Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions

Significant advances have occurred in the clinical care of persons living with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV) since the publication of the 2010 “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.” Reference Henderson, Dembry and Fishman1 Only 5 instances of healthcare personnel (HCP)-to-patient transmission of HBV (n = 2), HCV (n = 3), or HIV (n = 0) have occurred since this guideline was published, underscoring the low risk for these events. In addition, interventions have been developed to reduce risks for occupational exposures and injuries, rendering the healthcare environment less risky for both patients and HCP. Effective antiretroviral therapy can now fully suppress HIV, rendering the person noninfectious to others through sexual contact. Antivirals effectively suppress the viral load and slow the progression of HBV, and direct-acting antivirals (DAA) have made HCV a curable disease in almost all patients. Here, we examine this progress and address how the additional 10 years of experience and advances in medical progress necessitate modulation of the recommendations made in the 2010 SHEA guideline. Reference Henderson, Dembry and Fishman1

Issues related to the management of HCP who are living with bloodborne pathogens have been challenging and controversial. In 1991, the Centers for Disease Control and Prevention (CDC) published guidelines designed to prevent HCP-to-patient transmission of hepatitis B virus (HBV) and human immunodeficiency virus (HIV). 2

This set of guidelines stated that HCP, “… who are infected with HIV or HBV (and are HBeAg positive) should not perform exposure-prone procedures unless they have sought counsel from an expert review panel and been advised under what circumstances, if any, they may continue to perform these procedures. Such circumstances would include the facility’s notifying a prospective patient of the HCP’s seropositivity before the patient undergoes exposure-prone invasive procedures.” 2

SHEA has long been engaged on this matter, issuing a position paper regarding the management of HCP living with bloodborne pathogens in 1990, Reference Rhame, Pitt and Tapper3 followed by a more extensive updated guidance in 1997, Reference Henderson4 and a detailed set of recommendations in 2010. Reference Henderson, Dembry and Fishman1

Since all of these documents were published, the medical community has gained additional experience with the management of HCP living with bloodborne pathogens as well as additional insight into the factors that contribute to the risks for healthcare-associated transmission of these pathogens. Considerable progress has been made in the management of HBV, HCV, and HIV infection, in the development of sensitive molecular tests designed to measure viral load, and in the sophistication of that measurement. Additionally, clinical scientists have developed a variety of interventional strategies to reduce occupational risk, which has also reduced patient risk in the healthcare setting.

In 2012, CDC issued updated recommendations for the management of HCP and students living with HBV. 5 These guidelines controverted the 1991 guidelines (at least for HCP living with HBV), specifically noting,

“There is no clear justification for or benefit from routine notification of the HBV infection status of an HCP to his or her patient with the exception of instances in which an HCP transmits HBV to one or more patients or documented instances in which an HCP exposes a patient to a bloodborne infection.” 5

In addition, on CDC’s website at the top of the online location of the previously published 1991 guideline, a statement now reads that the “guidance related to HIV infection is retired” and that the “guidance for hepatitis B has been superseded.” 2,5 In 2013, the CDC Advisory Committee on Immunization Practices (ACIP) issued updated guidance about the assessment of immunity to HBV in HCP, including postexposure management strategies. Reference Schillie, Murphy and Sawyer6

More recently, the Communicable Disease Network of Australia (CDNA) published updated guidelines for managing HCP living with bloodborne pathogens, 7 the Public Health Agency of Canada (PHAC) published an exhaustive guideline for the prevention of transmission of bloodborne viruses from HCP to their patients. 8 The United Kingdom published guidance in July 2019 on the health clearance and management of HCP living with a bloodborne pathogen, 9 and CDC issued testing and follow-up information for HCP potentially exposed to HCV. Reference Moorman, Kamili and de Perio10

The following section summarizes the changes involved in the management and treatment of these pathogens since 2010.