evaluation of policies regarding physicians infected with blood‐borne pathogens • 

6
Evaluation of Policies Regarding Physicians Infected With Blood‐Borne Pathogens Author(s): Cherie Ng , MPH; John Swartzberg , MD, FACP Source: Infection Control and Hospital Epidemiology, Vol. 26, No. 4 (April 2005), pp. 410-414 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/502559 . Accessed: 16/05/2014 18:32 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. . The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaborating with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology. http://www.jstor.org This content downloaded from 195.78.109.14 on Fri, 16 May 2014 18:32:14 PM All use subject to JSTOR Terms and Conditions

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Evaluation of Policies Regarding Physicians Infected With Blood‐Borne Pathogens • Author(s): Cherie Ng , MPH; John Swartzberg , MD, FACPSource: Infection Control and Hospital Epidemiology, Vol. 26, No. 4 (April 2005), pp. 410-414Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/502559 .

Accessed: 16/05/2014 18:32

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

.

The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaboratingwith JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology.

http://www.jstor.org

This content downloaded from 195.78.109.14 on Fri, 16 May 2014 18:32:14 PMAll use subject to JSTOR Terms and Conditions

410 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY April 2005

EVALUATION OF POLICIES REGARDING PHYSICIANS

INFECTED WITH BLOOD-BORNE PATHOGENS

Cherie Ng, MPH; John Swartzberg, MD, FACP

Surgeons who are infected with blood-borne patho-gens, such as human immunodeficiency virus (HIV),hepatitis B virus (HBV), and hepatitis C virus (HCV), havepresented a controversial issue in the medical community.Public health officials have struggled to define and estab-lish the rights of infected healthcare workers while pre-venting surgeon-to-patient transmission and maintainingthe rights of patients. Formulation of an effective approachto preventing surgeon-to-patient transmission of blood-borne pathogens remains incomplete. At the center of thecontroversy is whether the risk of surgeon-to-patient trans-mission should be considered material or insignificant. Thematerial side of the debate maintains that any risk to thepatient is significant in the case of a life-threatening dis-ease. Thus, infected physicians must be restricted in theirpractice and their patients informed of their status to pro-tect the patients from accidental transmission. The insignif-icant faction argues that transmission of blood-bornepathogens is exceedingly rare with the use of standard pre-cautions and infection control procedures1 and that theknowledge is a private matter to be shared only if the sur-geon wishes.

The current Centers for Disease Control andPrevention (CDC) guidelines recommend that surgeonswho are infected with HIV and HBV (hepatitis B e antigen

[HBeAg] positive) should refrain from performing “expo-sure-prone” procedures and inform their patients of theirstatus2; there are no such restrictions for HCV.3 Under theTreasury Department Appropriations Act of 1992, statesare required to implement the CDC guidelines or theirequivalent to receive continued funding under the PublicHealth Service Act.4 However, whether private hospitalsagree with and follow the CDC guidelines or whetherthere is a lack of consensus (and policy) is unknown.Although a plethora of literature is available on the trans-mission of blood-borne pathogens, debate over currentCDC policies, and legal precedence, there is little sense inthe literature of what community hospitals are doing withthe available information.

To evaluate the severity of risk to a patient posed byan infected surgeon, several factors must be considered:the nature of the disease, the threshold of risk that is con-sidered acceptable, and whether the risk of transmissionis small enough to allow a surgeon to continue practicing(Table 1). If the risk posed by the surgeon is consideredsignificant, a further consideration is whether accommo-dations or restrictions, such as double-gloving or refrain-ing from performing exposure-prone procedures, will pre-vent transmission or reduce the risk of transmission to anacceptable level. Currently, the prevalence of blood-borne

The authors are from the School of Public Health, University of California, Berkeley, California.Address reprint requests to Cherie Ng, MPH, Department of Pathobiology, School of Public Health and Community Medicine, University of

Washington, Box 357238, Seattle, WA 98195. [email protected] authors thank Dr. Jef f Burack and Amy Nichols for lending their support, advice, and knowledge to the project and Dr. Sasha Kauffman

for donating his technical support.

OBJECTIVE: Formulating an effective approach to pre-venting surgeon-to-patient transmission of blood-borne pathogenshas been controversial. The objective of our study was to evaluatecurrent community hospital policies, if any, regarding restrictionson surgeons (general surgeons and obstetricians and gynecolo-gists) infected with blood-borne pathogens operating on patients.

