Perform Exposure Prone Procedures Research Articles

Clinical and occupational health management of healthcare workers living with chronic hepatitis B: UK policy and international comparisons.

Hepatitis B virus (HBV) is a highly infectious bloodborne virus, which remains endemic in large geographic areas and represents a major global healthcare challenge. HBV transmission from healthcare workers, who perform exposure prone procedures (EPP), to patients is a recognized transmission risk, which varies widely globally. Although the risk is small in developed countries, it increases significantly in high-prevalent, low-resource countries, representing a major challenge to these healthcare systems and underlining the necessity for robust guidance to be in place. The HBV landscape has evolved as a result of global vaccination programs, implementation of standard precautions and the advent of new generation antiviral agents (3rd generation nucleos(t)ide analogues). In light of the progress in the field, the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP) recently issued updated guidance, which essentially removes past barriers, restricting healthcare workers from performing EPPs solely on the basis of HBV DNA level, regardless of hepatitis B 'e' antigen and/or treatment status. Although the current recommendations remain conservative compared to those of other developed healthcare systems, UK practice is now in line with other high-income countries, while ensuring patient safety remains paramount, without unduly restricting HCWs from clinical practice. The current article presents the latest UKAP guidance, considers its implications for HCWs and compares it with the guidance from major international scientific societies and governing bodies.

Hepatitis B virus transmission and health care workers: Epidemiology, pathogenesis and diagnosis

Abstract Hepatitis B infection is a preventable disease, infecting approximately two billion people worldwide and causing a million deaths annually. Around 2 million healthcare workers are exposed to Hepatitis B and have ten times higher risk of contracting the disease due to occupational exposure. In Asia, the seroprevalence is estimated between 15%–21%. The diagnosis of Hepatitis B is done mainly by detection of viral markers with the help of serologic tests. Nowadays molecular tests are increasingly being used both for diagnosis and management of patients. Vaccination of the healthcare worker is of utmost importance in the prevention of hepatitis B virus infection as it decreases the transmission effectively. According to CDC guidelines, an infected healthcare worker should not perform exposure prone procedures at HBV DNA levels more than 1000 IU/ml and an expert panel monitors the treatment. Seven drugs have been approved by US-FDA for treatment of HBV infection. The incidence of HBV has decreased since the advent of universal precautions and safe disposal of infected waste and sharps. Inclusion of Hepatitis B vaccination in the universal immunisation programme is also a major step in reducing the incidence of HBV infections.

Hepatitis B virus infected health care workers in the Netherlands, 2000-2008

In response to the confirmed transmission of hepatitis B virus (HBV) from a surgeon to several patients in the Netherlands, a ‘Committee for Prevention of Iatrogenic Hepatitis B’ was established in 2000. During the years 2000–2008, the committee reviewed 99 cases of HBV-infected health care workers. Fifty of them were found to perform exposure prone procedures (EPPs). Because of high levels of HBV DNA (>100,000 copies/ml), a ban on performing EPPs was applied in 11/50 cases; 25/50 low-viremic health care workers were allowed to continue EPPs while their HBV load was being monitored; and 14/50 cases had stopped working or changed profession. In five restricted workers who started oral antiviral treatment, HBV replication was persistently suppressed, enabling the ban on EPPs to be lifted. Throughout the European Union different levels of HBV viremia have been chosen, above which health care workers are not allowed to perform EPPs. It remains unknown how this affects the safety of patients. Application in the Netherlands of a European or a British guideline would have, respectively, doubled or tripled the number of restricted health care workers.

