HomeMethodsStatementsThe Liver

The  RAZORS  Edge

Electric Razors as a Potential Vector for Viral Hepatitis 

To the Editor: 
Viral hepatitis is an important public health threat. In the United States the prevalence of chronic hepatitis C infection is approximately 1.5 percent and that of chronic hepatitis B infection is 5.5 percent. (1) The viruses that cause these infections are transmitted primarily through contaminated blood and body fluids, with the most efficient mode of transmission being direct, percutaneous exposure to blood. 
The rate of viral hepatitis is significantly higher among patients in the Veterans Affairs medical system than it is in the general population. As many as 24 percent of nonalcoholic patients in Veterans Affairs facilities who do not have liver disease have antibodies to hepatitis B, and 3.0 percent have antibodies to hepatitis C. (2) While rotating through the Veterans Affairs Hospital in Jamaica Plain, Massachusetts, I noted a dangerous practice that could be a potential source of transmission of hepatitis virus among patients. On rounds one morning, I observed a patient shaving with an electric razor labeled "9C" (identifying the ward). After this patient finished using the razor, another patient immediately picked it up and began using it. On inquiry, I learned that this razor was not regularly disinfected. In speaking with medical school colleagues who work within the Veterans Affairs system, I learned that the communal use of an electric razor is not unique to this hospital. 
Although I am not aware of whether hepatitis B or C virus has been isolated from electric razors, transmission of these and other pathogens through use of community razors is a potential hazard. Shaving is well known to cause abrasions and small cuts. Household contacts of persons infected with hepatitis viruses are counseled not to share razor blades or toothbrushes. (3) The observation that 38 percent of Sicilian barbers had antibodies to hepatitis C suggested that shaving is a potential route of transmission. (4) In this era of increased vigilance and care regarding blood-borne pathogens, I was surprised that the practice of sharing razors has not been questioned. Efforts should be made to replace community razors with the disposable, single-use variety in Veterans Affairs hospitals and in any other institution where they are in use. 
Colleen R. Kelly, M.D. 
Boston Medical Center 
Boston, MA 02118 
References 
1. 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. 
2. 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. 
3. Shapiro CN. Transmission of hepatitis viruses. Ann Intern Med 1994;120:82-4. 
4. Tumminelli F, Marcellin P, Rizzo S, et al. Shaving as potential source of hepatitis C virus infection. Lancet 1995;345:658. 
3/9/2000 

 

Issued in boot camp 1968
Contaminated razor blades as a possible source of hepatitis C virus infection

 Davis AR [letter]. Med J Aust 1995; 163: 275.

Davis AR, Kowalik AM. Hepatitis C virus transmission to heterosexual 
partner: bedroom or bathroom hazard? [letter] Med J Aust 1996; 164: 126.

Ann Intern Med 1994 Jul 15;121(2):153-4Related Articles, Books 
Comment on: •Ann Intern Med. 1994 Jan 1;120(1):82-4 
Don't share razors or toothbrushes.
Frothingham R. Publication Types: •Comment •Letter 
PMID: 8017739 [PubMed - indexed for MEDLINE]

 

Hepatitis Viruses May Be Transmitted by Shared Shaving Equipment 

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, see below:

US Veterans

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 States: the National Health and Nutrition 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.

Copyright 2001 by HIV and Hepatitis.com. All Rights Reserved


Hepatitis C virus RNA in dried serum spotted onto filter paper is stable at room temperature.

Clin Microbiol 1998 Oct;36(10):3070-2 Abe K, Konomi N Department of Pathology, National Institute of Infectious Diseases, Shinjuku-ku, Tokyo 162-8640, Japan. [Medline record in process]

To overcome the instability of viral RNA, we carried out hepatitis C virus (HCV) RNA detection in dried serum spotted onto filter paper. The spotted serum samples were stored at room temperature and then processed for PCR assay at intervals of 1, 2, 3, and 4 weeks. The results showed that serum HCV RNA is stable in a dried condition, as it was detectable in spotted serum samples stored for 4 weeks at room temperature. Furthermore, although the HCV RNA titer showed an approximately 10-fold reduction in virus yield in dried serum stored at room temperature for 4 weeks, the PCR results of frozen serum samples and dried serum samples matched completely. This storage method facilitates transport and analysis by nucleic acid amplification techniques even when freezing conditions are not available.    

Simple and Reliable Method for Detection and Genotyping of Hepatitis C Virus RNA in Dried Blood Spots Stored at Room Temperature

Mariacarmela Solmone,1 Enrico Girardi,1 Francesco Costa,2 Leopoldo Pucillo,1 Giuseppe Ippolito,1 and Maria R. Capobianchi1*

National Institute for Infectious Diseases L. Spallanzani, IRCCS,1 Central Laboratory Italian Red Cross, Rome, Italy2

Received 13 December 2001/ Returned for modification 14 April 2002/ Accepted 18 May 2002

 
We describe a simple, sensitive, and reproducible method for using whole blood collected onto filter paper (dried blood spots) for detection and genotyping of hepatitis C virus RNA that can be useful in large field studies, particularly in settings where collection, preparation, storage, and shipment of samples at controlled temperature can be difficult.

