Hepatitis B-related policies: Inconsistent patient safety in Indonesian hospitals

Abstract

As Indonesian medical practitioners and researchers with experience in many urban and rural Indonesian hospitals, we found some infection control-related patient safety policies that are nonevidentiary, reflecting an incomplete understanding of basic infection control as illustrated by the following case studies on hepatitis B virus (HBV)-related policies. An HBV surface antigen (HBsAg) screening policy for applicants of permanent positions was introduced by some hospitals as a measure of reducing cross infection to their patients. However, in certain instances, it is unclear whether patient safety or the care for employees with hepatitis B is the focus behind this policy, with visiting specialists not being screened and positive test results sometimes being overlooked for highly sought clinician applicants. HBsAg screening of surgical patients is unwarranted in Indonesia because of high endemicity (5%-26%)1Budihusodo U. Sulaiman H.A. Akbar H.N. Lesmana L.A. Waspodo A.S. Noer H.M. et al.Seroepidemiology of HBV and HCV infection in Jakarta, Indonesia.Gastroenterologia Japonica. 1991; 26: 196-201PubMed Google Scholar, 2Amirudin R. Akil H. Akahane Y. Suzuki H. Hepatitis B and C virus infection in Ujung Pandang, Indonesia.Gastroenterologia Japonica. 1991; 26: 184-188PubMed Google Scholar, 3Sulaiman H.A. Julitasari Sie A. Rustam M. Melani W. Corwin A. et al.Prevalence of hepatitis B and C viruses in healthy Indonesian blood donors.Trans R Soc Trop Med Hyg. 1995; 89: 167-170Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 4van Hattum J. Boland G.J. Jansen K.G. Kleinpenning A.S. van Bommel T. van Loon A.M. et al.Transmission profile of hepatitis B virus infection in the Batam region, Indonesia: evidence for a predominantly horizontal transmission profile.Adv Exp Med Biol. 2003; 531: 177-183Crossref PubMed Scopus (2) Google Scholar and patients bearing the cost under a fee-for-service system.5Azwar A. Pengantar administrasi kesehatan.2nd ed. Binarupa Aksara, Jakarta1988Google Scholar Nevertheless, some hospitals imposed this screening “to protect ourselves and also other patients” (senior nurse). For HBsAg(+) surgical patients, some central sterilization services departments (CSSDs) reprocessed used instruments with additional disinfectants. Because this reprocessing method is considered to deteriorate instruments, items from HBsAg(-) and untested patients undergo a shorter reprocessing procedure. Meanwhile, staff at another hospital discard items from HBsAg(+) patients because they admitted to doubt the adequacy of their CSSD sterilizing procedure. In some facilities, all HBsAg(+) patients are cohorted in multibed isolation rooms with other infectious patients, including patients with active pulmonary tuberculosis, without any protection, not even surgical masks. One ward nurse acknowledged this risk of additional morbidity for HBsAg(+) patients as “[the HBsAg(+) patients'] fate.” The hospital's infection control nurse explained that this isolation policy was intended to make health care workers more vigilant in preventing hepatitis B cross transmission. Although realizing the weakness of the policy, a medical practitioner explained, “Everybody is scared of getting infected by the HBsAg(+) patient.” This fear began with a suspected occupationally acquired fatal hepatitis in a nurse from a hepatitis patient in the same hospital, although neither the patient nor the nurse was confirmed to have had hepatitis B or that it was an occupational infection. Regardless of the underlying factor, the above-mentioned hepatitis B-related policies fail to consider patient safety. Vis-à-vis correctly applied Standard Precautions,6Rutala W.A. Weber D.J. Selection and use of disinfectants in healthcare.in: Mayhall C.G. Hospital epidemiology and infection control. 3rd ed. Lippincott Williams & Wilkins, Philadelphia2004Google Scholar these policies are at best redundant and at worst unethical and wasteful of limited resources. They create unnecessary expenditures and drain limited resources that could be directed toward effective and evidence-based patient safety programs. The excessive fear of HBV also creates a false sense of safety associated with HBsAg(-) patients and staff. The risks of patients with hepatitis C or HIV infection are often dismissed in remote hospitals without resources to routinely test these infections. Patients with unknown infection status (including nonsurgical patients without HBsAg testing) are often considered safe and their clinical items subjected to inadequate reprocessing, contrary to Standard Precautions that require all untested patients to be treated as positive.6Rutala W.A. Weber D.J. Selection and use of disinfectants in healthcare.in: Mayhall C.G. Hospital epidemiology and infection control. 3rd ed. Lippincott Williams & Wilkins, Philadelphia2004Google Scholar These irrational hospital policies are a major challenge to the patient safety thrust. Internal change is difficult because fear has infiltrated policies and organizational culture. The national hospital accreditation body must therefore evaluate existing HBV-related policies and practices. Continuing education in infection control and patient safety for health care workers and advocacy for evidence-based policy for hospital managers are urgently needed to avoid these wasteful and dangerous practices.