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Alan Franciscus
HCV Advocate

Sunday, July 29, 2012

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

Teens, adults and parents, who grapple with when to disclose their hepatitis B infection (HBV) can get some reassuring pointers from a new U.S. Centers for Disease Control and Prevention (CDC) report. The report explored whether restrictions should be imposed on HBV-infected physicians, dentists, and medical students and found that very few limitations should be imposed.

These guidelines were issued because some ill-informed hospitals and medical schools were arbitrarily restricting what medical procedures HBV-infected doctors could perform, and worse, telling infected medical students that they needed to make some career changes.

Many of these doctors and students faced a double whammy of discrimination. It is often medical students and doctors of Asian and African descent or who are gay who carry the highest risk of HBV infection. They were summarily told they could not practice their skills or pursue their educational dreams, according to complaints shared with the Hepatitis B Foundation. The foundation asked CDC to clarify its position on what, if any restrictions should be imposed on health care providers.

By and large, the CDC stuck to its earlier position that no restrictions should be imposed on HBV-infected physicians unless they performed high-risk surgical practices and had viral loads exceeding 1,000 international units per milliliter.

CDC based its recommendations on extensive research into provider-to-patient HBV infection transmission. Their findings should put to rest parents' and adults' fears about whether casual exposure poses an infection risk.

First some facts: Nearly every state and all schools and colleges require hepatitis
B immunizations. So the vast majority of children, teens, college students and 20- and 30-somethings have probably been immunized. As a result, brand new infections have declined 85% in the U.S. since the early 1990s. Similarly, HBV infections passed from patients to providers have declined markedly from 10,000 in 1983 to 100 in 2009.

While there are stories about viral hepatitis being transmitted through re-used syringes and medical equipment, there has been only one documented case of an infected surgeon infecting a patient since 1994. The last case of a dentist transmitting HBV to a patient was in 1987. Vaccinations and better standard precautions have clearly worked.

In fact, when unprotected sex and shared injecting equipment are taken out of the equation, it takes a lot to infect someone.

First, the infected person needs to have a high enough viral load (HBV DNA circulating in their blood) to pose an infection risk. Second, they need to have a cut, open sore, or severe rash that will discharge blood or body fluids. Third, that infectious blood or fluid must enter the other person's body through an open sore/wound or direct ingestion.

Now we know that's easy to do if you're having sex without a barrier/condom or if you're sharing drug works, but in normal interactions or play, the odds of infectious blood/body fluids finding their way into another person are high.

CDC experts write, "The vast majority of HBV-infected health-care personnel pose no risk for patients because they do not perform activities in which both the second and third conditions are met."

Another area of sometimes arbitrary (and scientifically unfounded) restrictions is the sports arena. The CDC has not weighed in on this area, but the American Academy of Pediatrics has. They too did a review of all research on hepatitis B transmission between athletes and found no basis for excluding HBV-infected athletes from sports, especially given universal hepatitis B immunization. 

Christine M. Kukka
Project Manager

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