 
Dried blood spots (DBS) have been used worldwide for the neonatal screening of congenital disorders (2, 8). Seroepidemiological studies have been conducted on DBS residual to neonatal screening to assess human immunodeficiency virus (HIV) prevalence among childbearing women (9, 10). Recently, several studies were focused on DBS for detecting drug resistance mutations (6) and for tracking global spreading of HIV type 1 subtypes (4) in proviral HIV DNA. However, RNA is notoriously less stable, and standardization of DBS for viral RNA detection would be of great benefit for application to large field studies, since DBS collection is easy, does not require skilled phlebotomists and expert technicians, and is suitable for storage and shipment to laboratory in settings where these issues are problematic. Recently, dried plasma spots and DBS have been used for HIV RNA detection and quantification, showing good correlation with titers obtained with conventional plasma samples (5, 11). However, these observations were limited to short storage at room temperature (11) or at 37°C (5), and a loss of viral titers occurred during storage.

For hepatitis C virus (HCV) RNA detection on dried spot samples, the available data are much less exhaustive. A complete match between frozen serum and dried plasma spots, though with a loss of titers after room temperature storage, has been observed (1).

This study was aimed at developing a simple, sensitive, and reproducible method for using DBS in HCV RNA detection and genotyping.

The study complied with all relevant national guidelines and institutional policies. Residual laboratory samples of EDTA-whole blood of 39 HCV antibody (Ab)-positive and 16 HCV Ab-negative patients, undergoing routine hematological controls, were used.

HCV Abs were determined by third-generation assay (Abbott Diagnostics). Among the Ab-positive patients, 34 had HCV RNA levels ranging between 9,640 and 5,100,000 IU/ml (Amplicor HCV Monitor; Roche Molecular Systems Inc.), and 5 were HCV RNA negative (Versant HCV TMA; Bayer Diagnostic Inc.). The HCV genotype was known for eight patients (four had 1b; two had 2a/2c; one had 3a; and one had 4c/4d).

DBS were realized within 5 h from venipuncture by carefully spotting, in multiple replicates for each patient, 50 µl of EDTA-whole blood on SS grade 903 filter paper (Schleicher & Schuell Inc.). Two DBS from each patient were pooled and processed for each assay.

HCV RNA detection was performed with both in-house reverse transcriptase PCR (RT-PCR) and transcription-mediated amplification (TMA). For RT-PCR, RNA extraction was performed with Boom technology, utilizing silica-based RNA isolation (3), which was purchased from Organon Teknika. Specifically, DBS were cut, placed in 9 ml of lysis reagent, rocked 2 h at room temperature, and removed; supernatants were extracted according to the manufacturer's instructions. Ten microliters out of the 50-µl RNA eluate underwent the subsequent steps. Reverse transcription was performed with 50 U of Moloney murine leukemia virus RT (Gibco BRL, Life Technologies) in 20 µl. Ten microliters of cDNA was used in the nested PCR, according to reference 13. The amplified products were analyzed by agarose gel electrophoresis (amplicon size, 197 bp). TMA, provided by Bayer S.p.A. Divisione Diagnostici Italia, is a recently developed HCV RNA qualitative detection method, based on 5' untranslated region-targeted magnetic separation, followed by reverse transcription and T7 RNA polymerase-driven isothermal amplification (15). DBS from each patient were soaked in 500 µl of distilled water supplemented with 400 µl of Target Capture Reagent and were incubated at 60°C for 60 min. Then supernatants were decanted; the subsequent extraction and detection steps followed the standard TMA protocol.

A total of 158 DBS pairs were tested (124 from 34 HCV patients; 24 from 19 HCV-negative individuals). On the whole, with both TMA and RT-PCR all the 124 DBS pairs from positive patients tested positive, and all the 24 DBS pairs from the HCV RNA-negative patients tested negative (sensitivity > 99%; specificity > 95%). No genotype restriction was observed.

The detection limit was established by limiting dilution analysis. Specifically, blood samples from two viremic patients (viral burdens, 604,000 and 807,000 IU/ml) were serially diluted with blood from an HCV-seronegative individual. Seven fivefold serial blood dilutions were spotted to form multiple replicate DBS strips. Four replicate pairs of each dilution (24 tests per run) were tested with TMA (after 1 and 5 weeks), giving a total of 48 tests performed, and with RT-PCR. The results, shown in Table 1, indicate that TMA was positive in 100, 85.7, and 75% of DBS containing, respectively, 1,328, 265, and 53 IU of HCV RNA. Similar sensitivity was observed with RT-PCR (not shown).


