Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Hepatitis C Virus Transmission From an Anesthesiologist to a Patient

Hepatitis C Virus Transmission From an Anesthesiologist to a Patient BackgroundAn 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.MethodsWe 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.ResultsOf 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.ConclusionsOur 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.HEPATITIS C virus (HCV) is most efficiently transmitted by direct percutaneous exposure to infectious blood, and like other bloodborne pathogens, HCV can be transmitted in the health care setting. The transmission of HCV from infected patients to health care workers is well recognized, most commonly through accidental needlestick injuries.Hepatitis C virus transmission from infected patients to other patients is less common; the few reported episodes have involved unsafe injection practices resulting in probable contamination of equipment used for flushing intravenous cathetersand of multiple-dose medication vials.Contaminated equipment that was not adequately cleaned or disinfected and that was shared among patients was implicated in one reportof HCV transmission to 2 patients during colonoscopy, and is the likely source for transmission among patients undergoing long-term hemodialysis.The transmission of HCV from infected health care workers to patients seems to be rare. There are 3 published reports of such transmission during performance of invasive procedures, onein which a cardiac surgeon with a chronic infection in Spain transmitted HCV to 5 patients, anotherin which a cardiac surgeon with a chronic infection in the United Kingdom transmitted HCV to one patient, and a thirdin which an anesthesiology assistant in Germany contracted HCV from a patient with a chronic infection and then transmitted the HCV to 5 other patients. Herein, we discuss the apparent transmission of HCV from an infected anesthesiologist to a patient.In January 1996, a 64-year-old man (patient A) without identified risk factors became ill with acute hepatitis 7 weeks after undergoing a thoracotomy at hospital X. He remained negative for all viral hepatitis serologic markers until 8 weeks after his surgery, when he seroconverted to antibody to HCV (anti-HCV) and his alanine aminotransferase level peaked at 1029 U/L. Ten weeks before surgery, his liver enzyme levels were normal, and 1 week before his surgery, he and his wife donated blood and both tested negative for anti-HCV. The anesthesiologist who administered anesthesia during patient A's thoracotomy developed scleral icterus and dark urine 3 days after patient A's procedure, at which time he stopped working. His alanine aminotransferase level was 1085 U/L and peaked a few days later at 1390 U/L. Serum drawn at his first visit was positive for anti-HCV and negative for serologic markers of acute hepatitis A or B. Six weeks later, his serum HCV RNA level was measured for the first time and was 37.92 million genome equivalents per milliliter (Quantiplex HCV RNA Assay [bDNA]; Chiron Corp, Emeryville, Calif) and the results of a liver biopsy showed findings consistent with acute hepatitis without chronic inflammation.We undertook an investigation to determine whether the anesthesiologist or another source at hospital X might have transmitted HCV to patient A, to assess the extent to which nosocomial transmission might have occurred, and to evaluate the specific events associated with transmission.PARTICIPANTS AND METHODSEPIDEMIOLOGIC INVESTIGATIONWe obtained serum samples from the 6 members of the surgical team who were present during patient A's thoracotomy, except the anesthesiologist, from whom we obtained a stored frozen sample that was collected during his acute illness. To further evaluate the possible source of infection for patient A and the extent to which nosocomial transmission of HCV might have occurred, we investigated 3 groups of patients at hospital X: (1) all patients treated by the anesthesiologist during the 6 months before his illness, (2) all patients not treated by the anesthesiologist who underwent surgery on the same day as patient A, and (3) all patients not treated by the anesthesiologist who underwent surgery in the same operating room as patient A during the week before or after his procedure. Beginning 6 months after his acute infection, the anesthesiologist worked at hospital Y for 18 months. He started a 6-month course of interferon 3 months before starting work at hospital Y, but therapy was unsuccessful and discontinued. He had detectable HCV RNA when tested on several occasions thereafter. To determine whether the anesthesiologist might have transmitted HCV to patients at hospital Y, we investigated all patients at hospital Y who were treated by him during that period. For both investigations, we sent each patient a letter that explained that an exposure to HCV might have occurred, provided information on HCV infection, and offered free HCV testing. Four or more attempts were made to contact nonresponders. We interviewed all participants who tested positive for HCV (including patient A and the anesthesiologist) regarding risk factors for HCV infection and past medical history, reviewed their medical records for evidence of prior HCV infection, and reviewed their surgical records for a detailed account of all procedures and events. A second serum specimen was requested for further testing. We asked the anesthesiologist, surgical team members, and operating room staff to describe infection-control practices and recall any specific incidents or breaks in technique. All reported occupational incidents at hospital X in the 6 months before the procedures were reviewed.LABORATORY METHODSSerologic TestingAll serum samples were tested for anti-HCV using a second-generation enzyme immunoassay (HCV 2.0; Abbott Laboratories, Abbott Park, Ill) or a third-generation enzyme immunoassay (HCV 3.0; Ortho Diagnostic Systems Inc, Raritan, NJ); repeatedly reactive results were confirmed with supplemental testing (HCV Matrix [Abbott Laboratories] or RIBA 3.0 [Chiron Corp]).Nucleic Acid Testing and SequencingWe tested specimens that were positive or indeterminate on supplemental testing for HCV RNA by nested reverse transcription polymerase chain reaction (RT-PCR) amplification of the 5′ noncoding region, as described previously.Hepatitis C virus RNA–negative samples were extracted a second time with the same procedure and incubated for an additional 45 minutes at 50°C with 25 U of reverse transcriptase (Boehringer Mannheim Corporation, Indianapolis, Ind) and 10 U of RNasin (Boehringer Mannheim Corporation). Polymerase chain reaction products were separated by electrophoresis on a 2% agarose gel (GIBCO-BRL, Life Technologies, Inc, Gaithersburg, Md), and specimens positive for HCV RNA were identified by ethidium bromide staining.For HCV RNA–positive specimens, HCV genotypes were determined from the 300-nucleotide sequence of the nonstructural coding region 5b using previously described methods and primers.Polymerase chain reaction products were purified and cycle sequenced using internal primers with dye terminator reaction chemistry, and electrophoresis and nucleotide identification were performed with an automated DNA sequencer (ABI 377; Applied Biosystems, Inc, Foster City, Calif). Genotypes were defined by comparing the sequences in question with published sequences using a multiple sequence alignment program (Pileup; Wisconsin Genetic Computer Group, Madison).Quasispecies of hypervariable region 1 (HVR1) were determined by limiting dilution PCR. For each specimen, nested RT-PCR, as previously described, was performed to determine the end-point titer using the following primers: first round, 1350F1 (forward primer 5′-GCTACTCCGGATCCCACAAGC-3′) and 1633R (reverse primer 5′-TCATTGCAGTTCAGGGCCGT-3′); and second round, 1426F1 (forward primer 