Assistant Failed to Follow Basic Safety Procedures

In what appears to be the first recorded case of its kind, German researchers say an anesthesiologist's assistant with an unbandaged cut on his finger was responsible for infecting five patients with the potentially fatal hepatitis C virus.

HCV is an insidious disease because it can go undetected for 10-20 years. But during that time it kills liver cells, leading to scarring of the organ. This in turn can lead to serious liver damage, such as cirrhosis, or to liver cancer. HCV is the number one reason for liver transplantation in the U.S.

Millions of people around the world, including approximately four million Americans, are currently infected with HCV, the majority of the cases being undiagnosed, according to the CDC. However, the annual rate of new cases detected in the general population has decreased since 1989.

Since identification of HCV in the 1980s and development of a screening test that became the standard in all blood donor programs, new incidents of the illness have been confined mainly to intravenous drug users, babies whose mothers are HCV-infected, and those who have high-risk sexual encounters. The National Institute for Drug Abuse estimates only a one in 100,000 chance exists of contracting the disease from transfused blood or blood products.

On rare occasions, people have been infected with HCV by a surgeon or anesthesiologist, but not by their assistants. Because of stringent health care regulations, called universal infectious disease control, it is unlikely that a patient could contract such an illness in a hospital. So what went wrong in Germany?

A group of German doctors, led by Stefan Ross, MD of the Essen University Institute of Virology in Essen, Germany, report in the Dec. 21, 2000 issue of The New England Journal of Medicine that it appears the spread of the disease occurred because of a lapse in protocol. The anesthesiology assistant with a cut on his finger never wore gloves because he said it diminished his sense of touch and interfered with his work.

Ross writes that the assistant likely was infected himself while aiding an anesthesiologist during a 1998 operation on a HCV-infected woman patient. The infected medical worker apparently had no other high-risk behavior factors usually associated with the illness that would have led to his infection.

Although the doctors could not definitely conclude that the virus was spread by the wound on the assistant's hand, within six weeks five patients at the Essen University Hospital contracted HCV: The infected assistant had helped administer anesthesia to all five. The researchers traced the transmission sequence from person to person using genetic analysis and detailed discussions with hospital employees.

"In our study, patients could have been exposed to minimal and invisible amounts of the assistant's blood or wound secretions directly through mucosal lesions" caused when the tubes and catheters were placed, Ross writes. "Other possible but less likely routes of transmission include inadvertent contamination of instruments or multidose vials with blood or wound secretions from the assistant."

Marlyn Mayo, MD, an assistant professor in UT Southwestern Medical Center at Dallas' (UTSW) Division of Digestive & Liver Diseases, says that a couple of similar cases have been reported in the past. However she tells WebMD that in those instances investigators discovered that the healthcare worker involved was stealing drugs from the medical facility and not taking precautions to prevent transmission of HCV.

Ross writes that "to our knowledge" cases of a nonsurgical assistant infecting others has occurred for the hepatitis B virus, but not C.

Regardless of the type, Mayo says, "it's technically possible that it could be transmitted by a small cut. But it's more likely in a case like this that the person was practicing some degree of risky behavior as in these other cases."

Robert Fontana, MD, a liver disease specialist at the University of Michigan Health System, says what's very unusual, for sure, is that any healthcare worker would not wear gloves.

"It can happen but it's extremely uncommon," Fontana says, adding that it's highly unlikely that the general population will contract HCV; it's intravenous drug users, prostitutes, homosexuals, people with multiple sex partners, and those who engage in sexual practices that allows blood exposure who are most likely to contract it. ... IV drug users account for at least 60% of all cases and in some areas of the country, as high as 80% of those who share needles are infected."

Those at the highest risk of infection who don't fall into the high-risk categories are medical workers who get pricked by needles while caring for already infected patients.

"In big hospitals, needle pricks are very common and about 5% of those healthcare workers will develop the chronic disease," Fontana says. Those who had transfusions of blood or blood products before 1992, also are at risk and should be screened for HCV and examined for liver damage."

Other possible risk factors are tattooing and body or ear piercing but UTSW's Mayo says these are not proven ways of transmitting the illness. The CDC lists them as suspected modes of infection.

However the disease is spread, doctors are worried that cases will soon skyrocket; baby boomers who freely used drugs in the 1960s and 1970s are now the ones being diagnosed with chronic HCV. The NIDA says that highest rates of new infection are in 20- to 39-year-olds, but the highest rates of chronic infections are among people 30 to 49 years of age.

"In five or 10 years we expect to see a large number of cases of cirrhosis and liver cancer as this group ages," says Mayo. That's when they will develop the signs that severe, possibly untreatable and fatal, liver damage has already occurred.

Currently there is no vaccine or cure for HCV, although there is a treatment that uses combination of interferon and ribavirin that helps some patients. Studies are also underway on another promising form of interferon called peg-interferon.

In the meantime, infections such as the ones reported by the German doctors could easily be prevented. Ross writes, "Whatever the precise mechanisms of HCV transmission in this outbreak, the spread of the virus could probably have been prevented if so-called universal precautions for infection control had been taken."

(From Excite.com)