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Patient-to-Patient Transmission of Hepatitis C Virus

Richard P. Wenzel, MD, MSc; and Michael B. Edmond, MD, MPH, MPA
[+] Article and Author Information

From Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA 23298.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Richard P. Wenzel, MD, MSc, Department of Internal Medicine, Virginia Commonwealth University, Old City Hall, Suite 405, PO Box 980663, Richmond, VA 23298-0663.

Current Author Addresses: Drs. Wenzel and Edmond: Department of Internal Medicine, Virginia Commonwealth University, Old City Hall, Suite 405, PO Box 980663, Richmond, VA 23298-0663.


Ann Intern Med. 2005;142(11):940-941. doi:10.7326/0003-4819-142-11-200506070-00014
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Cancer affects almost 10 million people in the United States (1) and leads to 560 000 deaths annually (2). Survivors frequently receive chemotherapy during multiple clinic visits each year. Because of pervasive dread associated with the diagnosis of cancer in western cultures, quality of treatment is defined by the health care team's assiduous attention to detail and sensitivity to patients' emotional needs.

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Digestive endoscopy as a preventable risk factor for transmitting Hepatitis C virus.
Posted on June 17, 2005
Emmanuel J RENE
Hépato-Gastroentérologie, Hopital Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018, Paris, FRANCE
Conflict of Interest: None Declared

Is digestive endoscopy a virtual or a real risk factor for transmitting Hepatitis C virus?

We want to stress that three steps are on the way to avoid preventable transmission:

1)The epidemiological one, (as reported in the June 7 issue of the Annals from the experience of Alesia Ciancio and colleagues (1), and the opinion of Richard P.Wenzel and Michael B. Edmond (2).), warrants a " widespread introduction of computerized medical records ("¦to generate"¦) better data on infectious outcomes." (2);

2)The non-epidemiological one, (actually risk management methods, namely, the Failure Mode & Effects Analysis, largely used in health care area, as well as non health care fields,(available at );

3)The interventional one, actually prevention, oriented either toward errors in the process before endoscopy of the next patients, such as cross contamination from other sources (3), either to hypotethical deficiences of the current " good process of infection-control care in endoscopy". This last one is currently sustained by some French medical authorities in insurance companies, who suggests that hepatitis C infected patients should be scoped at the end of an ordinary endoscopic session (4).

Steps 1 & 3 deserve respectively, progresses in computer coverage of health care centre, and ethical consideration as to avoid risk concentration as well as discrimination of hepatitis C infected patients.

Step 2, have been applied in our GI endoscopy suite (5). It led us to the following first conclusion: "Health care providers and patients should be helped to avoid routine endoscopy overuse."

-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;142:903-9. 2- Wenzel R P, Edmond MB Patient-to-patient transmission of hepatitis C virus. Ann Intern Med. 2005;142:940-1. & errata citation Ann Intern Med. 2005;142: XXX 3- Macedo de Oliveira A, White K, Leschinsky D, Beecham B, Vogt T, et al. An Outbreak of Hepatitis C Virus Infections among Outpatients at a Hematology / Oncology Clinic Ann Intern Med. 2005;142: 898-902. 4- Sicot C, Une contamination percoloscopique par le virus de l'hépatite C. Gastroenterol Clin Biol 2005;29:134-135, ( available at ) 5- René E, Vallot T, Vader JP, Croteau R, Helmreich R, Duval G, et al.« It has not yet occured, but might »:potential problems due to a routine endoscopy performed without clear indications for the procedure in a young adult. Am J Gastroenterol 2003; 98:S39.

Conflict of Interest:

None declared

Hygienic precautions rather than isolation , in order to prevent nosocomial HCV transmission
Posted on June 23, 2005
Michel Y Jadoul
Cliniques universitaires St Luc,Université catholique de Louvain
Conflict of Interest: None Declared

In their editorial (1), Wenzel and Edmond state that « all patients with vascular access lines should be considered vulnerable and should be shielded from an exposure to a roommate infected with a bloodborne pathogen". They quote a single study that reported a reduction from 6.8 % to 1 % of the yearly seroconversion rate of hemodialysis (HD) patients after the provision of dedicated space, equipment and nursing staff to isolate HCV (+) HD patients.

