Hospitals mull mandatory HIV testing for HCWs
Experts say forced tactics are harmful, unnecessary
As the U.S. Department of Health and Human Services begins a new initiative to reduce the transmission of HIV/AIDS, health care facilities once again are talking about a long-controversial issue — whether health care workers should be required to undergo screening for infection with HIV, or hepatitis B and C viruses (HBV, HCV).
Like the population at large, some clinicians — physicians, nurses, aides, and others — are infected with HIV and/or hepatitis. Also, health care workers are at increased risk for acquiring a bloodborne pathogen on the job through the exposure to the blood and body fluids of infected patients.
The potential for an infected clinician to transmit an infection to a patient is much lower, but the potential remains. And as the public takes an increased interest in patient safety, hospitals and other health care facilities wonder whether they should take steps to determine which health care workers caring for patients are infected and how to ensure that these personnel practice safely, if at all.
Plans to initiate mandatory testing and, possibly, practice restrictions on positive health care workers, pose complex ethical questions that are not immediately evident at first glance, says Kate Payne, RN, MSN, JD, an ethicist at St. Thomas Hospital in Nashville, TN.
"Our first reaction is almost always, of course,’" she says. "Of course, we should test health care workers and, of course, patients should have a right to know if their health care provider is infected. But, it is really not that simple."
Do health care workers who become infected with HIV or HBV enjoy fewer rights to privacy just by virtue of their occupation? If all health care workers who become infected with a bloodborne pathogen were then prohibited from providing patient care, what would the costs to the health care system and society be?
Payne and others participated in a forum in June at the annual meeting of the Association for Professionals in Infection Control and Epidemiology in San Antonio to discuss ways to ensure patient safety without trampling on the rights and dignity of health care workers living with HIV/AIDS, and HBV and HCV.
"Ethics is an external manifestation of our internal moral code," Payne told participants. "In this discussion, there are huge ethical issues surrounding disclosure [of a health care worker’s status]. We have to consider issues of beneficence, but not just beneficence toward patients, but also to the health care workers. There are also issues of informed consent for patients who are cared for by infected health care workers. But how would that be handled? Should all patients get a booklet disclosing everyone’s [HIV] status, and viral load and what kinds of procedures they might perform?"
Nothing exists in a vacuum, she added.
Hospitals must weigh all of the potential risks and benefits when deciding how to proceed.
The stigma of HIV/AIDS and, to a lesser extent the hepatitis viruses, are inducing health care facilities to consider measures that are really not justified by the risks that infected providers pose, adds Denise M. Cardo, MD, chief of the prevention and evaluation branch of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.
Health care workers are at increased risk for acquiring a bloodborne pathogen from patients because they are likely to come into contact with an infected patient’s blood or body fluids, she notes.
However, the reverse is not true. A patient would almost never come into contact with the blood or body fluids of a clinician. Only during very high-risk procedures, or instances of extreme noncompliance with basic universal infection control precautions would this occur, Cardo reports.
The statistics bear this out.
Transmission of bloodborne pathogens from health care personnel to patients is very rare; occurrences have been documented, though most are outside the United States, Cardo explains.
"There were several episodes from dentists to patients and surgeons to patients prior to the implementation of universal precautions," she reports.
Between the years 1972 and 2001, there have been only eight documented cases of HBV transmission from infected dentists to patients in this country, and only 27 cases worldwide during that time period. Most episodes of transmission occurred from the mid-1980s to the early 1990s.
Between the years 1988 and 2002, the CDC knows of nine infected health care workers worldwide known to have transmitted HCV to patients.
In the United States, there is only one known instance of a health care worker transmitting HIV to a patient. In 1990, a cluster of six patients treated by a dentist with AIDS was infected with HIV. Five of the six patients had dental extractions or root canal procedures, but the exact mechanism of transmission isn’t known.
Factors affecting transmission
Research indicates that the factors affecting provider-to-patient transmission of bloodborne pathogens are:
- the type of pathogen — higher risk for HBV transmission than for HCV, both of which more likely to be transmitted than HIV;
- health care provider infectivity;
- the potential for tissue or wound exposure to the provider’s blood — the type of procedure, degree of invasiveness, combined with the provider’s technique and skill and use of infection control practices.
