The Society for Healthcare Epidemiology of America (SHEA) has released new guidelines regarding the management of healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) calling for each to be handled differently in light of advances in clinical knowledge and the evolution of the science in infection prevention measures.
SHEA recommends that infected providers not be strictly prohibited from participating in patient-care activities solely on the basis of a bloodborne pathogen infection because the use of appropriate infection prevention procedures makes the risk of exposure and transmission exceedingly small.
“SHEA recommends a comprehensive approach to managing healthcare providers who are infected with any of these diseases to ensure that assessment of the provider-to-patient transmission risks are considered in the appropriate context and perspective,” says Neil Fishman, MD, president of SHEA and director of the Department of Healthcare Epidemiology and Infection Control at the University of Pennsylvania Health System.
Because HBV, HCV and HIV are most readily transmitted either parenterally or across mucous membranes, experts widely agree that the risk for transmission from an infected provider to a patient during the provision of routine healthcare is near zero. The guideline recommends both enhanced precautions (e.g., double-gloving) for patient care procedures and also addresses viral load thresholds at which an infected provider should refrain from conducting any Category III invasive procedures (procedures with a definite risk of transmission).
SHEA offered different recommendations for HBV, HCV, and HIV because different viral loads of each pathogen require different surveillance measures and have different levels of risk (see below).
SHEA previously issued these guidelines in 1990 and then 1997, and Fishman noted that the updated guidelines reflect the evolution of both research and practice.
“With the benefit of scientific research and advances in treatment, as well as clinical experience, we know so much more than we did even a decade ago about the risk management among infected providers,” Fishman says. “Healthcare providers who adhere to these guidelines should not have to disclose their status to a patient unless the provider is the source of an infection.” He added that the already low chances of transmission diminish even further with the adherence to these guidelines.
Fishman cautioned that the pool of science supporting these recommendations is limited in part because direct hypothesis-driven experimentation is virtually impossible and may be complicated further by a low rate of voluntary reporting of both infection status and high-risk provider-to-patient transmission events. While this translates to a narrower evidence base for this guideline in comparison to SHEA’s other guidelines, Fishman said infectious disease experts have broad experience working with these pathogens in the healthcare setting, and the science has substantially advanced since the guideline’s last publication.
Louise M. Dembry, MD, MPH, MBA, an author of the guidelines from Yale University School of Medicine and Yale-New Haven Hospital, said that similar to the accommodations made for other providers who have various health concerns, restriction from practice is not justified when the conditions are well managed and the provider practices in a safe, competent way. “Healthcare workers who are infected with bloodborne pathogens who seek ongoing care and treatment, and who take the necessary precautions to protect their patients and themselves, should by all means continue to practice” says Dembry. “These guidelines reflect the importance of patient safety as well as provider privacy and medical confidentiality, all of which are absolutely essential.”
-- SHEA recommended that HBV-infected providers who test either positive for HBV “e” antigen or negative for it but who have circulating HBV burdens equal to or greater than 104 genome equivalents (GE) per milliliter of blood use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for instances in patient care for which gloving is recommended, and that they not perform Category III activities identified as associated with a risk for provider-to-patient HBV transmission despite the use of appropriate infection prevention procedures.
-- SHEA recommended that HCV-infected providers who have circulating HCV viral burdens of greater than or equal to 104 GE/mL routinely use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for all instances in patient care for which gloving is routinely recommended, and that they not perform Category III activities associated with a risk for provider-to-patient transmission of HCV despite the use of appropriate infection prevention measures.
-- SHEA recommended that HIV-infected providers who have circulating HIV viral burdens of greater than or equal to 5 x 102 GE/mL routinely use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for all instances in patient care for which gloving is recommended, and that they not perform Category III activities associated with a risk for provider-to-patient transmission of bloodborne pathogen infection despite the use of appropriate infection prevention procedures.
To read the guidelines in their entirety, visit http://www.shea-online.org/publications/iche.cfm.