In a prospective longitudinal study of the incidence and risk factors for seroconversion for HCV in Belgian HD patients, we were able to reduce the yearly incidence of seroconversion from 1.41 % to 0.56 % and then 0 % (p = 0.014) by reinforcing hygienic precautions, without isolation (2, 3). The rationale for isolating anti-HCV (+) patients (in HD units and other healthcare settings) is highly debatable. Efficient isolation requires that infective patients be correctly identified. The window period between infection (and infectivity) and seroconversion makes serologic tests imperfect for that purpose , especially in immunocompromised patients, whereas the cost of the detection of HCV RNA precludes frequent testing in the many patients at risk. In addition, clustering of anti-HCV (+) patients, most of whom HCV RNA (+), in the same room might theoretically increase their risk of infection by multiple HCV strains. Finally, the much lower infectivity of HCV than of the hepatitis B virus suggests that nosocomial transmission of HCV may be prevented without isolation (3). In the prospective DOPPS observational study of over 8000 HD patients, the isolation of anti-HCV (+) patients was not associated (RR= 1.01, p = 0.99) with prevention of anti-HCV seroconversion. Overall, checking the actual application of basic hygienic precautions to prevent the transmission of all bloodborne pathogens appears highly preferable to isolating patients according to HCV status. An additional advantage of the former policy is the simultaneous prevention of the transmission of other bloodborne pathogens.

Prof. M. Jadoul, M.D. Clin. Univ. St. Luc Department of Nephrology Université Catholique de Louvain Avenue Hippocrate 10 1200 Brussels phone: +32 2 764 18 52 fax: +32 2 764 28 36 e-mail: jadoul@nefr.ucl.ac.be

References 1. Wenzel RP, Edmond MB. Patient-to-patient transmission of hepatitis C virus. Ann Intern Med 2005; 142: 940-941. 2. Jadoul M et al. Incidence and risk factors for hepatitis C seroconversion in hemodialysis: a prospective study. Kidney Int 1993; 44: 1322-1326. 3. Jadoul M et al. Universal precautions prevent hepatitis C virus transmission: a 54 month follow-up of the Belgian multicenter study. Kidney Int 1998; 53: 1022-1025. 4. Jadoul M. Should hemodialysis patients with hepatitis C virus antibodies be isolated? Semin Dial 1995; 8: 1-3. 5. Fissel RB et al. Patterns of hepatitis C prevalence and seroconversion in hemodialysis units from three continents: the DOPPS. Kidney Int 2004; 65: 2335-2342.

Conflict of Interest:

None declared

Judging digestive endoscopy as a preventable risk factor for transmitting Hepatitis C virus.
Posted on October 5, 2006
Emmanuel Rene
APHP; Hépato-Gastroentérologie, Hal Bichat-Claude Bernard, 46 Rue H; Huchard, 75018, Paris, FRANCE
Conflict of Interest: None Declared

In 2005 we raised the question:"Digestive endoscopy as a preventable risk factor for transmitting Hepatitis C virus".(1), as an answer to the editorial (2) of Richard P.Wenzel and Michael B. Edmond.

The editorialists' opinion was that nosocomial patient-to-patient transmission of hepatitis C virus warrants a " widespread introduction of computerized medical records ("¦to generate"¦) better data on infectious outcomes".

One year later, in France, this issue is re-emphasized by the decision of a French appellate court judged guilty by both a gastroenterologist and a health care center director. Whereas in 2003, the first instance court didn't implied the physician. A French medical authority in insurance companies suggested that hepatitis C infected patients should be scoped at the end of an ordinary endoscopic session (see #4 in ref. 1). So that a controversy remains on the consequences of the uncorrected shift of 2 patients (the "donor" and the "recipient") on the endoscopy list in this case.

Beside any controversy, shouldn't we be helped to generate better data on infectious outcomes, as to reinforce prevention?

Shouldn't both justify everyone care?

Isn't anyone concerned to be scoped at the end of an ordinary endoscopic session?

Won't then appear the complex process before endoscopy of the next patients, dealing with organization, devices, as well as human factors (such as those involved in cross contamination from other sources [see #4 in ref 2]) ?

Won't finally health care professionals and society share the need for help to work on the current " good process of infection-control care in endoscopy"... as a part of a whole.

-References

"“1 Rene E, Vallot T, El Attar M, Soule JC Digestive endoscopy as a preventible risk factor for transmitting Hepatitis C virus. (avaible at www.annals.org/cgi/eletters/142/11/940 )

"“2 Wenzel R P, Edmond MB Patient-to-patient transmission of hepatitis C virus. Ann Intern Med. 2005;142:940-1. and Erratum in: Ann Intern Med. 2005;143:395.

Conflict of Interest:

None declared

Accidental re-use of single use devices and prevention after exposure to blood during GI endoscopy.
Posted on December 15, 2006
Emmanuel René
Hopital Bichat-Claude Bernard APHP
Conflict of Interest: None Declared

Nosocomial patient-to-patient transmission of hepatitis C virus warrants a " widespread introduction of computerized medical records ("¦to generate"¦) better data on infectious outcomes". (1).

As for the reduction of the potential impacts of any accidental contamination (see #4 in ref. 2), we checked the current inclusion of the very accidental re-use of single use devices (such as endoscopic biopsy forceps or IV syringes), within the prevention after exposure to potentially infected blood(3).