Appropriate implementation and use of universal precautions has been shown to satisfactorily prevent the transmission of most pathogens from patients to providers — and vice versa, she explains.
"Overall, the risk of transmission is extremely low," Cardo says. "You have to have contact with blood or body fluids. Most patient care activities do not provide the opportunity for patient’s exposure to a provider’s blood."
However, techniques and procedures associated with provider-to-patient transmission include:
- digital palpation of a needle tip in a body cavity;
- simultaneous presence of the provider’s fingers and needle or other sharp instrument in a poorly visualized or highly confined space;
- wire, bone, or metal manipulation.
In 1991, the CDC released a guideline, Management of Healthcare Workers Infected with HBV or HIV, recommending against mandatory testing of health care workers, and advising that infected personnel who do not perform exposure-prone invasive procedures (EPIP) should not have their practices restricted.
However, it continues, infected providers should not perform EPIP unless they have been advised by a review panel of their peers to continue. The guideline also recommends prospective notification of patients of the provider’s serologic status prior to performance of EPIP.
Cardo says an increased emphasis by hospitals on adherence to recommended infection control measures can adequately protect patients without violating the confidentiality of infected workers.
She recommends an active voluntary program of HBV vaccination for all health care providers; implementation of and enforcement of the use of standard (universal) precautions; emphasizing protocols that prevent intraprocedure injury and the use of expert consultation and advisory panels to recommend best practices and policies.
But some health care providers are arguing that voluntary efforts aren’t enough —that too many health care workers already don’t strictly adhere to universal precautions and put patients at risk.
Particularly for surgeons and other health care workers practicing in high-risk environments, a stronger and more coercive approach is needed, says John Wickenden, MD, an orthopedic surgeon and a member of the Education Council of the American Academy of Orthopedic Surgeons, as well as the Maine Governor’s AIDS Advisory Committee, Subcommittee for Health Care Worker HIV Transmission.
Wickenden was a practicing orthopedic surgeon in a 100-bed Maine hospital from 1972 until his retirement at the end of 1999, and, part of that time, served as the hospital’s chief of surgery.
Surgeons, particularly orthopedic surgeons, practice in a manner that places them at high risk for both contracting a bloodborne illness and transmitting it to patients, he explains. And, he says, appropriate use of universal precautions in that setting often varies between "absent and sloppy."
"From my experience, the real surgical world is often a more dangerous, hostile and ignorant place than many theorists believe it to be," Wickenden says.
Surgeons perform their procedures in a bloodbath with their hands often buried deep inside bloody tissue, using drills and other instruments that spatter blood, tissue and sometimes bone fragments. Proper performance of procedures often requires that surgeons palpate the sharp ends of bones in patient tissue or manipulate bones and other devices with poor or no visualization, he adds.
Protective equipment enough?
Even with the advances in modern personal protective equipment, there is a limit to the amount of gear a surgeon can wear and still adequately perform the procedure, he notes.
Surgeons frequently receive wounds and cuts from broken bone ends, needlesticks, or injuries from other instruments, he notes. Thus, they are at extremely high risk of transmitting bloodborne pathogens during procedures.
Use of universal precautions has improved the situation over the past 20 years, but it is only a relative improvement, Wickenden advises.
The medical professional culture also has been hostile to attempts to introduce new, safer practices, he adds.
Wickenden says he has been HBV-positive for at least 30 years. He believes he contracted hepatitis B from a needlestick acquired when, as a resident in 1966, he treated a hospital patient suffering from fulminant hepatitis.
Though his serologic status was known — both to him and to his colleagues — throughout his entire medical career, no one ever suggested he not perform surgery.
"I am not aware of ever transmitting hepatitis B to a patient, but given the data, we are now aware of, I feel certain that I probably did," he notes.
