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Bloodborne infections in emergency medicine
Policy Statements Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.
Bloodborne Infections in Emergency Medicine Revised and approved by the ACEP Board of Directors April 2004.
Bloodborne Infections in Emergency Medicine [Ann Emerg Med. 2004;44:562-563.]
Human immunodeficiency virus (HIV), hepatitis, and other bloodborne infections affect increasing numbers of people, leaving emergency health care workers (HCWs) to confront a twofold challenge: ensuring that all individuals have access to emergency care and treatment regardless of HIV or other infectious disease status, and preventing exposure to and nosocomial transmission of those bloodborne infections. The risk of accidental transmission of HIV from infected HCWs to patients appears to be remote. However, there is greater evidence of the transmission of hepatitis B (HBV) and hepatitis C (HCV) from HCWs with active disease to patients.1,2 In light of this challenge, the American College of Emergency Physicians (ACEP) endorses the following principles and recommendations. PRINCIPLES d Appropriate care should be provided to all patients who seek emergency care, regardless of risk factors for or known infections with HIV or other bloodborne infections. d Mandatory testing for HIV, HBV, or HCV should not be a condition for patients to receive emergency services. 3-5 d Existing regulations and guidelines regarding infection control should be followed by emergency HCWs and institutions. d HCWs who have been potentially exposed to infectious body fluids should have access to immediate evaluation and, when indicated, postexposure prophylaxis.3,6,7 d HCWs infected with any bloodborne pathogen, who are not allowed to perform the duties of their specialty because of their serostatus, should receive compensation from disability insurance policies as if they were disabled.
HIV RECOMMENDATIONS 0196-0644/$30.00 Copyright Ó 2004 by the American College of Emergency Physicians.
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d HIV testing should be recommended to those patients who are at risk for the disease.8
ANNALS OF EMERGENCY MEDICINE
44:5
NOVEMBER 2004
POLICY STATEMENTS
d HIV testing and postexposure prophylaxis should be discussed with victims of sexual assault at such time as the treating physician believes that such discussion would be clinically appropriate.9 d HIV-positive patients should have the right to confidentiality and privacy; however, physicians should be allowed, without risk of liability, to exercise their professional discretion to confidentially inform an identified and unsuspecting third party at risk for HIV infection from the index patient. d ACEP strongly supports the rapid HIV testing of patients who are the source of a HCW’s occupational blood/body fluid exposure so as to guide treatment of the exposed provider.10 d Mandatory HIV testing should not be a condition of employment for HCWs. d HCWs should not be required to disclose their HIV status to employers unless their job performance is affected. d HCWs who are HIV positive should not be: —precluded from performing any medical services based on HIV status alone; —required to inform patients of their HIV status unless the patient is put at risk by exposure to the HCW’s blood or body fluid; —required to obtain informed consent before the delivery of emergency services. d Unless a practitioner is implicated in provider-topatient HIV transmission, HIV infection per se does not constitute a basis for barring a HCW from any patient-care activities, including invasive procedures.11 d Decisions to restrict the practice of HIV-positive HCWs should be individualized and based on uniform and objective performance standards for competence, ability to perform routine duties, and compliance with established guidelines and procedures, not on the presence of an HIV infection of the HCW.11
HEPATITIS B RECOMMENDATIONS d All emergency HCWs with any potential for blood exposure should receive HBV vaccine unless medically contraindicated and should be tested for immunity after vaccination.3 d The Centers for Disease Control and Prevention recommendations regarding clinical activity for HCWs who are HBsAg and/or HbeAg positive should be followed.4 HbeAg positive HCWs should double-glove routinely and should not perform those activities that have been identified epidemiologically as associated with a risk
NOVEMBER 2004
44:5
ANNALS OF EMERGENCY MEDICINE
for provider-to-patient HBV transmission despite the use of appropriate infection control procedures.11 d Hepatitis B testing and postexposure prophylaxis should be discussed with victims of sexual assault at such time as the treating physician believes that such discussion would be clinically appropriate.9 HEPATITIS C RECOMMENDATIONS d Mandatory HCV testing should not be a condition of employment for HCWs. d Unless a practitioner is implicated in provider-topatient HCV transmission, HCV infection per se does not constitute a basis for barring a HCW from any patient-care activities, including invasive procedures.11 d Decisions to restrict the practice of HCV-infected HCWs should be individualized and based on uniform and objective performance standards for competence, ability to perform routine duties, and compliance with established guidelines and procedures, not on the presence of HCV infection alone.11 Revised and approved by the ACEP Board of Directors April 2004.
