The prevalence of hepatitis C infection is 0.07–1.4% in the general population,² although the prevalence of hepatitis C infection in a high-risk group, such as intravenous drug abusers, is much higher (44%).³ Studies have shown healthcare workers are at an increased risk of acquiring hepatitis C infection.⁴ The average risk of hepatitis C seroconversion following sharps injury from a hepatitis C positive donor has been quoted as up to 10%.⁵ When 3411 orthopaedic surgeons attending a recent conference were anonymously tested for hepatitis C, 0.8% were found to be infected. This rose to 1.4% with increasing age of the surgeon.⁶

Overall, 223 orthopaedic surgeons reported on the total number of sharps injuries or eye exposure incidents sustained in the previous 12 months. The mean was 1.4 incidents in the last year (range, 0–12). The mean number of incidents during an orthopaedic career was 15.7 (range, 0–300), although 85 surgeons did not answer. Eighty-two surgeons (33%) stated they always reported sharps injuries and eye exposure incidents. Of the 166 who did not always report incidents, 119 provided reasons for not doing so. The most common reasons were that the reporting system was too complex (43 answers), that reporting was not done if the donor appeared unlikely to carry hepatitis C (19), that there was little point in reporting (including no current treatment; 14), and that solid sharps injuries were not reported (9).

Of the respondents, 208 (84%) stated a concern regarding transmission of hepatitis C to the surgeon due to occupational exposure; 2 did not answer. Some 204 (82%) were concerned when operating on intravenous drug abusers, 113 (46%) were concerned about patients with tattoos and 68 (27%) were concerned about younger patients. Other causes of concern included previous blood transfusions (15), haemophiliacs (13), homosexuals (12), immigrants (9), or a history of hepatitis B or HIV (8). Eleven replies stated that universal precautions should be applied to all patients. Table 1 lists the reasons for concern given.

Eighty-five responders (36%) felt that orthopaedic surgeons should be routinely tested for hepatitis C as part of working practice. Sixteen did not answer the question, but the remaining 148 (59.4%) did not agree with testing surgeons. The comments regarding this question are listed in Table 4. The most common reasons supporting testing were to avoid cross infection (19), knowledge of own hepatitis C status (10), and because hepatitis C is as dangerous as hepatitis B (2). Reasons against testing included the fact patients are not tested (18), no evidence of risk to patients (13), lack of compensation (7), lack of treatment in the event of a positive result (6), the cost of testing (4) and the damage to one's career (3). Table 2 lists all reasons given for and against testing of orthopaedic surgeons.

Of the respondents, 122 (59%) felt that hepatitis C positive surgeons should be restricted to low-risk procedures. Forty-one did not answer and the remaining 86 (35%) felt there should be no such limitation. With regard to pre-operative testing of high-risk patients, 177 respondents (77%) felt this was appropriate although 18 provided no answer. Of responders, 186 gave an estimate of population incidence of hepatitis C whilst 177 estimated the incidence of hepatitis C in intravenous drug abusers. The mean estimated population prevalence of hepatitis C was 3.5% (range, 0.01–20%) and the mean estimated incidence in drug abusers was 30.4% (range, 2–100%).

The risk of infection with hepatitis C by occupational exposure depends on three factors: (i) the prevalence of hepatitis C in the population; (ii) The number of exposure incidents a healthcare worker experiences; and (iii) the seroconversion rate (transmission rate) of hepatitis C with a single exposure. The risk from each exposure can be expressed as the factor of population prevalence and seroconversion rate. The risk of hepatitis C seroconversion following sharps injury from a hepatitis C positive donor has been estimated as 1.9% in longitudinal and prospective studies (95% CI 1.4–2.5%; range, 0–22%)4 although rates up to 10% have been quoted.⁴ Using the lower figure, the risk of seroconversion from a single exposure would be 0.133% (0.07% × 1.9%). The average number of career exposure incidents in our questionnaire was 15.7, making the career risk of hepatitis C seroconversion approximately 2.1%. Of sharps injuries, 85% are caused by suture needles⁷ which carry a lower risk of transmission of hepatitis C and the true risk of seroconversion may, therefore, be lower.

It can be noted that there is a wide variation in the number of incidents (eye exposure and sharps injuries) both over the preceding 12 months and over the surgeons' careers. These variations in incidents had no relationship to age or number of years as a consultant. It must be assumed that some of this variation is due to surgical practice as well as some procedures being more at risk from sharps injuries than others.

The low rate of reporting of sharps and eye exposure incidents (33% in our sample) is greatly different from the fact that 84% of orthopaedic surgeons were concerned about occupational hepatitis C exposure. This is comparable to previous studies which have shown that most surgeons are concerned regarding risks of blood-borne viral transmission during surgery whilst failing to comply with the recommendations regarding universal precautions and reporting of sharps incidents.⁸

Whilst only 36% felt it was reasonable to test surgeons routinely for hepatitis C, 77% stated that patients perceived as high-risk should be tested pre-operatively for hepatitis C. This either illustrates the greater concern surgeons have for their own safety, or the perception that risk of transmission is greatest from patient to surgeon. The population incidence of hepatitis C was overestimated in our study (mean of 3.45% compared to population incidence of 0.07–1.4%). The incidence of hepatitis C in intravenous drug users was estimated as 30.4% (mean) in our sample compared to a true prevalence of 44%3. Of respondents, 59% felt that hepatitis C positive surgeons should be restricted to low-risk procedures. Heptonstall¹ suggested that transmission was possible and infected surgeons should be transferred to low risk duties, whilst Cockcroft⁹ felt risks of transmission were too small to limit surgeons to low risk duties. Whilst evidence of the risk of surgeon-topatient transmission is conflicting, current UK Department of Health guidelines state that healthcare workers carrying hepatitis C should not perform exposure-prone procedures.¹⁰

Many orthopaedic surgeons routinely operate without eye protection or double gloving even when performing procedures where power tools are employed. Of surgeons responding to the questionnaire, 67% did not routinely report sharps injuries or eye contaminations. The most commonly given reasons for this were the complexity of the reporting procedure or lack of motivation to report. Double gloving is easy to adopt and has been shown to be effective in reducing viral transmission.¹¹ Many orthopaedic surgeons appear to be putting themselves at risk of hepatitis C infection by not adopting this practice. Whilst there is no proven post-exposure prophylaxis for hepatitis C, the use of interferon monotherapy may be indicated.¹² It is vital surgeons and other healthcare workers are aware of this as the earlier the treatment is started, the more effective the treatment.¹² A fear of stigmatisation and loss of employment may play a significant role in this reluctance to report incidents.

It appears many orthopaedic surgeons are ignorant of the incidence of hepatitis C and effective measures to reduce the risks of occupational exposure are not always used. More information on this blood-borne viral infection should be made available.