Hospitals must decide which workers to test

HIV, HBV, HCV policies may vary

At the Infected Health Care Worker Program in the Minnesota Department of Health, nurse specialist Stephen Moore, RN, MPH, has a case load of 150 health care workers who have HIV, hepatitis B or C. Some are administrators not involved in patient care. Only about 20 are nurses, doctors, or dentists who perform invasive procedures that are considered exposure-prone according to a 1991 guideline from the Centers for Disease Control and Prevention.

The new guideline of the Society for Healthcare Epidemiology of America (SHEA) provides some updated approaches to monitoring but also presents challenges, says Moore. Since the guideline was released in March, hospitals around the country have been reviewing the recommendations and determining how or whether they will adapt their policies. Many states have laws relating to health care workers infected with HIV or HBV, and hospitals must adapt any changes to those statutes.

"For the 15% of the licensed health care workers I deal with who have some chance of transmitting [a bloodborne pathogen], it probably has some benefits to raise awareness and send a message to the public that we do look out for this," Moore says. A Minnesota statute, dating from 1992, requires licensed health care workers who are infected with HIV, HBV or HCV to report their status to the commissioner of health or their licensing governing boards. Depending on the complexity of the health care worker's practice, the commissioner of health might refer the case to an expert review panel.

"We work hard with health care workers in modifying their practices to make sure people don't lose their careers," he says. "When we work with people, we treat them as if they have honor and ethics and they're good at what they do — they just happen to have this disease."

Bi-annual testing of viral load would add a new wrinkle to the monitoring. It also will raise the question of cost — who pays for the testing? Physicians and even some surgical techs may be independent contractors and may perform procedures at more than one hospital. Moore says he plans to meet with infection diseases experts and the state attorney general to consider policy changes. "I plan to seek input on the SHEA guidelines from infection preventionists, governing boards, and other state agencies," he says.

The Joint Commission accrediting body, based in Oakbrook Terrace, IL, expects hospitals to consider national guidelines related to health care workers infected with a bloodborne pathogen. But they don't necessarily have to adopt the monitoring protocol recommended by SHEA, says Robert Wise, MD, vice president of the Joint Commission's Division of Standards.

"We would expect the organization to have thought through how to handle a situation," he says. "We don't demand that they use the SHEA guideline, but we would expect some sort of national guideline be used to direct their policy."

A recent review of state laws and guidelines found that only one addressed hepatitis C and 15 required notification of patients before an invasive, exposure-prone procedure if the health care worker was infected with a bloodborne pathogen. None of them addressed the issue of viral burden, said Sarah Turkel, MPH, an investigator with the National Institutes of Health Clinical Center in Bethesda, MD, who presented the findings recently in Atlanta at Fifth Decennial International Conference on Healthcare-Associated Infections. In 19 states, the issues of possible practice restrictions are handled at the hospital level, her review found.

How often should you test HCWs?

A recent HBV transmission from an HBV-positive orthopedic surgeon to patients forced the University of Virginia Health System in Charlottesville to reconsider issues of testing and restrictions. The surgeon had been a non-responder to HBV vaccination. He discovered that he had hepatitis B infection — with a viral load of 17 million international units per ml of blood — in baseline testing after a reported sharps injury.

The health system then tested patients in 237 procedures and discovered two HBV-positive cases that were linked to the surgeon and four that were likely cases of transmission, says Kyle Enfield, MD, MS, assistant hospital epidemiologist, who presented the findings recently in Atlanta at the Fifth Decennial International Conference on Healthcare-Associated Infections.

After treatment, the surgeon was allowed to resume performing procedures, with restrictions, says Enfield. He must double-glove and must report any potential exposures. He must have a non-HBV-infected surgeon with him in the operating room. He is also restricted from performing the most exposure-prone procedures, such as total hip or total knee replacement.

The health system does not require him to reveal his HBV status to patients prior to surgery. "The risk of transmission with a low viral load is infinitesimally small," says Enfield.

UVA now conducts further testing of non-responders to the HBV vaccine to determine if they are HBV-infected, says Enfield. The health system does not require routine testing of surgeons who perform invasive, exposure-prone procedures. That is in keeping with the new SHEA guideline, which calls for "voluntary confidential testing" but not mandatory testing of health care providers.

Hospitals will need to make a determination about testing of providers, says Neil Fishman, MD, director of health care epidemiology, infection prevention and control at the University of Pennsylvania Health System in Philadelphia, an author of the guideline and president of SHEA.

"At the least, every institution should offer confidential and readily available testing to providers," he says. "Then it's up to each institution to decide whether that should be mandatory if someone is going to perform these exposure-prone procedures.

At the University of Pennsylvania, for example, Fishman says, "we make testing readily available and strongly recommended. We're considering whether to make it mandatory.

"It is mandated that people get skin tested for tuberculosis annually. In that regard a similar recommended for bloodborne pathogen testing is reasonable, particularly for individuals whose career is centered on... performing high risk procedures," he says.

For physicians, testing could take place when their credentials are periodically renewed, he says.