San Francisco: There is a striking disconnect between patients and infectious disease clinicians on the controversial issue of whether surgeons and other health care workers infected with bloodborne pathogens should disclose their status before performing invasive procedures, it was revealed in a debate last week at the IDWeek conference.
The interactive session allowed audience voting, with a baseline tally taken before the debate finding that 75% of IDWeek audience members feel providers should not inform patients of HIV and hepatitis infections. The public clearly expects to be informed if their surgeon has a bloodborne infection, said Michael Saag, MD, FIDSA, an infectious disease physician at the University of Alabama at Birmingham. Arguing in favor of provider disclosure in the debate, he cited a survey indicating that 89% of the public want to know their provider's HIV status, with 82% saying HBV and HCV disclosure should be mandatory.1
“There are ethical issues involved here, [including] maleficence -- which is ‘do no harm,’” Saag said. “There is also the legal obligation of duty to warn and that could lead to legal liability.”
Though very rare, cases of transmission from providers to patients have occurred with all three viruses. “It is possible that this transmission can occur and I think we need to be aware of this,” he said.
The issue exploded on the scene with infamous Florida HIV Dental Case in 1990, when six patients contracted HIV after receiving care from an HIV-positive dentist. In light of the case, the CDC issued guidelines recommending that health care workers performing exposure-prone procedures take precautions and inform patients of their status.2
Last year, the CDC updated the HBV portion of the recommendations, saying informed consent to patients is no longer practical or necessary if other measures are in place. 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 noted.3
Still, the CDC has never formally revised its 1991 HIV recommendations, possibly because the issue created a political firestorm at the time that included the late Sen. Jesse Helms, (R-NC) threatening to “horse whip” providers who did not reveal their HIV status.
“The cases are almost invariably associated with major public anxiety,” said Neil Fishman, MD, an infectious disease physician at the University of Pennsylvania in Philadelphia, who argued against disclosure in the debate. “The current polarity of our American political system as well as the dramatic immediacy and accessibility of the media almost invariably fuels controversy. When you get down to it this is really an ethical issue, not a scientific issue. We need to balance the risks and benefits of disclosure.”
Fishman coauthored the 2010 guidelines on the issue by the Society for Healthcare Epidemiology of America (SHEA), which recommended that providers with bloodborne infections be allowed to practice without informed consent if they adhered to infection control measures like double gloving and were periodically tested for the level of circulating virus.4 Viral levels may be suppressed with new medications. The arguments were convincing, as 82% of the audience voted for non-disclosure in a post-debate poll.
1.Tuboku-Metzger J, Chiarello L, Sinkowitz-Cochran R, et al. Public attitudes and opinions toward physicians and dentists infected with bloodborne viruses: Results of a national survey Am J Infect Control 2005;33:299-30
2. CDC. Update: Possible transmission of human deficiency virus to a patient during an invasive dental procedure – Florida. MMWR 1991;40:21-33
3.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.
4.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