the news to him, Marcil thought it was a joke, his wife recalled.

"I suppose I got HIV from the Holy Spirit," Marcil told the doctor.

Lamarche said she's certain her husband acquired HIV while in the downtown hospital. In her report, coroner Line Duschesne said nothing in Marcil's personal behaviour can explain how he became contaminated with HIV.

Héma-Québec, the provincial blood agency, and Transplant Quebec each carried out internal inquires and were able to show conclusively that they were not to blame. The hospital review, however, raised the possibility of exposure to HIV from a reused component of a gastro-intestinal endoscope.

The long, thin, lighted instrument is inserted into the gastro-intestinal tract to probe for narrowings, blockages or polyps. Although the instrument itself can be reused following sterilization, several attachments - like forceps - must be disposed of after each use.

Marcil had undergone several endoscopic procedures following his transplant, the coroner noted. In one instance, a container filled with diagnostic dye was also reused on him.

"The reuse of gastro-intestinal endoscopic material that is intended for single use (which was done at the time) ... could explain the hospital-acquired infection," wrote Dr. Anne-Marie Bourgault, of the infection-prevention unit of St. Luc.

"It would be impossible, however, to prove with certainty this mode of HIV transmission in the specific case of Mr. Marcil," she added in a letter to the coroner.

Officials with St. Luc Hospital - which is part of the Centre hospitalier de l'université de Montréal - refused to elaborate on Marcil's case.

"You have to understand that I cannot comment if there is a lawsuit," said Dr. Charles Bellavance, director of professional services.

Bellavance did say, though, that St. Luc, Hôtel Dieu and Notre Dame hospitals no longer reuse disposable instruments. That has been the official policy since June 2002 - a year after Marcil's death.

The coroner concluded that although Marcil died of a multifocal hepatoma - a cirrhosis-linked tumour that appeared in the transplanted organ - hospital-acquired infections "constitute a risk of accidental death."

Lamarche's lawyer, Jean-Pierre Ménard, specializing in medical malpractice lawsuits, said he's never handled a case as well-documented at this one, because physicians searched exhaustively for the source of the infection.

"We allege that the hospital did not take reasonable measures to assure the safety of the patient," Ménard said. "We allege that they reused an instrument which they knew should not have been reused, and therefore, this presented a risk for the patient."

Lamarche, who lives in a modest Dorval house, is convinced that her husband's condition deteriorated sharply after his HIV infection - with bouts of pneumonia. She said doctors told her there was still hope for Marcil until the HIV diagnosis.

"That damaged his new liver. He was getting worse and worse, weaker and weaker. He looked like a Holocaust victim."

aderfel@thegazette.canwest.com

Risk of Hepatitis C Transmission From Infected Medical Staff to Patients Model-Based Calculations for Surgical Settings R. Stefan Ross, MD; Sergei Viazov, PhD; Michael Roggendorf, MD   Arch Intern Med. 2000;160:2313-2316. Context  Concern is increasing in both the medical community and among the general public about the possible transmission of hepatitis C virus (HCV) from infected health care workers to their patients. Until now, no reliable estimates for the risk of such transmission exist. Objective  To estimate the probability of HCV transmission from a surgeon to a susceptible patient during invasive procedures. Design  A model consisting of 4 probabilities was used: (A) the probability that the surgeon is infected with HCV, (B) the probability that the surgeon might contract percutaneous injuries, (C) the probability that an HCV-contaminated instrument will recontact the wound, and (D) the probability of HCV transmission after exposure. Values for the calculations were taken from published studies. Results  When the surgeon's HCV status is unknown, the risk of HCV transmission during a single operation is 0.00018% ± 0.00002% (mean ± SD). If the surgeon is HCV RNA positive, this risk equals 0.014% ± 0.002%. The likelihoods of transmission in at least 1 of 5000 invasive procedures performed by a surgeon during 10 years are 0.9% ± 0.1% (HCV status unknown) and 50.3% ± 4.8% (HCV RNA positive), respectively. Conclusions  The calculated risks for HCV transmission from a surgeon to a susceptible patient during a single invasive procedure are comparable to the chance of acquiring HCV by receiving a blood transfusion. These figures could provide a basis for further discussions on this controversial subject and might also be relevant for future recommendations on the management of HCV-infected health care workers. From the Institute of Virology, National Reference Centre for Hepatitis C, Essen University Hospital, Essen, Germany. The authors have no commercial, proprietary, or financial interests in the products and companies described in this article. THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES A Proposed National Policy on Health Care Workers Living With HIV/AIDS and Other Blood-Borne Pathogens Gostin JAMA 2000;284:1965-1970. ABSTRACT | FULL TEXT   Risk of Hepatitis C Virus Transmission From an Infected Gynecologist to Patients: Results of a 7-Year Retrospective Investigation Ross et al. Arch Intern Med 2002;162:805-810. ABSTRACT | FULL TEXT   Personnel-to-Patient Transmission of Hepatitis C Virus: Underestimation of Exposure Rieger et al. Arch Intern Med 2001;161:1017-1018. FULL TEXT   Risk of HIV and Other Blood-Borne Infections in the Cardiac Setting: Patient-to-Provider and Provider-to-Patient Transmission PURO et al. Annals NYAS Online 2001;946:291-309. ABSTRACT | FULL TEXT