[Question #1164] Q#1104 follow-up - Please help!!

48 months ago
Drs. Handsfield & Hook,

First of all, I just wanted to say thank you so much to Dr. Hook for his very patient and informative responses on my previous question (#1104), regarding whether my Asian-born ex-gfs could present an HBV/HCV/HIV risk to my family (parents & siblings) through living in our house and sharing razors, toothbrushes, towels/washcloths etc over 1-2 months.

Dr. Hook's answers were very re-assuring, however I then unfortunately decided to research this further, and am now in a state of panic. First of all, I only looked up this topic on reputable, academic websites (i.e. academic institutions rather than random forums). What I read was very concerning - from the various studies published, HBV/HCV transmission by razors would seem a major risk. In particular my questions are:

1. http://www.ncbi.nlm.nih.gov/pubmed/15332269  This study is from 2004, however as of 2016 is cited on several European government/public health websites. It states that transmission by razor/barbershops likely account for 10-15% of all HBV & HCV cases in the non-intravenous drug user population (!) This is incredibly alarming, as from both your Drs' posts on here and on Medhelp, you have always indicated transmission by razor/barbershop would be negligible? I understand you are both renowned experts in the field, so I cannot understand why this reputable study would take a drastically different view?

2. http://www.sciencedirect.com/science/article/pii/S2221169115308960  This 2016 study by the University of Rome indicates HBV & HCV transmission by razor/barbershop is a considerable risk. Same question as above, essentially why do these reputable institutions take such a different view from your own expert opinions?
I apologise if I come across as doubting your advice, this isn't the case - I'm just desperately trying to reconcile these opposing views.

3. Studies referenced by CDC and other bodies indicate that young children with HBV/HCV-infected parents frequently become infected during childhood, despite not being born with HBV/HCV. Why is this the case if the risk of household exposure is so low? Is this because of the cumulative number of low-risk exposures over a number of years through childhood, and also because children tend to have much closer contact with their parents, compared to say two adult siblings living together?

I would be so grateful if you could help me understand all these points as a layman, particularly questions 1 & 2. I am extremely panicked right now, about the risk to my family.

Many thanks,

Edward W. Hook M.D.
Edward W. Hook M.D.
48 months ago

Jonathan, your anxiety is leading you astray and searching the internet is a perfect way to find misleading and incorrect information.  These experiences are behind you and you need to more on,  You do not even know that your exes even had hepatitis.  Further, you are misinterpreting the data you have found:

1.  This study is more than 11 years old.  If you read the abstract you'll see that the study was performed on people ONLY AFTER excluding people who had major risks for hepatitis such as transfusions and injection drug use.  After exclusion of this group in whom hepatitis is most common, only about 1 in 10 people with the infection acknowledged being shaved in a barbershop only increasing the risk for infection modestly in scientific terms.  For a person in the real world this study has little relevance.

2.  You are over-reading this paper, published in a minor journal that I have never heard of as well. You do not live in India or Kuwait where the authors consider barber exposures to be at risk

3.  Sigh, because young children are exposed to their parents in virtually every way imaginable.

I do not mean to be harsh but your anxiety is taking you off track. Not all scientific publications are fault free or high quality.  I can find you articles published in the literature which suggest that mosquitoes transmit HIV too but this is just not scientifically credible.  Without sounding arrogant, you asked for an expert opinion and I provided one based on over 35 years of Infectious Diseases practice.  If you chose to believe the internet sources you have found, that is you privilege.  If you chose to believe it, similarly, I am not sure what you are going to do about it - you have already told me that you do not want to talk with your family about this.    My sincere and heartfelt advice is to urge you not to worry and to move forward without concern. My opinion and advise is unchanged.  EWH

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48 months ago
Dr. Hook,

Thank you so much for the quick and extremely understanding and helpful response! I definitely take onboard your points. I just have a further question, this is just so I can complete my understanding in my mind  and finally move on with my life! Question is on one further article, I meant to also ask this originally, as on the face of it the % are alarmingly high -

3a) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069292  This article states that through the 1990s and early 2000s, in Italy cosmetic treatments made up around 30% of new HBV cases every year - when prevalence was higher and there were several thousand new cases per year. I checked the Italian public health site and these same % are also shown there.
This is stated to include "barbershop shaving, tattoos, piercing, manicure, acupuncture." Also this is presumably determined by questioning patients on their exposures. So is it the case here that this would be much more the result of tattoos, as opposed to barbershop shaving? And presumably a lot of respondents cannot pinpoint or have forgotten about an alternative previous exposure, or simply are untruthful? Is this the case even given the large sample of 1000+ cases?

