SHEA Management of Healthcare Personnel Living with Hepatitis B, Hepatitis C, or Human Immunodeficiency Virus in US Healthcare Institutions Guidance

Introduction

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.

Hepatitis B virus (HBV)

The use of hepatitis B vaccine has had a profound effect on the frequency with which HCP acquire HBV infection. Consonant with the US Department of Labor’s Occupational Safety and Health Administration (OSHA)’s Bloodborne Pathogen Standard, 11 all HCP must be offered the complete vaccination series. The current CDC guidelines 5 recommend that prevaccination testing not be routinely conducted, except for HCP who are at increased risk for HBV infection, such as HCP born to mothers from endemic countries and sexually active men who have sex with men. Reference Weinbaum, Williams and Mast12 The 2012 CDC guidelines 5 also recommend that the HBV vaccination series be followed by assessment of post-vaccination immunity (ie, determination of hepatitis B surface antibody [anti-HBs]). If the anti-HBs determination is negative, CDC recommends revaccination. 5 If the second course of vaccination does not produce protective levels of anti-HBs, CDC recommends that HCP be tested for hepatitis B surface antigen (HBsAg) and hepatitis B core antigen (anti-HBc) to determine infectivity. A recent report has documented 4 instances of chronic HBV infection in HCP who failed to respond to 2 courses of vaccination. Reference Guynn, Ciccone, Sickbert-Bennett and Weber13

The availability of antiviral therapy has changed the landscape for HCP living with hepatitis B. A substantial pharmacologic armamentarium has been developed to suppress hepatitis B viral load substantially, including 7 US Food and Drug Administration (FDA)–approved agents: tenofovir, entecavir, lamivudine, telbivudine, adefovir, interferon α, and pegylated interferon. Since the publication of the previous guidance, only 2 instances of HCP-to-patient transmission of HBV have been reported in the literature. Reference Enfield, Sharapov and Hall14,Reference Sugimoto, Nagakubo and Ito15 In both instances, neither HCP (an orthopedist and a gynecologic surgeon) was aware of the hepatitis B infection, and, thus, neither was on treatment. Both HCP had viral loads >10 8 (ie, ~2.0 × 10 7 IU/mL). Reference Enfield, Sharapov and Hall14,Reference Sugimoto, Nagakubo and Ito15 Several clinical studies have demonstrated that antiviral treatment can lower circulating HBV DNA levels in most patients, often to undetectable or nearly undetectable levels.

Hepatitis C virus (HCV)

The less effective and poorly tolerated interferon-plus-ribavirin therapies used since the 1980s for treatment of HCV infection have been replaced in the past decade by the development and FDA approval of >10 drugs or drug combinations that act directly on the hepatitis C virus (direct-acting antivirals, or DAA). The use of DAAs has resulted in sustained virologic response (SVR) rates of nearly 100%, in most cases curing HCV infection. Reference Chen and Chung16-Reference Welker and Zeuzem18 Since the publication of the 2010 SHEA guideline, with the exception of cases linked to substance use disorders among healthcare professionals engaged in recreational intranasal or intravenous drug use, including drugs diverted from appropriate medical use, Reference Hellinger, Bacalis and Kay19-Reference Williams, Perz and Bell27 only 3 instances of HCP-to-patient HCV transmission have been documented in the literature. Reference Bourigault, Nael and Garnier28-Reference Roy, Galmes-Truyols and Gimenez-Duran30 Each of these reports is notable because the individuals implicated in HCV transmission did not participate in exposure-prone procedures with the individuals who were identified as acutely infected; one case was associated with hemodialysis, another with postpartum care, and another with home care. Reference Bourigault, Nael and Garnier28-Reference Roy, Galmes-Truyols and Gimenez-Duran30 In each of these 3 cases, which occurred in Europe, the possibility of substance use disorder was neither entertained nor discussed.

Over the past decade, the importance of substance use disorder among HCP resulting in transmission of hepatitis C to patients has become even more apparent. Reference Hellinger, Bacalis and Kay19-Reference Williams, Perz and Bell27 In light of the significant expansion of the opioid epidemic in the United States, consideration should always be given to the possibility of substance use disorder when HCP-to-patient transmission of a bloodborne pathogen is detected. Curiously, in a 2013 review of HCP-associated outbreaks (including those caused by bloodborne pathogens), substance use was not discussed as a possible contributor to these outbreaks. Reference Danzmann, Gastmeier, Schwab and Vonberg31 Similarly, in other more recent reports outside the United States, substance use was not discussed as a potential contributing factor. Reference Muir, Chow, Tedder, Smith, Harrison and Holmes29,Reference Chung, Choi and Han32,Reference Deuffic-Burban, Delarocque-Astagneau, Abiteboul, Bouvet and Yazdanpanah33 Importantly, HCP substance use is a well-recognized, treatable illness, and SHEA emphasizes the importance of access to effective treatment for healthcare workers who are diagnosed with this illness.

Human immunodeficiency virus (HIV)

Antiretroviral therapy (ART) has markedly changed both the prognosis for persons living with HIV as well as the risk of transmission to others. Over the past decade, new drugs and combinations of drugs have rendered ART less toxic, better tolerated, and more efficacious. These drugs can fully suppress HIV viral load to undetectable levels in most persons. In addition, studies have demonstrated that persons living with HIV with undetectable viral loads do not transmit HIV sexually, even during unprotected sex, leading to the conclusion that “undetectable equals untransmittable (U = U)” by sexual routes. Reference Rodger, Cambiano and Bruun34,Reference Rodger, Cambiano and Bruun35 Since the magnitude of risk for a single unprotected sexual encounter approximates the magnitude of risk for occupational infection following a parenteral occupational exposure (eg, needlestick exposure to blood from a person living with HIV in the pre-antiretroviral era), these data are highly relevant. In addition, in the 10 years since the publication of the 2010 SHEA guideline, the authors were unable to identify any new reports of HCP-to-patient transmission of HIV.