CDC: No need to restrict employees with hepatitis C
Provider-to-patient risk remains very small
Despite growing concerns about the prevalence of hepatitis C virus (HCV) and the risk of its transmission during blood exposures, leading authorities say current guidelines provide adequate protections for patients of infected health care workers.
No cases of provider-to-patient transmission of HCV have been reported in the United States, notes Denise Cardo, MD, chief of the HIV infections branch at the Centers for Disease Control and Prevention’s Hospital Infections Program. Nonetheless, some experts on blood exposures have urged the CDC to update its guidelines to correct omissions and inconsistencies.1
CDC officials have said they are revising the agency’s 1991 guidelines, which focus on hepatitis B and HIV but don’t mention HCV. The guidelines state that patients undergoing "exposure-prone" procedures should be notified of a physician’s HIV or HBV status, but that issue has ultimately been left up to individual states. Federal law requires state health departments to adopt the CDC guidelines "or their equivalent."2
Level of protection varies by state
The result is a patchwork of different policies, says Patti Miller Tereskerz, JD, PhD, director of health law and policy at the International Healthcare Workers Safety Center at the University of Virginia in Charlottesville.
Some states require notification, but most do not. Hospitals are required to convene expert panels to determine what is an "exposure-prone" procedure and what restrictions, if any, should be placed on a provider.
"The level of protection patients receive, or whether or not [infection with a bloodborne pathogen] is even disclosed, is dependent not only on the state the patient is in, but also on the institution," she says. "We are pushing for uniform national guidelines so that a patient’s right to know whether or not a health care worker is infected and will be allowed to perform a procedure is not dependent on the institution or the state in which the procedure is performed."
Meanwhile, CDC officials point to the more recent guidelines of the Society of Healthcare Epidemiology of America (SHEA), released in 1996, which do not recommend restrictions for HCV-infected physicians and other health care workers and advise against patient notification. (See Hosptial Employee Health, August 1997, pp. 85-89.)
In 1991, the CDC was responding to widespread public alarm over the transmission of HIV to five patients of a dentist who had AIDS. The exact mechanism of those transmissions remains a mystery.
Different pathogens have different risks
The CDC acted quickly to reassure the public that they would not be at risk from HIV-infected physicians. Patients actually are at greater risk from HBV-infected surgeons; e-antigen-positive HBV has a transmission rate after a needlestick exposure of 30%, compared to .3% for HIV. SHEA recommends that e-antigen-positive HBV-infected health care workers should double-glove and should not perform procedures that have been epidemiologically identified as associated with a risk for provider-to-patient HBV transmission, such as cardiac surgery and major pelvic surgery, despite the use of appropriate infection control procedures.3
The alarm over HIV transmissions in dentists’ offices has long died down. Yet infection control experts and medical leaders clearly are concerned that the risk of HIV, HBV, or HCV could be exaggerated and that an infected physician or health care worker could be wrongly discriminated against.
Hospitals will act strongly — sometimes too strongly — to protect patients, says Cardo. "We’ve heard of cases in which the [infected] health care worker was not even performing such [exposure-prone] procedures and the health care worker wasn’t allowed to work," she says.
Investigations involving new cases of hepatitis C have failed to discover even a single link with a U.S. health care provider, notes Cardo. Likewise, surveillance hasn’t picked up connections between HCV infection and having undergone an invasive procedure.
"The first thing you have to do is ask the question, Is this a significant risk?’" says David K. Henderson, MD, deputy director for clinical care at the Warren G. Magnuson Clinical Center of the National Institutes of Health in Bethesda, MD. "As best we can tell in the year 2000, this is not a substantial risk. Right now, it is probably not [even] a measurable risk."
What bothers Tereskerz is the group of people evaluating the risk. The expert panels don’t include the point of view of the patient, she notes.
"There’s a terrible conflict of interest when you have health care workers regulating health care workers," she says. "We’re pushing for a committee that would represent multiple [medical] disciplines, as well as the patient’s interests. Right now, there’s nobody on the committee [recommended by CDC] who represents the patient’s interest."
Patient’s emotional suffering can cost you
Failing to consider the patient’s view can have legal consequences. In a recent article in Milbank Quarterly, a journal on health care policy, Tereskerz noted court cases in which patients won damages for the emotional suffering they endured after learning their surgeon was HIV-positive — even though they didn’t become infected.4
Given the bleak consequences of contracting HIV or HCV, patients may not consider even a remote risk to be acceptable, she says. "You [also] have to look at the ethics of the profession: Do no harm.’ Does that mean doing a little harm is OK, even if it’s rare?" says Tereskerz. "Are these ethical standards going to change because we’re faced with a difficult and hard decision to make?"
In her paper, Tereskerz refers to two HCV outbreaks reported in Spain in 1996 and 1998 related to a cardiac surgeon and an anesthetist. In one case, 217 patients were infected.
Then, too, there’s the issue of postexposure prophylaxis (PEP), which is now available for HIV but was not yet developed at the time that the CDC issued its provider-to-patient transmission guidelines.
If there is an exchange of blood between an HIV-infected provider and a patient during a procedure, the patient needs to be promptly notified and given the opportunity to begin PEP, says Cardo. The timing of PEP is critical, so infection control experts advise that counseling about PEP needs to begin as soon as possible after an exposure, including "recontact" between the provider’s and patient’s blood.5
"The standard of care should be exactly the same for the management of an exposure," whether it is a health care worker with a needlestick injury or a patient exposed to a provider’s blood, she says. "Appropriate testing should be performed on both."
To Donald Fry, MD, FACS, professor and chairman of the Department of Surgery at the University of New Mexico in Albuquerque, the lack of identified cases of provider-to-patient transmission of HIV, HBV, or HCV in recent years indicates that the problem has essentially resolved itself.
For example, while HBV once had a high prevalence rate among surgeons, health care workers now are routinely vaccinated and can completely avoid the risk of contracting HBV from a needlestick.
"I think the relative inactivity at CDC and from other agencies reflects the absence of a pressing agenda to do something given the absence of this being a continued problem," Fry says.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content