5′-TATTCCATGGTGGGGAACTGG-3′) and 1619R (reverse primer 5′-GCAGTCCTGTTGATGTGCCA-3′). Multiple PCRs (n = 30-40) were then performed at twice the serum dilution of the end-point PCR titer. Each PCR amplicon was purified and the nucleotide sequence determined as previously described.To evaluate the relatedness among samples of the same genotype, we compared the HVR1 quasispecies sequences of isolates from the investigation-related cases with isolates from participants in the Third National Health and Nutrition Examination Survey (NHANES III),2 of whom were from the same geographic region as hospitals X and Y. We conducted preliminary pairwise analysis using multiple sequence alignment programs (Pileup and Pretty; Wisconsin Genetic Computer Group). Distribution of nucleotide distances was calculated using the Jukes-Cantor distance correction (Evolutionary Distance; Wisconsin Genetic Computer Group). Unrooted phylogenetic trees were generated using computer programs (DNADIST and NEIGHBOR) with the Kimura 2-parameter correction (PHYLIP, version 3.5, written by J. Felsenstein, University of Washington, Seattle). Bootstrap analysis was done to evaluate the reliability of the phylogenetic tree analysis.RESULTSIDENTIFICATION OF CASESAll members of the surgical team, except the anesthesiologist, tested negative for anti-HCV at least 4 months after the thoracotomy was performed on patient A. Of the 47 patients at hospital X who underwent surgical procedures during which the anesthesiologist provided treatment in the 6 months preceding his acute illness, 35 (74%) were tested, of whom 2 (patients A and B) were positive for anti-HCV (Table 1). Of the 39 patients not treated by the anesthesiologist who underwent surgery at hospital X either on the same day as patient A or in the same operating room as patient A, 28 (72%) were tested, and 1 (patient C) tested positive for anti-HCV. Of the 735 patients at hospital Y treated by the anesthesiologist, 313 (43%) were tested, and 4 (patients D, E, F, and G) tested positive for anti-HCV. At hospital Y, the age, sex, and date of surgery of the patients who were tested were similar to those of the patients who were not tested. At both hospitals, patients were tested more than 6 months after exposure to the anesthesiologist.Evidence of HCV Infection Among Surgical Patients at Hospitals X and Y*Patient GroupTotal No. of PatientsPatients Tested†Positive for Antibody to HCV‡PatientGenotypeTreated by the anesthesiologistHospital X (6 mo before the acute illness)4735 (74)2 (6)A and B1aHospital Y (18 mo after unsuccessful antiviral therapy)735313 (43)4 (1)D and E F and G2a Negative for HCV RNANot treated by the anesthesiologist at hospital XSurgery on the same day as patient A1511 (73)0. . .. . .Surgery in the same operating room 1 wk before or after patient A2417 (71)1 (6)C3a*HCV indicates hepatitis C virus; ellipses, data not applicable.†Data are given as number (percentage) of the total.‡Data are given as number (percentage) of the patients tested.RELATEDNESS OF HCV ISOLATESWe detected HCV RNA in the serum of the anesthesiologist and patients A, B, C, D, and E, but not in the serum of patients F and G. Hepatitis C virus isolates from the anesthesiologist and patients A and B were classified as genotype 1a; patient C, genotype 3a; and patients D and E, genotype 2a.In a pairwise analysis, the sequences of the nonstructural coding region 5b of the anesthesiologist and patient A were identical to each other and differed from those of patient B by 5 nucleotides, and all clustered in a single group (Figure 1). The sequences of the 8 unrelated HCV RNA–positive persons (6 with genotype 1a and 2 with genotype 1b) from NHANES III specimens varied by 3.9% to 20.0% and fell into 3 clusters (Figure 1).Figure 1.Genetic relatedness obtained by pairwise analysis of the nonstructural coding region 5b sequences from investigation-related cases (the anesthesiologist and patients A and B) and from 8 hepatitis C virus (HCV)–infected persons from the general population not related to the investigation (shown as numbers). The percentage of nucleotide identity between isolates is measured by the horizontal distance connecting the isolates. Isolates from patients A and B and the anesthesiologist cluster in a single group. The sequences from patient A and the anesthesiologist are identical and differ from that of patient B by 5 nucleotides. The sequences from the 8 unrelated HCV RNA–positive persons vary by 3.9% to 20.0% and fall into 3 clusters.When we isolated the quasispecies from the anesthesiologist (11 amplicons), patient A (3 amplicons), and patient B (8 amplicons), only a single HVR1 sequence was obtained from each person. The nucleotide identity was 97.8% between the sequence of the anesthesiologist and that of patient A, and 100.0% between the sequence of the anesthesiologist and that of patient B. In contrast, the nucleotide identity of the HVR1 sequences was 46% to 75% between the 8 NHANES III participants and between the NHANES III participants and the anesthesiologist and patients A and B.When the phylogenetic distances of all HVR1 quasispecies were compared in an unrooted tree, sequences from the anesthesiologist and patients A and B clustered in a single group, with net genetic distances of 0% to 1.2% (Figure 2). Bootstrap analysis indicated that this cluster of sequences occurred with 100% probability. The quasispecies of the unrelated NHANES III participants clustered on distinct branches, with evolutionary distances of 30% to 93% from those of the investigation-related cluster (Figure 2).Figure 2.Unrooted tree of phylogenic distances of all HVR1 quasispecies. This unrooted tree shows the HVR1 sequences of all quasispecies identified from 8 NHANES III samples (shown as numbers) and those of the anesthesiologist and patients A and B. The quasispecies of the anesthesiologist and patients A and B cluster on a single branch, with a nucleotide identity of 97.8% between sequences of the anesthesiologist and patient A and of 100.0% between those of the anesthesiologist and patient B. The nucleotide identity was 46% to 75% between the 8 NHANES III participants and between the NHANES III participants and the anesthesiologist and patients A and B. HVR1 indicates hypervariable region; NHANES III, Third National Health and Nutrition Examination Survey.EVALUATION OF RISK FACTORS FOR HCV INFECTIONWe elicited risk factor histories from the anesthesiologist and patients A and B, who shared the same genotype (1a), and from patients F and G, who were positive for anti-HCV but negative for HCV RNA. Patient A reported no history of blood transfusions or injection drug use; had not undergone any other medical, surgical, or dental procedures in the 6 months before his thoracotomy; and tested negative for anti-HCV 1 week before the procedure. His only sexual contact was with his wife, who also tested negative for anti-HCV 1 week before patient A's procedure. Patient B, whose surgery took place 8½ weeks before that of patient A, was a 42-year-old woman who had tested positive for anti-HCV 1 week before her surgery, when she made an autologous blood donation. Patient F was a 58-year-old man who had a history of blood transfusion before 1990 and a history of chronic cholecystitis, pancreatitis, and cirrhosis. Patient G was a 49-year-old man who had a history of acute hepatitis in the 1980s (type unknown), incarceration, and approximately 10 lifetime sex partners.The anesthesiologist reported no history of blood transfusion or injection drug use. During the 12 months before his illness, he had 3 sex partners. In August 1994, he sustained a needlestick injury while administering anesthesia during a liver transplantation for a patient with chronic hepatitis C. He was negative for anti-HCV at the time of the injury and 3 months later, but he was not retested until 17 months later, with the onset of his acute symptoms.EVALUATION OF POTENTIAL