http://www.nejm.org:80/content/2000/0342/0024/1840.asp
The New England Journal of Medicine -- June 15, 2000 -- Vol. 342, No. 24
Electric Razors as a Potential Vector for Viral Hepatitis
To the Editor:
We thank Dr. Kelly (March 9 issue) (1) for her vigilance on behalf of
veterans treated by the Department of Veterans Affairs. Her suggestion that
the sharing of electric razors might be responsible for the relatively high
rates of viral hepatitis among veterans is provocative but seems
implausible. In the large seroepidemiologic study that she cited, military
service was an insignificant risk factor for hepatitis B infection relative
to other considerations. (2) The brief letter noting an increased
seroprevalence of antibodies to hepatitis C virus among Sicilian barbers
concerned barbers who used a straight razor on both their patrons and
themselves. (3) Although we do not condone the sequential sharing of
electric razors observed by Dr. Kelly, (1) we think that the risk of
hepatitis associated with such an event is very low from both an individual
and an epidemiologic perspective.
The policy at our medical center is that patients who ask to shave
themselves are to be given disposable, single-use, safety razors whenever
possible. However, many of our patients have an increased risk of bleeding
because they are receiving therapeutic anticoagulation or cancer
chemotherapy or because they have advanced liver disease; others have
impaired coordination as a result of neurologic disorders. Consequently,
the policy allows such patients to be given an electric razor, which is to
be returned directly after use and is to be thoroughly cleaned before being
given to another patient. The episode described by Dr. Kelly -- one patient
picks up the electric razor that another patient has just put down --
represents a clear violation of this procedure despite continued teaching
and reinforcement of the practice.
Dr. Kelly's observation has led us to review our current practices. We have
concluded that in our acute care hospital, the use of electric razors is
sufficiently limited that we can issue a new or sterilized electric razor
to each person who needs one during hospitalization. The electric razor
will be labeled with the patient's name, and the need to avoid sharing
razors will be strictly emphasized.
Robert D. Arbeit, M.D.
Richard P. Goodman, M.D.
Gordon L. Snider, M.D.
Veterans Affairs Boston Healthcare System
Boston, MA 02130-4893
References
1. Kelly CR. Electric razors as a potential vector for viral hepatitis. N
Engl J Med 2000;342:744-5.
2. McQuillan GM, Coleman PJ, Kruszon-Moran D, Moyer LA, Lambert SB,
Margolis HS. Prevalence of hepatitis B virus infection in the United
States: the National Health and Nutrition Examination Surveys, 1976 through
1994. Am J Public Health 1999;89:14-8.
3. Tumminelli F, Marcellin P, Rizzo S, et al. Shaving as potential source
of hepatitis C virus infection. Lancet 1995;345:658.
======================================
Dr. Kelly replies:
To the Editor:
I am pleased that my observation prompted a review of the policy and
practices at the Veterans Affairs hospital. Since the letter appeared, the
hospital staff has been vigilant about sterilizing electric razors after
patients have used them. I hope that other health care facilities where
these devices are in use will follow the example set by this hospital to
provide further protection to patients.
I agree that the risk of disease transmission associated with the sharing
of electric razors is probably very low, but nonetheless, it should not be
dismissed. The statement of Arbeit et al. that patients who "have an
increased risk of bleeding," including those with "advanced liver disease,"
are the patients who are very likely to be using these razors strengthens
the argument that the devices could be contaminated
with diseased blood.
It was not my intent to imply that electric razors are responsible for the
high rates of viral hepatitis among veterans. I cited the statistics (1)
only to underscore that the sharing of razors poses a greater risk in a
population in which the prevalence of disease is high.
Colleen R. Kelly, M.D.
