by Mary Govoni, CDA, RDH, MBA
Recent reports have appeared in national news publications as well as in professional journals regarding a rare patient-to-patient transmission of hepatitis B in a dental setting. The incident was published in the May 1, 2007, issue of the Journal of Infectious Diseases. The article can be accessed online at www.journals.uchicago.edu/JID. I believe it is important for dental professionals to read this article to gain an understanding of this occurrence for internal review of infection-control protocols and to be prepared to answer questions from patients regarding these news stories. It is also important to note that this is the only known case of patient-to-patient transmission of hepatitis B in a dental setting.
The key facts
These are the key facts about this incident. The transmission occurred in 2001 in an oral surgery practice in the Southwest. The source patient was identified as a 36-year-old female with a history of chronic hepatitis B and who had a high viral load at the time she had teeth extracted. The 60-year-old female patient who contracted hepatitis B also had teeth extracted in the same office on the same day. Both patients were treated by the same doctor and assistants and received the same medications. The virus from the source patient and the infected patient were found to be the same genotype and subtype, leading investigators to conclude that the 36-year-old patient was the source of the infection.
Health Department and Centers for Disease Control and Prevention investigators tested 25 of the 27 patients who were treated in the practice after the source patient (two patients refused testing). Interestingly, 16 of those 25 patients had been vaccinated for hepatitis B, which investigators believe may have limited the number of patients who might have been infected.
Investigators performed an on-site inspection of the dental facility to determine the cause of the transmission. Since both patients received the same intravenous medications and these medications are commonly drawn from multiple-dose vials, the medications were initially suspected as the source of the infection. Previous transmissions of hepatitis B and C have been linked to contaminated medication vials. Investigators reported that the team members prepared the medications following appropriate protocols to prevent contamination, so medications were ruled out as a possible source of the infection.
The practice also followed acceptable protocols for cleaning and sterilization of instruments, including sterilization of handpieces. It was reported that surface barriers were used in the treatment rooms, and both covered and uncovered surfaces were disinfected after surgical procedures. Clinical team members changed their personal protective equipment after each patient. Of the 15 clinical team members, 14 had been vaccinated for hepatitis B and none was found to be a carrier for hepatitis B. Monitoring logs for the sterilizer showed no evidence of problems with equipment function.
So what happened? We don’t know. Again, this is the first known patient-to-patient transmission documented in dentistry. Reports of this incident certainly bring to mind the very negative publicity following the disclosure of HIV transmission from a dentist to multiple patients in the early 1990s. As many of you know and experienced, the fallout from this story was very damaging to dentistry. It caused patients to be fearful and suspicious and, in some cases, to delay or forego treatment out of fear of contracting HIV.
Be prepared to answer questions
Will this isolated incident resurrect those fears and suspicions? Hopefully not, but in the event that it does, it is a good idea to be prepared to answer questions and to show and tell patients about your infection-control protocols. This incident should also serve as a reminder to make sure that your OSHA documentation about infection control is up-to-date and that your team members have participated in initial infection-control training as well as OSHA-required annual training updates. Document the hepatitis B vaccine status of your clinical team members, and most importantly, review and evaluate your office protocols for cleaning and disinfecting treatment rooms and cleaning and sterilizing instruments. The CDC’s Guidelines for Infection Control in Dental Health-Care Settings is an excellent resource for information regarding these protocols. You can access this information online at www.cdc.gov/mmwr/PDF/RR/RR5217.pdf. In addition, training and implementation materials are available from the Organization for Safety and Asepsis Procedures at www.osap.org and from the American Dental Association at www.ada.org.
Take a look around your facility on a regular basis. Is it clean and neat? This is especially important for the instrument processing area if your patients want to see how and where you sterilize instruments. Remember that perception is reality. Patients may view clutter and disorganization as a sign that infection control is not a priority.
Since this case is so rare, it is important to note that there are no recommendations for following any special protocols when treating patients who have chronic hepatitis B infections. Following standard precautions for wearing personal protective equipment, disinfection, and sterilization are believed to be appropriate to prevent cross-infection.
What is interesting to note in the recommendations from the investigators in this case is the importance of hepatitis B vaccination in the general population. If and when your patients question you, reassure them that you take all appropriate measures to protect them. But also suggest that they talk to their physicians about being vaccinated for hepatitis B as an additional precaution. You may want to have information available to give patients about hepatitis B and vaccination to prevent infection. The CDC has great fact sheets on both topics on their Web site, www.cdc.gov.
It is my hope that as you are reading this you haven’t experienced any fallout from the disclosure of this incident. But you can and should be prepared to deal with any and all patient concerns, as well as feel confident that you are providing the highest and safest level of care for your patients.
Mary Govoni, CDA, RDH, MBA, is the owner of Clinical Dynamics, a consulting company based in Michigan. She is a member of the Organization for Safety and Asepsis Procedures and is a featured speaker on the ADA Seminar Series. She also writes a column for Dental Office magazine. She can be contacted at [email protected].