FOR NOSOCOMIAL TRANSMISSIONBased on the patients' histories and the results of the molecular sequencing, we hypothesized that patient B was the source of the anesthesiologist's HCV infection, and the anesthesiologist was the source of patient A's infection (Figure 3). Patient B underwent a vaginal hysterectomy and colporrhaphy 8½ weeks before the onset of illness in the anesthesiologist. She received general anesthesia with oral endotracheal intubation, and a single peripheral intravenous catheter was placed, through which the anesthesiologist administered fentanyl citrate, midazolam hydrochloride, thiopental sodium, glycopyrrolate, neostigmine methylsulfate, succhinylcholine chloride, and vecuronium bromide.Figure 3.Temporal sequence of surgical procedures and illnesses in patients A and B and the anesthesiologist, by week. Anti-HCV indicates antibody to the hepatitis C virus.Patient A underwent a thoracotomy for wedge resection of a lung nodule. The procedure was converted from a thorascopically guided excision to an open thoracotomy because of difficulty visualizing the tumor. He did not receive any blood products. He received general anesthesia with oral endotracheal intubation, and an epidural catheter for thoracic anesthesia, a subclavian triple-lumen catheter, a radial arterial catheter, and a peripheral intravenous catheter were placed. Perioperatively, patient A received intravenous midazolam, fentanyl, thiopental, succinylcholine, vecuronium, neostigmine, glycopyrrolate, phenylephrine hydrochloride or ephedrine hydrochloride, and additional fentanyl via the epidural catheter. He received intravenous morphine sulfate and metoclopramide hydrochloride while in the postanesthesia care unit. During his 5-day hospitalization, he underwent no further invasive procedures.The anesthesiologist did not recall either patient A's or patient B's procedure. According to the anesthesia record for patient A, the anesthesiologist placed a double-lumen endotracheal tube and checked the position with fiberoptic bronchoscopy. After reviewing the anesthesia and operative records, the anesthesiologist said that he probably would have placed the peripheral intravenous catheter, epidural catheter, and radial arterial catheter, and that the surgeon probably placed the right subclavian triple-lumen catheter. He could not recall whether he placed the intravenous catheter in patient B. None of the surgical team, including the anesthesiologist, recalled any unusual events or incidents (eg, needlestick injuries) that occurred during either patient's procedure, and no incident reports were filed.The anesthesiologist stated that multidose vials were commonly used at hospital X, that he usually prepared his own medications, and that he always used a new needle and syringe. On a few occasions in the past, he might have injured himself opening a vial or an ampule. He stated that he wore single gloves for all procedures, except for placing peripheral intravenous catheters, when occasionally he did not wear gloves. He denied a history of dermatitis or other skin lesions on the hands. No incident reports involving the anesthesiologist were filed at hospital X in the 6 months before the thoracotomy.COMMENTOur investigation indicates that an anesthesiologist with an acute infection transmitted HCV to a patient while administering anesthesia during a thoracotomy, and that the source of the anesthesiologist's infection was another patient he treated almost 9 weeks before the onset of his illness. This scenario is supported by 2 findings. First, the time intervals between patient B's surgery and the anesthesiologist's acute hepatitis C and between patient A's surgery and his anti-HCV seroconversion are consistent with the average 6- to 7-week incubation period for hepatitis C. Second, the HVR1 quasispecies of the isolates of the anesthesiologist and patients A and B indicate that they are extremely closely related to each other. The close relationship of these quasispecies is in direct contrast to the high degree of variation observed among the quasispecies of unrelated HCV-infected persons in the general population studied in this investigation and among unrelated individual patients described by other investigators.Furthermore, the degree of relatedness among the sequences from the anesthesiologist and patients A and B is similar to or greater than that observed among HVR1 quasispecies from other investigationsof possible HCV transmission.The HCV sequence data also support the conclusion that the extent of transmission was limited to the anesthesiologist and patients A and B. Although the HCV genotype cannot be used to define the identity of virus isolates, it can be used to exclude unrelated isolates as possible sources of transmission. Hepatitis C virus genotype 1a was only found in the anesthesiologist and the 2 patients. The other HCV-infected patients identified during this investigation were infected with other genotypes. The anti-HCV–positive patients from whom HCV RNA could not be amplified reported exposures that strongly suggested that their HCV infections were acquired at some time before their surgical procedures.The transmission pattern involving the 2 patients and the anesthesiologist suggests that the anesthesiologist experienced at least 2 percutaneous exposures to his patients' blood during a 9-week period, neither of which he could recall. During neither of these surgical procedures did the anesthesiologist perform procedures that would have placed him at high risk for incurring an injury or placed him in contact with the blood of the patient.In addition, despite multiple interviews with the anesthesiologist and review of the operating room and medical records, we were unable to identify specific events that could have resulted in transmission of HCV.Anesthesiologists are at risk for percutaneous injuries and occupationally acquired bloodborne infections.However, reports of bloodborne pathogen transmission from infected health care workers to patients have involved primarily surgeons, gynecologists, or dentists,who are more likely to perform procedures wherein their blood has the potential to recontact the patient after a percutaneous injury. In general, anesthesiologists do not perform such procedures. In a prospective studyof more than 1300 surgical procedures, percutaneous injuries occurred in 6.9% of the procedures, but none involved an anesthesiologist.We are aware of only one other reportof an anesthesiologist transmitting a bloodborne pathogen to patients. The report describes an anesthesiologist addicted to narcotics who injected himself with patients' narcotics before injecting the remainder in the patient with the same needle and syringe. Similarly, an outpatient surgical technician with chronic HCV (who did not perform invasive procedures) self-injected patients' analgesic medications and transmitted HCV to approximately 40 patients.Although a recent studyshows that overall drug abuse rates are not higher among anesthesiologists when compared with those in other medical specialties, anesthesiologists are at highest risk for abuse of major opiates when compared with those in other medical specialtiesand are overrepresented among physicians in California's diversion program for substance-abusing physicians (representing 5% of licensed California physicians and 17.4% of physicians in the diversion program).The anesthesiologist involved in our investigation repeatedly denied injection drug or other substance abuse. However, because of the diversion program's strict assurances of confidentiality, we were not able to explore whether the anesthesiologist had participated in any substance abuse diversion program and could not rule out injection drug use as an explanation for transmission.Our investigation had several limitations. First, because there were not enough cases to compare attack rates among exposed and unexposed patients, we