Copyright ©The Author(s) 2015.
World J Hepatol. Mar 27, 2015; 7(3): 488-497
Published online Mar 27, 2015. doi: 10.4254/wjh.v7.i3.488
Table 1 Published cases of healthcare worker-to-patient transmission of hepatitis B virus
Ref.YearLocationType of providerHBeAg statusViral loadHBV status known to providerHBV status known to institutionNo. of patients infectedBreach in infection control identified
[7]1969United StatesNurseNot doneNot doneNoNo11a (11 possible)None
[8]1969-1974United StatesOral surgeonPositiveNot doneNot specifiedNot specified55 (10 probable, 45 possible)HCW did not wear gloves
[9]1973-1977SwitzerlandGeneral practitionerPositiveNot doneYesNot specified41 (41 possible)None
[10]1974United StatesRespiratory therapistPositiveNot doneNoNo4 (4 probable)HCW did not wear gloves, had an exudative dermatitis on hands, and reused syringes when accessing indwelling arterial catheters
[11]1975United StatesOral surgeonNot doneNot doneNot specifiedNot specified43 (43 probable)None
[12]1976-1979United KingdomSurgical registrarPositiveNot doneNoNo9 (7 probable, 2 possible)None
[13]1977-1978United KingdomSurgical registrar, gynecologic surgeryPositiveNot doneNoNo8 (6 probable, 2 possible)None
[14]1978United StatesDentistPositiveNot doneYesNot specified6 (2 probable, 4 possible)HCW did not wear gloves
[15]1978NorwayCardiac surgeonPositiveNot doneNoNo5 (5 probable)None
[16]1978-1979United StatesOral surgeonPositiveNot doneNoNo12 (4 probable, 8 possible)HCW did not wear gloves and had a generalized eczematous dermatitis, including hand involvement
[17]1979-1980United StatesObstetrician-gynecologistPositiveNot doneYesYes4 (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]1979-1981The NetherlandsCardiac surgeonNot reportedNot doneNot specifiedNot specified3 (3 probable)None
[18]1979-1981The NetherlandsPerfusion technicianPositiveNot doneNot specifiedNot specified11 (8 probable, 3 possible)Bleeding warts on HCW’s hands
[19]1980United StatesOral surgeonNot doneNot doneNot specifiedNot specified3 (3 probable)None
[20]1980-1983United KingdomPerfusion technicianPositiveNot doneYesNot specified6 (6 probable)HCW did not wear gloves, and had cuts and abrasions on hands
[20]1980-1983United KingdomSurgical registrarNot reportedNot doneNot specifiedNot specified5 (5 possible)None
[20]1980-1983United KingdomHouse officerNot reportedNot doneNot specifiedNot specified1 (1 possible)None
[21]1984United StatesObstetrician-gynecologistPositiveNot doneNot specifiedNot specified6 (6 probable)None
[22]1984-1985United StatesDentistPositiveNot doneNoNo24 (6 probable, 18 possible)HCW did not wear gloves
[23]1987United StatesGeneral surgeonPositiveNot doneYesNot specified5 (3 probable, 2 possible)None
[24]1987United KingdomObstetrician-gynecologistPositiveNot doneNoNo22 (6 probable, 16 possible)None
[25]1988United KingdomGeneral surgeonNegative1 × 107 copies/mLNoNo1 (1 confirmed)None
[25]1988United KingdomObstetrician-gynecologist, traineeNegative4.4 × 106 copies/mLNoNo3 (3 confirmed)None
[25]1988United KingdomObstetrician-gynecologist, traineeNegative5.5 × 106 copies/mLYesNot specified1 (1 confirmed)None
[25]1988United KingdomGeneral surgeon, urologist, clinical assistantNegative2.5 × 105 copies/mLNoNo1 (1 confirmed)None
[26]1988United KingdomCardiothoracic surgeon, traineePositiveNot doneNoNo17 (9 probable, 8 possible)None
[27]1991United KingdomSurgeonPositiveNot doneNoNo3 (3 possible)None
[28]1991CanadaOrthopedic surgeonPositiveNot doneYesYes2 (1 probable, 1 possible)None
[29]1991-1992United StatesThoracic surgeonPositive1 × 109 copies/mLYesNot specified19 (9 confirmed, 4 probable, 6 possible)None
[30]1991-1993United KingdomCardiothoracic surgeonPositiveNot doneYesNo20 (14 confirmed, 6 probable)None
