Title: Unusual Cases of Hepatitis B Virus Transmission
Description: Unusual Cases of Hepatitis B Virus Transmission

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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 those infected with HBV do not know how they contracted the virus. The following reports of some uncommon methods of HBV transmission illustrate how every susceptible person is at some (albeit limited) risk of HBV infection.

1. Between April 1984 and February 1985, 24 cases of HBV infection occurred among the patients of a dentist practicing in rural Indiana. Two of these patients died of fulminant hepatitis. The dentist had never had hepatitis symptoms, but blood tests indicated he was hepatitis B surface antigen (HBsAg) positive. Footnote source 1: Lethal outbreak of hepatitis B in a dental practice. Journal of American Medical Association, Volume 255, Number 23, pages 3260 through 3264, year 1986.

2. An investigation documented transmission from an HBV-infected elementary school student to a teacher who had no overt percutaneous or permucosal exposure to the student’s blood or infectious body fluids. The student did sneeze 
saliva and nasal secretions onto the teacher’s cracked, chapped hands. The teacher gave birth to an infant 3 weeks prior to her diagnosis, and her infant also tested HBsAg positive. The teacher and student were found to have the 
same HBV subtype and identical HBV DNA sequences. Footnote source 2: Hepatitis B virus transmission in an elementary school setting. Journal of American Medical Association, Volume 278, Number 24, pages 2167 through 2169, year 1997.

3. In Rhode Island, 35 patients of an acupuncturist became infected with HBV, the primary source for the outbreak being a patient in the practice. Investigators were not able to determine the precise mechanism of transmission, but theorized it was possibly due to inadequately sterilized needles or the transfer of infectious material from the acupuncturist’s hands to sterilized needles. Footnote source 3: A large outbreak of acupuncture-associated hepatitis B. American Journal of Epidemiology, volume 127, number 3, pages 591 through 598, year 1988.

4. In Japan, 5 of 10 members of a high school sumo wrestling club developed HBV infection in a one-year period. The asymptomatic index case often bled from injuries received while wrestling, presumably transmitting HBV to his teammates
through cuts and abrasions. Footnote source 4: An outbreak of hepatitis B in members of a high school sumo wrestling club. Journal of American Medical Association, Volume 248, Number 2, pages 213 through 214, year 1982.

5. In July 1992, a 47-year-old woman became ill with acute HBV infection after undergoing a thymectomy. The thoracic surgery physician-in-training who assisted in surgery had had acute HBV infection six months earlier and was subsequently found to be HBeAg positive. Though the hospital had used appropriate infection control procedures, further investigation identified 19 other infected patients. Footnote source 5: Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. New England Journal of Medicine Volume 334, Number 9, pages 549 through 554, year 1996.

6. CDC reported a case involving a 4-year-old boy in day care who developed acute HBV infection; another child at the center who had a history of biting and scratching was found to be chronically infected with HBV. Footnote source 6: Hepatitis B virus transmission between children in day care. Pediatric Infectious Diseases Journal Volume 8, Number 12, pages 870 through 875, year 1989.

7. In December 2001, the New York City Department of Health (NYCDOH) was informed of two elderly patients who had been diagnosed with acute HBV infection and who had visited the same physician. A follow-up investigation by NYCDOH 
found an additional 38 patients in the same practice who had acute HBV infection. Further study found that infection was strongly correlated with having received an injection at this office, where doses of atropine, dexamethasone, and vitamin B12 were drawn from multiple-dose vials into one syringe. Footnote source 7: Transmission of hepatitis B and C viruses in outpatient settings–New York, Oklahoma, and Nebraska, 2000-2002. MMWR Volume 52, Number 38, pages 901-906, year 2003.

8. Thirty patients who received autohaemo- therapy (a procedure that involves drawing the patient’s blood, mixing it with saline, and reinjecting the mixture) at an alternative medicine clinic in the U.K. were infected with HBV. Five had markers of chronic HBV infection. Contaminated saline in a repeatedly used bottle was the probable method of transmission. Footnote source 8: Molecular epidemiology of a large outbreak of hepatitis B linked to autohaemotherapy. Lancet, Volume 356, Number 9227, pages 379 through 384, year 2000.

9. In 1996, an outbreak of HBV infection was detected among patients attending an electroencephalogram (EEG) clinic in Toronto. A follow-up of all available patients found 75 who developed HBV infection from 1991 to 1996. All of 
the cases had had at least one EEG performed with reusable subdermal electrodes. The outbreak was a result of a common source of infection (a technician who was HBeAg positive) and inadequate infection control practices. Footnote source 9:  An outbreak of hepatitis B associated with reusable subdermal electroencephalo-gram electrodes. CMAJ volume 162, number 8, pages 1127 through 1131, year 2000.

10. In 1996, 9 residents of an Ohio nursing home were diagnosed with acute HBV infection and 2 with chronic HBV infection; all were diabetic. HBV infection was associated with fingerstick capillary sampling, specifically with the use of a lancet device with a re-used end cap. That same year, acute hepatitis B illness was diagnosed in 3 diabetic patients in a New York hospital. A review of serologic records of previous patients identified another 11 possible cases of nosocomially [hospital] acquired HBV infection. Transmission seems to have occurred through contamination of a fingerstick blood sampling device. Footnote source 10: Nosocomial hepatitis B virus infection associated with reusable fingerstick blood sampling devices– Ohio and New York City, 1996. MMWR volume 46, number 10, pages 217 through 221, year 1997.

11. The University of Sydney used molecular fingerprinting to provide evidence that a child chronically infected with HBV who had an exudative skin lesion and a history of biting had infected another child in the same day care center. Footnote source 11: Horizontal transmission of hepatitis B in a children’s day-care centre: a preventable event. Aust N Z J Public Health, volume 21, number 7, pages 791 through 792, year 1997.

