Hepatitis B in healthcare workers: Transmission events and guidance for management

Table 1 Published cases of healthcare worker-to-patient transmission of hepatitis B virus

Ref.	Year	Location	Type of provider	HBeAg status	Viral load	HBV status known to provider	HBV status known to institution	No. of patients infected	Breach in infection control identified
[7]	1969	United States	Nurse	Not done	Not done	No	No	11a (11 possible)	None
[8]	1969-1974	United States	Oral surgeon	Positive	Not done	Not specified	Not specified	55 (10 probable, 45 possible)	HCW did not wear gloves
[9]	1973-1977	Switzerland	General practitioner	Positive	Not done	Yes	Not specified	41 (41 possible)	None
[10]	1974	United States	Respiratory therapist	Positive	Not done	No	No	4 (4 probable)	HCW did not wear gloves, had an exudative dermatitis on hands, and reused syringes when accessing indwelling arterial catheters
[11]	1975	United States	Oral surgeon	Not done	Not done	Not specified	Not specified	43 (43 probable)	None
[12]	1976-1979	United Kingdom	Surgical registrar	Positive	Not done	No	No	9 (7 probable, 2 possible)	None
[13]	1977-1978	United Kingdom	Surgical registrar, gynecologic surgery	Positive	Not done	No	No	8 (6 probable, 2 possible)	None
[14]	1978	United States	Dentist	Positive	Not done	Yes	Not specified	6 (2 probable, 4 possible)	HCW did not wear gloves
[15]	1978	Norway	Cardiac surgeon	Positive	Not done	No	No	5 (5 probable)	None
[16]	1978-1979	United States	Oral surgeon	Positive	Not done	No	No	12 (4 probable, 8 possible)	HCW did not wear gloves and had a generalized eczematous dermatitis, including hand involvement
[17]	1979-1980	United States	Obstetrician-gynecologist	Positive	Not done	Yes	Yes	4 (1 probable, 3 possible)	HCW held needle in hand rather than a needle holder when suturing, noted several episodes of blood on hands after removing gloves
[18]	1979-1981	The Netherlands	Cardiac surgeon	Not reported	Not done	Not specified	Not specified	3 (3 probable)	None
[18]	1979-1981	The Netherlands	Perfusion technician	Positive	Not done	Not specified	Not specified	11 (8 probable, 3 possible)	Bleeding warts on HCW’s hands
[19]	1980	United States	Oral surgeon	Not done	Not done	Not specified	Not specified	3 (3 probable)	None
[20]	1980-1983	United Kingdom	Perfusion technician	Positive	Not done	Yes	Not specified	6 (6 probable)	HCW did not wear gloves, and had cuts and abrasions on hands
[20]	1980-1983	United Kingdom	Surgical registrar	Not reported	Not done	Not specified	Not specified	5 (5 possible)	None
[20]	1980-1983	United Kingdom	House officer	Not reported	Not done	Not specified	Not specified	1 (1 possible)	None
[21]	1984	United States	Obstetrician-gynecologist	Positive	Not done	Not specified	Not specified	6 (6 probable)	None