were not able to show a statistical association between the anesthesiologist and infected patients. Thus, we relied heavily on the temporal sequence of events and the genetic relatedness of the HCV isolates to link the anesthesiologist to patients A and B. Second, more than half of the anesthesiologist's patients at hospital Y did not submit a blood sample for anti-HCV testing, and we could have failed to detect one or more episodes of transmission. This low response rate is common in look-back investigations.However, we did not detect any infections that could be linked to the anesthesiologist among more than 300 patients tested, and the demographic characteristics of the patients who were tested did not differ from those of the patients who were not tested. Finally, we relied on the anesthesiologist's self-report of percutaneous injuries, compliance with standard procedures, and drug use; we had limited alternate sources that could validate the information he provided. His report could have been inaccurate because he had a disincentive to provide information that might damage his professional status. The absence of identifiable incidents that could explain transmission is common to most investigations of health care worker–to–patient transmission.Our investigation documented transmission of HCV from a health care worker to a patient that did not seem to occur during performance of his normal duties. Acute hepatitis C in a patient without commonly recognized risk factors and with a history of recent surgery or hospitalization should engender a thorough investigation into the potential nosocomial source(s) of transmission.Current guidelinesfor the prevention of transmission of bloodborne pathogens from health care workers to patients do not recommend restrictions of the professional activities of HCV-infected health care workers. All health care workers should follow a strict aseptic technique and standard precautions, including appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments.RRidzonKGallagherCCiesielskiSimultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick injury.N Engl J Med.1997;336:919-922.TMitsuiKIwanoKMasukoHepatitis C virus infection in medical personnel after needlestick accident.Hepatology.1992;16:1109-1114.KKiyosawaTSodeyamaETanakaHepatitis C in hospital employees with needlestick injuries.Ann Intern Med.1991;115:367-369.LBPolishMJTongRLCoRisk factors for hepatitis C virus infections among health care personnel in a community hospital.Am J Infect Control.1993;21:196-200.RSchvarczBJohanssonBNystromASonnerborgNosocomial transmission of hepatitis C virus.Infection.1997;25:74-77.TAllanderAGrubnerMNaghaviFrequent patient-to-patient transmission of hepatitis C virus in a haematology ward.Lancet.1995;345:603-607.AWidellBChristenssonTWiebeEpidemiologic and molecular investigation of outbreaks of hepatitis C virus infection on a pediatric oncology service.Ann Intern Med.1999;130:130-134.JBronowickiVVenardCBottePatient-to-patient transmission of hepatitis C during colonoscopy.N Engl J Med.1997;337:237-240.TAllanderCMedinSHJacobsonLGrillnerMAPerssonHepatitis C transmission in a hemodialysis unit: molecular evidence for spread of virus among patients not sharing equipment.J Med Virol.1994;43:415-419.LAMoyerMJAlterHepatitis C virus in the hemodialysis setting: a review with recommendations for control.Semin Dial.1994;7:124-127.JIEstebanJGomezMMartellTransmission of hepatitis C virus by a cardiac surgeon.N Engl J Med.1996;334:555-560.GJDuckworthJHeptonstallCAitkenfor the Incident Control Team and othersTransmission of hepatitis C virus from a surgeon to a patient.Commun Dis Public Health.1999;2:188-192.RSRossSViazovTGrossFHofmannHMSeippMRoggendorfTransmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients.N Engl J Med.2000;343:1851-1854.OVNainanTLCromeansHSMargolisSequence-specific, single-primer amplification and detection of PCR products for identification of hepatitis viruses.J Virol Methods.1996;61:127-134.MJAlterDKruszon-MoranOVNainanThe prevalence of hepatitis C virus infection in the United States, 1988 through 1994.N Engl J Med.1999;341:556-562.PSimmondsECHolmesTAChaClassification of hepatitis C virus into six major genotypes and a series of subtypes by phylogenetic analysis of the NS-5 region.J Gen Virol.1993;74:2391-2399.NEnomotoATakadaTNakaoTDateThere are two major types of hepatitis C virus in Japan.Biochem Biophys Res Commun.1990;170:1021-1025.JDevereauxPHaeberliOSmithiesA comprehensive set of sequence analysis programs for the VAX.Nucleic Acids Res.1984;12:387-395.JFelsensteinConfidence limits on phylogenies: an approach using the bootstrap.Evolution.1985;39:783-791.KSuzukiMMasashiYJohnsonConfirmation of hepatitis C virus transmission through needlestick accidents by molecular evolutionary analysis.J Infect Dis.1994;170:1575-1578.YHNiMHChangPJChenHHLinHYHsuEvolution of hepatitis C virus quasispecies in mothers and infants infected through mother-to-infant transmission.J Hepatol.1997;26:967-974.MHohneEScheierMRoggendorfSequence variability in the env-coding region of hepatitis C virus isolated from patients infected during a single source outbreak.Arch Virol.1994;137:25-34.Not AvailableRecommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures.MMWR Morb Mortal Wkly Rep.1991;40(RR-8):1-9.ESGreeneAJBerryJJaggerMulticenter study of contaminated percutaneous injuries in anesthesia personnel.Anesthesiology.1998;89:1362-1372.DMBellCNShapiroCACiesielskiMEChamberlandPreventing blood borne pathogen transmission from health-care workers to patients.Surg Clin North Am.1995;75:1189-1203.JITokarsDMBellDHCulverPercutaneous injuries during surgical procedures.JAMA.1992;267:2899-2904.XBoschHepatitis C outbreak astounds Spain.Lancet.1998;351:1415.LSehulsterJTaylorKHendricksMVanEgdomSWhiteleySManningHepatitis C outbreak linked to narcotic tampering in an ambulatory surgical center.In: Abstracts of the 1997 Interscience Conference on Antimicrobial Agents and Chemotherapy.Washington, DC: American Society for Microbiology Press; 1997:293.PHHughesCLStorrNABrandenburgDCBaldwinJCAnthonyDVSheehanPhysician substance abuse by medical specialty.J Addict Dis.1999;18:23-37.RTParisDICanavanPhysician substance abuse impairment: anesthesiologists vs other specialties.J Addict Dis.1999;18:1-7.JFArensSubstance abuse: one anesthesiologist's perspective.Bull Am Coll Surg.1993;78:10-14.CPeltonRMIkedaThe California physicians diversion program's experience with recovering anesthesiologists.J Psychoactive Drugs.1991;23:427-431.LMRobertMEChamberlainJLClevelandInvestigations of patients of health care workers infected with HIV: the Centers for Disease Control and Prevention database.Ann Intern Med.1995;122:653-657.CCiesielskiDMarianosCYOuTransmission of human immunodeficiency virus in a dental practice.Ann Intern Med.1992;116:798-805.RHarpazLVon SeidleinFMAverhoffTransmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control.N Engl J Med.1996;334:549-554.Centers for Disease Control and PreventionRecommendations 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.EABolyardOCTablanWWWilliamsMLPearsonCNShapiroSDDeitchmanGuidelines for infection control in health care personnel, 1998.Am J Infect Control.1998;26:289-354.Accepted for publication May 10, 2001.We thank Jon Rosenberg, MD, for his consultation regarding the first retrospective investigation; Betty Robertson for her consultation regarding genotype testing; and Natasha Kudyakova and the Orange County Public Health Laboratory for performing serologic testing.Corresponding author: Sara H. Cody, MD, Disease Prevention and Control, Santa Clara County Public Health Department, 2220 Moorpark Ave, Room 226L, San Jose, CA 95128 (e-mail: sara.cody@hhs.co.santa-clara.ca.us).Reprints: Duc J. Vugia, MD, MPH, California Department of Health Services, 2151 Berkeley Way, Room 708, Berkeley, CA 94704. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Loading next page...
