Health Protection Scotland (HPS) published an update to the ‘Integrated guidance on health clearance of healthcare workers and the management of healthcare workers infected with bloodborne viruses (hepatitis B, hepatitis C and HIV)’ on 30 July 2019. This guidance, from the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP), brings together past and new guidance on the management of bloodborne viruses (BBVs) in healthcare workers (HCWs). The key elements of the new guidance are as follows:
HCWs living with HBV
The guidance on restrictions of HCWs living with hepatitis B (HBV) to perform exposure-prone procedures (EPPs) is being updated. Previous guidance published in October 2017 restricted the practice of HCWs living with HBV if they were e-Antigen (HBeAg) positive and/or they had a pre-treatment viral load of >20,000 IU/mL (105 gEq/ml). These restrictions are now being removed provided HCWs meet the criteria for clearance and comply with monitoring by an occupational health service, as described in the updated guidance published by the UKAP. This change is due to the lower risk of virus transmission with new effective treatments which are now available for HBV. In addition, those HCWs living with HBV who wish to perform EPPs need to be registered on a confidential national register, the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses – Occupational Health Monitoring Register for BBV Infected HCWs (UKAP-OHR). The UKAP-OHR will be managed by Public Health England (PHE), which provides information about how to register HCWs onto the UKAP-OHR.
Changes to recommendations regarding patient notification/lookback exercises
Previous guidance recommended a series of investigations following the diagnosis of a BBV, i.e. HIV, HBV and hepatitis C (HCV), in a HCW who had undertaken EPPs, which included:
- Lookback initiatives to identify procedures undertaken by the HCW.
- The cross-matching of resultant records with databases holding records of people diagnosed with BBVs to determine if any procedures had led to a subsequent diagnosis of a BBV.
- Where appropriate, patient notification exercises involving the provision of information and the offer of a BBV.
A review by UKAP found that, in instances where an HCW was identified as BBV infected but there was no initial evidence of HCW to patient transmission, patient notification exercises failed to identify any such transmissions. It was furthermore found that such investigations are resource-intensive and patient notification often causes anxiety among those contacted.
As a result of this review, the criteria for undertaking a detailed public health investigation and patient notification have been revised and these will now only be undertaken in circumstances where it is known, or suspected, that a patient has acquired infection from a HCW or where there is concern about the practice of the HCW which could have led to increased risk of exposure.
The changes described above are important in ensuring that the management of HCWs living with BBVs is proportionate, reflects the changing treatment options now available and current understanding of the long-term aspects of living with these infections, while ensuring that patient safety is not compromised.
It is hoped that the removal of restrictions on EPP practice, and the recommendation that patient notification/lookback exercises are only undertaken in exceptional circumstances, will reassure HCWs and give them the confidence to seek advice and testing for BBVs if they are concerned about exposures either in the workplace or in other settings.
The UKAP encourages the identification and treatment of BBVs as this has considerable benefits for HCWs. Treatments for HBV, if required, and HIV are generally safe, easy to take and highly effective in suppressing the viruses. For HCV, a short course of treatment is safe, easy to take and, for almost everyone, curative.