[22]	1984-1985	United States	Dentist	Positive	Not done	No	No	24 (6 probable, 18 possible)	HCW did not wear gloves
[23]	1987	United States	General surgeon	Positive	Not done	Yes	Not specified	5 (3 probable, 2 possible)	None
[24]	1987	United Kingdom	Obstetrician-gynecologist	Positive	Not done	No	No	22 (6 probable, 16 possible)	None
[25]	1988	United Kingdom	General surgeon	Negative	1 × 107 copies/mL	No	No	1 (1 confirmed)	None
[25]	1988	United Kingdom	Obstetrician-gynecologist, trainee	Negative	4.4 × 106 copies/mL	No	No	3 (3 confirmed)	None
[25]	1988	United Kingdom	Obstetrician-gynecologist, trainee	Negative	5.5 × 106 copies/mL	Yes	Not specified	1 (1 confirmed)	None
[25]	1988	United Kingdom	General surgeon, urologist, clinical assistant	Negative	2.5 × 105 copies/mL	No	No	1 (1 confirmed)	None
[26]	1988	United Kingdom	Cardiothoracic surgeon, trainee	Positive	Not done	No	No	17 (9 probable, 8 possible)	None
[27]	1991	United Kingdom	Surgeon	Positive	Not done	No	No	3 (3 possible)	None
[28]	1991	Canada	Orthopedic surgeon	Positive	Not done	Yes	Yes	2 (1 probable, 1 possible)	None
[29]	1991-1992	United States	Thoracic surgeon	Positive	1 × 109 copies/mL	Yes	Not specified	19 (9 confirmed, 4 probable, 6 possible)	None
[30]	1991-1993	United Kingdom	Cardiothoracic surgeon	Positive	Not done	Yes	No	20 (14 confirmed, 6 probable)	None
[31]	1991-1996	Canada	Electroencephalogram technician	Positive	Not done	No	No	75 (4 confirmed, 71 possible)	HCW did not wear gloves and used reusable subdermal EEG electrodes
[32]	1993	United Kingdom	General surgeon	Positive	Not done	No	No	2 (2 confirmed)	None
[33]	1993-1994	United Kingdom	General surgeon, trainee	Positive	Not done	Not specified	Not specified	11 (1 confirmed, 10 possible)	None
[33]	1994	United Kingdom	General surgeon, trainee	Positive	Not done	Not specified	Not specified	2 (2 possible)	None
[33]	1994	United Kingdom	Urologist, trainee	Positive	Not done	Not specified	Not specified	1 (1 possible)	None
[34]	1995-1999	The Netherlands	General surgeon	Positive	5 × 109 GE/mL	No	No	28 (8 confirmed, 20 possible)	HCW noted glove perforations
[35]	1996	United Kingdom	Orthopedic surgeon	Negative but anti-HB e positive (pre-core mutant)	Not done	Yes	Yes	1 (1 confirmed)	None
[36]	1999	United Kingdom	Cardiothoracic surgeon	Negative but anti-HB e positive (pre-core mutant)	1.03 × 106 GE/mL	Yes	Yes	2 (2 confirmed)	None
[37]	2001	United Kingdom	General surgeon	Negative	> 106 copies/mL	No	No	3 (3 confirmed)	None
[38]	2009	United States	Orthopedic surgeon	Positive	> 17.9 million IU/mL	No	No	8 (2 confirmed, 6 possible)	None
[39]	2010	Japan	Obstetrician-gynecologist	Positive	1.6 × 109 copies/mL	No	No	1 (1 confirmed)	None

