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42. Rowland LP, Araki S, Carmel P. Contracture in McArdle’s disease. Arch Neurol 1965,13: 541-44.

43. Vignos PJ, Warner JL. Glycogen, creatine and high energy phosphate in human muscledisease. J Lab Clin Med 1973; 62: 579-90.

44 Thomson WHS, Smith I. X-Linked recessive (Duchenne) muscular dystrophy (DMD)and purine metabolism: effects of oral allopurinol and adenylate. Metabolism 1978;27: 151-63.

45 Brenton DP, Edwards RHT, Grindrod SR, Tofts PS. Computerised x-ray tomographyto determine human skeletal muscle size and composition in health and disease. JPhysiol 1981; 317: 3P.

46. Bárány M. Discussion contribution. In: Rowland LP, ed. Pathogenesis of humanmuscular dystrophies. Amsterdam: Excerpta Medica, 337-40.

47. Chalovich JM, Burt CT, Cohen SM, Glonek T, Bárány M. Identification of anunknown 31P nuclear magnetic resonance from dystrophic chicken as L-serineethanolaminephosphodiester. Arch Biochem Biophys 1977; 182: 683-89.

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10: 13-35.

Public Health

INTERRUPTION OF HEPATITIS BTRANSMISSION BY MODIFICATION OF A

GYNAECOLOGIST’S SURGICAL TECHNIQUE

MITCHELL CARLDONALD P. FRANCIS

DURWARD L. BLAKEY

JAMES E. MAYNARD

Hepatitis Laboratories Division, Center for Infectious Diseases,Centers for Disease Control, U.S. Department of Health and Human

Services, World Health Organisation Collaborating Center forReference and Research on Viral Hepatitis, Phoenix, Arizona, and

Mississippi State Health Department, U.S.A.

Summary Between January, 1979, and January, 1980,hepatitis B developed in three women with-

in 6 months of their undergoing gynaecological surgery at acommunity hospital in Mississippi. Subsequent investi-

gation revealed another case of hepatitis B associated withgynaecological surgery. The gynaecologist who carried outall four operations (gynaecologist A) was a chronic carrier ofhepatitis B. Hepatitis B surface antigen subtyping on serumfrom gynaecologist A and from one of the hepatitis B patientsgave identical results. Patients of gynaecologist A whounderwent total abdominal hysterectomies or bilateral

salpingo-oophorectomies were at a greater risk of acquiringhepatitis B than were patients in whom the same procedureswere carried out by a control group of gynaecologists. Aftergynaecologist A modified his surgical technique and beganwearing two pairs of gloves during surgery, there was nofurther hepatitis B transmission to his surgical patients.

INTRODUCTION

HEPATITIS B is a major cause of morbidity and mortality inthe U.S.A. In 1980 alone, 18 660 cases of hepatitis B werereported to the Centers for Disease Control,’ and this figuremay represent only a small percentage of the cases of icterichepatitis B in the U.S.A. during that year.2 Chronic liverdisease will develop in approximately 10% of these patients asa consequence of hepatitis B infection. 3The risk of transmission of hepatitis B by health-care

professionals is believed to be small.4 Although it is estimatedthat 0 - 6% of health-care professionals are chronic carriers ofhepatitis B,5 only a small number of outbreaks of hepatitis Bcaused by these subjects have been reported.6-9 We nowreport the investigation of an outbreak of hepatitis B

transmitted by a gynaecological surgeon (gynaecologist A) inMississippi.

PATIENTS AND METHODS

Case Definition

Any woman with hepatitis B confirmed with testing for hepatitisB surface antigen (HBsAg) by radioimmunoassay (RIA) who hadundergone surgery by gynaecologist A in the 6 months before theonset of symptoms satisfied. the case definition in this study.

Investigation of Initial OutbreakThe investigation began in March, 1980, after three women who

had been operated on by gynaecologist A in a community hospital inMississippi began to show symptoms of hepatitis B betweenJanuary, 1979, and January, 1980. Gynaecologist A had beenknown to be a carrier of HBsAg since October, 1978.

