FAQs: Health Care Provider Recommendations
What are the recommendations for hepatitis B vaccination of healthcare workers?
The US CDC recommends the following for healthcare worker HepB vaccination:
If you don’t have documented evidence of a complete hepB vaccine series, or if you don’t have a blood test that shows you are immune to hepatitis B (i.e., no serologic evidence of immunity or prior vaccination) then you should:
- Get a 3-dose series of Recombivax HB or Engerix-B (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2) or a 2-dose series of Heplisav-B, with the doses separated by at least 4 weeks.
- Get an anti-HBs serologic test 1-2 months after the final dose.
WHO recommends HepB vaccination of healthcare workers in its Table 4: Summary of WHO Position Papers – Immunization of Health Care Workers.
The Immunization Action Coalition has a helpful handout about Hepatitis B and Healthcare Personnel which answers frequently asked questions about how to protect healthcare personnel from HBV infection.
What are the recommendations for a healthcare worker who may have been exposed to hepatitis C virus?
The US CDC has developed recommendations for Testing and clinical management of health care personnel potentially exposed to hepatitis C virus. The recommendations are summarized below:
Baseline testing of the source patient and HCP should be performed as soon as possible (preferably within 48 hours) after the exposure. A source patient refers to any person receiving health care services whose blood or other potentially infectious material is the source of the HCP's exposure. Two options are recommended for testing the source patient. The first option is to test the source patient with a nucleic acid test (NAT) for HCV RNA. This option is preferred, particularly if the source patient is known or suspected to have recent behaviors that increase risk for HCV acquisition (e.g., injection drug use within the previous 4 months) or if risk cannot be reliably assessed. The second option is to test the source patient for antibodies to hepatitis C virus (anti-HCV), then if positive, test for HCV RNA. For HCP, baseline testing for anti-HCV with reflex to a NAT for HCV RNA if positive should be conducted as soon as possible (preferably within 48 hours) after the exposure and may be simultaneous with source-patient testing. If follow-up testing is recommended based on the source patient's status (e.g., HCV RNA positive or anti-HCV positive with unavailable HCV RNA or if the HCV infection status is unknown), HCP should be tested with a NAT for HCV RNA at 3-6 weeks postexposure. If HCV RNA is negative at 3-6 weeks postexposure, a final test for anti-HCV at 4-6 months postexposure is recommended. A source patient or HCP found to be positive for HCV RNA should be referred to care. Postexposure prophylaxis of hepatitis C is not recommended for HCP who have occupational exposure to blood and other body fluids.
What resources are available on safe injection practices in healthcare settings?
The One & Only Campaign is a public health effort, led by the US CDC and the Safe Injection Practices Coalition (SIPC), to eliminate unsafe medical injections. The website contains resources for staff training such as videos, checklists, posters and a pocket card. Patient education materials are also available.
The WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care settings is an evidence-based policy document that specifically addresses the use of safety-engineered injection devices for therapeutic injections.
The Global Health Sector Strategy on Viral Hepatitis 2016-2021 targets for safe injections are:
- 50% of injections administered with safety-engineered devices in and out of health facilities by 2020
- 90% of injections administered with safety-engineered devices in and out of health facilities by 2030
What are the recommendations for health workers infected with viral hepatitis B and C in the provision of surgical medical assistance? Are there any restrictions in providing the surgical assistance?
Health care workers who are HBsAg+ or HCV RNA /core antigen+ should be allowed to conduct medical procedures with the exception of exposure prone procedures; a list of these procedures are provided in the referenced publications. In this situation, an expert committee can guide the conduct of the health care worker and the clinical facility’s oversight of health care workers. Regarding HCV, most of the guidelines do not consider guidance when curative HCV therapies are readily available. When HCV therapies are available, a health care facility can consider requesting HCV + health care workers receive treatment before practicing exposure prone procedures. This will raise issues including HCV testing of health care workers particularly those practicing exposure procedures, documentation of cure among others. An expert committee can advise recommendations appropriate for your country.
Key points from this document include:
- Chronic HBV infection in itself should not preclude the practice or study of medicine, surgery, dentistry, or allied health professions. Standard Precautions should be adhered to rigorously in all health-care settings for the protection of both patient and provider.
- CDC discourages constraints that restrict chronically HBV-infected health-care providers and students from the practice or study of medicine, dentistry, or surgery, such as repeated demonstration of persistently non-detectable viral loads on a greater than semiannual frequency; pre-notification of patients of the HBV-infection status of their care giver; mandatory antiviral therapy with no other option such as maintenance of low viral load without therapy; and ◦forced change of practice, arbitrary exclusion from exposure-prone procedures, or any other restriction that essentially prohibits the health-care provider from practice or the student from study.
