Download Ohio Department of Health Updated Recommendations for HIV

Ohio Department of Health
Updated Recommendations
for HIV, HCV, and HBV
Infected Healthcare Workers,
2006
Kathleen M. Koechlin PhD, MPH, RN
Hepatitis C Coordinator
Ohio Department of Health
Bureau of Infectious Disease Control
[email protected]
614-644-2714
A page of acronyms
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ODH = Ohio Department of Health
HCW = healthcare worker
HIV = human immunodeficiency virus
HCV = hepatitis C virus
HBV = hepatitis B virus
CDC = Centers for Disease Control and Prevention
OSHA = Occupational Safety and Health
Administration
EPA = Environmental Protection Agency
JCAHO = Joint Commission on Accreditation of
Healthcare Organizations
History – Federal Mandate
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Section 633 of the Treasury, Postal
Service, and General Appropriations
Act of 1991 mandated that all states
establish recommendations for the
practice of HCWs infected with a
bloodborne pathogen including HIV
and HBV
History – State Mandate
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Ohio House Bill 419 passed by the 119th
General Assembly in 1992
– Mandated the Director of Health to create the
Task Force on the Transmission of Bloodborne
Pathogens by Healthcare Professionals
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Establish and keep current guidelines/
recommendations in accordance with the CDC
guidelines
– Required the Ohio dental, medical, and nursing
boards to adopt rules establishing that Universal
Blood and Body Fluid Precautions be used by all
persons licensed by these boards
CDC Recommendations July 12, 1991
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Based on the following considerations:
– Infected HCWs who adhere to Universal
Precautions and do not perform invasive
procedures pose no risk for transmitting HIV or
HBV to patients
– Infected HCWs who adhere to Universal
Precautions and who perform certain exposureprone procedures pose a small risk for
transmitting HBV to patients
– HIV is transmitted much less readily than HBV
– Until further data are available, precautions must
be taken to prevent HIV and HBV transmission
during procedures that have been linked to
HCW-to-patient HBV transmission or that are
considered exposure-prone
Background – Previous Infection
Control Practice Recommendations
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Universal Precautions
Appropriately disinfected and sterilized
instruments and other reusable equipment
Training of HCWs on infection control
HBV vaccine for all HCWs who might be
exposed to blood in an occupational setting
Background – Transmission of
HBV During Invasive Procedures
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As of 1991, published reports of 20 clusters
in which a total of over 300 patients were
infected with HBV in association with
treatment by an HBV-infected HCW
– Of HCWs whose HBeAg status was determined
(17 of 20), all were HBeAg positive
– Each report indicated that the potential existed
for contamination of surgical wounds or
traumatized tissue, either from a major break in
standard infection-control practices or from
unintentional injury to the infected HCW during
invasive procedures
Background – Transmission of
HIV During Invasive Procedures
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Cluster of HIV infections among patients in the
practice of one dentist with AIDS (5 of 850 patients
evaluated through June 1991)
Two studies when patients were cared for by a
general surgeon and a surgical resident who had
AIDS, all patients tested HIV negative
Of 143 patients treated by an HIV+ dental student,
all were HIV616 patients of an HIV+ general surgeon all tested
HIV- except for one who had a history of injection
drug use
Further evaluation of a substantially larger number
of patients whose exposure-prone procedures have
been performed by HIV-infected HCWs is needed
Exposure-Prone
Procedures
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Certain oral, cardiothoracic, colorectal, and
OB/GYN procedures
Characteristics of exposure-prone
procedures:
– Digital palpation of a needle tip in a body cavity
– Simultaneous presence of the HCW’s fingers and
a needle or other sharp instrument or object in a
poorly visualized or highly confined anatomic site
CDC Recommendations
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All HCWs should adhere to Universal
Precautions
No basis for recommendations to restrict the
practice of HCWs infected with HIV or HBV
who perform invasive procedures not
identified as exposure-prone, provided they
practice the recommended surgical or dental
technique and comply with Universal
Precautions and current recommendations
for sterilization/ disinfection
CDC Recommendations,
continued
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Exposure-prone procedures should be identified by
medical/surgical/dental organizations and
institutions at which the procedures are performed
HCWs who perform exposure-prone procedures
should know their HIV antibody status
HCWs who perform exposure-prone procedures and
do not have serologic evidence of immunity to HBV
from vaccination or previous infection should know
their HBsAg status and, if positive, should know
their HBeAg status
CDC Recommendations,
continued
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HCWs who are infected with HIV or HBV
(and are HBeAg+) should not perform
exposure-prone procedures unless they
have sought counsel from an expert review
panel and been advised under what
circumstances, if any, they may continue to
perform these procedures
Mandatory testing of HCWs for HIV, HBsAg,
or HBeAg is not recommended
HCWs whose practices are
modified because of HIV or HBV
status….