 
/lp/american-medical-association/hepatitis-c-virus-transmission-from-an-anesthesiologist-to-a-patient-QFu9CBmuI0

References (35)

Publisher
American Medical Association
Copyright
Copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/archinte.162.3.345
Publisher site
See Article on Publisher Site

Abstract

BackgroundAn 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.MethodsWe 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.ResultsOf 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.ConclusionsOur 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.HEPATITIS C virus (HCV) is most efficiently transmitted by direct percutaneous exposure to infectious blood, and like other bloodborne pathogens, HCV can be transmitted in the health care setting. The transmission of HCV from infected patients to health care workers is well recognized, most commonly through accidental needlestick injuries.Hepatitis C virus transmission from infected patients to other patients is less common; the few reported episodes have involved unsafe injection practices resulting in probable contamination of equipment used for flushing intravenous cathetersand of multiple-dose medication vials.Contaminated equipment that was not adequately cleaned or disinfected and that was shared among patients was implicated in one reportof HCV transmission to 2 patients during colonoscopy, and is the likely source for transmission among patients undergoing long-term hemodialysis.The transmission of HCV from infected health care workers to patients seems to be rare. There are 3 published reports of such transmission during performance of invasive procedures, onein which a cardiac surgeon with a chronic infection in Spain transmitted HCV to 5 patients, anotherin which a cardiac surgeon with a chronic infection in the United Kingdom transmitted HCV to one patient, and a thirdin which an anesthesiology assistant in Germany contracted HCV from a patient with a chronic infection and then transmitted the HCV to 5 other patients. Herein, we discuss the apparent transmission of HCV from an infected anesthesiologist to a patient.In January 1996, a 64-year-old man (patient A) without identified risk factors became ill with acute hepatitis 7 weeks after undergoing a thoracotomy at hospital X. He remained negative for all viral hepatitis serologic markers until 8 weeks after his surgery, when he seroconverted to antibody to HCV (anti-HCV) and his alanine aminotransferase level peaked at 1029 U/L. Ten weeks before surgery, his liver enzyme levels were normal, and 1 week before his surgery, he and his wife donated blood and both tested negative for anti-HCV. The anesthesiologist who administered anesthesia during patient A's thoracotomy developed scleral icterus and dark urine 3 days after patient A's procedure, at which time he stopped working. His alanine aminotransferase level was 1085 U/L and peaked a few days later at 1390 U/L. Serum drawn at his first visit was positive for anti-HCV and negative for serologic markers of acute hepatitis A or B. Six weeks later, his serum HCV RNA level was measured for the first time and was 37.92 million genome equivalents per milliliter (Quantiplex HCV RNA Assay [bDNA]; Chiron Corp, Emeryville, Calif) and the results of a liver biopsy showed findings consistent with acute hepatitis without chronic inflammation.We undertook an investigation to determine whether the anesthesiologist or another source at hospital X might have transmitted HCV to patient A, to assess the extent to which nosocomial transmission might have occurred, and to evaluate the specific events associated with transmission.PARTICIPANTS AND METHODSEPIDEMIOLOGIC INVESTIGATIONWe obtained serum samples from the 6 members of the surgical team who were present during patient A's thoracotomy, except the anesthesiologist, from whom we obtained a stored frozen sample that was collected during his acute illness. To further evaluate the possible source of infection for patient A and the extent to which nosocomial transmission of HCV might have occurred, we investigated 3 groups of patients at hospital X: (1) all patients treated by the anesthesiologist during the 6 months before his illness, (2) all patients not treated by the anesthesiologist who underwent surgery on the same day as patient A, and (3) all patients not treated by the anesthesiologist who underwent surgery in the same operating room as patient A during the week before or after his procedure. Beginning 6 months after his acute infection, the anesthesiologist worked at hospital Y for 18 months. He started a 6-month course of interferon 3 months before starting work at hospital Y, but therapy was unsuccessful and discontinued. He had detectable HCV RNA when tested on several occasions thereafter. To determine whether the anesthesiologist might have transmitted HCV to patients at hospital Y, we investigated all patients at hospital Y who were treated by him during that period. For both investigations, we sent each patient a letter that explained that an exposure to HCV might have occurred, provided information on HCV infection, and offered free HCV testing. Four or more attempts were made to contact nonresponders. We interviewed all participants who tested positive for HCV (including patient A and the anesthesiologist) regarding risk factors for HCV infection and past medical history, reviewed their medical records for evidence of prior HCV infection, and reviewed their surgical records for a detailed account of all procedures and events. A second serum specimen was requested for further testing. We asked the anesthesiologist, surgical team members, and operating room staff to describe infection-control practices and recall any specific incidents or breaks in technique. All reported occupational incidents at hospital X in the 6 months before the procedures were reviewed.LABORATORY METHODSSerologic TestingAll serum samples were tested for anti-HCV using a second-generation enzyme immunoassay (HCV 2.0; Abbott Laboratories, Abbott Park, Ill) or a third-generation enzyme immunoassay (HCV 3.0; Ortho Diagnostic Systems Inc, Raritan, NJ); repeatedly reactive results were confirmed with supplemental testing (HCV Matrix [Abbott Laboratories] or RIBA 3.0 [Chiron Corp]).Nucleic Acid Testing and SequencingWe tested specimens that were positive or indeterminate on supplemental testing for HCV RNA by nested reverse transcription polymerase chain reaction (RT-PCR) amplification of the 5′ noncoding region, as described previously.Hepatitis C virus RNA–negative samples were extracted a second time with the same procedure and incubated for an additional 45 minutes at 50°C with 25 U of reverse transcriptase (Boehringer Mannheim Corporation, Indianapolis, Ind) and 10 U of RNasin (Boehringer Mannheim Corporation). Polymerase chain reaction products were separated by electrophoresis on a 2% agarose gel (GIBCO-BRL, Life Technologies, Inc, Gaithersburg, Md), and specimens positive for HCV RNA were identified by ethidium bromide staining.For HCV RNA–positive specimens, HCV genotypes were determined from the 300-nucleotide sequence of the nonstructural coding region 5b using previously described methods and primers.Polymerase chain reaction products were purified and cycle sequenced using internal primers with dye terminator reaction chemistry, and electrophoresis and nucleotide identification were performed with an automated DNA sequencer (ABI 377; Applied Biosystems, Inc, Foster City, Calif). Genotypes were defined by comparing the sequences in question with published sequences using a multiple sequence alignment program (Pileup; Wisconsin Genetic Computer Group, Madison).Quasispecies of hypervariable region 1 (HVR1) were determined by limiting dilution PCR. For each specimen, nested RT-PCR, as previously described, was performed to determine the end-point titer using the following primers: first round, 1350F1 (forward primer 5′-GCTACTCCGGATCCCACAAGC-3′) and 1633R (reverse primer 5′-TCATTGCAGTTCAGGGCCGT-3′); and second round, 1426F1 (forward primer 5′-TATTCCATGGTGGGGAACTGG-3′) and 1619R (reverse primer 5′-GCAGTCCTGTTGATGTGCCA-3′). Multiple PCRs (n = 30-40) were then performed at twice the serum dilution of the end-point PCR titer. Each PCR amplicon was purified and the nucleotide sequence determined as previously described.To evaluate the relatedness among samples of the same genotype, we compared the HVR1 quasispecies sequences of isolates from the investigation-related cases with isolates from participants in the Third National Health and Nutrition Examination Survey (NHANES III),2 of whom were from the same geographic region as hospitals X and Y. We conducted preliminary pairwise analysis using multiple sequence alignment programs (Pileup and Pretty; Wisconsin Genetic Computer Group). Distribution of nucleotide distances was calculated using the Jukes-Cantor distance correction (Evolutionary Distance; Wisconsin Genetic Computer Group). Unrooted phylogenetic trees were generated using computer programs (DNADIST and NEIGHBOR) with the Kimura 2-parameter correction (PHYLIP, version 3.5, written by J. Felsenstein, University of Washington, Seattle). Bootstrap analysis was done to evaluate the reliability of the phylogenetic tree analysis.RESULTSIDENTIFICATION OF CASESAll members of the surgical team, except the anesthesiologist, tested negative for anti-HCV at least 4 months after the thoracotomy was performed on patient A. Of the 47 patients at hospital X who underwent surgical procedures during which the anesthesiologist provided treatment in the 6 months preceding his acute illness, 35 (74%) were tested, of whom 2 (patients A and B) were positive for anti-HCV (Table 1). Of the 39 patients not treated by the anesthesiologist who underwent surgery at hospital X either on the same day as patient A or in the same operating room as patient A, 28 (72%) were tested, and 1 (patient C) tested positive for anti-HCV. Of the 735 patients at hospital Y treated by the anesthesiologist, 313 (43%) were tested, and 4 (patients D, E, F, and G) tested positive for anti-HCV. At hospital Y, the age, sex, and date of surgery of the patients who were tested were similar to those of the patients who were not tested. At both hospitals, patients were tested more than 6 months after exposure to the anesthesiologist.Evidence of HCV Infection Among Surgical Patients at Hospitals X and Y*Patient GroupTotal No. of PatientsPatients Tested†Positive for Antibody to HCV‡PatientGenotypeTreated by the anesthesiologistHospital X (6 mo before the acute illness)4735 (74)2 (6)A and B1aHospital Y (18 mo after unsuccessful antiviral therapy)735313 (43)4 (1)D and E F and G2a Negative for HCV RNANot treated by the anesthesiologist at hospital XSurgery on the same day as patient A1511 (73)0. . .. . .Surgery in the same operating room 1 wk before or after patient A2417 (71)1 (6)C3a*HCV indicates hepatitis C virus; ellipses, data not applicable.†Data are given as number (percentage) of the total.‡Data are given as number (percentage) of the patients tested.RELATEDNESS OF HCV ISOLATESWe detected HCV RNA in the serum of the anesthesiologist and patients A, B, C, D, and E, but not in the serum of patients F and G. Hepatitis C virus isolates from the anesthesiologist and patients A and B were classified as genotype 1a; patient C, genotype 3a; and patients D and E, genotype 2a.In a pairwise analysis, the sequences of the nonstructural coding region 5b of the anesthesiologist and patient A were identical to each other and differed from those of patient B by 5 nucleotides, and all clustered in a single group (Figure 1). The sequences of the 8 unrelated HCV RNA–positive persons (6 with genotype 1a and 2 with genotype 1b) from NHANES III specimens varied by 3.9% to 20.0% and fell into 3 clusters (Figure 1).Figure 1.Genetic relatedness obtained by pairwise analysis of the nonstructural coding region 5b sequences from investigation-related cases (the anesthesiologist and patients A and B) and from 8 hepatitis C virus (HCV)–infected persons from the general population not related to the investigation (shown as numbers). The percentage of nucleotide identity between isolates is measured by the horizontal distance connecting the isolates. Isolates from patients A and B and the anesthesiologist cluster in a single group. The sequences from patient A and the anesthesiologist are identical and differ from that of patient B by 5 nucleotides. The sequences from the 8 unrelated HCV RNA–positive persons vary by 3.9% to 20.0% and fall into 3 clusters.When we isolated the quasispecies from the anesthesiologist (11 amplicons), patient A (3 amplicons), and patient B (8 amplicons), only a single HVR1 sequence was obtained from each person. The nucleotide identity was 97.8% between the sequence of the anesthesiologist and that of patient A, and 100.0% between the sequence of the anesthesiologist and that of patient B. In contrast, the nucleotide identity of the HVR1 sequences was 46% to 75% between the 8 NHANES III participants and between the NHANES III participants and the anesthesiologist and patients A and B.When the phylogenetic distances of all HVR1 quasispecies were compared in an unrooted tree, sequences from the anesthesiologist and patients A and B clustered in a single group, with net genetic distances of 0% to 1.2% (Figure 2). Bootstrap analysis indicated that this cluster of sequences occurred with 100% probability. The quasispecies of the unrelated NHANES III participants clustered on distinct branches, with evolutionary distances of 30% to 93% from those of the investigation-related cluster (Figure 2).Figure 2.Unrooted tree of phylogenic distances of all HVR1 quasispecies. This unrooted tree shows the HVR1 sequences of all quasispecies identified from 8 NHANES III samples (shown as numbers) and those of the anesthesiologist and patients A and B. The quasispecies of the anesthesiologist and patients A and B cluster on a single branch, with a nucleotide identity of 97.8% between sequences of the anesthesiologist and patient A and of 100.0% between those of the anesthesiologist and patient B. The nucleotide identity was 46% to 75% between the 8 NHANES III participants and between the NHANES III participants and the anesthesiologist and patients A and B. HVR1 indicates hypervariable region; NHANES III, Third National Health and Nutrition Examination Survey.EVALUATION OF RISK FACTORS FOR HCV INFECTIONWe elicited risk factor histories from the anesthesiologist and patients A and B, who shared the same genotype (1a), and from patients F and G, who were positive for anti-HCV but negative for HCV RNA. Patient A reported no history of blood transfusions or injection drug use; had not undergone any other medical, surgical, or dental procedures in the 6 months before his thoracotomy; and tested negative for anti-HCV 1 week before the procedure. His only sexual contact was with his wife, who also tested negative for anti-HCV 1 week before patient A's procedure. Patient B, whose surgery took place 8½ weeks before that of patient A, was a 42-year-old woman who had tested positive for anti-HCV 1 week before her surgery, when she made an autologous blood donation. Patient F was a 58-year-old man who had a history of blood transfusion before 1990 and a history of chronic cholecystitis, pancreatitis, and cirrhosis. Patient G was a 49-year-old man who had a history of acute hepatitis in the 1980s (type unknown), incarceration, and approximately 10 lifetime sex partners.The anesthesiologist reported no history of blood transfusion or injection drug use. During the 12 months before his illness, he had 3 sex partners. In August 1994, he sustained a needlestick injury while administering anesthesia during a liver transplantation for a patient with chronic hepatitis C. He was negative for anti-HCV at the time of the injury and 3 months later, but he was not retested until 17 months later, with the onset