Updated CDC Recommendations for the Management of Hepatitis B Virus–Infected Health-Care Providers and Students

Recommendations and Reports
July 6, 2012 / 61(RR03);1-12

Prepared by

Scott D. Holmberg, MD

Anil Suryaprasad, MD

John W. Ward, MD

Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

The material in this report originated in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Kevin Fenton, MD, PhD, Director, and the Division of Viral Hepatitis, John W. Ward, MD, Director.

Corresponding preparer: Scott D. Holmberg, MD, Division of Viral Hepatitis, 1600 Clifton Rd, NE, MS G-37, Atlanta, GA 30329. Telephone: 404-718-8550; Fax: 404-718-8585; E-mail: sdh1@cdc.gov.

Summary

This report updates the 1991 CDC recommendations for the management of hepatitis B virus (HBV)–infected health-care providers and students to reduce risk for transmitting HBV to patients during the conduct of exposure-prone invasive procedures (CDC. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991;40[No. RR-8]). This update reflects changes in the epidemiology of HBV infection in the United States and advances in the medical management of chronic HBV infection and policy directives issued by health authorities since 1991.
The primary goal of this report is to promote patient safety while providing risk management and practice guidance to HBV-infected health-care providers and students, particularly those performing exposure-prone procedures such as certain types of surgery. Because percutaneous injuries sustained by health-care personnel during certain surgical, obstetrical, and dental procedures provide a potential route of HBV transmission to patients as well as providers, this report emphasizes prevention of operator injuries and blood exposures during exposure-prone surgical, obstetrical, and dental procedures.
These updated recommendations reaffirm the 1991 CDC recommendation that HBV infection alone should not disqualify infected persons from the practice or study of surgery, dentistry, medicine, or allied health fields. The previous recommendations have been updated to include the following changes: no prenotification of patients of a health-care provider's or student's HBV status; use of HBV DNA serum levels rather than hepatitis B e-antigen status to monitor infectivity; and, for those health-care professionals requiring oversight, specific suggestions for composition of expert review panels and threshold value of serum HBV DNA considered "safe" for practice (<1,000 IU/ml). These recommendations also explicitly address the issue of medical and dental students who are discovered to have chronic HBV infection. For most chronically HBV-infected providers and students who conform to current standards for infection control, HBV infection status alone does not require any curtailing of their practices or supervised learning experiences. These updated recommendations outline the criteria for safe clinical practice of HBV-infected providers and students that can be used by the appropriate occupational or student health authorities to develop their own institutional policies. These recommendations also can be used by an institutional expert panel that monitors providers who perform exposure-prone procedures.

Introduction

In 1991, CDC published recommendations to prevent transmission of bloodborne viruses from infected health-care providers to patients while conducting exposure-prone invasive procedures (1). These recommendations did not prohibit the continued practice of invasive surgical techniques by HBV-infected surgeons, dentists, and others, provided that the nature of their illnesses and their practices are reviewed and overseen by expert review panels. Essential elements of the 1991 CDC recommendations relevant to HBV included that 1) there be no restriction of activities for any health-care provider who does not perform invasive (exposure-prone) procedures; 2) exposure-prone procedures should be defined by the medical/surgical/dental organizations and institutions at which the procedures are performed; 3) providers who perform exposure-prone procedures and who do not have serologic evidence of immunity to HBV from vaccination should know their HBsAg status and, if that is positive, also should know their hepatitis B e-antigen (HBeAg) status; and 4) providers who are infected with HBV (and are HBeAg-positive) should seek counsel from and perform procedures under the guidance of an expert review panel (1).
The 1991 recommendations also recommended that an HBV-infected health-care provider who performed exposure-prone procedures, broadly defined, should notify patients in advance regarding the provider's seropositivity. However, scientific data and clinical experience accumulated since 1991 demonstrate that the risk for HBV and other bloodborne virus transmission from providers in health-care settings is extremely low. In addition, improvements in infection control practices put into effect since 1991 have enhanced both health-care provider and patient protection from exposure to blood and bloodborne viruses in health-care settings.
This report is intended to guide the practices of chronically HBV-infected providers and students and the institutions that employ, oversee, or train them; it does not address those with acute HBV infection. This report is limited to the provider-to-patient transmission of HBV; it does not address infection control measures to prevent bloodborne transmission of HBV to patients through receipt of human blood products, organs, or tissues because these measures have been described elsewhere (2). Nor does this report provide comprehensive guidance about prevention of patient-to-health-care provider bloodborne pathogen transmission because this guidance also has been published previously (3,4). On the basis of a through literature review, reports of providers who experienced curtailed scope of practice, and expert consultation, CDC considered the following issues when developing these recommendations:1) very rare or, for most types of clinical practice, no detected transmission of HBV from providers to patients; 2) nationally decreasing trends in the incidence of acute HBV infection in both the general population and health-care providers; 3) successful implementation and efficacy of policies promoting hepatitis B vaccination; 4) evolving and improving therapies for HBV infection; 5) guidelines in the United States and other developed countries that propose expert-based approaches to the risk management of infected health-care providers; 6) the adoption of Standard Precautions (formerly known as universal precautions) as a primary prevention intervention for the protection of patients and providers from infectious agent transmission; 7) the implementation of improved work practice and engineering controls, including safety devices; 8) the testing and vaccination of providers; 9) increasing availability of HBV viral load testing; and 10) instances of restrictions or prohibitions for HBV-infected providers and students that are not consistent with CDC and other previous recommendations.

Updated CDC Recommendations for the Management of Hepatitis B Virus–Infected Health-Care Providers and Students