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should, whenever possible, be provided
opportunities to continue appropriate
patient-care activities
should be given career counseling and ways
to retain a job so that the continued use of
the HCW’s talents, knowledge and skills can
be maintained
HCWs whose practices are
modified because of HBV
status….
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Should be re-evaluated periodically to
determine whether their HBeAg status
changes
Notification of Patients
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The public health benefit of notification of
patients who have had exposure-prone
procedures performed by HCWs infected
with HIV or positive for HBeAg should be
considered on a case-by-case basis, taking
into consideration:
– Specific risks
– Confidentiality issues
– Available resources
Additional Needs
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Clearer definition of the nature, frequency, and
circumstances of blood contact between patients
and HCWs during invasive procedures
Development and evaluation of new devices,
protective barriers, and techniques that may
prevent such blood contact without adversely
affecting the quality of patient care
More information on the potential for HIV and HBV
transmission through contaminated instruments
Improvements in sterilization and disinfection
techniques for certain reusable equipment and
devices
Identification of factors that may influence the
likelihood of HIV or HBV transmission after
exposure to HIV or HBV infected blood
Ohio Department of Health Updated
Recommendations for HIV, HCV, and
HBV Infected Healthcare Workers, 2006
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In the early 1990s the original document (created in response
to the federal and state mandates) developed
recommendations for HCWs infected with HIV and HBV
Developed by a committee of Ohio’s medical and public health
communities in conjunction with the ODH
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Ohio State Medical Board
Ohio Board of Nursing
Ohio State Dental Board
Ohio Hospital Association
Ohio Dental Association
Ohio Osteopathic Association
Ohio State Medical Association
Ohio Nurses Association
Association of Ohio Health Commissioners
Physicians with expertise in HIV
Ohio Department of Health Updated
Recommendations for HIV, HCV, and
HBV Infected Healthcare Workers, 2006
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In 2004-2005, the ODH reviewed those recommendations
given current science and a new understanding of HCV and its
significance
The revision process solicited comments from:
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Ohio State Medical Board
Ohio Board of Nursing
Ohio State Dental Board
Ohio Hospital Association
Ohio Dental Association
Ohio Osteopathic Association
Ohio State Medical Association
Ohio Nurses Association
Association of Ohio Health Commissioners
Infectious Diseases Society of Ohio
Principles Guiding Policy
Development
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Universal and/or Standard Precautions are the most
effective means of preventing transmission of any
bloodborne pathogen both to and from HCWs
Medical practices, including Universal or Standard
Precautions and improved engineering controls,
decrease the risk of bloodborne pathogen
transmission
Mandatory HIV screening of all HCWs in Ohio is
inappropriate
Risk of HCV transmission from an infected HCW to
patients appears to be very low
There is some evidence that transmissibility of
these viruses is reflected in certain biochemical
markers (e.g., HBeAg, HIV-RNA viral load)
Ohio’s Policy
Recommendations
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CDC’s guidelines and OSHA’s Bloodborne
Pathogen Standard are the basis
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Universal Precautions and Standard Precautions
Infection Control
Training and Education
Hepatitis B Vaccination
Counseling and Testing
Infected HCWs
Review Panels
Universal Precautions and
Standard Precautions
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All HCWs must strictly adhere to the
Universal Precautions set forth by the OSHA
All HCWs must follow CDC guidelines for
Standard Precautions
Ohio medical, dental, and nursing boards
have mandated the use of Universal
Precautions for license holders who perform
exposure-prone procedures
Employers must keep records of training,
observe practices, and ensure compliance
with Universal and/or Standard Precautions
Infection Control
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All HCWs must strictly adhere to appropriate
infection control procedures (guidelines set
forth by the CDC and regulations of the EPA
and OSHA)
HCWs who have exudative lesions or
weeping dermatitis should refrain from all
direct patient care and from handling
patient care equipment and devices used in
performing invasive procedures until the
condition resolves
Training and Education
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Proper infection control techniques
– Comply with CDC guidelines concerning barrier
techniques, Standard Precautions, and
recommendations for ongoing training
– OSHA requires training by employers for persons
with occupational exposure to potentially
infectious substances
– Training should be required in professional and
