Unusual cases of hepatitis b virus transmission

One reason some parents don’t vaccinate their children against the hepatitis B virus (HBV) is their belief that their child has no risk of ever coming in contact with the virus. “My child will never be sexually promiscuous or addicted to drugs! Why does he or she need to be protected against hepatitis B?” Of course, it is impossible to predict which children will grow up and engage in risky behavior. But let’s assume for a moment that this hypothetical parent is right . . . does this mean that his or her child has no possibility of ever coming in contact with HBV?The truth is that transmission of HBV can sometimes occur in unusual ways. Approximately 30% of people newly infected with HBV do not know how they contracted the virus. The following reports of some uncommon methods of HBV transmission illustrate how every unvaccinated person is at some (albeit limited) risk of HBV infection. 1. Between April 1984 and February 1985, thymectomy. The thoracic surgery physician- found 75 who developed HBV infection 24 cases of HBV infection occurred among in-training who assisted in surgery had had from 1991 to 1996. All of the cases had had the patients of a dentist practicing in rural acute HBV infection six months earlier at least one EEG performed with reusable Indiana. Two of these patients died of subdermal electrodes. The outbreak was a fulminant hepatitis. The dentist had never positive. Though the hospital had used result of a common source of infection (a had hepatitis symptoms, but blood tests appropriate infection control procedures, technician who was HBeAg positive) and indicated he was hepatitis B surface antigen further investigation identified 19 other 10. In 1996, 9 residents of an Ohio nursing home 2. An investigation documented transmission 6. CDC reported a case involving a 4-year-old from an HBV-infected elementary school and 2 with chronic HBV infection; all were student to a teacher who had no overt infection; another child at the center who had diabetic. HBV infection was associated with percutaneous or permucosal exposure to a history of biting and scratching was found fingerstick capillary sampling, specifically the student’s blood or infectious body with the use of a lancet device with a re-used fluids. The student did sneeze saliva and end cap. That same year, acute hepatitis B nasal secretions onto the teacher’s cracked, 7. In December 2001, the New York City illness was diagnosed in 3 diabetic patients chapped hands. The teacher gave birth to an in a New York hospital. A review of serologic infant 3 weeks prior to her diagnosis, and informed of two elderly patients who had records of previous patients identified another her infant also tested HBsAg positive. The 11 possible cases of nosocomially [hospital] teacher and student were found to have the and who had visited the same physician. acquired HBV infection. Transmission seems to have occurred through contamination of a found an additional 38 patients in the same practice who had acute HBV infection. 3. In Rhode Island, 35 patients of an Further study found that infection was 11. The University of Sydney used molecular acupuncturist became infected with HBV, strongly correlated with having received fingerprinting to provide evidence that a the primary source for the outbreak being a an injection at this office, where doses of child chronically infected with HBV who patient in the practice. Investigators were not atropine, dexamethasone, and vitamin B12 had an exudative skin lesion and a history able to determine the precise mechanism of were drawn from multiple-dose vials into of biting had infected another child in the transmission, but theorized it was possibly due to inadequately sterilized needles or the transfer of infectious material from 8. Thirty patients who received autohaemo- 12. Outbreaks of HBV infection occurred in 5 the acupuncturist’s hands to sterilized therapy (a procedure that involves drawing chronic hemodialysis centers in California, the patient’s blood, mixing it with saline, Nebraska, and Texas from April through and reinjecting the mixture) at an alternative August 1994. Transmission of HBV from 4. In Japan, 5 of 10 members of a high medicine clinic in the U.K. were infected hemodialysis patients with chronic HBV school sumo wrestling club developed with HBV. Five had markers of chronic infection to susceptible patients was believed HBV infection in a one-year period. The HBV infection. Contaminated saline in a to have resulted from failure to identify asymptomatic index case often bled from repeatedly used bottle was the probable and isolate HBV-infected patients during injuries received while wrestling, presumably dialysis; sharing of staff, equipment, and transmitting HBV to his teammates through supplies among patients; and failure to 9. In 1996, an outbreak of HBV infection vaccinate susceptible patients against the was detected among patients attending 5. In July 1992, a 47-year-old woman became ill an electroencephalogram (EEG) clinic in with acute HBV infection after undergoing a Toronto. A follow-up of all available patients Technical content reviewed by the Centers for Disease Control and Prevention, May 2007.