- Providers, residents, and medical and dental students with active HBV infection (i.e., those who are HBsAg-positive) who do not perform exposure-prone procedures but who practice non- or minimally invasive procedures (see reference for a Box with list of procedures referred to as Category II) should not be subject to any restrictions of their activities or study.
- Surgeons, including oral surgeons, obstetrician/gynecologists, surgical residents, and others who perform exposure-prone procedures, i.e., those listed under Category I activities (Box), should fulfill the following criteria:
- Consonant with the 1991 recommendations and Advisory Committee on Immunization Practices (ACIP) recommendations, their procedures should be guided by review of a duly constituted expert review panel with a balanced perspective (i.e., providers' and students' personal, occupational or student health physicians, infectious disease specialists, epidemiologists, ethicists and others as indicated above) regarding the procedures that they can perform and prospective oversight of their practice. Confidentiality of the health-care provider's or student's HBV serologic status should be maintained.
- HBV-infected providers can conduct exposure-prone procedures if a low or undetectable HBV viral load is documented by regular testing at least every 6 months unless higher levels require more frequent testing; for example, as drug therapy is added or modified or testing is repeated to determine if elevations above a threshold are transient.
- CDC recommends that an HBV level 1,000 IU/ml (5,000 GE/ml) or its equivalent is an appropriate threshold for a review panel to adopt. Monitoring should be conducted with an assay that can detect as low as 10–30 IU/ml, especially if the individual institutional expert review panel wishes to adopt a lower threshold.
See reference for a list exposure-prone procedure
SHEA recommends that HCV-infected providers who have circulating HCV viral burdens of greater than or equal to 104 GE/mL routinely use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for all instances in patient care for which gloving is routinely recommended, and that they not perform those Category III activities (see reference) identified as associated with a risk for provider-to-patient transmission of blood-borne pathogen infection despite the use of appropriate infection control procedures.
SHEA also recommends that an HCV-infected provider who has a viral burden of less than 104 GE/mL not be excluded from any aspect of patient care, including the performance of Category III procedures (Tables 1 and 2), so long as the infected provider
- is not detected as having transmitted infection to patients;
- obtains advice from an Expert Review Panel about continued practice;
- undergoes follow-up routinely by Occupational Medicine, who tests the provider twice annually to demonstrate the maintenance of a viral burden of less than 104 GE/mL;
- also receives follow-up by a personal physician who has expertise in the management of HCV infection and who is allowed by the provider to communicate with the Expert Review Panel about the provider’s clinical status;
consults with an infection control expert about optimal infection control procedures (and strictly adheres to the recommended procedures, including the
- routine use of double-gloving during Category II and Category III procedures and frequent glove changes during procedures, particularly if performing technical tasks known to compromise glove integrity [e.g., placing sternal wires]);
- agrees to the information in and signs a contract or letter from the Expert Review Panel that characterizes her or his responsibilities (discussed in more detail in other recommendation in the reference).
SHEA Recommendations include:
- HCV-infected providers should not be prohibited from participating in patient-care activities solely on the basis of their HCV infection (A-III).
- HCV-infected providers should not be restricted from participating in Category I or Category II Procedures (A-III); providers infected with HCV who have circulating viral burdens of greater than or equal to 104 GE/mL should refrain from performing Category III procedures (B-III).
- Healthcare providers who have circulating HCV burdens of less than 104 GE/mL should be allowed to perform those Category III activities identified as associated with a risk for provider-to patient transmission of blood borne pathogens, so long as the infected provider (1) is not detected as having transmitted infection to patients; (2) obtains advice from an Expert Review Panel about continued practice; (3) undergoes follow-up routinely by Occupational Medicine staff (or an appropriate public health official), who tests the provider twice per year to demonstrate the maintenance of a viral burden of less than 104 GE/ mL; (4) also receives follow-up by a personal physician who has expertise in the management of HCV infection and who is allowed by the provider to communicate with the Expert Review Panel about the provider’s clinical status; (5) consults with an expert about optimal infection control procedures (and strictly adheres to the recommended procedures, including the routine use of double-gloving for Category II and Category III procedures and frequent glove changes during procedures, particularly if performing technical tasks known to compromise glove integrity [e.g., placing sternal wires]); and (6) agrees to the information in and signs a contract or letter from the Expert Review Panel that characterizes her or his responsibilities