doi:10.1016/j.annemergmed.2004.06.009
REFERENCES 1. Harpaz R, Von Seiddlein L, Averhoff FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med. 1996;334:549-554. 2. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C by a cardiac surgeon. N Engl J Med. 1996;334:555-559. 3. Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep. 1997;46(RR-18):1-42. 4. Centers for Disease Control. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR Morb Mortal Wkly Rep. 1991;40(RR-8). 5. Department of Labor, Occupational Safety and Health Administration, 29 CFR Part 1910.1030: Occupational Exposure to Bloodborne Pathogens; Final Rule. Federal Register. Dec 6, 1991. 6. Centers for Disease Control and Prevention. Recommendations for follow-up of health-care workers after occupational exposure to Hepatitis C Virus. MMWR Morb Mortal Wkly Rep. 1997;46:603-606. 7. Centers for Disease Control and Prevention. Public Health Service Guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep. 1998;47(RR-7):1-33. 8. Janssen RS, St. Louis ME, Satten GA, et al. HIV infection among patients in US acute care hospitals. Strategies for the counseling and testing of hospital patients. N Engl J Med. 1992;327:445-452. 9. Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1):1-116. 10. Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med. 2003;348:826-833. 11. Society for Healthcare Epidemiology of America. Management of healthcare workers infected with hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or other bloodborne pathogens. Infect Cont Hosp Epidemiol. 1997;18:349-363.
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Bloodborne Infections in Emergency Medicine Revised and approved by the ACEP Board of Directors April 2004.
Bloodborne Infections in Emergency Medicine [Ann Emerg Med. 2004;44:562-563.]
Human immunodeficiency virus (HIV), hepatitis, and other bloodborne infections affect increasing numbers of people, leaving emergency health care workers (HCWs) to confront a twofold challenge: ensuring that all individuals have access to emergency care and treatment regardless of HIV or other infectious disease status, and preventing exposure to and nosocomial transmission of those bloodborne infections. The risk of accidental transmission of HIV from infected HCWs to patients appears to be remote. However, there is greater evidence of the transmission of hepatitis B (HBV) and hepatitis C (HCV) from HCWs with active disease to patients.1,2 In light of this challenge, the American College of Emergency Physicians (ACEP) endorses the following principles and recommendations. PRINCIPLES d Appropriate care should be provided to all patients who seek emergency care, regardless of risk factors for or known infections with HIV or other bloodborne infections. d Mandatory testing for HIV, HBV, or HCV should not be a condition for patients to receive emergency services. 3-5 d Existing regulations and guidelines regarding infection control should be followed by emergency HCWs and institutions. d HCWs who have been potentially exposed to infectious body fluids should have access to immediate evaluation and, when indicated, postexposure prophylaxis.3,6,7 d HCWs infected with any bloodborne pathogen, who are not allowed to perform the duties of their specialty because of their serostatus, should receive compensation from disability insurance policies as if they were disabled.
HIV RECOMMENDATIONS 0196-0644/$30.00 Copyright Ó 2004 by the American College of Emergency Physicians.
