UCLA surgeon infected 19 with hepatitis B, report says
By Jennifer K. Morita
Daily Bruin Staff
Despite using proper surgery precautions, a UCLA heart surgeon
unknowingly infected 19 patients with the hepatitis B virus four
years ago, according to a recently released report by outbreak
investigators.
In the summer of 1992, a woman who had undergone surgery several
months before at UCLA, came down with Hepatitis. The woman,
according to Center for Disease Control epidemiologist Rafael
Harpaz, did not have any risk factors for hepatitis.
"One of the surgery participants had himself had hepatitis B
several months prior to surgery, and so an investigation was
launched to see if there were any additional cases aside from this
one patient," said Harpaz, who conducted the investigation.
After examining the surgeon’s patients as well as other patients
who had surgery at UCLA at the same time, investigators discovered
that 19 people, all patients of the UCLA surgeon, showed evidence
of recent infection.
None of the other patients showed any signs of infection,
according to Harpaz.
But after conducting interviews, collecting blood specimens from
medical records, examining the duration of surgery, the instruments
and the operating rooms, investigators were unable to find
anything.
"We really didn’t turn up any clues with that approach," Harpaz
said.
Harpaz added that the surgeon appeared to be following universal
precautions, regulations that prevent the spread of blood-born
pathogens by wearing gloves, masks and carefully disposing of all
needles and infectious waste.
"From all the interviews, he apparently used good technique,"
Harpaz said. "His colleagues all confirmed that fact."
Further interviews, however, revealed that the surgeon – whose
name was not released – used a slightly different surgical method
during heart surgeries.
Harpaz explained that during heart surgery when surgeons have to
open up the chest area, they deal with sharp, bony surfaces.
"The surgeon had a very minor modification compared to other
surgeons and it’s theoretically possible that this might be
associated with the transmission," Harpaz said.
"The final clue, and a very intriguing one, is the fact that he
claimed that when he would be operating for long periods of time,
his fingers would become very sore from the suturing, from the
sheer forces of the sutures on his fingers," Harpaz said.
In order to see if the surgeon’s sore fingers had anything to do
with the transmission, investigators had the surgeon simulate what
he does during surgery by tying sutures.
"After he tied for a long period of time, he developed small
paper cuts on his fingers," said Harpaz. "We had him rinse his
hands with saline and that saline contained evidence of the
hepatitis B virus."
But investigators still are unsure how the blood containing the
virus leaked through the plastic gloves the surgeon was
wearing.
"It’s known that gloves do develop leaks, especially during long
surgeries," said Harpaz, adding that if gloves do tear or the
surgeon sticks himself with a needle, the gloves are changed as
soon as possible.
"Some people do routinely change their gloves and the surgeon
began doing it routinely later on, but there’s no recommendation
regarding that point," Harpaz said.
Harpaz stressed that the results of the investigation are
theoretical and no direct evidence has been found.
"But we’ve looked for a lot of things and that’s one of the
things that turned up as a possibility," he said.
According to the report, the outbreak could have been prevented
if the surgeon had been immunized for the hepatitis B virus. The
vaccine, developed in the early 1980s, is recommended for all
medical workers due to the increased health risk in dealing with
needles and blood samples, said Loring Dales, a medical
epidemiologist with the California State Department of Health
Services.
"It’s not state law, but most or all hospitals in the country
now have developed policies requiring staff to be immunized or
tested," Dales said. "It’s a widespread practice."
According to Dales, California recently passed a law requiring
hepatitis B vaccinations for children entering school. But the
vaccine is more to protect the physicians and medical care workers
than the patients, Harpaz said.
"The risk of infection from the patient to surgeon is much
greater than the other way around," said Harpaz. "This is very
rare."
According to Harpaz, since the 1992 outbreak at UCLA, no other
outbreaks have been reported in the United States and only 10
outbreaks worldwide.
"The numbers are still fairly small," said Harpaz. "There’s
something like 25 million surgical procedures done annually so the
risk is still pretty low."
Although Harpaz said that there’s good evidence that "almost
all" graduating medical students are vaccinated, James Cherry, who
was head of infection control at UCLA during the time of the
outbreak, said that the UCLA surgeon was not vaccinated.
About 1,500 to 2,000 hepatitis B cases are reported annually in
California, according to California State Department of Health
Services reports.Comments to webmaster@db.asucla.ucla.edu