of his acute symptoms.EVALUATION OF POTENTIAL FOR NOSOCOMIAL TRANSMISSIONBased on the patients' histories and the results of the molecular sequencing, we hypothesized that patient B was the source of the anesthesiologist's HCV infection, and the anesthesiologist was the source of patient A's infection (Figure 3). Patient B underwent a vaginal hysterectomy and colporrhaphy 8½ weeks before the onset of illness in the anesthesiologist. She received general anesthesia with oral endotracheal intubation, and a single peripheral intravenous catheter was placed, through which the anesthesiologist administered fentanyl citrate, midazolam hydrochloride, thiopental sodium, glycopyrrolate, neostigmine methylsulfate, succhinylcholine chloride, and vecuronium bromide.Figure 3.Temporal sequence of surgical procedures and illnesses in patients A and B and the anesthesiologist, by week. Anti-HCV indicates antibody to the hepatitis C virus.Patient A underwent a thoracotomy for wedge resection of a lung nodule. The procedure was converted from a thorascopically guided excision to an open thoracotomy because of difficulty visualizing the tumor. He did not receive any blood products. He received general anesthesia with oral endotracheal intubation, and an epidural catheter for thoracic anesthesia, a subclavian triple-lumen catheter, a radial arterial catheter, and a peripheral intravenous catheter were placed. Perioperatively, patient A received intravenous midazolam, fentanyl, thiopental, succinylcholine, vecuronium, neostigmine, glycopyrrolate, phenylephrine hydrochloride or ephedrine hydrochloride, and additional fentanyl via the epidural catheter. He received intravenous morphine sulfate and metoclopramide hydrochloride while in the postanesthesia care unit. During his 5-day hospitalization, he underwent no further invasive procedures.The anesthesiologist did not recall either patient A's or patient B's procedure. According to the anesthesia record for patient A, the anesthesiologist placed a double-lumen endotracheal tube and checked the position with fiberoptic bronchoscopy. After reviewing the anesthesia and operative records, the anesthesiologist said that he probably would have placed the peripheral intravenous catheter, epidural catheter, and radial arterial catheter, and that the surgeon probably placed the right subclavian triple-lumen catheter. He could not recall whether he placed the intravenous catheter in patient B. None of the surgical team, including the anesthesiologist, recalled any unusual events or incidents (eg, needlestick injuries) that occurred during either patient's procedure, and no incident reports were filed.The anesthesiologist stated that multidose vials were commonly used at hospital X, that he usually prepared his own medications, and that he always used a new needle and syringe. On a few occasions in the past, he might have injured himself opening a vial or an ampule. He stated that he wore single gloves for all procedures, except for placing peripheral intravenous catheters, when occasionally he did not wear gloves. He denied a history of dermatitis or other skin lesions on the hands. No incident reports involving the anesthesiologist were filed at hospital X in the 6 months before the thoracotomy.COMMENTOur investigation indicates that an anesthesiologist with an acute infection transmitted HCV to a patient while administering anesthesia during a thoracotomy, and that the source of the anesthesiologist's infection was another patient he treated almost 9 weeks before the onset of his illness. This scenario is supported by 2 findings. First, the time intervals between patient B's surgery and the anesthesiologist's acute hepatitis C and between patient A's surgery and his anti-HCV seroconversion are consistent with the average 6- to 7-week incubation period for hepatitis C. Second, the HVR1 quasispecies of the isolates of the anesthesiologist and patients A and B indicate that they are extremely closely related to each other. The close relationship of these quasispecies is in direct contrast to the high degree of variation observed among the quasispecies of unrelated HCV-infected persons in the general population studied in this investigation and among unrelated individual patients described by other investigators.Furthermore, the degree of relatedness among the sequences from the anesthesiologist and patients A and B is similar to or greater than that observed among HVR1 quasispecies from other investigationsof possible HCV transmission.The HCV sequence data also support the conclusion that the extent of transmission was limited to the anesthesiologist and patients A and B. Although the HCV genotype cannot be used to define the identity of virus isolates, it can be used to exclude unrelated isolates as possible sources of transmission. Hepatitis C virus genotype 1a was only found in the anesthesiologist and the 2 patients. The other HCV-infected patients identified during this investigation were infected with other genotypes. The anti-HCV–positive patients from whom HCV RNA could not be amplified reported exposures that strongly suggested that their HCV infections were acquired at some time before their surgical procedures.The transmission pattern involving the 2 patients and the anesthesiologist suggests that the anesthesiologist experienced at least 2 percutaneous exposures to his patients' blood during a 9-week period, neither of which he could recall. During neither of these surgical procedures did the anesthesiologist perform procedures that would have placed him at high risk for incurring an injury or placed him in contact with the blood of the patient.In addition, despite multiple interviews with the anesthesiologist and review of the operating room and medical records, we were unable to identify specific events that could have resulted in transmission of HCV.Anesthesiologists are at risk for percutaneous injuries and occupationally acquired bloodborne infections.However, reports of bloodborne pathogen transmission from infected health care workers to patients have involved primarily surgeons, gynecologists, or dentists,who are more likely to perform procedures wherein their blood has the potential to recontact the patient after a percutaneous injury. In general, anesthesiologists do not perform such procedures. In a prospective studyof more than 1300 surgical procedures, percutaneous injuries occurred in 6.9% of the procedures, but none involved an anesthesiologist.We are aware of only one other reportof an anesthesiologist transmitting a bloodborne pathogen to patients. The report describes an anesthesiologist addicted to narcotics who injected himself with patients' narcotics before injecting the remainder in the patient with the same needle and syringe. Similarly, an outpatient surgical technician with chronic HCV (who did not perform invasive procedures) self-injected patients' analgesic medications and transmitted HCV to approximately 40 patients.Although a recent studyshows that overall drug abuse rates are not higher among anesthesiologists when compared with those in other medical specialties, anesthesiologists are at highest risk for abuse of major opiates when compared with those in other medical specialtiesand are overrepresented among physicians in California's diversion program for substance-abusing physicians (representing 5% of licensed California physicians and 17.4% of physicians in the diversion program).The anesthesiologist involved in our investigation repeatedly denied injection drug or other substance abuse. However, because of the diversion program's strict assurances of confidentiality, we were not able to explore whether the anesthesiologist had participated in any substance abuse diversion program and could not rule out injection drug use as an explanation for transmission.Our investigation had several limitations. First, because there were not enough cases to compare attack rates among exposed and unexposed