 

View this table:
[in this window]
[in a new window]
  		TABLE 1. Establishment of detection limit of HCV qualitative RNA assay (TMA) applied to DBSa

 

 
To evaluate the cross-contamination risk, a panel of DBS strips was prepared by spotting in close vicinity and, in alternate order, 15 blood samples from HCV RNA-positive patients and 15 blood samples from HCV Ab-negative individuals. Representative RT-PCR results are shown in Fig. 1, indicating a complete correspondence between expected and observed results. Similar results were obtained with TMA (not shown).
 


View larger version (73K):
[in this window]
[in a new window]
  		FIG. 1. Detection of HCV RNA in DBS from HCV-positive and -negative individuals. To control the risk of cross-contamination in using DBS for HCV RNA detection, DBS strips were prepared with blood from 30 different patients that was expected to be positive (uneven lines) or negative (even lines). The strips were spotted to realize a lattice of alternately HCV RNA-positive and -negative samples. DBS strips were wrapped in their individual paper covers and stored together in the same plastic bag for 1 week at room temperature before the assay. Representative results obtained with RT-PCR are shown.

 

 
To test the stability of HCV RNA in DBS over time, a set of replicate DBS from 16 HCV RNA-positive patients was stored at room temperature and assayed at intervals of 2 to 4 weeks over an 11-month period. The results indicate that 100% positivity was preserved along the whole observation period.

To test the suitability of DBS for HCV genotyping, a replicate set of DBS from the eight patients with known genotype, stored at room temperature for 11 months, was extracted as for RT-PCR and genotyped by using the Line Probe assay (Bayer Diagnostic Inc.). The genotype, determined in all tested DBS, was in agreement with that obtained on frozen serum samples.

On the whole, our findings show that DBS, stored at room temperature for prolonged periods, are suitable for HCV RNA detection and are also useful for HCV genotyping. The assessment of HCV genotype distribution at population level may help in defining the epidemiological dynamics of HCV infection (12, 14). Since HCV genotype may influence the response to antiviral treatment, severity of infection, and performance of diagnostic assays (7, 16), these aspects are particularly relevant in view of the possibility of using the method described here in large field studies and for application in settings where collection, centrifugation, storage, and shipment can be difficult, as is often the case in developing countries.

 ACKNOWLEDGMENTS
This work was supported by the Italian Ministry of Health, Ricerca Corrente e Finalizzata.


FOOTNOTES  
* Corresponding author. Mailing address: Laboratory of Virology, National Institute of Infectious Diseases L. Spallanzani, Via Portuense 292, 00149 Rome, Italy. Phone: 39 0655170434. Fax: 39 065582346. E-mail: mrcapobianchi@libero.it.

