Healthcare Workers Infected with Hepatitis, HIV

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<http://www.infectioncontroltoday ... -hiv-infection.html>

SHEA Releases Guidelines on Management of Healthcare Workers Infected with
Hepatitis, HIV
02/16/2010

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.”
Recommendations
-- 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>.

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