Digestive Endoscopy Is Not a Major Risk Factor for Transmitting Hepatitis C Virus

To the Editor. We appreciated the paper by Ciancio and colleagues on the risk of hepatitis C virus (HCV) infection through endoscopy in Italy1. No HCV seroconversion was detected in 912 subjects sharing the endoscope with an anti-HCV-positive subject. Cleaning and disinfection of instruments was always performed according to international guidelines2 and only disposable vials of anestetics were used. Although the number of patients is low to firmly exclude a finding due to chance (95%CI of the incidence=0 -4.2 per 1000 persons), the study suggest that good practice can be effective on the field. Unfortunately, effective guidelines are not uniformly implemented. Nationwide data collected through the Integrated Epidemiological System for Acute Viral Hepatitis (SEIEVA) can give "real world" information on the topic of endoscopy and HCV infection in Italy. SEIEVA covers 60% of the Italian population and has been described in details elsewhere3. Briefly, a standardized questionnaire on oro-fecal and parenteral risk factors is administered to all acute symptomatic hepatitis cases reported; the interviewer is blinded to the viral etiology. We analyzed data on risk factors reported by 886 nonA-nonB/HCV-positive and 4,022 hepatitis A cases (used as controls) notified in the period 2000- 2004 and older than 14 years (only few hepatitis C cases were 14 years old or younger). The information on endoscopy performed within six months before disease onset was available for 86% of hepatitis C and 88% of hepatitis A cases; it was reported by 10.1% and 1.5% of them, respectively (OR=7.41; 95%CI=5.10-10.82). Digestive endoscopy represented 67% of the total. In 1.8% of hepatitis C cases endoscopy was the only risk factor reported among those routinely recorded. At multivariate analysis (adjusting for socio-demographics, i.v. drug use, blood transfusion, piercing/tattooing, barbershop shaving, acupuncture, manicure/pedicure, odontoiatry, surgery, dialysis, living or having sex with a HCV-positive subject, and number of sexual partners) endoscopy resulted as an independent predictor of acute hepatitis C (adjusted OR=2.61; 95%CI=1.10- 6.21). This finding is consistent with a previous SEIEVA report on iatrogenic procedures and HCV infection in the period 1994-19994 (adjusted OR for endoscopy=2.1; 95%CI=1.2-3.6). We cannot exclude the use of multidose vials of anestethic during endoscopy.

In conclusion, certainly endoscopy is not a major factor of HCV spread in Italy, accounting only for a minority of new infections. However, these and possibly other viral infections can be effectively prevented by implementation of available guidelines, as shown by Ciancio1. More efforts are needed to widely adopt safer standards of care in medical settings.

1) Ciancio A, Manzini P, Castagno F, D'Antico S, Reynaudo P, Coucourde L, et al. Digestive endoscopy is not a major risk factor for transmitting hepatitis C virus. Ann Intern Med. 2005; 142: 903-9.

2) Rey JF, Kruse A, Axon T, Petersen C, Reid A, Sorkin M, et al. ESGE guidelines for the prevention of endoscopic transmission of type C hepatitis and update on Creutzfeldt-Jakob disease. European Society for Gastrointestinal Endoscopy. Endoscopy. 1997; 29: 203-204.

3) Mele A, Rosmini F, Zampieri A, Gill ON and SEIEVA Collaborating Group. Integrated epidemiological system for acute viral hepatitis in Italy (SEIEVA): description and preliminary results. Eur J Epidemiol. 1986; 2:300-304.

4) Mele A, Spada E, Sagliocca L, Ragni P, Tosti ME, Gallo G, et al. Risk of parenterally transmitted hepatitis following exposure to surgery or other invasive procedures: results from the hepatitis surveillance system in Italy. J Hepatol. 2001; 35: 284-289.

Conflict of Interest:

None declared

TO THE EDITOR

Ciancio and colleagues (1) reported that properly performed digestive endoscopy is not a major risk factor for the transmission of HCV. The authors report that all 8260 patients undergoing endoscopy in 3 units and 2 blood banks in northwestern Italy remained negative for anti-HCV 6 months after the procedure. This issue is of relevance in those patients requiring repeated endoscopic procedures (2), including Inflammatory Bowel Diseases (IBD) patients. In a multicenter study, we reported the prevalence and risk factors for HCV and HBV infection in 332 patients with CD, 162 with Ulcerative Colitis (UC) and 374 controls (C)(3). Risk factors considered were: age, gender; area, occupation, surgery, number of transfusions, esophagogastroduodenoscopy, colonoscopy, IBD duration and extent. In CD, HCV or HBV infection was detected in 24.7% of patients. HCV prevalence was higher in CD than in UC (7.4% vs 0.8%; p=0.001) and comparable to C (5.1%; p=n.s.). However, in the age groups < 50 years, HCV prevalence was higher in CD than in C (6.8% vs 1.9%; p=0.01). HBcAb positivity was higher in CD (10.9%) and UC (11.5%) than in C (5.1%; p=0.01 and p=0.02). In agreement with Ciancio and colleagues (1), we found that previous endoscopy and the number of endoscopies do not represent risk factors for HCV or HBV infection. HCV infection in CD was associated with surgery (OR 1.71; 95% CI 1.00-2.93; p=0.04), transfusions (OR 3.39; 95% CI 1.04-11.04; p=0.04) and age (OR 2.3; 95% CI 1.61-3.56; p<0.001). In IBD, HBV infection was associated with age (CD: OR 2.08; 95% CI 1.37-3.17; p=0.001; UC: OR 1.71; 95% CI 1.07-2.75; p=0.02) and southern area (CD: OR 4.32; 95% CI 1.00-18.6; p<0.04; UC: OR 4.32; 95% CI 1.00-18.6; p=0.04), and also with female gender in CD (OR 2.68; 95% CI 1.37-3.17; p=0.001) and with disease duration in UC (OR 1.20; 95% CI 1.06-1.36; p=0.002). Ciancio and colleagues (1), tested patients before and after endoscopy performed from January 1999 to December 2002 in northwestern Italy. In our study, HCV infection was searched from June 1997 to March 1999 in patients with endoscopy performed at any time in Units from both northern and southern Italy (showing a higher HCV prevalence)(3,4). This supports that endoscopy is not a major risk factor for HCV infection also in IBD, even when considering procedures performed before 1996. The high proportion of IBD patients showing HBV and/or HCV infection (3,4) however suggest careful medical handling of IBD patients, in order to prevent virus transmission in this population at high risk of infection.

References 1. Ciancio A, Manzini P, Castagno F, D'Antico S, Reynaudo P, Coucourde L, et al. Digestive endoscopy is not a major risk factor for transmitting hepatitis C virus. Ann Intern Med 2005: 142: 903-909. 2. Bronowicki JP, Venard V, Bottè C, Monhoven N, Gastin I, Chonè L, et al. Patient-to-patient transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997; 337: 237-240. 3. Biancone L, Pavia M, Del Vecchio Blanco G, D'Incà R, Castiglione F, De Nigris F, et al. Hepatitis B and C virus infection in Crohn's Disease. Inflammatory Bowel Diseases 2001; 7(4): 287-294. 4. Biancone L, Del Vecchio Blanco G, Castiglione F, Bresci A, Pallone F, Sturniolo GC, on behalf of the GISC. Immunomodulatory drugs in Crohn's Disease patients with hepatitis B or C virus infection. Gastroenterology 2002; 122(2):593-594.

Conflict of Interest:

None declared