http://www.yomiuri.co.jp/newse/20050427wo71.htm   Hepatitis C scare halts use of surgical adhesive The Yomiuri Shimbun The Health, Labor and Welfare Ministry on Tuesday ordered a pharmaceutical company to stop the sale of an imported surgical tissue adhesive after an elderly man was found to have contracted the hepatitis C virus after his liver functions weakened following an operation. The man, who is in his 70s, suffered decreased liver function following an operation in May last year, during which the tissue adhesive Takokonbu was used. One of the basic ingredients in Takokonbu is fibrinogen, which is found in human blood, and is culled from blood supplies in the United States. The adhesive is used to prevent blood and other bodily fluids from leaking from internal organs during surgery. Takokonbu has been shipped to medical institutions throughout the country. Copyright 2005 The Yomiuri Shimbun

Previous Volume 334:555-561 February 29, 1996 Number 9 Next

Transmission of Hepatitis C Virus by a Cardiac Surgeon

Juan I. Esteban, M.D., Jordi Gómez, Ph.D., María Martell, Ph.D., Beatriz Cabot, Ph.D., Josep Quer, Ph.D., Joan Camps, M.D., Antonio González, M.D., Teresa Otero, M.T., Andrés Moya, Ph.D., Rafael Esteban, M.D., and Jaime Guardia, M.D.

ABSTRACT

Background In the course of a study conducted from 1992 through 1994 of the efficacy of screening blood donors for antibodies to hepatitis C virus (HCV), we found that two patients had acquired hepatitis C after cardiac surgery, with the transmission apparently unrelated to blood transfusions. Because their surgeon had chronic hepatitis C, we sought to determine whether he was transmitting the virus to his patients.

Methods Of 222 of the surgeon's patients who participated in studies of post-transfusion hepatitis between 1988 and 1994, 6 contracted postoperative hepatitis C, despite the use of only seronegative blood for transfusions. All six patients had undergone valve-replacement surgery. Analyses were performed to compare nucleotide sequences encompassing the hypervariable region at the junction between the coding regions for envelope glycoproteins E1 and E2 in the surgeon, the patients, and 10 controls infected with the same HCV genotype.

Results The surgeon and five of the six patients with hepatitis C unrelated to transfusion were infected with HCV genotype 3; the sixth patient had genotype 1 and was considered to have been infected from another source. Thirteen other patients of the surgeon had transfusion-associated hepatitis C and were also infected with genotype 1. The average net genetic distance between the sequences from the five patients with HCV genotype 3 and those from the surgeon was 2.1 percent (range, 1.1 to 2.5 percent; P<0.001), as compared with an average distance of 7.6 percent (range, 6.1 to 8.3 percent) between the sequences from the patients and those from the controls. The results of a phylogenetic-tree analysis indicated a common epidemiologic origin of the viruses from the surgeon and the five patients.

Conclusions Our findings provide evidence that a cardiac surgeon with chronic hepatitis C may have transmitted HCV to five of his patients during open-heart surgery.

Source Information

From the Liver Unit, Department of Medicine, Hospital General Universitari Vall d'Hebron, Universitat Autònoma, Barcelona (J.I.E., J. Gomez, M.M., B.C., J.Q., J.C., A.G., T.O., R.E., J. Guardia) and the Department of Genetics, Universitat de Valencia, Valencia (A.M.) — both in Spain.

Address reprint requests to Dr. Juan Esteban at Servei de M. Interna-Hepatología, Hospital General Universitari Vall d'Hebron, P° Vall d'Hebron 119, 08035 Barcelona, Spain.

Full Text of this Article

Related Letters:
Transmission of Hepatitis Viruses by Surgeons
Goodman D. B.P., Deysine M., Wittig G., Jorde U. P., Kressel A. B., Potasman I., Pick N., Harpaz R., Shapiro C. N., Cherry J. D., Esteban J. I., Esteban R., Guardia J., Gerberding J. L.
Extract | Full Text  
N Engl J Med 1996; 335:284-287, Jul 25, 1996. Correspondence

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January 2005

EL PASO, Tx - A Beaumont Army Hospital staff member contracts Hepatitis "c" and now several patients are also infected. Up to 5% of all the patients tested so far have tested positive for Hepatitis "c", it's a disease that can destroy the liver.

Just after 3 o'clock today the public received confirmation that a staff member at William Beaumont Army Medical Center had tested positive for Hepatitis "c". A hospital spokesperson said this person will no longer have contact with patients.

The hospital identified two cases of exposure to Hepatitis "c" two months ago, which prompted an extensive review of health records between July and October of this year. The investigation led to the testing of 155 surgical patients, 8 of which were found to be positive.

There are several ways to transmit Hepatitis "c": by sharing needles or other drug injection equipment, through unsterile tattooing or body piercing equipment, any blood-to-blood contact through a tooth brush, razor blade, or other hygenic tools

The disease is rarely transmitted through sexual contact, but is possible when infected blood is present. Hepatitis "c "can also be passed from mother to child during pregnancy or childbirth.

However, there are some misconceptions about the disease. It can not be transmitted by kissing, coughing, sneezing, or other social contact. The only way to check for Hepatitis "c" is with a blood test.

If you were a patient at William Beaumont anytime this year, from July to October and think you may have been infected call, officials as that you call 915-569-4444.

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Surgeon Declines Safety Advice
LI doctor with hepatitis C still opening, closing chests

By Roni Rabin
STAFF WRITER

March 30, 2003  A prominent Manhasset heart surgeon who infected patients with blood-borne hepatitis C continues to open and close patients' chest cavities, hospital officials said, despite being advised the procedures place patients at risk.

