Debate: Should infected surgeons disclose status?

Debate: Should infected surgeons disclose status?

ID Week 2013

If I was a patient, I would want to know’

There is a striking disconnect between patients and infectious disease clinicians on the controversial issue of whether surgeons and other health care workers infected with bloodborne pathogens should disclose their status before performing invasive procedures, as evidenced by a debate on the subject recently in San Francisco at the IDWeek conference.

The interactive session allowed audience voting, with a baseline tally taken before the debate finding that 75% of IDWeek audience members feel providers should not inform patients of HIV and hepatitis infections.

The U.S. public clearly expects to be informed if their surgeon has a bloodborne infection, said Michael Saag, MD, FIDSA, an infectious disease physician at the University of Alabama at Birmingham. Arguing in favor of provider disclosure in the debate, he cited a survey indicating that 89% of the public want to know their provider’s HIV status, with 82% saying HBV and HCV disclosure should be mandatory.1

"There are ethical issues involved here, [including] maleficence — which is do no harm,’" Saag said. "There is also the legal obligation of duty to warn and that could lead to legal liability."

Though very rare, cases of transmission from providers to patients have occurred with all three viruses. "It is possible that this transmission can occur and I think we need to be aware of this," he said.

Indeed, last year there was a published report of a surgeon with HBV who infected as many as eight patients, though public health officials did not encourage informed consent in light of the case. Instead, they underscored the need for providers to know their HBV status and seek the counsel of an expert review panel if they perform invasive or so called "exposure-prone" procedures.2

In general, the level of circulating virus makes HBV more likely to be transmitted than HCV, and both hepatitis infections are much more likely to be spread from provider to patient than HIV. It was HIV, however, that brought the issue to the forefront in the infamous Florida HIV Dental Case in 1990, when the late Kimberly Bergalis and five other patients contracted HIV after receiving care from an HIV-positive dentist. The case was never definitively solved — partly due to the absence of dental records — though the initial molecular epidemiology seemed to suggest the patients were infected by the dentist, the late David Acer, DDS, of Stuart, FL.3

In light of the case, the CDC issued guidelines recommending that health care workers performing exposure-prone procedures should know their HIV status, and their hepatitis B surface antigen and hepatitis B e-antigen status. Health care workers infected with HIV or hepatitis B (and e-antigen positive) were further instructed not to perform exposure-prone procedures unless they had sought counsel from an expert review panel and been advised under what circumstances, if any, they might continue to perform these procedures. Such circumstances would include "notifying prospective patients of the health care worker’s seropositivity before they underwent exposure-prone invasive procedures," the CDC recommended in the 1991 guidelines.⁴

Last year, the CDC updated the HBV portion of the recommendations, saying informed consent to patients is no longer practical or necessary if other measures are in place. Moreover, routine mandatory disclosure might actually be counterproductive to public health, as providers and students might perceive that a positive test would lead to loss of practice or educational opportunities. This misperception might lead to avoidance of HBV testing, vaccination, treatment and management, effectively driving HBV carriers underground, the CDC noted.5

Issue could become politicized again

Still, the CDC has never formally revised its 1991 HIV recommendations, possibly because the issue created a political firestorm at the time that included the late Sen. Jesse Helms, (R-NC) threatening to "horse whip" providers who did not reveal their HIV status.

"The cases are almost invariably associated with major public anxiety," said Neil Fishman, MD, an infectious disease physician at the University of Pennsylvania in Philadelphia, who argued against disclosure in the debate. "The current polarity of our American political system as well as the dramatic immediacy and accessibility of the media almost invariably fuels controversy. When you get down to it this is really an ethical issue, not a scientific issue. We need to balance the risks and benefits of disclosure."

Fishman co-authored the 2010 guidelines on the issue by the Society for Healthcare Epidemiology of America (SHEA), which recommended that providers with bloodborne infections be allowed to practice without informed consent if they adhered to infection control measures like double gloving and were periodically tested for the level of circulating virus.⁶In addition, viral load for HIV and hepatitis can be reduced by various antiviral medications, an option that was not available to the CDC in its original guidelines. When the CDC recently recommended that the public — particularly baby boomers — be tested for HCV virus, the agency referred Hospital Infection Control & Prevention to the SHEA guidelines regarding a question about HCV-positive health care workers. (See HIC, Feb. 2013, p. 16.)

"The SHEA guidelines published in 2010 say that disclosure is not required unless the provider has been the source for an exposure to a patient," Fishman told IDWeek attendees. "I believe that the burdens [of disclosure] are not justified in the face of what we see is an extremely low risk. Simply stated, the risk of notification does not outweigh the benefits. We do practice above all do no harm,’ but I think it is very clear that notification of serostatus would introduce a greater harm to patient care."

Fishman was convincing, as an electronic poll taken after the debate showed that 87% of the audience said providers should not reveal their serostatus for HIV, HBV and HCV. Though that was an increase from the baseline of 75%, there was still some question about the issue among some in attendance.

"If I was a patient, I would want to know," one infectious disease physician said.

References

1. Tuboku-Metzger J, Chiarello L, Sinkowitz-Cochran R, et al. Public attitudes and opinions toward physicians and dentists infected with bloodborne viruses: Results of a national survey Am J Infect Control 2005;33:299-30
2. Enfield KB, Sharapov U, Hall KK, et al. Transmission of hepatitis B virus from an orthopedic surgeon with a high viral load. Clin Infect Dis 2012; 56:21824.
3. Centers for Disease Control and Prevention. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990; 39:489-493.
4. CDC. Update: Possible transmission of human deficiency virus to a patient during an invasive dental procedure Florida. MMWR 1991;40:21-33
5. Holmberg SD, Suryaprasad SD, Ward JW. Updated CDC recommendations for the management of hepatitis B virus-infected healthcare providers and students. MMWR 2012;61(RR-3):1-12.
6. Henderson DK, Dembry L, Fishman NO, et al. Society for Healthcare Epidemiology of America. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infect Control Hosp Epidemiol 2010; 31:203-32