5 6 2
d HIV testing should be recommended to those patients who are at risk for the disease.8
ANNALS OF EMERGENCY MEDICINE
44:5
NOVEMBER 2004
POLICY STATEMENTS
d HIV testing and postexposure prophylaxis should be discussed with victims of sexual assault at such time as the treating physician believes that such discussion would be clinically appropriate.9 d HIV-positive patients should have the right to confidentiality and privacy; however, physicians should be allowed, without risk of liability, to exercise their professional discretion to confidentially inform an identified and unsuspecting third party at risk for HIV infection from the index patient. d ACEP strongly supports the rapid HIV testing of patients who are the source of a HCW’s occupational blood/body fluid exposure so as to guide treatment of the exposed provider.10 d Mandatory HIV testing should not be a condition of employment for HCWs. d HCWs should not be required to disclose their HIV status to employers unless their job performance is affected. d HCWs who are HIV positive should not be: —precluded from performing any medical services based on HIV status alone; —required to inform patients of their HIV status unless the patient is put at risk by exposure to the HCW’s blood or body fluid; —required to obtain informed consent before the delivery of emergency services. d Unless a practitioner is implicated in provider-topatient HIV transmission, HIV infection per se does not constitute a basis for barring a HCW from any patient-care activities, including invasive procedures.11 d Decisions to restrict the practice of HIV-positive HCWs should be individualized and based on uniform and objective performance standards for competence, ability to perform routine duties, and compliance with established guidelines and procedures, not on the presence of an HIV infection of the HCW.11
HEPATITIS B RECOMMENDATIONS d All emergency HCWs with any potential for blood exposure should receive HBV vaccine unless medically contraindicated and should be tested for immunity after vaccination.3 d The Centers for Disease Control and Prevention recommendations regarding clinical activity for HCWs who are HBsAg and/or HbeAg positive should be followed.4 HbeAg positive HCWs should double-glove routinely and should not perform those activities that have been identified epidemiologically as associated with a risk
NOVEMBER 2004
44:5
ANNALS OF EMERGENCY MEDICINE
for provider-to-patient HBV transmission despite the use of appropriate infection control procedures.11 d Hepatitis B testing and postexposure prophylaxis should be discussed with victims of sexual assault at such time as the treating physician believes that such discussion would be clinically appropriate.9 HEPATITIS C RECOMMENDATIONS d Mandatory HCV testing should not be a condition of employment for HCWs. d Unless a practitioner is implicated in provider-topatient HCV transmission, HCV infection per se does not constitute a basis for barring a HCW from any patient-care activities, including invasive procedures.11 d Decisions to restrict the practice of HCV-infected HCWs should be individualized and based on uniform and objective performance standards for competence, ability to perform routine duties, and compliance with established guidelines and procedures, not on the presence of HCV infection alone.11 Revised and approved by the ACEP Board of Directors April 2004.
doi:10.1016/j.annemergmed.2004.06.009
REFERENCES 1. Harpaz R, Von Seiddlein L, Averhoff FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med. 1996;334:549-554. 2. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C by a cardiac surgeon. N Engl J Med. 1996;334:555-559. 3. Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep. 1997;46(RR-18):1-42. 4. Centers for Disease Control. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR Morb Mortal Wkly Rep. 1991;40(RR-8). 5. Department of Labor, Occupational Safety and Health Administration, 29 CFR Part 1910.1030: Occupational Exposure to Bloodborne Pathogens; Final Rule. Federal Register. Dec 6, 1991. 6. Centers for Disease Control and Prevention. Recommendations for follow-up of health-care workers after occupational exposure to Hepatitis C Virus. MMWR Morb Mortal Wkly Rep. 1997;46:603-606. 7. Centers for Disease Control and Prevention. Public Health Service Guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep. 1998;47(RR-7):1-33. 8. Janssen RS, St. Louis ME, Satten GA, et al. HIV infection among patients in US acute care hospitals. Strategies for the counseling and testing of hospital patients. N Engl J Med. 1992;327:445-452. 9. Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1):1-116. 10. Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med. 2003;348:826-833. 11. Society for Healthcare Epidemiology of America. Management of healthcare workers infected with hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or other bloodborne pathogens. Infect Cont Hosp Epidemiol. 1997;18:349-363.
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