CDC: HBV carriers pose little threat if managed

Influx of HBV+ immigrants spurs concern

Some foreign-born medical and dental students with chronic hepatitis B virus are being subjected to Draconian policies or rejected from schools and institutions, though in most cases they can be managed with very little threat to patient safety, the Centers for Disease Control and Prevention reports.

For most chronically HBV-infected providers and students who conform to current standards for infection control, HBV infection status alone does not require any curtailing of their practices or supervised learning experiences, the CDC emphasizes in updated guidelines on HBV infected providers.1

“This creates a problem, and as we actually looked deeper into it we could see no reasons why normal students would pose any risks to patients,” says Scott Holmberg, MD, chief of epidemiology and surveillance at the CDC’s viral hepatitis branch. “At least 25% of our medical and dental students entering now are from Asian countries and when you add in countries of sub-Saharan Africa, the Middle East and other places there is very high HBV endemicity.”

In countries where HBV endemicity in the population is high, many people acquire the virus at birth and go on to become asymptomatic chronic carriers.

“It is a tremendous issue. We have immigrant and refugee populations that are being assimilated into society,” says Ruth Carrico, PhD, RN, CIC, an associate professor at the School of Public Health and Information Sciences at the University of Louisville, KY. “We have an influx of a lot of physicians from other countries coming in to the U.S. and they are going to try to get back involved in the health care system. We need to figure out how we are going to not only help them do that but recognize what infectious — for want of a better word — ‘baggage’ they may be bringing with them. We need to recognize that is part of our responsibility as they are integrated into society and health care professions. The question is how to help them be successful and protect our patients.”

Threats of dismal, acceptance denied

There have been several recent instances in which HBV-infected persons have been threatened with dismissal or actually dismissed from surgical practice on the basis of their HBV infection, and others have had their acceptances to medical or dental schools rescinded or deferred because of their infection, the CDC reports. Some of these instances have involved requirements that the infected provider, applicant, or student demonstrate undetectable HBV viral load or hepatitis B e-antigen negativity and, in at least one case, that this be demonstrated continuously by weekly testing. These actions might not be based on clear written guidance and procedures at the institutions involved, the CDC reports.

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, the CDC recommends. Beyond typical medical and dental studies, the CDC also addresses convening expert review panel to oversee the practice of surgeons and others who perform exposure-prone procedures.

“Those guidelines are mainly for the exceptional case — someone who is doing invasive surgery or exposure prone procedures and has hepatitis B infection and has a high viral load,” Holmberg says. “We think these are the situations under which transmission might occur, albeit rarely.”

In general, the CDC recommends that all health-care providers at risk for HBV infection be tested and that all those found to be susceptible should receive the vaccine. Such testing is likely to detect chronically infected health-care providers and students. All health-care providers and students should receive hepatitis B vaccine according to current CDC recommendations. Vaccination 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 after revaccination should be tested for HBsAg and anti-HBc to determine their infection status, the CDC recommends.

Striking an ethical balance

The updated HBV guidelines reflect changes in the epidemiology of HBV infection in the United States and advances in the medical management of chronic HBV infection. In updating guidelines from 1991, the CDC said informed consent to patients is no longer practical or necessary if other measures are in place.

“We felt that [disclosure] was really tantamount to just never operating,” Holmberg says. “Any patient who is told their surgeon has HBV, HIV or hepatitis C would probably opt not to go that surgeon. And the fact of the matter is that we at CDC do not know of any instances where infected surgeons with HBV, HIV, and HCV are actually telling their patients they are infected. We felt it was completely impractical.”

Moreover, routine mandatory disclosure might actually be counterproductive to public health, as providers and students might perceive that a positive test would lead to loss of practice or educational opportunities. This misperception might lead to avoidance of HBV testing, vaccination, treatment and management, effectively driving HBV carriers underground.

The CDC guidelines include a review by three external ethicists, who concluded that guidelines “that allow providers with HBV to practice while requiring those doing exposure-prone procedures to be monitored to maintain low load strike the right balance between protecting patients’ interests and providers’ rights.” They noted that providers have an ethical and professional obligation to know their HBV status and to act on such knowledge accordingly. Morever, the ethicists and a CDC Consult Subcommittee supported the new recommendation that mandatory disclosure of provider HBV status to patients was no longer warranted, concluding that the 1991 recommendation for disclosure was “discriminatory and unwarranted.”

In addition, the Consult Subcommittee determined that there was no scientific or ethical basis for the restrictions that some medical and dental schools have placed on HBV-infected students and concluded that such restrictions were detrimental to the professions as well as to the individual students.

Symptomatic acute HBV infections in the United States, as reported through health departments to CDC, have declined approximately 85% from the early 1990s to 2009, following the adoption of universal infant vaccination and catch-up vaccinations for children and adolescents, the CDC notes. If declining trends continue, an ever-increasing proportion of patients receiving health care and their providers will be protected by receipt of hepatitis B vaccination. While provider to patient transmission of HBV is extremely rare, patient-to-health-care provider transmission also has markedly declined. Reflecting this trend, the reported number of acute HBV infections among providers in the U.S. — not all of which reflect occupational exposure — decreased from approximately 10,000 in 1983 to approximately 400 in 2002 and to approximately 100 by 2009, the CDC reports. Parenteral and needlestick exposures are mainly responsible for HBV transmission in health-care settings. Those have been dramatically reduced through increased use of needle safety devices, puncture-resistant needle and sharp object disposal containers, and the use of ports and other needleless vascular access.

Improved HBV medications can lowwer the level of circulating virus to near undetectable levels, making it possible for infected providers to continue their medical practice under appropriate oversight. The newer medications are effective in suppressing viral replication, and it is expected that they will be used for any newly identified HBV-infected health-care providers who are performing exposure-prone procedures and have HBV virus levels above the CDC recommended threshold of 1,000 IU/ml. However, clinicians caring for infected health-care providers or students who are not performing exposure-prone procedures and who are not subject to expert panel review should consider both the benefits and risks associated with life-long antiviral therapy for chronic HBV, the CDC emphasized.

References

  1. Holmberg SD, Suryaprasad SD, Ward JW. Updated CDC recommendations for the management of hepatitis B virus-infected healthcare providers and students. MMWR 2012;61(RR-3):1-12.
  2. Henderson DK, Dembry L, Fishman NO, et al. Society for Healthcare Epidemiology of America. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infect Control Hosp Epidemiol. 2010; 31:203-32