Prolonged antiviral therapy for hepatitis B virus‐infected health care workers: a feasible option to prevent work restriction without jeopardizing patient safety

To prevent transmission of hepatitis B virus (HBV) from health care workers (HCWs) to patients, highly viraemic HCWs are often advised to restrict performing exposure prone procedures (EPPs). To prevent loss of highly qualified medical personnel and simultaneously minimize transmission risk to patients, we offered highly viraemic HCWs antiviral therapy and evaluated the effects of this strategy. Eighteen chronic HBV-infected HCWs have been monitored every 3-6 months for a median period of 5.6 years (range 1.1-12.5 years). Antiviral therapy was offered if HBV DNA was above 10(5) copies/mL and EPPs were performed or active liver disease was present. Median HBV DNA levels, the percentage of days with HBV DNA above 10(3), 10(4) and 10(5) copies/mL, and reduction of HBV DNA during antiviral treatment have been analysed for hepatitis B e antigen (HBeAg)-positive and HBeAg-negative HCWs separately. Prolonged viral suppression was achieved in both HBeAg-positive, as well as HBeAg-negative HCWs. In HBeAg-negative HCWs treatment with interferon or lamivudine maintained HBV DNA levels below 10(5) copies/mL. For HBeAg-positive HCWs continuous treatment with tenofovir or entecavir was essential for reaching low viraemia persistently. In 2004, median HBV DNA levels in both HBeAg-negative and HBeAg-positive HCWs were below 10(3) copies/mL and all HCWs executed their professional work full-range. For both HBeAg-positive and HBeAg-negative HCWs, antiviral treatment is effective in persistent suppression of virus levels below 10(5) copies/mL. This observation supports antiviral therapy as a viable management option instead of work restriction, with the provision of regular expert monitoring including quantification of HBV DNA.

ACOG Committee Opinion No. 332: Hepatitis B and Hepatitis C Virus Infections in Obstetrician-Gynecologists

Hepatitis B and hepatitis C may be transmitted form patients to health care workers and from health care workers to patients. To reduce the risk, all obstetrician-gynecologists who provide clinical care should receive hepatitis B virus vaccine. Obstetrician-gynecologists who are hepatitis B surface antigen positive and e antigen positive should not perform exposure prone procedures until they have sought counsel from an expert review panel. Because the risk of hepatitis C virus transmission is lower than that of hepatitis B virus transmission, routine testing of health care workers is not recommended, and hepatitis C virus-positive health care workers are not required to restrict professional activities.

Doctor-to-patient transmission of Hepatitis B virus: the potential of antiviral therapy for prevention

Hepatitis B virus (HBV)-infected health-care workers (HCWs) have infected patients during medical procedures. In many countries HBV-infected HCWs are restricted in performing exposure prone procedures based on either HBeAg status or serum HBV DNA level. To prevent loss of skilled HCWs and to minimize transmission risk, highly viraemic HCWs can be offered antiviral therapy. Nucleoside analogues have proven to be effective in reducing transmission of HIV and HBV in the setting of vertical mother-to-infant transmission. Following the same rationale, suppression of viral load in HBV-infected HCWs could minimize the risk of doctor-to-patient transmission to such an extent that job modifications are no longer indicated. To limit the risk of drug resistance, the use of combination therapy is advocated. We describe two chronic HBV-infected HCWs treated with antiviral therapy, eventually leading to well-tolerated and highly effective combination therapy with lamivudine and tenofovir, with continuation of medical practice.

Comparison of commercial assays for the quantification of HBV DNA load in health care workers: calibration differences