Heart surgeons are most likely to sustain injuries or puncture their gloves at the very beginning of the operation, when they cut through the breastbone, or at the conclusion, when they use wire to sew the sternum back together. But a North Shore University Hospital-Manhasset spokesman said other surgeons are not available to step in and assist Dr. Michael Hall at the start and end of surgery, and that Hall, who has hepatitis C, prefers to complete the procedure himself.

State officials have said Hall almost certainly infected three and possibly more patients with the illness during previous surgeries. Hospital spokesman Terry Lynam emphasized that no new infections are known to have occurred since Hall implemented new precautions - including wearing double layers of latex gloves - to prevent needle sticks and cuts that could transmit the virus.

"Dr. Hall's patients, all of whom consent in writing to have him as their surgeon with full knowledge of his health status, insist, or at least prefer, that he be present and perform as much of the procedure as possible," Lynam said. "The hospital does not have a large enough surgical staff to have someone step in and do the closing. It's not Mass. General."

Hall did not return phone calls.

Hall, one of the top-ranked cardiac surgeons in the state, has continued to operate since state officials disclosed the cluster of infections last year, but he is required to inform patients of his condition and to warn them of a slight risk of hepatitis C infection during surgery. The virus can cause long-term liver damage, cirrhosis and cancer.

State health investigators were never able to figure out exactly how the virus was transmitted to patients from the surgeon, but the infections presumably occurred when Hall stuck or nicked himself and bled into an open surgical wound.

Several published studies of other heart surgeons who transmitted hepatitis C to patients said the transmissions most probably occurred during the sternal closure. And a 1988 study in the medical journal The Lancet said 40 percent of cardiac surgeons punctured their gloves during the sternal closure, compared to 12 percent during the actual procedure.

Closing the sternum after surgery typically involves threading wires through holes in the breastbone and then tying them. The wires can apparently slice through latex gloves.

The state health department initially advised the surgeon to modify his technique and either defer the closure to a colleague or assistant or adopt an alternative method of closing the chest, using clamps, which are less likely to injure the surgeon.

But the state reversed its recommendation after a nationally respected cardiac surgeon hired by North Shore evaluated his surgical technique, saying it was "exemplary," and that it carried "a very low risk" of viral transmission.

"The operative conduct . . . reflects efficient and appropriate technical maneuvers" that "minimize the likelihood of sharp object penetration of the surgeon" that could lead to transmission, said the Aug. 15, 2002, report by Duke University Medical Center professor of surgery Dr. Robert H. Jones. Jones serves on the New York State Cardiac Advisory Committee, which has ranked Hall as one of the state's top heart surgeons in recent years.

Jones' report, however, includes a recommendation that Hall consider deferring the opening and closing of the chest to a colleague.

"This would remove the risk of blood-borne infection from [Hall] to the patient during the sternal opening and closing . . . when needle punctures of personnel are most common," Jones wrote.

A year earlier, in August 2001, Dr. Barbara Wallace, who heads the state's bureau of communicable disease control, had made the same recommendation in a letter to North Shore's infection control director, Dr. Bruce Farber. In it, she wrote that Hall should modify his surgery by "deferring the closure . . . to another member of the surgical team" or "using clamps rather than wire to close the chest cavity."

That same August, Stan F. Kondracki, the state's regional epidemiology program manager, wrote an e-mail to Miriam Alter, at the U.S. Centers for Disease Control and Prevention, and said that in light of the recent discovery of the surgeon's infection, "We are developing interim control measures such as . . . having someone else open and close the chest cavity." In parentheses, it added "surgeon feels most likely time for puncture through the glove is when surgical wires are used for closure."

State epidemiologists who observed Hall operate on the same day as Jones' visit, last Aug. 14, also raised the subject, under the heading of "areas for improvement." Dr. Stephanie Noviello and Rachel Stricof said Hall occasionally left suture needles dangling and tied sutures with needles attached, and noted that he placed his fingers near the exit point of the needle when wiring the sternum.

"He forced the sternal wire needles off and then tied the wires off himself, which may pose an increased risk of exposure," according to their reports, obtained under the Freedom of Information Act.

In a recent telephone interview, Jones said his suggestions were mere recommendations and that it would be inappropriate for him to tell another surgeon how to "run his team."

He said it was common practice for cardiac surgeons at academic medical centers to ask an assistant surgeon or surgeon in training to open and close the patient, and that he rarely opens and closes his own patients, usually deferring to a doctor in training.

But, Jones said, Hall did not want to do so.

"He likes to stay with the patient until the very end, and that's fine," Jones said. "He thinks the disadvantage of letting someone else do it outweighs the advantage of eliminating any very, very remote chance that he's going to injure himself.

"Everything in medicine is a risk-benefit ratio," Jones said. "That's the surgeon's call."

Several months after Jones' visit, North Shore's senior vice president for quality management, Yosef D. Dlugacz, appealed to the state to condone Hall's closing of his patients, citing Jones' report and Hall's low rate of post-operative complications with the closure.

State officials agreed.

"Our epidemiologists made recommendations with the caveat that a cardiac surgeon would review them," state health spokeswoman Kristine Smith said. "We believe the patient is at less risk if [Hall] does the closure . . . due to his low sternal wound complication rate."

Smith said state officials believe Hall is taking appropriate precautions, including using blunt needles to penetrate through the sternum during the closing, and announcing sharp instruments in the operating room.

"We feel they are following the necessary procedures," Smith said. She added, "The informed consent is obviously the most essential change."