As to evaluate the current french behaviour in this situation, we submitted through the French National Gastroenterology Society the following question: " What is your practice in the case of any accidental re-use of single use devices (such as endoscopic biopsy forceps or IV syringes) ? "

This web mediated gallup poll allows one or several of the following 5 answers ( through "yes" or "no" icons): 1- "I always include the very accidental re-use of single use devices (such as endoscopic biopsy forceps or IV syringes), within the prevention after exposure to potentially infected blood" 2- "I always scope the patients known to be infected at the end of the list" 3- "I report the incident as a risk factor but without including it within the scope of exposure to potentially infected blood prevention" 4- "I don't think this event to be a risk factor" 5- "I have seen none of the above statement within official recommandations"

Among the 80 GI practitioners who, at this time, visited the poll, 15 votes were according to a bimodal repartition ( answer 1 & 5); none viewer voted for answer 2, 3 nor 4.

Of interest is the claim of french GI practitioners that current inclusion of the very accidental re-use of single use devices (such as endoscopic biopsy forceps or IV syringes), within the prevention after exposure to potentially infected blood, is waranted although not mentionned within official recommandations.

References:

1 Wenzel R P, Edmond MB Patient-to-patient transmission of hepatitis C virus. Ann Intern Med. 2005;142:940-1. and Erratum in: Ann Intern Med. 2005;143:395.

2- Rene E, Vallot T, Duval G, Soule JC. Digestive endoscopy as a preventible risk factor for transmitting Hepatitis C virus. Ann Intern Med. Rapid communication, June 20, 2005.

3- Roome AJ, Hadler JL Thomas AL et al. Hepatitis C Virus Infection Among Firefighters, Emergency Medical Technicians, and Paramedics Selected Locations, US, 1991-2000. MMWR 2000;49:660-5.

Conflict of Interest:

None declared

Viral transmission uring endoscopy sessions : the Ottawa hypothetical case under evaluation.
Posted on December 4, 2011
Emmanuel J., Ren?, Professor of Medicine
Bichat-Claude Bernard Hal PARIS FRANCE
Conflict of Interest: None Declared

Emmanuel RENE, MD, Hepato-Gastroenterologie, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, FRANCE, & AFGRIS vice- pdt. Dr. I. Levy statement, @ , is incorrect. The error is the risk management method chosen as to generate data on viral transmission risk (1,2). In turn, it is due to, first: the lack of "widespread introduction of computerized medical records (...to generate...) better data on infectious outcomes", as required since 2005 in the Annals (2); Second, since Dr. Levy? cannot rely on direct data, his statement was sustained by a panel expert leading to the publication of "transmission rate" associated with flex scope procedures: "less than 1 in 1 million for Hepatitis B, less than 1 in 50 million for Hepatitis C, and less than 1 in 3 billion for HIV" (which means respectively, 10 to the minus 6, 20 to the minus 7, and 30 to the minus 9). The context of lacking "computerized medical records (...to generate...) better data on infectious outcomes", makes those data "too much on to be true". Studying a French similar simulation, the risk management methodologist favored (data not shown), the Failure Mode and Effect Analysis (FMEA, ), as to assess the risks in such situations. This method consists in establishing the Risk Priority Number (RPN), by calculating the product of the 3 following factors, its severity, its occurrence rate, and its detection availability. Though a weak index, since RPNs have no value or meaning in themselves, it is the only available risk expression. In conclusion: aren?t we, as any correctly informed patient should be, aware of the infectious risks of our scopes, because their high heat sensitivity, (which precludes them from the classical disinfection ways of the non-disposable surgical tools), as well as the quite tiny size of the scope?s biopsy channel, (up to now a non disposable channel, and yet at risk of containing residues, themselves contaminant candidates for the next biopsy forceps. This may improve due to a recent patent of mine)?

. -

Eratum :Viral transmission uring endoscopy sessions : the Ottawa hypothetical case under evaluation.
Posted on December 8, 2011
Rene, RENE, Professor of medicine
Bichat-Claude Bernard Hal Paris France
Conflict of Interest: None Declared

I made an error in indicating the rate risk for HIV. Indeed, I did a mistake copying the risk stated in . Therefore I mentioned wrongly the statement as {"less than 1 in 3 billion for HIV" (which means and 30 to the minus 9)}. Actually it should have been see the statement {"les than 1 person in 3 milliards for HIV " (which means and 3 to the minus 10)}. Did we realize that, since according to the UN the whole humanity is estimated to 7 milliards (october 31 2011)< http://fr.wikipedia.org/wiki/Population_mondiale>, therefore roughfly half of them should have been scoped and surveyed at least one year, to lead to that value?

Conflict of Interest:

None declared

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