Wickenden also is gay and has lived openly with his partner in their small community for several years and been active in local politics and civic life. Yet, no one ever asked whether he had been tested for HIV. He is HIV-negative, but did not know his negative status until he underwent voluntary testing at a medical conference in the 1990s.
When, as chief of surgery at his local hospital, he encouraged surgeons to get vaccinated against HBV, along with other hospital staff, very few of them did.
The hospital board also soundly rejected Wickenden efforts to require surgeons to get the HBV vaccine as a condition of maintaining hospital privileges. Similarly, his attempts to mandate the use of double-gloving and use of protective eye equipment in the operating room, following unsuccessful voluntary initiatives, also were defeated; and, a large percentage of the surgeons sought his removal as chief of surgery.
Wickenden says that surgeons who are HBV-, HCV-, or HIV-positive should not continue to perform surgery, and that measures should be taken to force surgeons and other high-risk providers to get appropriate vaccinations if they are not yet infected. He stops short, however, of currently advocating for mandatory bloodborne pathogen testing of any health care provider.
Surgeons known to be HIV-positive or carrying the HBV or HCV virus can face the loss of their entire professional career and the financial disaster that that would entail, Wickenden notes.
Currently, most disability insurance policies do not cover inability to work due to infection with a bloodborne pathogen.
Disclosure of a practitioner’s serologic status now also leaves the clinician vulnerable to legal action by patients who may have been exposed before the provider knew of his or her status.
Measures to protect providers from legal action, and to provide for their financial viability if they must stop practicing surgery must be in place first, Wickenden says. But the day when surgeons and other personnel practicing in high-risk situations are required to be screened for bloodborne pathogens is coming, he adds.
Stronger enforcement of infection prevention and control measures are possible without moving toward mandatory testing and disclosure, argues Tammy S. Lundstrom, MD, vice president and chief quality safety officer at Detroit Medical Center, a multihospital system in southeastern Michigan.
A specialist in infectious diseases, infection control and epidemiology, Lundstrom continues to see patients in an infectious diseases clinic. Among her patients are several health care workers who are positive for HIV, HBV and HCV, she notes.
With treatment, a person infected with hepatitis or HIV can reduce their viral loads (the amount of virus circulating in the blood) to undetectable levels, which lowers the already low risk of transmission to a patient.
And Lundstrom emphasizes, the vast majority of health care workers do not perform the invasive procedures that would put them at risk of transmitting.
A program of mandatory testing and disclosure would deter health care workers from reporting exposures that occur in health care facilities and from seeking testing and treatment they may need, she adds.
"I am definitely not in favor of mandatory testing," she says. "However, I am a proponent of free, voluntary, anonymous testing, that is widely available and then being able to shunt that person to treatment and follow-up should they test positive for a bloodborne illness."
Such a program would encourage infected health care workers to get the treatment they need, while improving protections for patients.
At the same time, certain precautions and preventive measures should be more strongly implemented and enforced than they currently are in most facilities, Lundstrom adds. These, she says, include:
- double-gloving during surgical procedures;
- reducing the use of sharps and needles;
- using less invasive procedures when possible;
- use of sharps with engineered safety features;
- avoiding placement of many pairs of hands in the operating field;
- using a neutral zone for passing sharps during surgery.
These practices have been recommended for years, but not widely implemented.
Given the severe consequences faced by health care workers who have their serologic status publicly disclosed vs. the very low risk of transmission in most cases, less drastic measures should be implemented before facilities seriously consider a program of mandatory testing, she concludes.
Sources
- Denise M. Cardo, MD, Acting Chief, HIV Infections Branch, Hospital Infections Program, National Center for Infectious Disease, Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333.
- Kate Payne, RN, MSN, JD, St. Thomas Hospital, 4220 Harding Road, Nashville, TN 37205.
- Tammy Lundstrom, MD, Vice President and Chief Quality Safety Officer, Detroit Medical Center-Wayne State University, 202 Harper OF, Detroit, MI 48202.
- John Wickenden, MD, Penobscot Bay Orthopedics, Four Glen Cove Drive, Rockport, ME 04841.
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