vocational schools
– Training is recommended as part of continuing
professional education programming
– Training is encouraged to be performed in
accordance with the OSHA and the JCAHO
requirements but should include HCWs outside
these employer domains
Hepatitis B Vaccination
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HCWs susceptible to HBV infection and
with the potential of coming into
contact with blood or other potentially
infectious materials while working
should receive vaccination against HBV
Counseling and Testing
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Mandatory testing of all HCWs for HIV, HCV, or HBV
is NOT recommended
Testing should NOT be a condition of employment,
licensure or certification
HCWs who perform exposure-prone invasive
procedures should know their HIV, HCV and HBV
status
HCWs should be acutely aware of incidents that
pose a risk of acquiring a bloodborne pathogen
during work duties and should immediately report
any percutaneous or mucous membrane exposure
to the blood or other potentially infectious material
of a patient
All HIV, HCV and HBV test results are protected by
medical confidentiality standards and should only
be released to individuals who have a legitimate
need to know
Infected HCWs
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Infected HCWs who adhere to Universal and
Standard Precautions and do not perform invasive
procedures pose no risk for transmission of a
bloodborne infection to a patient
Infected HCWs who adhere to Universal and
Standard Precautions and do perform invasive
procedures pose a small risk for transmission to a
patient
HCWs who are infected with a bloodborne
pathogen have an obligation to seek advice from
their personal physician in evaluating their specific
medical conditions, and to examine the possible
need for assistance from a review panel
HCWs or their personal physician(s) should contact
the appropriate review panel for advice and
consultation regarding a HCW’s evaluation
Review Panels
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Institutional Review Panels
Non-institutional review panel
convened by the Director of the ODH
Institutional Review Panels
– Composition (at a minimum)
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An infectious disease physician or an advanced
practice nurse in infectious diseases
A HCW who holds the same license and performs
the same procedures as the infected HCW
An infection control specialist who has expertise in
Standard Precautions and OSHA requirements
An occupational health/employee health expert
from the facility where the HCW practices
The local health commissioner or designee
An attorney
An individual with expertise in legislative mandates
impacting workplace obligations toward infected
HCWs
Institutional Review Panels
– Composition, continued
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The HCW’s personal physician should
be consulted by the panel, after
appropriate authorization, about the
HCW’s current functional status
All institutional review panels should
include at least two individuals who
are from outside the institution
Institutional Review Panels
– other requirements:
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All institutional panels making
recommendations regarding HIV, HCV or
HBV positive HCWs must receive approval
from the Director of Health before the panel
acts as the review panel
Institutions should have an employee
testing policy consistent with CDC and ODH
recommendations and not in violation of
state or federal law
Institutional Review Panels
– other requirements:
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Any institutional panel must report to the
Director of Health the status of compliance
with panel recommendations by a HCW
receiving guidance from the panel
– The HCW shall be identified by an assigned case
number for purposes of reporting to the Director
of Health
– The HCW’s name will only be associated with the
case number if any action by a licensing board
must be taken
– The Director of Health will receive a timetable
for the re-evaluation, progress and compliance
of each HCW under the review of an institutional
panel
Non-institutional Review
Panels – Composition (at a
minimum)
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Members will be selected by the Director of
Health on a case-by-case basis to ensure
familiarity with the specific professional
duties of the HCW
The composition of this panel must be
equivalent to the composition of the
institutional panel with the following
exceptions:
– The state epidemiologist or designee must be
included
– The occupational health specialist will be
designated by the Director of Health if this panel
relates to non-institutional workers and a noninstitutional panel is convened
Review Panel Duties
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Evaluate the HCW’s medical condition and
ability to perform specific job duties
Make recommendations to the Director of
Health concerning the circumstances under
which the HCW may perform exposureprone procedures
Recommendations shall be based on the
HCW’s impairment and shall consider his or
her likelihood of performing exposure-prone
procedures
Institutional Panel Duties
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Evaluate the HCW’s medical condition and
ability to perform specific occupational