Boston Medical Center
Boston, MA 02118
References
1. Mendenhall CL, Seeff L, Diehl AM, et al. Antibodies to hepatitis B virus
and hepatitis C virus in alcoholic hepatitis and cirrhosis: their
prevalence and clinical relevance. Hepatology 1991;14:581-9.
http://www.hivandhepatitis.com/hepb/b03240001.html
Hepatitis Viruses May Be Transmitted by Shared Shaving Equipment
Physician finds inadequate infection control practices after observing
shared electric razor at VA Hospital
by Harvey S. Bartnof, MD
Precautions against transmission of blood-born viruses by shared shaving
equipment and toothbrushes have been standard for HIV, HBV (hepatitis B
virus) and HCV (hepatitis C virus). This has been the case even without
unequivocal evidence for transmission by shared shaving equipment or
toothbrushes. Even though the main routes of transmission of these viruses
have been unprotected sexual contact, transfusion of blood or blood
products (in the past), and shared injection equipment, there have been
isolated case reports of other types of blood exposure as the vehicle for
transmission. Toothbrushes and shaving equipment
can carry minute amounts of blood that could be vectors for transmitting
HIV, HBV or HCV. After witnessing patients sharing an electric razor,
Colleen R. Kelly, MD, from Boston Medical Center in Massachusetts wrote a
letter to the Editor at the New England Journal of Medicine.
Dr. Kelly was a rotating physician at a local Veterans' Affairs (VA)
Hospital in Jamaica Plains, Massachusetts. She observed a male inpatient
using an electric shaver labeled "9C," indicating Ward 9C. After he was
finished shaving, another male patient immediately started using the same
shaver, without any disinfectant used or changing the shaver heads or
screen. She subsequently was informed that the shaver was not regularly
disinfected. Moreover, in discussing the issue with her colleagues, she
found out that "communal" sharing of electric shavers without routine
disinfection was common. Dr. Kelly was concerned that such practices could
risk transmitting blood-borne infections, due to small abrasions and cuts.
Electric shavers generally are associated with fewer cuts and abrasions
that lead to visible blood than manual (non-electric) shavers with
disposable blades. Nonetheless, Dr. Kelly has a point. She recommended that
the practice of communal sharing of shavers be abandoned at the VA
Hospitals and other institutions. Instead, she recommended that single-use,
disposable, non-electric shavers should be used. Her recommendations should
be adopted, and persons with HIV, HBV, or HCV should be reminded that
shaving equipment and toothbrushes should not be shared.
Dr. Kelly quoted some references in the medical literature documenting a
significantly higher rate of HBV and HCV infections within the VA medical
system. In a 1991 publication from the journal Hepatology, up to 24% of VA
patients had
antibodies to HBV (not chronic infection), excluding those with alcoholic
liver disease. The same article reported that 3% of VA patients have
antibodies to HCV (approximately 70-85% would have chronic hepatitis C).
However, that percentage for HCV infection is outdated. In a non-random
sample of 26,000 US veterans tested on March 17, 1999, 7% were HCV
positive, and 19% (out of 791 veterans tested) at the San Francisco VA
Medical Center were HCV positive. To read more about those reports and
their associated behavioral risk factors for HCV transmission,
CLICK BELOW:
http://www.hivandhepatitis.com/conferences/idsa.html#usveterans
(US Veterans)
http://www.hivandhepatitis.com/conferences/aasld.html#sfveterans
(San Francisco Veterans)
Dr. Kelly also quoted a 1995 Lancet report finding that 38% of Sicilian
(Italy) barbers were HCV positive.
3/24/00
References:
Kelly CR. Electric razors as a potential vector for viral hepatitis.
The New England Journal of Medicine 2000 March 9;342(10)
McQuillan GM and others. Prevalence of hepatitis B virus infection in the
United Examination Surveys, 1976 through 1994. American Journal of Public
Health 1999; 89:14-18.
Mendenhall CL and others. Antibodies to hepatitis B virus and hepatitis C
virus in alcoholic hepatitis and cirrhosis: their prevalence and clinical
relevance. Hepatology 1991; 14:581-589.
Shapiro CN. Transmission of hepatitis viruses. Annals of Internal Medicine
1994;120:82-84.
Tumminelli F and others. Shaving as potential source of hepatitis C virus
infection. Lancet 1995;345: 658.
HepC
VSG
HEPHIVE