^aCases included only admitted pts with a dx of icteric “serum hepatitis”. HBeAg: Hepatitis B virus e antigen; HBV: Hepatitis B virus; GE: Genome equivalents; HCW: Healthcare worker; EEG: Electroencephalogram.

Table 2 Guidelines for management of hepatitis B virus-infected healthcare workers

	CDC	SHEA	ACS	Canada	UK	Europe	Australia
Screening	All HCWs at risk for HBV infection should be tested	Not addressed in guideline	All surgeons should know their HBV status	Mandatory for all HCWs who perform EPPs	Mandatory for all HCWs who perform EPPs, can be done post-vaccination	Mandatory for all HCWs who perform EPPs, can be done post-vaccination	Annual testing recommended for all HCWs who perform EPPs
Vaccination	All HCWs susceptible to HBV infection should be vaccinated	Not addressed in guideline	All surgeons who are antibody negative should be vaccinated	Mandatory for all HCWs who perform EPPs	Mandatory for all HCWs who perform EPPs	Recommended for all HCWs	Recommended for all HCWs
Post- vaccination serology	Recommended	Not addressed in guideline	Recommended	Recommended	Recommended	Recommended	Not addressed in guideline
Frequency of testing/ monitoring	Every 6 mo	Every 6 mo	Not specified	Every 12 mo	Every 12 mo, or every 3 mo while on antiviral therapy	Every 12 mo if HBeAg negative, every 3 mo if HBeAg positive or on antiviral therapy	Every 3 mo if on antiviral therapy, every 12 mo if cleared HBsAg
Viral load limit	1000 IU/mL or 5000 GE/mL	104 GE/mL	Not specified	Not specified	103 GE/mL	104 GE/mL	Undetectable by PCR assay
HBeAg	Not required to be negative	Not required to be negative	Not required to be negative	Not required to be negative	Must be negative	Not required to be negative	Not addressed in guideline
Restriction of practice	EPPs restricted if viral load greater than set threshold	Category III procedures restricted if viral burden greater than or equal to 104 GE/mL or HBeAg positive	Determined by expert panel	Determined by expert panel	If HBeAg positive or if viral load greater than 103 GE/mL	If viral load greater than 104 GE/mL	If HBV DNA level detectable
Definition of EPPs	Yes	Yes	No	Yes	Yes	Yes	Yes
Expert panel recommended	Yes	Yes	Yes, if HBeAg positive or high viral load	Yes, if HBsAg positive	No, recommend monitoring by an occupational health physician	No	Yes
Pre-emptive patient notification	No	No	Not specified	No	No	Optional for HCWs with HBV DNA levels above the cut-off level in order to continue practicing EPPs	No

CDC: Centers for Disease Control and Prevention, United States; SHEA: Society for Healthcare Epidemiology of America, United States; ACS: American College of Surgeons, United States; Canada: Laboratory Centre for Disease Control of Health Canada; UK: Department of Health, United Kingdom; Europe: European Consensus Group; Australia: Australian Government, Department of Health and Aging; HCW: Healthcare worker; HBV: Hepatitis B virus; IU: International units; GE: Genome equivalents; HBeAg: Hepatitis B e antigen; EPP: Exposure-prone procedure; PCR: Polymerase chain reaction; HBsAg: Hepatitis B surface antigen.

Table 3 Categories of exposure-prone procedures

CDC

Category I. Procedures known or likely to pose an increased risk of percutaneous injury to a healthcare provider that have resulted in provider- to-patient transmission of HBV. These procedures are limited to major abdominal, cardiothoracic, and orthopedic surgery, repair of major traumatic injuries, abdominal and vaginal hysterectomy, caesarean section, vaginal deliveries, and major oral or maxillofacial surgery. Techniques that have been demonstrated to increase the risk for healthcare provider percutaneous injury and provider-to-patient blood exposure include: digital palpation of a needle tip in a body cavity and/or the simultaneous presence of a health care provider’s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site

Category II. These procedures pose low or no risk for percutaneous injury to a HCW or, if a percutaneous injury occurs, it usually happens outside of a patient’s body and generally does not pose a risk for provider-to-patient blood exposure. These include: surgical and obstetrical/gynecologic procedures that do not involve the techniques listed for Category I, the use of needles or other sharp devices when the HCW’s hands are outside a body cavity, dental procedures other than major oral or maxillofacial surgery, insertion of tubes, endoscopic or bronchoscopic procedures, internal examination with a gloved hand that does not involve the use of sharp devices, and procedures that involve external physical touch

SHEA

Category I. Procedures with de minimis risk of bloodborne virus transmission: regular history-taking and/or physical or dental examinations; routine dental preventive procedures, diagnostic procedures, orthodontic procedures, prosthetic procedures, cosmetic procedures not requiring local anesthesia; routine rectal or vaginal examination; minor surface suturing; elective peripheral phlebotomy; lower gastrointestinal tract endoscopic examinations and procedures; hands-off supervision during surgical procedures and computer-aided remote or robotic surgical procedures; and psychiatric evaluations