duties
Monitor compliance with Universal
Precautions, Standard Precautions and
appropriate infection control techniques
Provide guidance and education to assist
the infected HCW in achieving strict
adherence to established standards
Modification of practice recommendations
when appropriate
Institutional Panel Duties,
continued
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Render a decision regarding the HCW’s
ability to perform occupational duties
– Include a report of recommendations to be
reviewed with and followed by the HCW
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Copy of the report is filed with the Director of Health
– If HCW accepts recommendations, the panel will
establish a schedule to review the case and to reevaluate the HCW’s adherence to recommendations and
ability to continue specific occupational duties
 Copies of re-evaluations filed with Director of Health
 Should the HCW become non-compliant with the
panel recommendations or become unfit for duty,
the panel shall file a report with the Director of
Health who will notify the appropriate licensing
board
Non-institutional Panel
Duties
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Evaluate the HCW’s medical condition and
ability to perform specific occupational
duties
Monitor compliance with Universal
Precautions, Standard Precautions and
appropriate infection control techniques
Provide guidance and education to assist
the infected HCW in achieving strict
adherence to established standards
Modification of practice recommendations
when appropriate
Non-institutional Panel
Duties, continued
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A decision regarding the HCW’s ability to
perform occupational duties will be filed
with the Director of Health
The panel will establish a schedule for
periodic re-evaluation of the HCW
– Copies of the re-evaluation reports will be filed
with the Director of Health
– Should the HCW become non-compliant with the
panel recommendations or become unfit for
duty, the panel shall file a report with the
Director of Health who will notify the appropriate
licensing board
Confidentiality
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All information obtained by a review panel
regarding HIV, HCV or HBV infected HCWs
shall be held in confidence in accordance
with all applicable federal and state laws
Members of the review panel must sign a
statement of confidentiality regarding the
information they receive as a member of a
review panel
Enforcement
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Noncompliance shall be reported
immediately to the Director of Health
and further action will be taken as
necessary
Enforcement, continued
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Upon completing review of all relevant
information
– The panel prepares a preliminary report of its
findings and recommendations
– A copy of this report is forwarded to the HCW
– No later than 60 days after providing the copy to
the HCW, the panel convenes informally to
review the report with the HCW
Enforcement, continued
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At the informal review:
– The HCW may appear in person, with, or by
such other representative as the HCW feels is
appropriate
– The HCW may, in advance of or at the informal
review, present additional relevant information
and his or her positions, arguments, or
contentions in writing or verbally
– The panel may adopt, reverse, or modify the
preliminary report and notify the HCW within 30
days of the informal review in the panel’s final
report and recommendation
Enforcement, continued
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After the panel’s final report:
– The HCW may, within 30 days, request the
Director of Health review the panel’s final report
and recommendations
– The HCW may include written objections to the
panel’s final report and recommendations along
with the request for the Director’s review
– The Director of Health may request such
additional information the Director feels is
appropriate to conduct the requested review
– The Director shall affirm, reverse, or modify the
panel’s final report and recommendations
– The decision of the Director to affirm, reverse, or
modify the panel’s report and recommendations
is final and not subject to appeal
Articles of Interest
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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;334:549-54.
AIDS/TB Committee of 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;18:349-63.
Articles of Interest
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Reitsma AM, Closen ML, Cunningham M, et
al. Infected physicians and invasive
procedures: Safe practice management.
Clinical Infectious Diseases 2005;40:166572.
Perry JL, Pearson RD, Jagger J. Infected
health care workers and patient safety: A
double standard. Am J Infect Control
2006;34:313-9.
References
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Recommendations for Preventing
Transmission of Human Immunodeficiency
Virus and Hepatitis B Virus to Patients
During Exposure-Prone Invasive Procedures.
MMWR 40(RR08); 1-9.
http://www.cdc.gov/mmwr/preview/mmwrh
tml/00014845.htm
Ohio Department of Health Updated
Recommendations for HIV, HCV, and HBV
Infected Healthcare Workers, 2006.
http://www.odh.ohio.gov/alerts/alerts.aspx