DESIGN: A survey on hospital policies regarding sur-geons infected with blood-borne pathogens was sent to infectioncontrol officers at Northern California community hospitals (n =113).

RESULTS: Forty-five hospitals responded to the survey.

Of these, only 6 (13.3%) had a policy. Of the 39 (86.7%) that didnot have a policy, only 3 hospitals were planning on implement-ing one.

CONCLUSIONS: Many community hospitals are unin-terested in instituting a policy regarding the practice of surgeonsinfected with blood-borne pathogens. Possible reasons includethe lack of concern on the individual level, difficulty in definingexposure-prone procedures, and the nature of the relationshipbetween medical staff and community hospitals (Infect ControlHosp Epidemiol 2005;26:410-414).

ABSTRACT

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Vol. 26 No. 4 HOSPITAL POLICIES FOR INFECTED PHYSICIANS 411

pathogens among surgeons practicing in the UnitedStates is considered to be low. In a study by Panlilio et al.,only 0.14% were HIV positive, 17% had evidence of eithercurrent or past HBV infection and 0.4% were positive formarkers of chronic HBV infection, and 0.9% were positivefor HCV infection.5 Although this study excluded sur-geons with known infection, the results indicate a lowerprevalence of HIV and HCV than in the general popula-tion. In contrast, the seroprevalence of HBV is much high-er among surgeons than among the general population;however, the percentage with chronic HBV is comparablein the two groups.5

The risk of an infected surgeon transmitting a blood-borne pathogen to a patient during a procedure variesdepending on the type of procedure, the skill of the sur-geon, the number of injuries sustained, the equipmentused, and the prevalence of the disease. Published investi-gations of outbreaks of blood-borne pathogens reporttransmission rates per procedure ranging from 0.0000024%to 0.000024%,6,7 0.4% to 13%,1 and 0.2% to 0.48%8,9 for HIV,HBV, and HCV, respectively (Table 1). Despite these mea-surably small transmission rates, courts and some hospi-tals believe this risk is a significant threat to patients andhave opted for a “zero risk” standard. For example, in themuch publicized case of Doe v University of MarylandMedical System Corporation, Dr. Doe, an HIV-positive neu-rosurgery resident, was fired against the advice of anexpert review panel that concluded that Dr. Doe should beallowed to continue practicing with certain restrictions thatwould prevent him from posing any significant risk topatients. Theoretically, healthcare workers who are HIVpositive are protected from employment discriminationunder the Americans with Disabilities Act (ADA).10,11

However, provisions in the ADA grant that an employee isnot qualified to perform the job if he or she poses a “directthreat to the health and safety of others.” In the case of Dr.Doe, the court supported the hospital’s decision to fire theresident by stating that the plaintiff was not qualified underthe ADA because he would always pose some risk regard-less of any accommodations.12,13

Despite the attention given to the difficult and com-plex issue of surgeons infected with blood-bornepathogens, little, if anything, has been done to documentwhat types of policies community hospitals are applying

within their institutions. The cases brought to court havegarnered widespread attention, but the manner in whichand extent to which hospitals, and specifically communityhospitals, have mobilized to prepare for this potentialtragedy have been minimal. Consequently, we conducted asurvey to better understand how community hospitals areinterpreting the governmental guidelines and data regard-ing transmission of blood-borne pathogens and how theyare translating these into policy, if at all. Specifically, theobjective of our study was to evaluate current hospital poli-cies, if any, within Northern California regarding restric-tions on surgeons infected with blood-borne pathogenswho operate on patients.

METHODS

The survey of community hospital policies was con-ducted during January 2003 among Northern Californiacommunity hospitals. Community hospitals were chosenas a criterion because whereas all hospitals should adoptthe state or CDC regulations, community hospitals areless regulated by public monies. All hospitals were subjectto Occupational Safety and Health Administration require-ments and no known physician-to-patient transmissionevent had previously occurred.