Lists were compiled of all patients treated surgically bygynaecologist A between January, 1979, and January, 1980, and ofall patients treated surgically by a group of other gynaecologists atthis hospital during that time; the types of operations for each of thepatients were noted. The names were compared with a list of allknown cases of hepatitis B in that area between January, 1979, andMarch, 1980. The hospital records for the three patients withhepatitis B were reviewed to identify other possible sources ofhepatitis B infection.Gynaecologist A voluntarily suspended his practice during the

initial investigation. At this time he was interviewed in detail abouthis surgical technique. At the end of the initial investigation, theMississippi State Health Department allowed gynaecologist A tocontinue his surgical practice after he agreed to modify his surgicaltechnique and to obtain informed consent from all his surgicalpatients. In addition, it was agreed that the Hepatitis LaboratoriesDivision of the Centers for Disease Control in cooperation with theMississippi State Health Department would monitor byquestionnaire all patients who were operated on by gynaecologist Aand by the control group of gynaecologists between April andSeptember, 1980.

Patient Follow-up Study

Questionnaires were sent in September, 1980 (6 months aftergynaecologist A began to modify his technique) to 278 patients whoreceived surgical treatment from either gynaecologist A or thecontrol group of gynaecologists between April and June, 1980: inMarch, 1981 (12 months after gynaecologist A began to modify histechnique) questionnaires were sent to 462 patients treated betweenApril and September, 1980. The questionnaires were designed todetect clinical hepatitis. In this follow-up study, a surgical patient ofgynaecologist A who became jaundiced and was positive for HBsAgwould be defined as having hepatitis B.

Laboratory TestingSerum from gynaecologist A was tested in March, 1980, with RIA

for HBsAg, antibody against hepatitis B core antigen (anti-HBc),

732

and antibody against HBsAg (anti-HBs) (’Ausria’, ’Corab’, and’Ausab’, respectively, Abbott Laboratories, Chicago), with

rheophoresis and with RIA for hepatitis B e antigen (HBeAg), andwith RIA for antibody against HBeAg (anti-HBe). The HBsAg titrewas determined with end-point titration by RIA," and Dane’particles were counted by means of immune electron microscopy. 12HBsAg subtyping was carried out by immunodiffusion. 13 A secondserum sample obtained from gynaecologist A 1 year later was testedwith RIA for HBsAg and with rheophoresis and RIA for HBeAg.The HBsAg titre was again determined with end-point titration byRIA, and Dane particles were counted again by means of immuneelectron microscopy.Serum samples from the patients were tested with RIA for HBsAg

at the time of diagnosis of hepatitis B, and HBsAg subtyping byimmunodiffusion was carried out on the serum of one patient.

RESULTS

Comparison of the names of all surgical patients ofgynaecologist A and those of control patients against the listof all known cases of hepatitis B in the metropolitan arearevealed another case of hepatitis B who had been treated bygynaecologist A, bringing’ the number of cases in thisoutbreak to four. In addition, hepatitis B developed within 6months of surgery in one woman treated surgically by acontrol gynaecologist. None of the cases had other risk factorsfor hepatitis B (intravenous drug use, medical employment,&c). All the four treated by gynaecologist A had undergonelaparotomy. Two had dilatation and curettage with totalabdominal hysterectomies and bilateral salpingo-oophorectomies, one had a bilateral salpingo-oophorectomywith release of adhesions, and one patient had a totalabdominal hysterectomy and appendicectomy. At the time ofthe investigation only one patient remained HBsAg-positive;subtyping showed the HBsAg to be of the ayw subtype, thesame as that of gynaecologist A. This subtype is relativelyrare in the U.S.A. 14,15 Review of the hospital records of thepatients showed that the only possible source of hepatitis B towhich all four of gynaecologist A’s patients had been exposedwas the gynaecologist himself.From July, 1978, to December, 1979, gynaecologist A