Until recently, carriers of hepatitis B virus (HBV) were allowed to undertake exposure prone procedures providing their serum did not contain HBeAg. However, the recent description of hepatitis B transmission events occurring from HBV-infected health care workers who conduct exposure prone procedures demonstrated that the then current Department of Health guidelines needed to be revised. As part of a series of studies carried out to determine if viral load measurements are a more secure means of assessing the conduct of exposure prone procedures, the suitability of commercially available assays for HBV DNA detection and quantification were investigated. This study describes a comparative analysis on the performances of three assays each based on a different methodology. The assays included the QUANTIPLEX HBV DNA Assay (bDNA), (Chiron Diagnostics Ltd.), the AMPLICOR HBV Monitor Test, (Roche Diagnostics Systems) and the Digene Hybrid Capture System HBV DNA Assay (Digene Corporation). Calibration curves from experiments using the Eurohep ad and ay HBV DNA standard controls indicated a close correlation between the three assays over the dynamic ranges claimed by the manufacturers, although the Quantiplex assay did appear to be over-reporting. This became more apparent when testing patients undergoing anti-viral therapy where the Quantiplex assay consistently over-reported by 0.5 log 10 when compared with the Amplicor assay. The results of this study indicate that based on its dynamic range, the Amplicor HBV Monitor test is the most appropriate assay for the routine investigation of anti-HBe carriers, which will have lower levels of HBV DNA. The investigation also highlights the need for using accepted standard HBV DNA control sera. This will be essential when using an assay to establish whether health care workers who are hepatitis B carriers can be allowed to perform exposure prone procedures under the new guidelines of the UK Department of Health.

Hepatitis B--are surgeons putting patients at risk?

The 1993 Department of Health guidelines permit a surgeon who is hepatitis B surface antigen (HBsAg) positive but e-antigen (HBeAg) negative to perform exposure prone procedures, unless demonstrated to have infected patients. However, there is increasing evidence of transmission of hepatitis B to patients from health care workers in this supposedly low infectivity category. The Occupational Physician must decide whether existing guidelines represent an adequate risk assessment and indeed whether this is an acceptable risk for patients. If an NHS Trust continues to follow these guidelines it may be in breach of its duty of care to patients. Yet refusing to allow such carriers to operate without testing for additional serological markers may be unlawful discrimination. Further research is clearly needed as well as an urgent review of the guidelines.

Implementation of Department of Health guidelines for hepatitis B vaccination: a regional audit of NHS occupational health policies and procedures.

The objective of this study was to assess the implementation of the UK Health Departments' guidelines on protecting healthcare workers and patients from hepatitis B infection. The survey took place in February 1994 in the form of a postal questionnaire survey of occupational health departments. The study frame was the 18 district-based occupational health departments in the northern region of the NHS. The main outcome measures were compliance with the national guidelines on vaccination and the assessment of the hepatitis B status of employees performing exposure prone procedures. Compliance with the guidelines was variable. There were marked variations in the interpretation of serological data and there was a failure to establish the hepatitis B status of surgeons, in some cases. There is a need to provide training for occupational health practitioners about hepatitis B and to ensure that there is a uniform standard of practice within the NHS.

Hepatitis B and admission to medical school: an audit of British medical school policy.

In 1993 the health departments in the United Kingdom issued guidance on hepatitis B,1 requiring all healthcare workers (including medical students) who perform exposure prone procedures to be vaccinated against hepatitis B and to have their serological response to the vaccine checked. Healthcare workers who perform invasive procedures and who do not respond to vaccination must be tested for hepatitis B carrier status. Those who are found to be positive for surface antigen without “e” markers (HBsAg positive) need not be excluded from any work. Workers who have “e” markers (HBeAg positive) should be excluded from invasive procedures. In 1994 the Committee of Vice Chancellors and Principals agreed guidelines for universities on the fitness of students to practise medicine.2 They recommended that “all …

Immunity to hepatitis B among health care workers performing exposure prone procedures.

All health care staff who have contact with blood or bloodstained body fluids should be vaccinated against hepatitis B.1 More recent recommendations are that all surgeons should be immunised against hepatitis B by mid-1994 and all staff involved in exposure prone procedures by mid-1995,2 exposure prone procedures being those in which injury to the employee could result in exposure of a patient's open tissues to the employee's blood. We examined the immunity of staff of two health authorities and estimated the risk of a health care worker who performs exposure prone procedures being an infectious carrier of hepatitis B. Dudley Health Authority and Hammersmith and Queen Charlotte's Special Health Authority separately introduced policies before and in keeping with the government's guidelines2 in 1993 and 1991 respectively. All employees performing exposure prone procedures were asked to provide evidence of immunity to hepatitis …