Approximately 123 community hospitals are locatedin Northern California. These hospitals were identifiedvia the Internet from hospital listings and hospital websites. One hundred thirteen were considered eligible forthis study and were recruited by mail. The remaining 10hospitals were excluded because either they were notidentified during the original search or it was unknown atthe time whether they were community hospitals. A letteremphasizing the voluntary nature of the survey and strictconfidentiality was included with a self-administered ques-tionnaire that was sent to the infection control officer ofeach hospital. Information from the questionnaire wasused to assess hospital policies regarding the preventionof blood-borne pathogens and the management of sur-geons infected with them. The survey questions coveredareas such as screening for HIV, HBV, and HCV; avail-ability of counseling and treatment or prophylaxis for per-cutaneous injuries; testing physicians as a source of infec-tion (source testing); and policies on patient notification,serologic follow-up, coworker notification, restrictions on

TABLE 1FACTORS USED IN ASSESSING THE IMPACT OF RISK OF SURGEON-TO-PATIENT TRANSMISSION*

Factor HIV HBV HCV

Risk of surgeon-to-patient transmission per procedure (%) < 0.0001 0.4–13 0.2–0.48Mode of transmission Usually blood-borne Usually blood-borne Usually blood-borneLength of infectivity Lifelong Transient (except in carriers) Transient (except in carriers)Severity of risk Severe Usually mild Moderate

HIV = human immunodeficiency virus; HBV = hepatitis B virus; HCV = hepatitis C virus.*Data from references 5 through 9.

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412 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY April 2005

physicians infected with blood-borne pathogens, andinformed consent.

RESULTS

Of 113 letters sent, 5 were returned due to unknownaddresses, meaning that 108 hospitals received the sur-vey. Forty-five (41.7%) of these hospitals responded. Only2 hospitals (4.4%) screened physicians for HBV, and nonescreened for HIV or HCV. Thirty-eight hospitals respond-ed that they always offered counseling and treatment aftera percutaneous injury, and 7 reported that they offeredthis sometimes. Forty-four of the hospitals provided ananswer to the question regarding requiring source testingof physicians. Eight (18.2%) required source testing of aphysician if epidemiologically indicated, 29 (65.9%) didnot, and 7 (15.9%) did not know. When asked whetherthey currently possessed a policy concerning themanagement of physicians infected with blood-bornepathogens, only 6 hospitals (13.3%) indicated that theydid. Of the 39 hospitals (86.7%) that did not currently havea policy, only 3 were planning to implement one in thefuture; 20 had no plans to implement a policy and 16 didnot know whether there were plans to create a policy(Table 2).

Of the six hospitals that had a policy, only one hada policy that referred directly to physicians infected withall three blood-borne pathogens. One policy referred tophysicians with HIV and HBV, one referred only to

physicians with HIV, and one referred only to physicianswith HCV. Two policies contained no direct references.Three of five hospital policies called for notification ofprevious patients, two of five hospital policies called forserologic testing of the physician, and two of five policiescalled for notification of coworkers. Four of five hospitalsallowed physicians to continue practicing if theywere infected with HIV, HBV (HBeAg unknown), HBV(HBeAg negative), HBV (HBeAg positive), or HCV. Only one of these four hospitals required any practicerestrictions and none required informed consent ofpatients.

DISCUSSION

The purpose of this study was to begin to provide alucid description of hospital policies surrounding blood-borne pathogens. The results of the survey indicate thatfew community hospitals in Northern California haveaddressed the issue of blood-borne pathogen infection insurgeons. A large majority (86.7%) did not possess a poli-cy, and slightly more than half of those without a policy(51.3%) were not planning on implementing one in thenear future. Although we had no prior hypothesis regard-ing the number of hospitals with policies, the low numberwas surprising given the potential repercussions in termsof publicity, finances, and liability.

There are multiple explanations for why hospitals areseemingly unconcerned with this issue. One contributingexplanation may be the lack of concern on the individuallevel. Generally, infection with blood-borne pathogens isthought to be an important and complex issue. Although itis difficult to track the true numbers of percutaneousinjuries, minor wounds are not rare events for healthcareworkers. Despite the risks associated with even minorinjury, underreporting of injuries is a common practice forreasons including lack of time, dissatisfaction with post-exposure procedures, and lack of perception concerningthe risks of acquiring blood-borne pathogens.14,15 The pres-ence of underreporting implies that it is possible for aphysician to become seropositive for a blood-bornepathogen before he or she is aware of infection and thuspotentially put patients at risk. Therefore, steps must betaken to encourage reporting and either follow-up testingor regular testing to prevent unknown infection with blood-borne pathogens.