patients, we were not able to show a statistical association between the anesthesiologist and infected patients. Thus, we relied heavily on the temporal sequence of events and the genetic relatedness of the HCV isolates to link the anesthesiologist to patients A and B. Second, more than half of the anesthesiologist's patients at hospital Y did not submit a blood sample for anti-HCV testing, and we could have failed to detect one or more episodes of transmission. This low response rate is common in look-back investigations.However, we did not detect any infections that could be linked to the anesthesiologist among more than 300 patients tested, and the demographic characteristics of the patients who were tested did not differ from those of the patients who were not tested. Finally, we relied on the anesthesiologist's self-report of percutaneous injuries, compliance with standard procedures, and drug use; we had limited alternate sources that could validate the information he provided. His report could have been inaccurate because he had a disincentive to provide information that might damage his professional status. The absence of identifiable incidents that could explain transmission is common to most investigations of health care worker–to–patient transmission.Our investigation documented transmission of HCV from a health care worker to a patient that did not seem to occur during performance of his normal duties. Acute hepatitis C in a patient without commonly recognized risk factors and with a history of recent surgery or hospitalization should engender a thorough investigation into the potential nosocomial source(s) of transmission.Current guidelinesfor the prevention of transmission of bloodborne pathogens from health care workers to patients do not recommend restrictions of the professional activities of HCV-infected health care workers. All health care workers should follow a strict aseptic technique and standard precautions, including appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments.RRidzonKGallagherCCiesielskiSimultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick injury.N Engl J Med.1997;336:919-922.TMitsuiKIwanoKMasukoHepatitis C virus infection in medical personnel after needlestick accident.Hepatology.1992;16:1109-1114.KKiyosawaTSodeyamaETanakaHepatitis C in hospital employees with needlestick injuries.Ann Intern Med.1991;115:367-369.LBPolishMJTongRLCoRisk factors for hepatitis C virus infections among health care personnel in a community hospital.Am J Infect Control.1993;21:196-200.RSchvarczBJohanssonBNystromASonnerborgNosocomial transmission of hepatitis C virus.Infection.1997;25:74-77.TAllanderAGrubnerMNaghaviFrequent patient-to-patient transmission of hepatitis C virus in a haematology ward.Lancet.1995;345:603-607.AWidellBChristenssonTWiebeEpidemiologic and molecular investigation of outbreaks of hepatitis C virus infection on a pediatric oncology service.Ann Intern Med.1999;130:130-134.JBronowickiVVenardCBottePatient-to-patient transmission of hepatitis C during colonoscopy.N Engl J Med.1997;337:237-240.TAllanderCMedinSHJacobsonLGrillnerMAPerssonHepatitis C transmission in a hemodialysis unit: molecular evidence for spread of virus among patients not sharing equipment.J Med Virol.1994;43:415-419.LAMoyerMJAlterHepatitis C virus in the hemodialysis setting: a review with recommendations for control.Semin Dial.1994;7:124-127.JIEstebanJGomezMMartellTransmission of hepatitis C virus by a cardiac surgeon.N Engl J Med.1996;334:555-560.GJDuckworthJHeptonstallCAitkenfor the Incident Control Team and othersTransmission of hepatitis C virus from a surgeon to a patient.Commun Dis Public Health.1999;2:188-192.RSRossSViazovTGrossFHofmannHMSeippMRoggendorfTransmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients.N Engl J Med.2000;343:1851-1854.OVNainanTLCromeansHSMargolisSequence-specific, single-primer amplification and detection of PCR products for identification of hepatitis viruses.J Virol Methods.1996;61:127-134.MJAlterDKruszon-MoranOVNainanThe prevalence of hepatitis C virus infection in the United States, 1988 through 1994.N Engl J Med.1999;341:556-562.PSimmondsECHolmesTAChaClassification of hepatitis C virus into six major genotypes and a series of subtypes by phylogenetic analysis of the NS-5 region.J Gen Virol.1993;74:2391-2399.NEnomotoATakadaTNakaoTDateThere are two major types of hepatitis C virus in Japan.Biochem Biophys Res Commun.1990;170:1021-1025.JDevereauxPHaeberliOSmithiesA comprehensive set of sequence analysis programs for the VAX.Nucleic Acids Res.1984;12:387-395.JFelsensteinConfidence limits on phylogenies: an approach using the bootstrap.Evolution.1985;39:783-791.KSuzukiMMasashiYJohnsonConfirmation of hepatitis C virus transmission through needlestick accidents by molecular evolutionary analysis.J Infect Dis.1994;170:1575-1578.YHNiMHChangPJChenHHLinHYHsuEvolution of hepatitis C virus quasispecies in mothers and infants infected through mother-to-infant transmission.J Hepatol.1997;26:967-974.MHohneEScheierMRoggendorfSequence variability in the env-coding region of hepatitis C virus isolated from patients infected during a single source outbreak.Arch Virol.1994;137:25-34.Not AvailableRecommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures.MMWR Morb Mortal Wkly Rep.1991;40(RR-8):1-9.ESGreeneAJBerryJJaggerMulticenter study of contaminated percutaneous injuries in anesthesia personnel.Anesthesiology.1998;89:1362-1372.DMBellCNShapiroCACiesielskiMEChamberlandPreventing blood borne pathogen transmission from health-care workers to patients.Surg Clin North Am.1995;75:1189-1203.JITokarsDMBellDHCulverPercutaneous injuries during surgical procedures.JAMA.1992;267:2899-2904.XBoschHepatitis C outbreak astounds Spain.Lancet.1998;351:1415.LSehulsterJTaylorKHendricksMVanEgdomSWhiteleySManningHepatitis C outbreak linked to narcotic tampering in an ambulatory surgical center.In: Abstracts of the 1997 Interscience Conference on Antimicrobial Agents and Chemotherapy.Washington, DC: American Society for Microbiology Press; 1997:293.PHHughesCLStorrNABrandenburgDCBaldwinJCAnthonyDVSheehanPhysician substance abuse by medical specialty.J Addict Dis.1999;18:23-37.RTParisDICanavanPhysician substance abuse impairment: anesthesiologists vs other specialties.J Addict Dis.1999;18:1-7.JFArensSubstance abuse: one anesthesiologist's perspective.Bull Am Coll Surg.1993;78:10-14.CPeltonRMIkedaThe California physicians diversion program's experience with recovering anesthesiologists.J Psychoactive Drugs.1991;23:427-431.LMRobertMEChamberlainJLClevelandInvestigations of patients of health care workers infected with HIV: the Centers for Disease Control and Prevention database.Ann Intern Med.1995;122:653-657.CCiesielskiDMarianosCYOuTransmission of human immunodeficiency virus in a dental practice.Ann Intern Med.1992;116:798-805.RHarpazLVon SeidleinFMAverhoffTransmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control.N Engl J Med.1996;334:549-554.Centers for Disease Control and PreventionRecommendations 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.EABolyardOCTablanWWWilliamsMLPearsonCNShapiroSDDeitchmanGuidelines for infection control in health care personnel, 1998.Am J Infect Control.1998;26:289-354.Accepted for publication May 10, 2001.We thank Jon Rosenberg, MD, for his consultation regarding the first retrospective investigation; Betty Robertson for her consultation regarding genotype testing; and Natasha Kudyakova and the Orange County Public Health Laboratory for performing serologic testing.Corresponding author: Sara H. Cody, MD, Disease Prevention and Control, Santa Clara County Public Health Department, 2220 Moorpark Ave, Room 226L, San Jose, CA 95128 (e-mail: sara.cody@hhs.co.santa-clara.ca.us).Reprints: Duc J. Vugia, MD, MPH, California Department of Health Services, 2151 Berkeley Way, Room 708, Berkeley, CA 94704.

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Feb 11, 2002

There are no references for this article.