Category II. Procedures for which bloodborne virus transmission is theoretically possible but unlikely: locally anesthetized ophthalmologic surgery; locally anesthetized operative, prosthetic, and endodontic dental procedures; periodontal scaling and root planing; minor oral surgical procedures; minor local procedures under local anesthesia; percutaneous cardiac procedures; percutaneous and other minor orthopedic procedures; subcutaneous pacemaker implantation; bronchoscopy; insertion and maintenance of epidural and spinal anesthesia lines; minor gynecological procedures; male urological procedures; upper gastrointestinal tract endoscopic procedures; minor vascular procedures; amputations; breast augmentation or reduction; minimum-exposure plastic surgical procedures; total and subtotal thyroidectomy and/or biopsy; endoscopic ear, nose, and throat surgery and simple ear and nasal procedures; ophthalmic surgery; assistance with an uncomplicated vaginal delivery; laparoscopic procedures; thorascopic procedures; nasal endoscopic procedures; routine arthroscopic procedures; plastic surgery; insertion of, maintenance of, and drug administration into arterial and central venous lines; endotracheal intubation and use of laryngeal mask; and obtainment and use of venous and arterial access devices that occur under complete antiseptic technique, using universal precautions, “no-sharp” technique, and newly gloved hands

Category III. Procedures for which there is definite risk of bloodborne virus transmission or that have been classified previously as “exposure-prone:” general surgery; general oral surgery; cardiothoracic surgery; open extensive head and neck surgery involving bones; neurosurgery, other intracranial procedures, and open-spine surgery; nonelective procedures performed in the emergency department; obstetrical/gynecological surgery; orthopedic procedures; extensive plastic surgery; transplantation surgery except skin and corneal transplantation; trauma surgery; interactions with patients in situations during which the risk of the patient biting the physician is significant; and any open surgical procedure with a duration of more than 3 h, probably necessitating glove change

ACS

Not provided

Canada

Procedures during which transmission of HBV, HCV, or HIV from a HCW to patients is most likely to occur and includes the following: (1) digital palpation of a needle tip in a body cavity or the simultaneous presence of the HCW’s fingers and a needle or other sharp instrument or object in a blind or highly confined anatomic site; (2) repair of major traumatic injuries; or (3) major cutting or removal of any oral or perioral tissue, including tooth structures, during which there is potential for the patient’s open tissues to be exposed to the blood of an injured HCW

UK

Exposure-prone procedures are those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker. These include procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside a patient’s open body cavity, wound, or confined anatomical space where the hands or fingertips may not be completely visible at all times

Europe

Exposure-prone procedures are invasive procedures where there is potential for contact between the skin of the HCW and sharp surgical instruments, needles, or sharp tissues in body cavities or poorly visualized/confined body sites

Australia

Category 1: A procedure where the hands and fingertips of the HCW are visible and outside of the body most of the time and the possibility of injury to the worker’s gloved hands from sharp instruments and/or tissues is slight

Category 2: A procedure where the fingertips of the HCW may not be visible at all times but injury to the worker’s gloved hands from sharp instruments and/or tissues is unlikely. If injury occurs it is likely to be noticed and acted upon quickly to avoid the HCW’s blood contaminating a patient’s open tissues

Category 3: A procedure where the fingertips are out of sight for a significant part of the procedure, or during certain critical stages, and in which there is a distinct risk of injury to the worker’s gloved hands from sharp instruments and/or tissues. In such circumstances it is possible that exposure of the patient’s open tissues to the HCW’s blood may go unnoticed or would not be noticed immediately

CDC: Centers for Disease Control and Prevention, United States; SHEA: Society for Healthcare Epidemiology of America, United States; ACS: American College of Surgeons, United States; Canada: Laboratory Centre for Disease Control of Health Canada; UK: Department of Health, United Kingdom; Europe: European Consensus Group; Australia: Australian Government, Department of Health and Aging; HCW: Healthcare worker; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HIV: Human immunodeficiency virus.