REFERENCES

  1. Abe, K., and N. Konomi. 1998. Hepatitis C virus RNA in dried serum spotted onto filter paper is stable at room temperature. J. Clin. Microbiol. 36:3070-3072.[Abstract/Free Full Text]
  2. Anonymous. 2000. Newborn screening: a blueprint for the future executive summary: newborn screening task force report. Pediatrics 106:386-388.[Free Full Text]
  3. Boom, R., C. J. Sol, M. M. Salimans, C. L. Jansen, P. M. Wertheim-van Dillen, and J. van der Noordaa. 1990. Rapid and simple method for purification of nucleic acids. J. Clin. Microbiol. 28:495-503.[Medline]
  4. Cassol, S., B. G. Weniger, P. G. Babu, M. O. Salminen, X. Zheng, M. T. Htoon, A. Delaney, M. O'Shaughnessy, and C. Y. Ou. 1996. Detection of HIV-1 env subtypes A, B, C, and E in Asia using dried blood spots: a new surveillance tool for molecular epidemiology. AIDS Res. Hum. Retrovir. 12:1435-1441.[Medline]
  5. Cassol, S., M. J. Gill, R. Pilon, M. Cormier, R. F. Voigt, B. Willoughby, and J. Forbes. 1997. Quantification of human immunodeficiency virus type 1 RNA from dried plasma spots collected on filter paper. J. Clin. Microbiol. 35:2795-2801.[Abstract]
  6. Cassol, S. A., S. Read, B. G. Weniger, P. Gomes, N. Lapointe, C. Y. Ou, and G. Babu. 1996. Dried blood spots collected on filter paper: an international resource for the diagnosis and genetic characterization of human immunodeficiency virus type 1. Mem. Inst. Oswaldo Cruz 91:351-358.[Medline]
  7. Dusheiko, G. M., H. Schmilovitz-Weiss, D. Brown, F. McOmish, P. L. Yap, S. Sherlock, N. McIntyre, and P. Simmonds. 1994. Hepatitis C virus genotypes: an investigation of type-specific differences in geographic origin and disease. Hepatology 19:13-18.[Medline]
  8. Guthrie, R. 1992. The origins of newborn screening. Screening 1:5-15.[Medline]
  9. Gwinn, M., M. Pappaioanou, J. R. George, W. H. Hannon, S. C. Wasser, M. A. Redus, R. Hoff, G. F. Grady, A. Willoughby, A. C. Novello, et al. 1991. Prevalence of HIV infection in childbearing women in the United States. Surveillance using newborn blood samples. JAMA 265:1704-1708.[Abstract]
  10. Ippolito, G., M. Stegagno, E. Girardi, F. Costa, L. Ravŕ, M. L. Aebischer, E. Guzzanti, et al. 1996. Temporal and geographical trends of anti-HIV-1 antibodies screening among newborns in Italy, 1990-1993. J. Acquir. Immune Defic. Syndr. 12:63-68.
  11. Iscus, S. A., D. Brambilla, L. Grosso, J. Schock, and M. Cronin. 1998. Quantification of human immunodeficiency virus type in plasma by using blood dried on filter paper. J. Clin. Microbiol. 36:258-260.[Abstract/Free Full Text]
  12. Kiyosawa, K. 1997. The value of hepatitis C virus genotyping to epidemiological and clinical studies. J. Gastroenterol. Hepatol. 12:623-624.[Medline]
  13. Okamoto, H., S. Okada, Y. Sugiyama, S. Yotsumoto, T. Tanaka, H. Yoshizawa, F. Tsuda, Y. Miyakawa, and M. Mayumi. 1990. The 5'-terminal sequence of hepatitis C virus genome. Jpn. J. Exp. Med. 60:167-177.[Medline]
  14. Ray, S. C., R. R. Arthur, A. Carella, J. Bukh, and D. L. Thomas. 2000. Genetic epidemiology of hepatitis C virus throughout Egypt. J. Infect. Dis. 182:698-707.[CrossRef][Medline]
  15. Sarrazin, C., G. Teuber, R. Kokka, H. Rabenau, and S. Zeuzem. 2000. Detection of residual hepatitis C virus RNA by transcription-mediated amplification in patients with complete virologic response according to polymerase chain reaction-based assays. Hepatology 32:818-823.[Medline]
  16. Zein, N. N., J. Rakela, E. L. Krawitt, K. R. Reddy, T. Tominaga, D. H. Persing, et al. 1996. Hepatitis C virus genotypes in the United States: epidemiology, pathogenicity, and response to interferon therapy. Ann. Intern. Med. 125:634-639.

 

Journal of Clinical Microbiology, September 2002, p. 3512-3514, Vol. 40, No. 9
0095-1137/02/$04.00+0     DOI: 10.1128/JCM.40.9.3512-3514.2002
Copyright © 2002, American Society for Microbiology. All Rights Reserved.
 

 

Please sign this petition http://www.gopetition.com/info.php?currentregion=0&petid=755 

Description/History:
Hepatitis C is an incurable, non-preventable blood-borne virus which damages the liver. It can be fatal in almost 85% of infected persons, most from cirrhosis, others from liver cancer and autoimmune disease.

The many people who are infected are not sick, or are unaware that they even have it until, for instance, they donate blood.
Some people have had it for 25 years.

Infection can not only be passed by blood transfusions or by sharing needles but, ALSO, by sharing razors, toothbrushes, or nail clippers, from nail salons, barber shops, and tattoo/piercing parlors.

During the Vietnam Era, military persons were vaccinated in assembly line fashion. It is now being debated whether or not the government should be responsible for testing, medicating, and counseling all Veterans.

Most people associate Hepatitis with IV drug use, unsafe and promiscuous sex, or by drinking unclean water. (It is extremely rare that Hepatitis C is passed on by sex).

The public needs to know ALL the facts.

Did you know that nearly 5 times as many people are infected with Hepatitis C than those infected with AIDS/HIV? And that experts believe that, this year, 9 million, in the U.S. alone are unaware that they are infected?

This petition asks that public service announcements be frequently heard and that the announcements should NOT only be targeted at blood transfusion recipients, IV drug users, or AIDS/HIV victims, but, to all Veterans and, ALSO, to the "Average Joe", who might share a razor with their spouse.

How many husbands shave their pregnant wives' legs because she cannot reach her ankles? How many teenagers decide to shave for the first time, using Dad or Mom's razor, unsuspecting that the razor may be contaminated by blood of a parent who, unknowingly, has been infected for at least 25 years?

The facts need to be heard about this epidemic.

Please sign this petition http://www.gopetition.com/info.php?currentregion=0&petid=755 

 

 
Revised: July 26, 2001 .All information is posted without profit or payment for research and is for educational purposes only, in accordance with Title 17 U.S.C. section 107.

HomeMethodsStatementsThe Liver