Although regular testing should be important to theindividual physician, the CDC does not recommendrequired testing for blood-borne pathogens because it isconsidered to be an invasion of privacy. However, althoughtesting is not required, should a physician test positive,the CDC recommends that patients be notified. TheCDC’s recommendation of disclosure to patients is as fol-lows: Should a healthcare worker become “infected withHIV or HBV (and [be] HBeAg positive) [he or she]should not perform exposure-prone procedures unlessthey have sought counsel from an expert review panel and[have] been advised under what circumstances, if any,they may continue to perform these procedures. Such cir-

TABLE 2CHARACTERISTICS OF THE HOSPITALS SURVEYED

No. of hospitals surveyed 108No. of hospitals that responded 45 41.7%No. of hospitals that conduct screening for (n = 45)

HIV 0 0.0%HBV 2 4.4%HCV 0 0.0%

Treatment and counseling after percutaneous injury (n = 45)Always 38 84.4%Sometimes 7 15.6%Never 0 0.0%

Physician source testing (n = 44)Yes 8 18.2%No 29 65.9%Unknown 7 15.9%

Have a policy pertaining to physicians infected with BBPs (n = 45)Currently have 6 13.3%Do not have 39 86.7%

Planning to implement 3 7.7%Not planning to implement 20 51.3%Unknown whether will implement 16 41.0%

HIV = human immunodeficiency virus; HBV = hepatitis B virus; HCV = hepatitis C virus; BBPs = blood-borne pathogens.

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Vol. 26 No. 4 HOSPITAL POLICIES FOR INFECTED PHYSICIANS 413

cumstances would include notifying prospective patientsof the [healthcare worker’s] seropositivity before theyundergo exposure-prone invasive procedures.”2 Althoughthe goal of disclosure is to protect patients, disclosurealso has the potential to create disproportionate fear ofliability within the hospital administration and lead to neg-ative publicity and discrimination against the physician.As a result, a healthcare worker can lose patients, status,and his or her job. Thus, physicians have expressedstrong concern over the potential loss of livelihood, priva-cy, and status within the medical community and with thepublic should they disclose their status in the case of aninfection.

In contrast to the CDC’s recommendations, someindividuals judge the decision to disclose or restrict prac-tice to be a private one that should be made voluntarily.16

This opinion is partially supported by the NationalCommission on AIDS, which does not recommend a blan-ket policy of disclosure for healthcare workers infectedwith blood-borne pathogens. Such a policy “would notonly fail to make the health care workplace any safer, itwould also have a deleterious effect on access to healthcare. Mandatory disclosure of a health care worker’s HIVserostatus does little, if anything, to enhance the patient’ssafety. It inflates the risk of HIV transmission out of pro-portion to other risks and is inconsistent with the princi-ples and practice of informed consent.”17 This is not indirect agreement with the CDC’s recommendations.

A further obstacle to implementing a policy is defin-ing exposure-prone procedures. The CDC guidelinesassign this task to an expert review panel that is assembledon a case-by-case basis, leaving little guidance on how towrite an explicit policy that will work for all situations:“Exposure-prone procedures should be identified by med-ical/surgical/dental organizations and institutions at whichthe procedures are performed.”2 The advantage of definingexposure-prone procedures on a case-by-case basis is thatthe degree of “exposure” depends on several variable fac-tors such as the procedure, the physician’s skill, and theequipment used. The disadvantage of this approach is thatbecause the panel is composed of different individuals ineach case, there is no assurance of consistency given twosimilar situations. The one hospital in the survey thatrestricted the practice of infected physicians only looselydefined exposure-prone procedures as those epidemiologi-cally indicated to have a high risk of transmission.