www.immunize.org/catg.d/p2100nrs.pdf • Item #P2100 (5/07) Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.vaccineinformation.org • www.immunize.org 13. A study of 920 employees in a large 20. In August 2002, the Oklahoma State epidemiologic techniques discovered that the residential institution for the develop- Department of Health investigated a pain woman’s virus was identical to virus isolated mentally disabled in Oregon found an overall remediation clinic where they discovered a from an HBsAg-positive woman who had prevalence of 10% for anti-HBc, a marker certified registered nurse anesthetist routinely had teeth extracted at the same oral surgeon of present or past HBV infection. Antigen reused needles and syringes. They tested 793 earlier the same day. Despite intensive positivity was significantly associated with patients for hepatitis C virus (HCV), HBV, investigation, no deficiencies in infection a history of working directly with clients.13 and HIV infection. A total of 69 HCV and 31 HBV infections were identified that probably 14. From June 1989 through March 1990, 26 These examples are not presented to scare. Such patients in a California hospital contracted modes of transmission are relatively rare, and acute HBV infection. A retrospective 21. Twenty-two cases of acute hepatitis B disease sexual activity is still the predominant source of cohort study indicated that transmission of were linked to a Florida dermatologist’s HBV infection among U.S. adults. However, these the virus occurred percutaneously through practice during 1985-1991. Since the reports demonstrate that one can acquire HBV contamination of the stabilizing platform on dermatologist was not HBsAg positive, the infection without engaging in so-called “risky” outbreak is believed to have resulted from behavior. the dermatologist’s failure to apply either 15. A general surgeon in the Netherlands
An editorial about the report summarized in #26 universal precautions or sterile surgical infected a number of patients with HBV over stated: “There and in other instances investigators four years of practice (transmission from have been unable to explain how the virus traveled the surgeon was confirmed in 8 patients, from person A to person B—and that is troubling. 22. In a Mississippi nursing home in 2003, two probable in 2, and possible in 18). Two It is troubling because it suggests that there are residents died of acute hepatitis B, prompting patients were chronically infected, and one aspects of transmission of bloodborne disease that an investigation. Nine percent of all residents remain poorly understood.”25 case of secondary transmission to a spouse tested HBsAg positive; among residents who routinely received fingersticks for On the average, any baby born in the United States who isn’t vaccinated against HBV has a 5 percent 16. Eleven cases of HBV infection were
glucose monitoring, 14 of 38 had acute HBV chance of acquiring HBV infection during his detected among 65 members of the Okayama infection. In this facility, the spring-loaded or her lifetime. By avoiding obvious means of University’s football team during a period of barrel of a fingerstick device was used for exposure, people can reduce the odds of becoming 19 months. All players with acute hepatitis B infected. But in reality, as the U.S. Public Health virus infection belonged to the same training 23. Because barbers may be exposed to Service so succinctly stated, “Anyone can get HBV group as an HBeAg carrier on the team, their customers’ blood, a study in Turkey infection.”26 Fortunately, the availability of hepatitis with transmission presumably occurring attempted to determine the prevalence B vaccine means no one has to get infected.
through contact with open wounds during of HBV and HCV infection in barbers compared to a comparison group. The Sources 17. In Israel, a butcher who was chronically
prevalence of antibodies against HBV was 1. Lethal outbreak of hepatitis B in a dental practice. infected with HBV infected 3 of his co- higher in the group of 176 barbers (39.8%) workers, who in turn infected their spouses. than in the control group (28.3%). Most of 2. Hepatitis B virus transmission in an elementary The workers shared knives. If the index the seropositive subjects had been exposed school setting. JAMA Vol. 278(24):2167-9, 1997.
