SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus

This guideline provides the updated recommendations of the Society for Healthcare Epidemiology of America (SHEA) regarding the management of healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or the human immunodeficiency virus (HIV). For the reasons cited in the guideline, SHEA continues to recommend that, although some aspects of the approach to and administrative management of each of these infectious syndromes in healthcare providers are similar, separate management strategies for healthcare workers who are infected with these unrelated viruses remain appropriate. As we did in both prior iterations of this document, SHEA emphasizes the use of appropriate infection control procedures to minimize exposure of patients or providers to blood, emphasizes that transfers of blood from patients to providers and from providers to patients should be avoided, and recommends that infected healthcare providers should not be totally prohibited from participating in patient-care activities solely on the basis of a bloodborne pathogen infection. The types of procedures assessed by the panel as associated with an increased risk for provider-to-patient transmission of these pathogens are discussed in detail. For each pathogen, recommendations are graduated according to the relative viral load level of the infected provider (Tables 1 and 2). However, SHEA emphasizes that, because of the complexity of these cases, each such case will be slightly different from the next, and each should be independently considered in context.

Healthcare Workers and HIV Health Issues

Should healthcare workers (HCWs) be routinely tested for HIV? The authors reviewed the literature on the risk and incidence of HIV transmission from HCW to patients and offer recommendations for HIV testing in HCWs in Singapore. Management of HCWs who are tested seropositive for HIV infection is also discussed in this paper. Key words: AIDS, HIV testing, occupational, transmission

Preventing bloodborne pathogen transmission from health-care workers to patients. The CDC perspective

The development of recommendations to manage the risk of bloodborne pathogen transmission from health-care workers to patients during invasive procedures has been difficult, primarily because of the limitations of available scientific data. Ultimately, both health-care workers and patients will be protected best by compliance with infection control precautions and by development of new instruments, protective equipment, and techniques that reduce the likelihood of intraoperative blood exposure without adversely affecting patient care.

Patients treated by a thoracic surgeon with HIV. A review

Transmission of HIV from healthcare worker to patient has been documented in one report. Though the means of transmission in that case remains unknown, procedures that involve exposure to blood or mucous membranes are thought to carry an increased risk. Because of previous evidence of transmission of hepatitis B by cardiothoracic surgeons, they have been identified as a group known to perform exposure-prone invasive procedures with a risk of viral transmission. A retrospective review of 612 patients of a cardiothoracic surgeon who is HIV-positive was conducted in an attempt to identify any instance of viral transmission. A total of 189 patients received HIV testing and counseling. No positive test results were obtained.

Determining the HIV status of patients of three HIV-positive Navy dentists

The prevalence of human immunodeficiency virus infection has caused the risk of HIV transmission in the health care setting to become a major public concern. Navy medical records were reviewed to investigate the HIV status of 2,887 patients treated by three HIV-positive dentists.

The thrifty genotype and non-insulin dependent diabetes

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Risks to surgeons and patients from HIV and hepatitis: guidelines on precautions and management of exposure to blood or body fluids. Joint Working Party of the Hospital Infection Society and the Surgical Infection Study Group

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‘Look-Back’ Notifications for HIV/HBV-Positive Healthcare Workers

In December 1990, the Society for Hospital Epidemiology of America (SHEA), in conjunction with the Association for Practitioners in Infection Control, published a position paper entitled, ‘The HIV-Infected Healthcare Worker,” in which we outlined our approach to the evaluation and management of such individuals. In that position paper, we wrote that we did not favor widespread or compulsory testing for human immunodeficiency virus (HIV), hepatitis B, or other bloodborne pathogens for any group of healthcare workers including those doing invasive procedures. We indicated that the vast majority of patient contacts, including most invasive procedures, could be safely carried out by healthcare workers infected with HIV or other bloodborne pathogens, provided that such individuals were familiar with and adhered to proper infection control practices including those of “Universal Blood and Body Fluid Precautions” and assuming that such individuals had no other evidence of functional impairment due to medical, emotional, or neurological disease, which could affect their capacity to carry out such procedures. We recognized, however, that a small subset of invasive procedures, principally those involving by-feel manipulation of pointed or sharp objects within body cavities (including “blind” sewing) might pose a heightened risk of accidental injury and inadvertent transmission of bloodborne pathogens. We suggested therefore that healthcare workers infected with HIV or hepatitis B virus (HBV) be counseled to avoid, voluntarily, that small subset of procedures that in the past had been linked epidemiologically to the transmission of hepatitis B virus.