carried out 1425 surgical procedures. The proceduresassociated with transmission of hepatitis B were totalabdominal hysterectomy and bilateral salpingo-oophorectomy alone, and appendicectomy, release of

adhesions, and dilatation and curettage performed with totalabdominal hysterectomy. For patients undergoing the

surgical procedures associated with hepatitis transmission,the risk of hepatitis B was significantly higher in the patientsof gynaecologist A than that in patients of the control group ofgynaecologists (p = 0 - 040 for total abdominal hysterectomyand p = 0 - 056 for bilateral salpingo-oophorectomy, Fisher’sexact test, one-tailed).Serum from gynaecologist A taken at the time of the

investigation was positive for HBsAg by RIA. Rheophoresisshowed no HBeAg in his serum, but it was weakly positive forHBeAg when tested with RIA. The serum was anti-HBe-negative. The HBsAg titre of this specimen was 1:100 000,and no Dane particles were detected with immune electronmicroscopy. The second serum sample from gynaecologist A,obtained 1 year later, was also positive for HBsAg but wasnegative for HBeAg, both by rheophoresis and by RIA, andnegative for anti-HBe. The HBsAg titre was again 1:100 000,and again no Dane particles were detected with immuneelectron microscopy.When we interviewed gynaecologist A about his surgical

technique, we learned that he often held a surgical needle in

his hand during suturing instead of using a needle holder. Inaddition, he remembered finding blood on his hand afterremoving his gloves at the end of the surgical procedureseveral times during the year of the outbreak. The

Mississippi State Health Department allowed gynaecologistA to resume his surgical practice after he agreed to use aneedle holder during suturing and to wear two pairs of glovesduring surgery. He also agreed to change gloves and surgicalinstruments if he pricked himself with a needle or otherinstrument or if he tore his glove. Each patient to be operatedon by gynaecologist A was required to give written informedconsent, indicating that she knew her gynaecologist hadtransmitted hepatitis and that it was possible that he could doso again.

Of patients who underwent gynaecological surgery duringthe 3 months after gynaecologist A began to modify histechnique, 58 (70 - 7%) of 82 patients treated by gynaecologistA and 126 (64 - 307o) of the 196 patients treated by the controlgroup returned completed questionnaires. No patient fromeither group had symptoms of hepatitis after her gynaecologi-cal surgery. Of patients who underwent surgery during the 6months after gynaecologist A began to modify his technique,83 (62-4%) of 133 patients treated by gynaecologist A and224 (68-1%) of 329 treated by the control group returnedcompleted questionnaires. Again, no patient had symptomsof hepatitis B after gynaecological surgery.

DISCUSSION

In this outbreak both serological and epidemiologicalevidence indicated that hepatitis B was transmitted bygynaecologist A to four of his patients. The transmission ofhepatitis B by gynaecologist A seems to have resulted from acombination of the type of surgery carried out and the

surgical technique used. The increased risk of transmissionassociated with procedures requiring laparotomy is

presumably related to the increased risk of accidental needleprick during this technically complicated procedure. In twoprevious outbreaks of hepatitis B transmitted bygynaecological surgeons, major operative procedures werealso involved; in the firstS transmission was associated withoperative procedures that required laparotomy, and in thesecond (M. T. Osterholm, A. G. Dean, and B. D. Wolvert,unpublished), transmission was associated with vaginalhysterectomy. In addition, gynaecologist A’s surgicaltechnique was such that HBsAg-positive blood could comeinto contact with any surface within the surgical field.This study and others, published6,s and unpublished, have

confirmed that only medical and dental practitioners whoseserum is positive for HBeAg transmit hepatitis B, as might beexpected in light of previous studies correlating HBeAg withinfectivity. 16-18 By inference from specimens obtained 4V2-9months after transmission, gynaecologist A may havetransmitted hepatitis B with relatively low levels of

circulating hepatitis B virus.No further transmission of hepatitis B was found after

gynaecologist A began wearing two pairs of gloves duringsurgery and altered his surgical techniques. Gynaecologist Adoes not recall either pricking himself with a needle orinstrument or finding blood on this hand after any surgicalprocedure since he made these changes. Although his secondsample was negative for HBeAg by RIA, the HBsAg titre ofthis sample was identical to that of the first serum sample. Inaddition, no Dane particles were detected in either specimenby immune electron microscopy. Thus, during the 6-monthfollow-up study, gynaecologist A’s blood had the same

