An orthopedic surgeon with hepatitis B virus (HBV) infection (HB e antigen positive, viral load > 17 million IU/ml) was identified during baseline evaluation for a needlestick injury in facility A. Review of hepatitis B (HB) vaccination history for the surgeon revealed completion of two 3-dose series, but a protective level of surface antibody (anti-HBs) was never achieved and HB surface antigen (HBsAg) testing was not performed at that time. Coincidentally, a patient of the surgeon (patient 1) was diagnosed with symptomatic acute HBV infection and had no apparent risk factors for HBV exposure except for recent orthopedic surgery by this surgeon at facility A.
To determine: (1) whether the surgeon was the source of the patient’s HBV infection, and (2) if the surgeon transmitted virus to other orthopedic patients.
Serum samples collected from the surgeon and patient were sent to CDC for HBV DNA sequence analysis. Interviews were conducted with the surgeon and colleagues to gain information on exposure opportunities and surgical practices. A total of 349 procedures were performed on 329 patients by the surgeon at facility A from August 2008 - May 2009. Patients were notified by letter of their potential HBV exposure and recommended to undergo free testing at facility A. Characteristics of the surgical procedures for the 329 patients were evaluated by reviewing operative records.
A total of 237 (72%) of the notified patients were tested. A second patient with acute HBV infection (patient 2) and 6 with evidence of resolved HBV infection were identified. Of the six with resolved infection, four had no identifiable lifetime risks for HBV infection. HBV isolated from the infected surgeon and both patients with acute infection were genotype D and genetically related by the genomic sequence analysis (>99.9% genetic identity). Patient 1 had total knee replacement (TKR) surgery and patient 2 had a total hip replacement (THR) surgery; patients with resolved infection had TKR (n=3) or THR (n=3) surgery. Among 229 patients who tested negative for HBV infection, 183 (80.3%) had undergone either TKR or THR surgery. No breaches in infection control or surgical technique were identified.
We documented HBV transmission during orthopedic surgery to patients whose surgeon had a high viral load. This event highlights the importance of testing healthcare workers (HCWs) who fail to achieve a protective level of antibody after the HB vaccine for HBsAg. Consequently, facility A introduced several policy changes including: the classification of orthopedic surgery as an exposure-prone procedure, and the routine evaluation of HCWs who do not achieve a protective surface antibody level after HB vaccination.