case cut or punctured himself, his HBV- 3. A large outbreak of acupuncture-associated hepatitis contaminated blood could have tainted a 24. After a nursing home resident in North knife that other butchers later used, making 4. An outbreak of hepatitis B in members of a high Carolina developed acute hepatitis B, it possible for the infection to be transmitted school sumo wrestling club. JAMA 248(2):213-4, the other residents were tested for HBV from the knife to them through a break in infection. Of the 45 residents who received 5. Transmission of hepatitis B virus to multiple patients fingersticks for glucose monitoring, 18% had from a surgeon without evidence of inadequate 18. Hepatitis B virus infection was transmitted acute HBV infection. Only single-use lancets infection control. N Engl J Med 334(9):549-54, by a cardiothoracic surgeon to 2 patients were used and insulin vials were not shared during coronary artery bypass surgery. among patients. However, patients shared 6. Hepatitis B virus transmission between children in Both patients presented with serious clinical one glucometer which was not routinely day care. Pediatr Infect Dis J 8(12):870-5, 1989.
illness 12 weeks after surgery. The surgeon cleaned between patients. Other equipment 7. Transmission of hepatitis B and C viruses in may have been contaminated with blood outpatient settings–New York, Oklahoma, and as well, allowing HBV to be indirectly Nebraska, 2000-2002. MMWR 52(38):901-6, 19. In 1986, 4 cases of HBV infection were
linked to an oral surgeon practicing in New 8. Molecular epidemiology of a large outbreak of Hampshire. One of the patients developed 25. Six persons in Italy developed acute HBV hepatitis B linked to autohaemotherapy. Lancet infection from their adopted children, all of 9. An outbreak of hepatitis B associated with reusable reported 8 other outbreaks of HBV infection subdermal electroencephalogram electrodes. CMAJ 162(8)1127-31, 2000.
traceable to general dentists or oral surgeons 26. A 60-year-old woman who was not sexually from 1974 to 1986, with the number of active, did not use IV drugs, and had clinically infected patients in each outbreak no contact with HBV-infected persons developed acute hepatitis B. Molecular 10. Nosocomial hepatitis B virus infection associated procedures during 4 Years. Infect Control Hosp care facilities—Mississippi, North Carolina, and Los with reusable fingerstick blood sampling devices– Angeles County, California, 2003-2004. 54(9):220- Ohio and New York City, 1996. MMWR 46(10):217- 16. Horizontal transmission of hepatitis B virus among players of an American football team. Arch Intern 22. Prevalence of hepatitis B and C virus infection in 11. Horizontal transmission of hepatitis B in a children’s barbers in the Sivas region of Turkey. Occup Med day-care centre: a preventable event. Aust N Z J 17. Hepatitis B–an occupational risk for butchers? Ann 23. Hepatitis B “by proxy”: an emerging presentation 12. Outbreaks of hepatitis B virus infection among 18. Acute hepatitis B in two patients transmitted from an of chronic hepatitis B in children. J Pediatr hemodialysis patients–California, Nebraska, and e antigen negative cardiothoracic surgeon, Commun Gastroenterol Nutr 44(2):268-9, 2007.
Texas, 1994. MMWR Vol. 45(14):285-9, 1996.
24. Patient-to-patient transmission of hepatitis B 13. Hepatitis B and workers in institutions for the 19. Epidemiologic notes and reports: outbreak of virus associated with oral surgery. J Infect Dis mentally retarded: risk of infection for staff in patient hepatitis B associated with an oral surgeon–New care. Am J Prev Med 5(3):170-4, 1989.
25. Transmission of hepatitis B in the health care setting: 14. Nosocomial transmission of hepatitis B virus 20. Patient-to-patient transmission of hepatitis B in the elephant in the room… or the mouse? Jour Infect associated with the use of a spring-loaded finger-stick a dermatology practice. Am J Public Health device. N Engl J Med 326(11):721-5, 1992.
26. Important information about hepatitis B, hepatitis B 15. Transmission of hepatitis B virus from a surgeon to 21. Transmission of hepatitis B virus among persons vaccine, and hepatitis B immune globulin. U.S. Dept. his patients during high-risk and low-risk surgical undergoing blood glucose monitoring in long-term of Health and Human Services, May 1992.

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