733

infectivity, which presumably reflects a stable carrier state.This suggests that the absence of further hepatitis Btransmission was secondary to the alteration in surgicaltechnique, but gynaecologist A may have been less infectiousduring the entire follow-up study than at the time of hepatitisB transmission. This possibility cannot be investigatedbecause no serum specimen taken at the time of transmissionis available.This outbreak and investigation have important

implications for the almost 1% of health-care professionalswho are chronic carriers of hepatitis B. It emphasises thathealth-care professionals must take extreme care to avoidexposing patients to their potentially infectious body fluidsand shows that it is possible to interrupt transmission ofhepatitis B by modification of techniques. The modificationof those techniques causing transmission of hepatitis B can beaccomplished by carefully controlling conditions, and thismay be a far better solution to the problem of health-careprofessionals who transmit disease than dismissal or cessationof practice.We thank Bert Murphy and Charles Schable for serological testing, Clif

Gravelle for electron microscopy, and Marlene Nichols, Teresa Dinse, andNancy Axelrod for preparation of the manuscript.

Correspondence should be addressed to M. C., Hepatitis LaboratoriesDivision, 4402 North Seventh Street, Phoenix, Arizona 85014, U.S.A.

REFERENCES

1 Centers for Disease Control. Morbid Mortal Weekly Rep 1981; 29: 632.2. Centers for Disease Control. Morbid Mortal Weekly Rep 1975; 24: 165-66.

3. Redeker A. Viral hepatitis: clinical aspects. Am J Med Sci 1975; 270: 9-16.4. Maynard JE. Viral hepatitis as an occupational hazard in the health care profession In:

Vyas GN, Cohen SN, Schmid R, eds. Viral hepatitis. Philadelphia: The FranklinInstitute Press, 1978: 321-32.

5. Denes AE, Smith JL, Maynard JE, Doto IL, Berquist KR, Finkel AJ. Hepatitis Binfection in physicians: results of a nationwide seroepidemiologic survey. JAMA1978; 239: 210-12.

6. Rimland D, Parkin WE, Miller GB, Schrack WD. Hepatitis B outbreak traced to anoral surgeon. N Engl J Med 1977; 296: 953-58.

7. Hadler SC, Sorley DL, Acree KH, et al. An outbreak of hepatitis B in a dental practice.Ann Intern Med (in press).

8. Communicable Disease Surveillance Centre and the Epidemiological ResearchLaboratory of the Public Health Laboratory. Acute hepatitis B associated withgynaecological surgery. Lancet 1980; i: 1-6.

9. Goodwin D, Fannin SL, McCracken BB. An oral-surgeon related hepatitis-B outbreak.California Morbid Weekly Rep (California State Department of Health) 1976; 14:1-2.

10. Jambazian A, Holper JC. Rheophoresis: a sensitive immunodiffusion method fordetection of hepatitis associated antigen. Proc Soc Exp BiolMed 1972; 140: 560-64.

11. Bond WW, Petersen NJ, Favero MS. Viral hepatitis B: aspects of environmentalcontrol. Hlth Lab Sci 1977; 14: 235-52.

12. Dane DS, Cameron CH, Briggs M. Virus-like particles in serum of patients withaustralia-antigen-associated hepatitis. Lancet 1970; i: 695-98.

13. Murphy B, Tabor E, McAuliffe V, et al. Third component, HBeAg/3, of hepatitis Beantigen system, identified by three different double-diffusion techniques. J ClinMicrobiol 1978; 8: 349-50.

