CDC recommendations for managing HBV+ HCWs

According to guidelines updated in 2012,1 the Centers for Disease Control and Prevention recommends the following measures for identifying and managing hepatitis B virus–infected health-care providers and students:

Practice Scope

Chronic HBV infection in itself should not preclude the practice or study of medicine, surgery, dentistry, or allied health professions. Standard precautions should be adhered to rigorously in all health-care settings for the protection of both patient and provider.

CDC discourages constraints that restrict chronically HBV-infected health-care providers and students from the practice or study of medicine, dentistry, or surgery, such as

— repeated demonstration of persistently nondetectable viral loads on a greater than semiannual frequency;

— prenotification of patients of the HBV-infection status of their care giver;

— mandatory antiviral therapy with no other option such as maintenance of low viral load without therapy; and

— forced change of practice, arbitrary exclusion from exposure-prone procedures, or any other restriction that essentially prohibits the health-care provider from practice or the student from study.

Hepatitis B Vaccination and Screening

All health-care providers and students should receive hepatitis B vaccine according to current CDC recommendations. Vaccination (3-dose series) should be followed by assessment of hepatitis B surface antibody to determine vaccination immunogenicity and, if necessary, revaccination. Health-care providers who do not have protective concentration of anti-HBs (>10 mIU/ml) after revaccination (i.e., after receiving a total of 6 doses) should be tested for HBsAg and anti-HBc to determine their infection status.

Prevaccination serologic testing is not indicated for most persons being vaccinated, except for those providers and students at increased risk for HBV infection, such as those born to mothers in or from endemic countries and sexually active men who have sex with men.

Providers who are performing exposure-prone procedures also should receive prevaccination testing for chronic HBV infection. Exposure of a patient to the blood of an HBV-infected health-care provider, in the performance of any procedure, should be handled with postexposure prophylaxis and testing of the patient in a manner similar to the reverse situation (i.e., prophylaxis for providers exposed to the blood of an HBV-infected patient).

Expert Panel Oversight Not Needed

Providers, residents, and medical and dental students with active HBV infection (i.e., those who are HBsAg-positive) who do not perform exposure-prone procedures but who practice non- or minimally invasive procedures should not be subject to any restrictions of their activities or study. They do not need to achieve low or undetectable levels of circulating HBV DNA, hepatitis e-antigen negativity, or have review and oversight by an expert review panel, as recommended for those performing exposure-prone procedures. However, they should receive medical care for their condition by clinicians, which might be in the setting of student or occupational health.

Expert Panel Oversight Recommended

Surgeons, including oral surgeons, obstetrician/gynecologists, surgical residents, and others who perform exposure-prone procedures, should fulfill the following criteria:

Their procedures should be guided by review of a duly constituted expert review panel with a balanced perspective (i.e., providers’ and students’ personal, occupational or student health physicians, infectious disease specialists, epidemiologists, ethicists and others as indicated above) regarding the procedures that they can perform and prospective oversight of their practice. Confidentiality of the health-care provider’s or student’s HBV serologic status should be maintained.

HBV-infected providers can conduct exposure-prone procedures if a low or undetectable HBV viral load is documented by regular testing at least every 6 months unless higher levels require more frequent testing; for example, as drug therapy is added or modified or testing is repeated to determine if elevations above a threshold are transient.

The CDC recommends that an HBV level 1,000 IU/ml (5,000 GE/ml) or its equivalent is an appropriate threshold for a review panel to adopt. Monitoring should be conducted with an assay that can detect as low as 10–30 IU/ml, especially if the individual institutional expert review panel wishes to adopt a lower threshold.

Spontaneous fluctuations (blips) of HBV DNA levels and treatment failures might both present as higher-than-threshold (1,000 IU/ml; 5,000 GE/ml) values. This will require the HBV-infected provider to abstain from performing exposure-prone procedures, while subsequent retesting occurs, and if needed, modifications or additions to the health-care provider’s drug therapy and other reasonable steps are taken.

Institutional Policies and Procedures

Hospitals, medical and dental schools, and other institutions should have written policies and procedures for the identification and management of HBV-infected health-care providers, students, and school applicants. These policies should include the ability to identify and convene an expert review panel aware of these and other relevant guidelines and recommendations before considering the management of HBV-infected providers performing exposure-prone procedures.

Reference

1. Holmberg SD, Suryaprasad A, Ward JW. Updated CDC recommendations for the management of hepatitis B virus–infected health-care providers and students. MMWR 2012;61(RR-3):1–12.