3b) Also the same Italian public health figures state around 20% of these cases reported living with an HBV/HCV-infected person? Although this is a % of a relatively large sample (1000+ cases), can I assume here that these would be either sexual partners or families living together over an extended number of years, e.g. children growing up in a household with HBV-infected parents?

I apologise in advance for using up more of your valuable time, but once I have the understanding on the above, I can hopefully finally move on from this! So basically I just want to check my understanding is correct - and that although these % seem high and are from a reputable source, they have no impact on the risks in the specific case of my family & I?

Thank you so much again Dr.

48 months ago
Also sorry just to clarify, the new HBV cases mentioned in the above mentioned research paper and the Italian public health body - those are new acute HBV cases (in case that makes any difference).

Through the 1990s and 2000s, this is at least 1000+ cases each year. So for barber shaving/tattoos to make up 30% of these each year, and for household exposure to be 20% - both of these seem alarmingly high.

So I would be so grateful for any valuable insight you could give on my questions 3a) & 3b), thank you again Dr. I will then try my best to move on with my life.


Edward W. Hook M.D.
Edward W. Hook M.D.
48 months ago

Sigh, you now quote yet another obscure journal and pick out the parts that feed your insecurities - this is not good use of your time and does you no meaningful good for all of the reasons I have tried (clearly unsuccessfully) to explain.  The paper you quote celebrates successes in reducing hepatitis transmission by interventions which reduce major routes of transmission (i.e. needle sharing, sexual transmission) and states that the remaining transmission now occurs increasingly through minor transmission routes such as "beauty treatments" using improperly sterilized equipment and this leads you to assume that this means your household is now infected with the virus. 

One final comment, as we have learned long ago from the HIV epidemic, when people are surveyed about risks which may involve socially unacceptable activities such as injection drug use or unprotected sex, they tend to under report them.  I suspect that this sort of mis-reporting too contributes to the small proportion of transmission that you are fixated on.

I really have nothing more to say.  EWH

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48 months ago
Dr. Hook,

Thank you so much again, your answer explains a lot and gives me a great deal of reassurance.

I apologise again for testing your patience, and I realise it seems this is not helping to reassure me - however on the contrary, I am in a drastically calmer state compared to just 24 hours ago! Having the proper understanding has really helped me to think I can move past this.

So on your points about obscure journals - just to check, as a final question I saw these 2 articles in the reputable BMJ:

4i) http://www.bmj.com/content/345/bmj.e8700  Documents an outbreak of HBV in a village where barbershop/razors were mentioned as a significant factor in transmission. Is this to be believed? Or because of the relatively small sample size, people not being willing to discuss their real exposure and other reasons you've listed above - am I correct in thinking this would not change your view?

4ii) http://m.adc.bmj.com/content/84/4/373.9.full Discussion by UK doctor about the risks of HBV/HCV transmission to pilgrims to Mecca, from barbershops. Although this indicates there are risks, am I correct in assuming this does not change your view? (given it seems more generalist discussion than detailing specific cases/outbreaks)

Very sorry again Dr, this really is the final time (as I realise there are only 3 question follow-ups allowed anyhow). I just want to check your responses apply to a reputable journal such as the BMJ - if I can just be reassured on the two above points, I will finally move on with my life!

Thank you so much again Dr.
Edward W. Hook M.D.
Edward W. Hook M.D.
48 months ago

I'm sorry, I should have said this before. This site is dedicated and exists to provide expert opinion and advice, based on our combined more than 70 years of practice, study of the medical literature and attendance at medical meetings and advisory meetings. It is not meant to serve to interpret the medical literature or interpret obscure data for readers who are engaged in anxiety driven internet sources.  This note will end this exchange and the thread will be closed in a few hours.  EWH


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