14. Sobeslavsky O. HBV as a global problem. In: Vyas GN, Cohen SN, Schmid R, eds.Viral hepatitis. Philadelphia: The Franklin Institute Press, 1978: 347-56.

15. Dodd RY. Hepatitis B antigen: regional variation in incidence and subtype ratio in theAmerican Red Cross donor population. Am J Epidemiol 1973; 97: 111-15.

16. Stevens CE, Neurath AR, Szmuness W, Beasley RP, Ikram H. Correlations betweeenHBeAg/anti-HBe, HBsAg titer, HBsAg-associated albumin binding sites andinfectivity. In: Vyas GN, Cohen SN, Schmid R, eds. Viral hepatitis. Philadelphia:The Franklin Institute Press, 1978: 211-15.

17. Hindman SH, Gravelle CR, Murphy BL, Bradley DW, Budge WR, Maynard JE. "e"antigen, Dane particles, and serum DNA polymerase activity in HBsAg carriers.Ann Intern Med 1976; 85: 458-60.

18. Okada K, Kamiyama I, Inomata M, Imai M, Miyakawa Y, Mayumi M. e antigen andanti-e in the serum of asymptomatic carrier mothers as indicators of positive andnegative transmission of hepatitis B virus to their infants. N Engl J Med 1976; 294:746-49.

General Practice

WORK-LOAD IN A RURAL PRACTICE OVERTHE PAST EIGHTEEN YEARS

JOHN B. WILSON

Lochmaben, Dumfriesshire

DURING the past eighteen years I have published a series ofpapers relating to the work-load in a rural practice.I-4 Thelast of these papers was published in 1975, and the timetherefore seems ripe for another review. As in the previousstudies, a note was made of all visits and consultations duringthe month of November.The only major change in the organisation of the practice

since 1972 has been the appointment of a trainee for each ofthe past six years. This has added a new dimension to thepractice. No practitioner in a busy practice likes his patientsto become over-visited, so the presence of the trainee

probably gives rise to few extra visits or consultations,although the opportunity is always taken to allow him to seeany interesting or instructive cases.The latest figures (table I) show a continuation of the trend

already described4 from the doctor visiting in the home to thepatient visiting the doctor in his surgery. As in the previous

TABLE I-WORK-LOAD IN A RURAL PRACTICE, 1963-81

studies, the factors causing this change would seem to be thereduction in the size of the farm-workers’ families and the

near-necessity for every family living in the country to own acar. The drift from country to town continues, for most farmsemploy only one tractor-man and one dairyman or

stockman-jobs often taken over by one of the farmer’s familyor occasionally by the farmer himself.A further factor in reducing the number of visits to the

home is the tendency to avoid revisiting patients with acutediseases; such is the faith both doctor and patient have inantibiotic therapy!The ratio of the number of patients who attend the surgeryto the number of home visits has, over the eighteen yearscovered by these statistics, been almost exactly reversed, andsince the number of surgery consultations seen in a specifiedperiod is double the number of home visits made in the sametime, this reversal denotes a considerable saving in thedoctor’s time. No longer, however, is there time during thesurgery hour to catch up with the filing or the letter writing;the secretary now performs these tasks.The presence of the trainee and the reduction in the

number of home visits should mean that more time can be

spent in the garden or on the golf course; but though thepressure on my time has been reduced, Parkinson’s law stilloperates, so that even now I am seldom home for lunch beforeone o’clock or for tea before five o’clock.The age distribution of patients seen has varied little over

the years (table II). Only the numbers of patients of workingage who required attention have increased, but that increasehas now levelled off. Perhaps the most surprising finding isthat the attention required by the elderly has remainedsteady, for much is heard of the additional work which will berequired in the future by this ever-growing group of patients.At the other end of the age-scale the health of the childrenseems to be excellent. For some not very obvious reason fewer