The difficulty in defining exposure-prone proce-dures also makes it difficult to evaluate practice restric-tions. Study participants had varying opinions regardingwhether an infected surgeon should be able to practiceand under what conditions. Interestingly, the numbers ofresponses for practice without restrictions, practice withrestrictions, and discontinue practice were comparablefor HIV, HBV, and HCV, with the responses for HIVskewed slightly more toward restricting or discontinuingpractice. When the likelihoods of surgeon-to-patient trans-mission were compared, the transmission of HIV was sorare that continued practice with or without restrictions

was much more plausible than for HBV or HCV (Table 1).Although the consequences of HIV are much greater,HBV is 100 times more infective than HIV and has causeda larger number of outbreaks. There have been only tworeported clusters of physician-to-patient transmission ofHIV in the Western world,18 whereas there have beenat least 29 outbreaks associated with HBV.1 In theNetherlands, a surgeon was implicated in infecting at least8 patients even though he performed low-risk proce-dures.19 Furthermore, the CDC recommends that onlyHBeAg-positive healthcare workers refrain from perform-ing exposure-prone procedures, yet up to one-fifth ofinfected surgeons who are HBeAg negative may still havehigh virus titers and are potentially as infectious as thosewho are HBeAg positive.20 Although HCV is not as wellstudied, it appears to have a lower surgeon-to-patienttransmission rate than HBV. However, there is a muchhigher chance of developing long-term carriage, whichcan lead to severe sequelae such as cirrhosis, hepatocel-lular carcinoma, or both.

Almost all of the hospitals reported that they haveno mandatory testing for blood-borne pathogens. Dothey consider the risk insignificant enough that theexpense and hassle of testing are infeasible, or is the lackof mandatory testing a strategy to retain and attractphysicians to their medical staf f? The relationshipbetween the medical staff and the community hospital issuch that physicians on the medical staff have no finan-cial or contractual obligations to the hospital. The hospi-tal relies on the physicians to refer patients. If a hospitalrequired testing and a physician either disagreed withthe practice or found it inconvenient, he or she could eas-ily join the medical staff of a hospital that did not requiretesting. Should a hospital wish to begin requiring testing,the proposed policy must be discussed and voted on bysuccessive committees on which representatives of themedical staff sit. Given the controversial nature of theissue, it is difficult not only to broach but also to bring acommittee to agree on. However, regardless of whetherhospitals have a policy regarding infected physicians, it isimperative that the health of the physician and the patientbe protected.

This is the first study to quantitatively examine pol-icy implementation in community hospitals. With its con-centration on community hospitals, the study examinedpreviously undocumented policies of portions of the med-ical community that are relatively less regulated by theCDC guidelines. The only other study found to surveyhospitals was performed by Ristinen and Mamtani. Fivemajor medical centers in the New York City metropolitanarea were surveyed to determine their policies on HBV.The study found that all five generally observed the rec-ommendations the CDC published in 1991 and that fewrestricted the clinical privileges of healthcare workerswith HBV (HBeAg negative).21 Other studies have documented surgeons’ personal attitudes, knowledge,and practices regarding blood-borne pathogens, but nonehave addressed attitudes toward policy.22,23

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414 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY April 2005

There are several limitations to our study. Thestudy cannot be generalized because it was localized toone area within California. Because information was notobtained from all hospitals, it is unknown whether therewas significant responder bias. Although the survey wasdesigned to be short and concise to encourage participa-tion, the disadvantage of such a strategy was the smallamount of information gathered from each hospital. Moredetailed information would have been helpful in deter-mining the extent to which a hospital was concerned withinfected medical staff. Further study must be directedtoward examining the policies of a larger number of com-munity hospitals across the United States and whethercommunity hospitals are prepared to manage a physicianinfected with a blood-borne pathogen and to prevent andhandle a surgeon-to-patient transmission. In addition, aninvestigation at the individual level of how physicians viewcurrent policies and what types of policies they woulddeem appropriate would elucidate the best dynamic forapproaching a policy on physicians infected with blood-borne pathogens.

Although surgeon-to-patient transmission of blood-borne pathogens is a relatively rare event, it is one that isof serious concern to patients, surgeons, and hospitalsand is devastating to emotions, economics, and reputa-tion. The difficult nature of the issues surrounding physi-cians infected with blood-borne pathogens does not trans-late well into a concrete policy that can be easily agreedon, as demonstrated by the debate over the current CDCguidelines. Our study is a step toward elucidating thecommunity-level dynamics of a relevant topic that isbecoming more so with the rise in the prevalence of HCV.There must be a dialogue regarding a consistent way thathospitals should definitively respond to a practicing sur-geon infected with a blood-borne pathogen and an infect-ed surgeon transmitting infection to a patient. The CDCshould continue to evaluate its current guidelines andredesign them to offer better guidance to medical institu-tions. Community hospitals that are without a policyshould be encouraged to create one.

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