SHEA updates guidelines on infected workers
SHEA updates guidelines on infected workers
Restrict only workers with HBV e antigen
Health care workers infected with HIV or hepatitis C virus should be permitted to perform invasive procedures without informing patients of their infections unless the workers have been implicated in a transmission incident, according to a new position statement on the controversial issue by the Society for Healthcare Epidemiology of America (SHEA).1
In updating its 1990 stance, SHEA also recommended that surgeons infected with the highly infectious hepatitis B virus e antigen should not perform procedures that have previously been linked to transmission to patients, even when infection control measures were taken (i.e., cardiac surgery).2,3 While recommending double-gloving for all infected workers, SHEA noted that because of the extremely high viral titer associated with HBV e antigen positivity, "barriers may be relatively ineffective in preventing transmission." (See recommendations, p. 107.)
SHEA argued for comprehensive education concerning bloodborne pathogens for all health care providers and trainees, but recommended against specific competence-monitoring procedures directed at infected health care workers. Rather, infected providers should be managed in the context of a comprehensive approach to all impaired providers. While emphasizing the importance of worker privacy and medical confidentiality, SHEA recommended that infected workers be managed with their permission under the combined efforts of their facility’s occupational health service and their personal physicians.
"The occupational health service should try to maintain some liaison with the infected individual’s health care provider so there is some degree of sharing of information with, obviously, appropriate confidentiality guards," says Michael Tapper, MD, the chairman of the SHEA AIDS/TB committee that issued the guidelines. "If something occurs in the health status of a worker infected with any bloodborne pathogen, that provider can share that information with the health service and they can make appropriate accommodations."
In revising its guidelines, SHEA broke from similar guidelines by the Centers for Disease Control and Prevention, which call for invasivists (i.e., surgeons) infected with HIV or HBV e antigen to go before review panels and inform prospective patients of their infection.4 Regarding informed consent, SHEA was consistent with its former policy, reiterating that such disclosures would very likely require an infected health care worker to abandon the profession.
"SHEA feels that such a position is unwarranted," the position paper states. "In the absence of an adverse patient exposure to blood or blood-containing body fluids, the risk for health care worker-to-patient transmission is so small that it cannot be measured accurately, and the jeopardy to an infected health care worker’s career is so overwhelming that routine disclosure does not appear justified."
SHEA revised its 1990 position statement in part because of concerns its former guidelines and those by the CDC were being cited to justify removing HIV-positive health care workers from jobs, to pressure workers to be tested, or in legal claims by patients charging emotional damage even if no infection occurred, Tapper says.
"There have been occasions when a worker’s HIV status has become known to the institution where they were working and their privileges were withdrawn," he says. "There was a concern that both the existing CDC guidelines and the older SHEA guidelines were being used to reinforce those positions."
The CDC is considering revising its guidelines, but wants to review data on all three viruses first, says Denise Cardo, MD, acting director of the HIV infections branch in the CDC hospital infections program. Since the 1991 CDC guidelines were published in the wake of the cases of reported transmission of HIV to six dental patients in Florida, there have been additional reports of transmission of all three viruses including a case of HIV transmission from a orthopedic surgeon in France. 5-7 (See story in Hospital Infection Control, March 1997, pp. 33-36.)
"And not only that, but we’ll also review the [new] data in terms of options for treatment for HIV that may decrease viral load and the risk of transmission," she says. "We are going to review everything to make this decision."
The agency may include any revisions in the upcoming Guideline for Infection Control in Health Care Personnel, which is expected to be completed sometime this fall by the CDC’s Hospital Infection Control Practices Advisory Committee. It remains unclear, however, whether the CDC will attempt to amend the controversial informed consent clause, or how new guidelines would be dovetailed into the existing state and federal statutes based on the 1991 guidelines. The CDC could formally update its 1991 guidelines, or simply provide additional information and guidance to be used by the expert review panels that assess infected workers.
"That is something that hasn’t been decided, and it’s not just up to our branch," Cardo says. "It’s a major decision."
Even with the additional reported transmissions of bloodborne viruses, SHEA argued that intense surveillance for new cases throughout the 1990s underscores that the likelihood of such events occurring is extremely low but will remain inevitable over time.
"Because of the nature of health care, provider-to-patient transmission of bloodborne pathogen infection, albeit rare, will continue to occur," SHEA stated.
References
1. AIDS/TB Committee for the Society for Healthcare Epidemiology of America. Management of healthcare workers infected with hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or other bloodborne pathogens. Infect Control Hosp Epidemiol 1997; 18:349-363.
2. Rhame FS, Pitt H, Tapper ML, et al. Position paper: The HIV-infected health care worker. Infect Control Hosp Epidemiol 1990; 11:647-656.
3. Harpaz R, Von Seidlein L, Averhoff FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549-554.
4. Centers for Disease Control. Recom mendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40:1-9.
5. Centers for Disease Control. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990; 39:489-493.
6. Centers for Disease Control. Update: Transmission of HIV infection during an invasive dental procedure Florida. MMWR 1991; 40:21-33.
7. Esteban Jl, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334:555-560.
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