William Fiser, MD, is one of few surgeons who has acknowledged publicly he is infected with hepatitis C virus (HCV). Last year, he published a letter in Infection Control and Hospital Epidemiology that discussed surgeon-to-patient transmission of bloodborne pathogens.1 He was also featured in an article in Newsday, a Long Island (N.Y.) daily; the headline was telling: "Deciding to Step Away."2 After becoming ill with HCV, he resigned his private practice and took a faculty position in the surgery department at the University of Arkansas medical center.

Dr. Fiser can't pinpoint a specific injury, but believes he was infected from an occupational sharps injury, since he had no other risk factors for HCV and has sustained multiple needlesticks during his career. This should sound an alarm for all OR staffers in the outpatient setting. Here is Dr. Fiser's story, and the changes he advocates based on his experience.

Multiple needlesticks
Although Dr. Fiser had been performing surgery for 20 years and cardiovascular surgery for 15, until 1999, he had never been tested for HCV.

"I had my head buried in the sand as far as my risk of being infected - although I was very compulsive about handwashing and universal precautions," says Dr. Fiser.

He believes cardiac surgeons are at higher risk than most other surgical specialists for acquiring and transmitting HCV and other bloodborne pathogens. "Cardiac surgeons typically get many, many needlesticks over the course of their careers," says Dr. Fiser. "We routinely use 80 to 100 suture needles per operative case."

But surgeries of all specialties pose a risk. And surgeons tend not to report their sharps injuries, which means there is no documentation if a surgeon is infected. And often, reporting injuries isn't exactly easy to do.

The runaround
When Dr. Fiser learned a patient he had operated on 10 months earlier - his office receptionist - was infected with HCV, he recalled her aortic arch replacement: "In the middle of the procedure, the [4-0 Prolene] suture needle stuck my left forefinger. It was a pretty deep stick. I remember it well because my hand was dripping blood - some dripped into her mediastinum. I had to stop and change gloves."

Dr. Fiser was devastated that he might have infected one of his patients and he worried others may have been infected. He contacted the Centers for Disease Control and Prevention (CDC) to request an investigation.

"They told me I had to go through the state," says Dr. Fiser. "So I called the Arkansas Department of Health and reported my case and the possible transmission to one of my patients. The chief epidemiologist was disturbed that neither of our cases had been reported by the lab that did our blood work. However, the HCV reporting guidelines, which are based on CDC recommendations, only require reporting of acute hepatitis C cases."

Acute hepatitis C is defined as alanine aminotransferase levels at least six times above normal. As Dr. Fiser wrote in his letter, the CDC's policy means, "most health departments record only a tiny fraction of all newly diagnosed cases of HCV." Further, "only a small minority of surgical patients infected with HCV become symptomatic and even fewer do so early enough to recognize any possible relationship to their prior surgery."1

The state epidemiologist submitted a request to the CDC to help investigate, but the CDC refused because there wasn't a cluster of infections. This revealed a gaping hole in the policy: It's difficult to determine whether a cluster of infections exists unless an investigation is conducted.

In 2002, Dr. Fiser received results from ribonucleic acid mapping indicating he probably wasn't the source of his patient's HCV infection. But Dr. Fiser believes he easily could have been - and that patients and healthcare workers need greater protection from intraoperative blood exposures and the transmission risk they pose.

Mandatory testing
Before his HCV infection, Dr. Fiser opposed mandatory testing of physicians for bloodborne pathogens. He now thinks surgeons and scrub nurses should be tested when they join a facility's medical staff.

"After that, both groups should be tested whenever there is a percutaneous injury or other significant blood exposure," he wrote in his letter.

But, he says, "most intraoperative, percutaneous injuries aren't reported or recorded. A more ethical approach would be for serology to be drawn and reported to the injured [worker] any time there is a percutaneous injury during a procedure."

Currently, many, if not most, physicians avoid getting tested. Dr. Fiser attributes this to the lack of a "logical, well-thought-out plan" for managing infected physicians. He points to a Minnesota law, passed in 2000, as a good model: Physicians infected with HCV, hepatitis B or HIV are assigned a monitor by the state health department; they sign a contract agreeing to eliminate exposure-prone procedures and make other practice modifications as recommended by the monitor.

Dr. Fiser believes the most important safety measures surgeons can adopt are use of blunt suture needles and double-gloving. "Careful hand washing and universal precautions aren't enough. When there can be greater than two million viral particles of HCV per ml of blood, it doesn't take a large exposure to get infected."

Dr. Fiser writes in his letter that many cardiovascular surgeons and their assistants "have the preconceived notion that they cannot operate wearing double gloves. I used to be one of those surgeons, but I am now certain that cardiac surgeons can operate effectively wearing double gloves."1

He thinks more effective barriers, such as puncture-proof gloves, need to be developed. "These kinds of innovations would be more expensive, and right now everyone is trying to contain cost. Blunt suture needles also need to be more widely used. But where is the incentive to change?"

The OR is one of the highest-risk clinical settings for sharps injuries, yet it's been one of the most resistant to implementing safer devices. Dr. Fiser says more data regarding surgeon-to-patient transmission of pathogens might help convince surgeons to adopt safety measures. "If the CDC did turn over this rock and tried to define the extent of the problem, the data would be compelling," he says. "It's easy not to change when you have little or no data."

References
1. Fiser WP. Should surgeons be tested for blood-borne pathogens? Infect Control Hosp Epidemiol 2002;23(6):296-297.
2. Rabin R. Deciding to step away. Newsday 12/27/02, p. A03.