12. Outbreaks of HBV infection occurred in 5 chronic hemodialysis centers in California, Nebraska, and Texas from April through August 1994. Transmission of HBV from hemodialysis patients with chronic HBV infection to susceptible 
patients was believed to have resulted from failure to identify and isolate HBV-infected patients during dialysis; sharing of staff, equipment, and supplies among patients; and failure to vaccinate susceptible patients against the 
hepatitis B virus. Footnote source 12: Outbreaks of hepatitis B virus infection among hemodialysis patients–California, Nebraska, and Texas, 1994. MMWR Volume 45, number 14, pages 285 through 289, year 1996.

13. A study of 920 employees in a large residential institution for the develop- mentally disabled in Oregon found an overall prevalence of 10% for anti-HBc, a marker of present or past HBV infection. Antigen positivity was significantly associated with a history of working directly with clients. Footnote source 13:  Hepatitis B and workers in institutions for the mentally retarded: risk of infection for staff in patient care. American Journal of Preventive Medicine, volume 5, number 3, pages 170 through 174, year 1989.

14. From June 1989 through March 1990, 26 patients in a California hospital contracted acute HBV infection. A retrospective cohort study indicated that transmission of the virus occurred percutaneously through contamination of 
the stabilizing platform on a spring-loaded fingerstick device. Footnote source 14: Nosocomial transmission of hepatitis B virus associated with the use of a spring-loaded finger-stick device. New England Journal of Medicine, Volume 326, number 11, pages 721 through 725, year 1992.

15. A general surgeon in the Netherlands infected a number of patients with HBV over four years of practice (transmission from the surgeon was confirmed in 8 patients, probable in 2, and possible in 18). Two patients were chronically infected, and one case of secondary transmission to a spouse was identified. Footnote source 15: Transmission of hepatitis B virus from a surgeon to his patients during high-risk and low-risk surgical procedures during 4 Years. Infection Control in Hospital Epidemiology, volume 23, number 6, pages 306 through 312, year 2002.

16. Eleven cases of HBV infection were detected among 65 members of the Okayama University’s football team during a period of 19 months. All players with acute hepatitis B virus infection belonged to the same training group as 
an HBeAg carrier on the team, with transmission presumably occurring through contact with open wounds during training. Footnote source 16: Horizontal transmission of hepatitis B virus among players of an American football team. Archives of Internal Medicine, volume 160, number 16, pages 2541 through 2545, year 2000.

17. In Israel, a butcher who was chronically infected with HBV infected 3 of his co- workers, who in turn infected their spouses. The workers shared knives. If the index case cut or punctured himself, his HBV- contaminated blood could have tainted a knife that other butchers later used, making it possible for the infection to be transmitted from the knife to them through a break in their skin. Footnote source 17: Hepatitis B–an occupational risk for butchers? Annuals of Internal Medicine, volume 116, number 5, page 428, year 1992.


18. Hepatitis B virus infection was transmitted by a cardiothoracic surgeon to 2 patients during coronary artery bypass surgery. Both patients presented with serious clinical illness 12 weeks after surgery. The surgeon was HBsAg positive. Footnote source 18: Acute hepatitis B in two patients transmitted from an e antigen negative cardiothoracic surgeon, Commun. Diseases Public Health, volume 3, number 4, pages 250 through 252, year 2000.

19. In 1986, 4 cases of HBV infection were linked to an oral surgeon practicing in New Hampshire. One of the patients developed severe complications; another became chronically infected with HBV. CDC reported 8 other outbreaks of HBV 
infection traceable to general dentists or oral surgeons from 1974 to 1986, with the number of clinically infected patients in each outbreak ranging from 3-55. Footnote source 19: Epidemiologic notes and reports: outbreak of hepatitis B associated with an oral surgeon–New Hampshire. MMWR, volume 36, number 9, pages 132 through 133, year 1987.

20. In August 2002, the Oklahoma State Department of Health investigated a pain remediation clinic where they discovered a certified registered nurse anesthetist routinely reused needles and syringes. They tested 793 patients 
for hepatitis C virus (HCV), HBV, and HIV infection. A total of 69 HCV and 31 HBV infections were identified that probably were acquired in the clinic. Footnote source 20: Transmission of hepatitis B and C viruses in outpatient settings–New York, Oklahoma, and Nebraska, 2000-2002. MMWR, volume 52, number 38, pages 901 through 906, year 2003.

21. Twenty-two cases of acute hepatitis B disease were linked to a Florida dermatologist’s practice during 1985-1991. Since the dermatologist was not HBsAg positive, the outbreak is believed to have resulted from the dermatologist’s 
failure to apply either universal precautions or sterile surgical technique. Footnote source 21: Patient-to-patient transmission of hepatitis B in a dermatology practice. American Journal of Public Health, volume 83, number 12, pages 1689 through 1693, year 1993.

These examples are not presented to scare. Such modes of transmission are relatively rare, and sexual activity is still the predominant source of HBV infection among U.S. adults. However, these reports demonstrate that one can 
acquire HBV infection without engaging in so-called “risky” behavior. On the average, any baby born in the United States has a 5 percent chance of acquiring HBV infection during his or her lifetime. By avoiding obvious means of 
exposure, people can reduce the odds of becoming infected. But in reality, as the U.S. Public Health Service so succinctly stated, “Anyone can get HBV infection.” Footnote source 22: Important information about hepatitis B, hepatitis B vaccine, and hepatitis B immune globulin. U.S. Department of Health and Human Services, May 1992.

Fortunately, the availability of hepatitis B vaccine means no one has to get infected.

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www.immunize.org/catg.d/p2100nrs.pdf
Item #P2100 (June 2004)

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