Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Providers

In February 2019 the Public Health Agency of Canada (or PHAC) released a new guideline to stakeholders in all healthcare professions titled the Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Settings. The new guideline is intended to provide a national framework to guide health care organizations to develop policies and procedures to prevent transmission of HIV, Hepatitis B and Hepatitis C from infected HCWs to patients in any healthcare setting. This new national guideline replaces Health Canada’s 1998 Proceedings of the Consensus Conference on Infected Health Care Workers.

Since the 1998 guideline was released, there have been major advances in the prevention, diagnosis and treatment of all three of these BBVs. So, there was a real need to replace the 1998 consensus document with a current evidence-based guideline.

The process began in 2011 as PHAC assembled a Task Group to develop the new guideline. The Task Group included members with expertise in infectious diseases, hepatology, medical microbiology and virology, infection prevention and control, public health, occupational health, obstetrics and gynecology, medical ethics and dentistry.

Six systematic reviews were conducted to determine the risk of transmission of HIV, HBV and HCV from infected HCWs to patients and to determine the infectivity of each virus as it related to the viral load of the source. In addition, three environmental scans were performed to provide information on lookback investigations, Expert Review Panels and disclosure of the HCW’s serological status.

Stakeholders were identified and had input as the new guideline was being developed. This included ACFD (Association of Canadian Faculties of Dentistry), CDRAF (Canadian Dental Regulators) and the Federation of Dental Hygiene Regulatory Authorities of Canada.

This guideline applies to health care workers in all professions and also includes students in healthcare programs, so it is an important guideline document for students and practitioners in dentistry, dental hygiene and other oral health care professions. The recommendations contained in the guideline document have been developed to aid those involved in assessing and managing healthcare workers (HCWs) infected with these BBVs. This could include regulatory bodies, treating physicians or Expert Review Panels formed to assess individual situations. It provides guidance with respect to the scope of practice for infected HCWs.

Following the recommendations in this guideline will allow infected HCWs to continue to practice safely and it will improve patient safety.

So…to begin with, it is important that all healthcare workers who perform exposure-prone procedures or EPPs know their own serological status with respect to HIV, hepatitis B and hepatitis C.

One of the key points in the new guideline is that there is an expectation that all HCWs will adhere to Routine Practices at all times and in all settings. Failure to do so can result in the transmission of BBVs.

As long as infected HCWs adhere to Routine Practices, the risk of transmission of BBVs from an infected HCW to a patient is negligible….with one exception. If the infected HCW is performing EPPs, the risk is increased but is considered a minimal risk.

Exposure-prone procedures (EPPs) are defined as “invasive procedures where there is a risk that injury to the HCW may result in the exposure of the patient’s open tissues to the blood of the HCW.”

One example of an EPP could be a surgical extraction of a third molar.

The new guideline includes the following definition of an EPP.

EPPs with risk of transmission include:

1. Digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs); or the simultaneous presence of the HCW’s fingers and a needle or other sharp instrument or object (such as bone splinters, sternal wires etc.) in a blind or highly confined anatomic site, e.g., as may occur during major abdominal, cardiothoracic, vaginal, pelvic and/or orthopedic operations

2. Repair of major traumatic injuries
3. Cutting or removal of any oral or perioral tissue, during which the patient’s open tissues may be exposed to the blood of an injured infected HCW.

The guideline states that transmission has been documented with several surgical and dental procedures, but evidence is lacking to definitively categorize specific medical and dental procedures with respect to transmission risk. Risk categories for these procedures have been developed based more on expert consensus. So, this guideline does not provide a detailed list of procedures that should be categorized as EPPs, but criteria have been provided and the guideline’s recommendation is that experts in the appropriate specialties determine which procedures meet the criteria for an EPP.

When we developed our updated policy on Infected HCWs at Dalhousie, we formed a committee to develop our definition of procedure-specific EPPs. The committee included representation from dental hygiene, periodontics and oral and maxillofacial surgery. Our definition of EPPs was based on a review of the literature.

So, if we were in a situation where a student became infected with HIV, Hep B and/or Hep C, and we had to restrict them from performing EPPs for a period of time, we would be able to act quickly and modify their clinical program until their condition was medically managed.

With respect to hepatitis B, there are several very effective vaccines that will provide immunity to the HCW and protect them from acquiring hepatitis B. Hepatitis B vaccination is generally a requirement prior to admission to many healthcare programs including dentistry.

Percutaneous injuries can and do occur and can place the HCW at risk of acquiring HIV or hepatitis C. If the HCW is not immune to hepatitis B, they are also at risk of acquiring hepatitis B.

Another key point to note in the guideline is the importance of training and education in preventing injuries in any healthcare program.

It’s impossible for there to be zero risk of transmission of BBVs but the good news is that there are vaccines that can provide immunity to hepatitis B, there are very effective treatment modalities for hepatitis C and HIV. So….the risk of transmission can be rendered negligible.

Transmission rates from past exposure incidents vary among the three BBVs. Transmission rates were lowest for HIV (0-3%) and highest for Hepatitis B (0.06-11.1%). Hepatitis C transmission rates ranged in between those values (0.04-3.7%).

HCWs infected with HIV, Hepatitis B and/or Hepatitis C that do not perform EPPs should have no practice restrictions.

For any HCWs (including students) infected with HIV, Hepatitis B and/or Hepatitis C that DO PERFORM EPPs, they should adhere to the following recommendations.

There are some recommendations that are common to all three BBVs.

The first recommendation is that the infected HCW must be under the care of a physician that has expertise in the management of the particular BBV.

The second recommendation is that the infected HCW must be medically managed according to the current recommendations for the BBV.

Specific to a HCW infected with HBV, any HCW infected with HBV is restricted from performing EPPs until they

1. a) have a HBV DNA level below 10³ IU/ml (5 x 10³ GE/ml)

AND

1. b) have their HBV DNA level monitored and assessed regularly (every 3 to 6 months)

Any HCW infected with HCV is restricted from performing EPPs until they

1. a) have an undetectable viral load at least 12 weeks post-treatment

Any HCW infected with HIV is restricted from performing EPPs until they

1. a) either are on effective antiretroviral therapy OR have been diagnosed as an elite controller

AND

1. b) have an undetectable viral load

The key factors in reducing the risk of transmission of BBVs from HCWs to patients include the following:

1. adherence to Routine Practices
2. developing immunity to hepatitis B through hepatitis B vaccination
3. proper training and education of HCW trainees in any health care program to prevent and manage percutaneous injuries that can put them at risk of acquiring HCV and HIV
4. HCWs taking responsibility for knowing their own serological status (especially for those HCWs performing EPPs)

Although zero transmission risk is impossible to attain, with the availability of effective vaccines to immunize HCWs against Hep B , effective treatment regimens for Hep C resulting in a sustained virologic response and very effective antiretroviral therapies to suppress HIV, the risk of transmission from HCW to patient is negligible.

The new guideline provides an evidence-based, pan-Canadian approach for the management of HCWs infected with BBVs and provides clear recommendations to reduce the risk of transmission of these diseases from HCWs to patients.

1. FULL PHAC GUIDANCE DOCUMENT LINK
2. CCDR LINK

Dalhousie University Policy Links

1. Policy for Students & Student Applicants with Infectious Diseases
2. Policy for Clinical Faculty  & Support Staff with Infectious Diseases
3. Dr. Blaine Cleghorn Bio