[31]1991-1996CanadaElectroencephalogram technicianPositiveNot doneNoNo75 (4 confirmed, 71 possible)HCW did not wear gloves and used reusable subdermal EEG electrodes
[32]1993United KingdomGeneral surgeonPositiveNot doneNoNo2 (2 confirmed)None
[33]1993-1994United KingdomGeneral surgeon, traineePositiveNot doneNot specifiedNot specified11 (1 confirmed, 10 possible)None
[33]1994United KingdomGeneral surgeon, traineePositiveNot doneNot specifiedNot specified2 (2 possible)None
[33]1994United KingdomUrologist, traineePositiveNot doneNot specifiedNot specified1 (1 possible)None
[34]1995-1999The NetherlandsGeneral surgeonPositive5 × 109 GE/mLNoNo28 (8 confirmed, 20 possible)HCW noted glove perforations
[35]1996United KingdomOrthopedic surgeonNegative but anti-HB e positive (pre-core mutant)Not doneYesYes1 (1 confirmed)None
[36]1999United KingdomCardiothoracic surgeonNegative but anti-HB e positive (pre-core mutant)1.03 × 106 GE/mLYesYes2 (2 confirmed)None
[37]2001United KingdomGeneral surgeonNegative> 106 copies/mLNoNo3 (3 confirmed)None
[38]2009United StatesOrthopedic surgeonPositive> 17.9 million IU/mLNoNo8 (2 confirmed, 6 possible)None
[39]2010JapanObstetrician-gynecologistPositive1.6 × 109 copies/mLNoNo1 (1 confirmed)None
Table 2 Guidelines for management of hepatitis B virus-infected healthcare workers
ScreeningAll HCWs at risk for HBV infection should be testedNot addressed in guidelineAll surgeons should know their HBV statusMandatory for all HCWs who perform EPPsMandatory for all HCWs who perform EPPs, can be done post-vaccinationMandatory for all HCWs who perform EPPs, can be done post-vaccinationAnnual testing recommended for all HCWs who perform EPPs
VaccinationAll HCWs susceptible to HBV infection should be vaccinatedNot addressed in guidelineAll surgeons who are antibody negative should be vaccinatedMandatory for all HCWs who perform EPPsMandatory for all HCWs who perform EPPsRecommended for all HCWsRecommended for all HCWs
Post- vaccination serologyRecommendedNot addressed in guidelineRecommendedRecommendedRecommendedRecommendedNot addressed in guideline
Frequency of testing/ monitoringEvery 6 moEvery 6 moNot specifiedEvery 12 moEvery 12 mo, or every 3 mo while on antiviral therapyEvery 12 mo if HBeAg negative, every 3 mo if HBeAg positive or on antiviral therapyEvery 3 mo if on antiviral therapy, every 12 mo if cleared HBsAg
Viral load limit1000 IU/mL or 5000 GE/mL104 GE/mLNot specifiedNot specified103 GE/mL104 GE/mLUndetectable by PCR assay
HBeAgNot required to be negativeNot required to be negativeNot required to be negativeNot required to be negativeMust be negativeNot required to be negativeNot addressed in guideline
Restriction of practiceEPPs restricted if viral load greater than set thresholdCategory III procedures restricted if viral burden greater than or equal to 104 GE/mL or HBeAg positiveDetermined by expert panelDetermined by expert panelIf HBeAg positive or if viral load greater than 103 GE/mLIf viral load greater than 104 GE/mLIf HBV DNA level detectable
Definition of EPPsYesYesNoYesYesYesYes
Expert panel recommendedYesYesYes, if HBeAg positive or high viral loadYes, if HBsAg positiveNo, recommend monitoring by an occupational health physicianNoYes
Pre-emptive patient notificationNoNoNot specifiedNoNoOptional for HCWs with HBV DNA levels above the cut-off level in order to continue practicing EPPsNo
Table 3 Categories of exposure-prone procedures
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
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
Not provided
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
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
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
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