Immunocompromised HCWs need IC education
Cases raise ethical questions
Health care workers who are immunocompromised can raise difficult policy issues because of their heightened risk of infection from patients, but clinicians generally advise they can continue working with few special restrictions if they practice rigorous infection control.
Faced with a complex set of issues raised by such cases, the best course may be educating workers about the risks of immunosuppression and emphasizing the need for infection control measures to prevent exposure, says Leigh Donowitz, MD, an author of a book on infection control and the health care worker and professor of pediatrics at the University of Virginia in Charlottesville.1
"I truly believe in our infection control methods," she tells Hospital Infection Control. "If they are used, these individuals should be fine. But it would behoove them to be very scrupulous about infection control, whereas someone else who is not immune compromised could maybe get away with being more cavalier -- not that they should."
Health care workers may be immunocompromised due to cancer, neutropenia, transplant, HIV-infection, or therapy with steroids or immunosuppressive agents. Their immune-deficient state may make them particularly vulnerable to the variety of infection risks that face all health care workers.
Standard protective measures for the immunocompromised health care worker include knowledge of immune status to infectious diseases for which there is a vaccine available. (In addition, Donowitz recommends they should receive an annual influenza vaccine, routine tuberculosis screening, early medical evaluation for all infectious illnesses, early prophylaxis for exposures, and therapy for subsequent infections. They should work under the assumption that all patients may be infected or colonized with pathogens, and thus routinely use gloves and carefully wash hands when handling all body substances. Likewise, it is important that such workers understand the risks and discuss them with both their personal physicians and employee health officials at the facility, she says.
"While they work, it is best if somebody knows their situation, " she says. "It is a health care issue only because they are exposed to more infectious illnesses, and they have to recognize that some of those, should they become infected, are going to be life threatening to them."
Indeed, the immunosuppressed worker raises a host of ethical and legal questions for hospitals that are further complicated by issues of personal privacy and medical confidentiality. Limiting liability by relieving the worker of duties of some perceived risk may seem the best course from a hospital administrative view. On the other hand, medical conditions which render immunosuppression may well be viewed as disabilities under the Americans with Disabilities Act, which requires "reasonable accommodation" by employers. Ironically, epidemiologists and employee health professionals who allow immunosuppressed workers to continue their duties out of deference to their individual rights and a belief in infection control measures, may be seen by some as uncaring.
"Often, these cases are not discussed fully in the institution because of the privacy and medical confidentiality of the health care worker involved," says David Henderson, MD, deputy director of the clinical center at the National Institutes of Health in Bethesda, MD. "There are only whisperings going on around the institution, and other health care workers may view your willingness to put that person at risk as transmitting a message to the rest of the institution that you don't care about your employees."
In an overview of the issue recently in Washington, DC, at the annual conference of the Society for Healthcare Epidemiology of America (SHEA), Henderson said a particularly threatening situation is when a health care worker who is HIV-positive is working with TB patients.
"I think all of us worry every day about the risk of transmission of TB to such individuals," he said.
Indeed, there are data suggesting the HIV-infected health care workers exposed to TB could be more prone to both initial infection and subsequent progression to TB disease. However, those very workers may be particularly committed to working with HIV patients, who may also be infected with TB. In that regard, Henderson said he recently consulted on a case that involved an HIV-infected worker who wanted to continue working in an HIV clinic that had a high prevalence of TB patients.
"The institution's lawyers and insurers were concerned -- they wanted to take the person out of the [clinic]," he said. "Ultimately, in that instance, the worker got his way. He elected to continue working, and they worked with him to try to manage the environment as best he could. I think in fairness, he did not have a death wish and worked hard with them to try and maintain the best possible infection control precautions that he could."
Immunocompromised health care workers should not have to identify themselves, but those who choose to come forward must be given the opportunity to work in a lower-risk environment, he adds.
"You have to give them the opportunity for reasonable accommodation," he said.
"After the health care worker has this opportunity, if she or he elects to work in a high risk environment, you have to make certain they understand the risk that they are taking." *
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