Analyzing dental procedures performed by an HIV-positive dental student

No evidence of HIV transmission was found between an HIV-positive dental student and 163 treated patients.

Cross-infection risks associated with current procedures for using high-speed dental handpieces

When a dye solution used to simulate patient material was either injected into high-speed dental handpiece (drill) waterlines or applied to the equipment externally, internal air turbine chambers became contaminated. These chambers served as a reservoir of the material, which was slowly dislodged by air expelled during subsequent handpiece operation and which was diluted by water spray used for cooling the drilling surface. Considering the fact that patient materials could reside in internal parts of the equipment that are not usually disinfected and that the material may be subsequently sprayed into cuts and abrasions in the oral cavity, the common approach to reprocessing handpieces (external wiping in combination with flushing) may pose unacceptably high risks to those individuals treated soon after infected patients. Therefore, unless reliable data on cross-infection frequencies are obtained and prove it unnecessary, heat-treating high-speed handpieces between each patient should be considered an essential component of standard procedures whenever universal precautions are practiced in dentistry.

A look-back investigation of patients of an HIV-infected physician. Public health implications

BACKGROUND

Transmission of the human immunodeficiency virus (HIV) to five patients receiving care from an HIV-infected dentist in Florida has recently been reported. Current data indicate that the risk of HIV transmission from health care workers to patients is low. Despite this low risk, programs to notify patients of past exposure to an HIV-infected health care worker are being conducted with increasing frequency.

METHODS

We recently conducted an investigation of all the patients cared for by an HIV-infected family physician during a period when he had severe dermatitis caused by Mycobacterium marinum on his hands and forearms. After reviewing the patients' records, we notified 336 patients who had undergone one or more procedures (digital examination of a body cavity or vaginal delivery) placing them at potentially increased risk of HIV infection. The patients were offered tests for HIV infection and counseling.

RESULTS

Of the 336 patients, 325 (97 percent) had negative tests for HIV antibody, 3 (1 percent) refused testing, 1 (less than 1 percent) died of a cause unrelated to HIV infection before notification, and the HIV-antibody status of 7 (2 percent) remained unknown. The direct and indirect public health costs of this investigation were approximately $130,000.

CONCLUSIONS

The results of this investigation raise important questions about the risk of HIV transmission from health care workers to patients and the usefulness of HIV look-back programs, particularly in the light of recently published recommendations from the Centers for Disease Control. We propose that before a look-back investigation is undertaken, there should be a clearly identifiable risk of transmission of the infection, substantially higher than the risk requiring limitation of an HIV-infected health care worker's practice prospectively.

Human immunodeficiency virus transmission in health care settings: risk and risk reduction

Surveillance data and case reports document that health care workers (HCWs) risk occupationally acquired human immunodeficiency virus (HIV) infection. Transmission of HIV to patients of an infected HCW during invasive procedures has also been reported. The risk to a susceptible HCW depends on the prevalence of HIV infection among patients, the nature and frequency of occupational blood exposures, and the risk of transmission per exposure. Blood exposure rates vary by occupation, by procedure, and by compliance with preventive measures. Future efforts to protect both HCWs and patients must include improved surveillance, risk assessment, study of postexposure prophylaxis, and an emphasis on exposure prevention, including development of safer medical devices, work practices, and personal protective equipment that are acceptable to HCWs and do not adversely affect patient care.

Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures

This document has been developed by the Centers for Disease Control (CDC) to update recommendations for prevention of transmission of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in the health-care setting. Current data suggest that the risk for such transmission from a health-care worker (HCW) to a patient during an invasive procedure is small; a precise assessment of the risk is not yet available. This document contains recommendations to provide guidance for prevention of HIV and HBV transmission during those invasive procedures that are considered exposure-prone.