ROWAN UNIVERSITY POLICY

Title: HIV, HBV and HCV
Subject: Health and Safety
Policy No: HS: 2013:02
Applies: University-wide
Issuing Authority:

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 Senior Vice President, Health Sciences
Responsible Officer: Senior Vice President, Health

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Sciences 

Adopted: 10/15/13

Last Revision: 1/29/15

Last Reviewed: 1/29/15

I. PURPOSE

To set RowanSOM requirements for Human Immunodeficiency Virus, Hepatitis B Virus and Hepatitis C Virus (HIV, HBV and HCV) testing, evaluation immunization, and impact on the allowed clinical activities of RowanSOM employees, faculty, housestaff and students who have or will have patient contact, contact with research subjects, or contact with potentially infectious materials during their employment or studies at RowanSOM.

II. ACCOUNTABILITY

Under the Dean and Associate Deans for Academic and Clinical Affairs shall ensure compliance with this policy. The deans of the patient-care units shall implement this policy.

III. APPLICABILITY

This policy shall apply to all interns and residents (including clinical fellows), hereinafter called "house officers" or "housestaff," enrolled in any RowanSOM-sponsored graduate medical education program conducted in any health-care facility participating in the program, and all visiting, exchange or special-program housestaff from other institutions. New housestaff will preferably be in full compliance with this policy prior to beginning their programs, but must be in full compliance within six months of beginning their duties.

IV. DEFINITIONS

1. Bloodborne Blood borne viral hepatitis/hepatitideshepatitis's shall mean those systemic viral infections primarily involving the liver which have a high potential for transmission via blood or body fluids, such as hepatitis B and hepatitis C.
2. Category I procedures shall  shall mean the Category I procedures listed in "Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students" (Attachment B). Category I procedures are listed by the Centers for Disease Control and Prevention (CDC) if they are known or likely to pose an increased risk of percutaneous injury to a health-care provider that have resulted in provider-to-patient transmission of HBV.
3. Category II procedures shall mean the Category II procedures listed in "Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students" (Attachment B). Category II procedures include all invasive and noninvasive procedures that are not included in Category I, as they are deemed by the CDC to pose low or no risk for percutaneous injury to a health-care provider, or, if a percutaneous injury occurs, it usually happens outside a patient's body and generally does not pose a risk for provider-to-patient blood exposure.
4. Standard Precautions is  is a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status. Standard Precautions is a combination and expansion of Universal Precautions and Body Substance Isolation. Standard Precautions is based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions includes hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield. Also, equipment or items in the patient environment likely to have been contaminated with infectious fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for handling, contain heavily soiled equipment, and properly clean and disinfect or sterilize reusable equipment before use on another patient).
5. RowanSOM HBV Committee is a group of designated individuals, who may include the campus Occupational Medicine/Employee Health Service directors, campus Student Health Directors and representatives from Legal Management, Human Resources, infectious disease experts and hepatology experts, along with representatives of RowanSOM or clinical unit with knowledge of the essential functions of the position or program of study in question. F. "RowanSOM Individuals" shall mean all RowanSOM employees, faculty, housestaff and students.

V. REFERENCES

1. Disabilities and Students/Applicants
2. Student Essential Functions
3. Rowan University Student Health Requirements
4. Management of Potential Occupational/Educational 00-01-40-40:10 Exposures to HIV, HBV and HCV
5. Rowan University School of Osteopathic Medicine Policy: Housestaff Immunizations and Health Requirements
6. Rowan University School of Osteopathic Medicine Policy: Bloodborne Pathogens
7. Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students. MMWR July 6, 2012; Vol. 61/No.3
8. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR September 30, 2005;54 (RR-9).
9. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. CDC MMWR October 16, 1998;47(RR-19).
10. SHEA Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus. Infection Control and Epidemiology. March 2010; Vol. 31/No.3
11. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). CDC MMWR Nov 25, 2011;60(7):1-45.

VI. POLICY

1. All RowanSOM Individuals shall comply with the infection control policies and procedures of their respective Schools or patient-care units, with the training requirements described in University policy, Bloodborne Pathogens, with the Standard Precautions guidelines established by the Centers for Disease Control and Prevention (CDC), with the New Jersey Department of Health and Senior Services infection control standards for hospitals (N.J.A.C. 8:43G-14.1(b) 2), and with the Occupational Safety and Health Administration's (OSHA) "Bloodborne Pathogens Standard" (29 CFR 1910.1030) as promulgated by the New Jersey Public Employees Occupational Safety and Health Act (PEOSHA). Continued clinical privileges will be dependent upon full compliance with all appropriate infection control procedures.
2. RowanSOM Individuals and accepted applicants who have HBV, HCV or HIV may not, by reason of such disability, be excluded from participation in or be denied the benefits of RowanSOM's services, programs or activities, except as provided in this policy.

VII. ATTACHMENTS

1. Attachment 1, Policy Implementation Procedures
2. Attachment 2, Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students. MMWR July 6, 2012; 61(3) (CDC Classification of exposure-prone patient care procedures).
3. Attachment 3, Table: Follow-up Plan for RowanSOM individuals with Hepatitis B Virus Infection
4. Attachment 4, Example Student Health/Occupational Medicine counseling letter for HBV positive RowanSOM individuals receiving no HBV Committee review (HBV<1,000 IU/ml, and Category I procedures not required, but reasonable expected. See EXHIBIT C)
5. Attachment 5, CDC Recommendation - Notification of Patients of HBV-Infected Health-Care Providers
6. Attachment 6, Excerpt from: SHEA Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus

ATTACHMENT 1

Policy Implementation Procedures

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1. As recommended for all health-care workers, RowanSOM individuals who are infected with HIV and/or HCV should follow strict aseptic technique and standard precautions including, but not limited to, appropriate hand washing frequencies and techniques; protective barriers; and appropriate use of sharps disposal containers, sharps with engineered sharps injury protections, and other safer medical devices, as required by the PEOSHA/OSHA Bloodborne Pathogens standard and RowanSOM policy, Bloodborne Pathogens.
2. RowanSOM individuals must be provided with explicit procedures to be followed in the event of a potential exposure, in accordance with University policy, Management of Potential Occupational/Educational Exposures to HIV, HBV, and HCV, 00-01-40-40:10.
3. RowanSOM individuals who have reason to believe they may be infected with HIV, HBV and/or HCV because of occupational exposure or non-occupational high risk activities have a duty to periodically determine their serostatus as frequently as is indicated by the nature of their risk. If found to be infected with HIV, HBV and/or HCV, these individuals shall consult with the Student Health Services director or Occupational Medicine/Employee Health Service director. Such directors shall refer all such matters to the HBV Committee for appropriate review in accordance with this policy.
   Individuals who are found to be infected with HIV or HCV shall be counseled by the Student Health Service director or Occupational Medicine/Employee Health Service director as to the appropriate precautions necessary to protect patient safety, including current recommendations by the Society for Healthcare Epidemiology of America (SHEA). Refer to attachment F for a link to the SHEA guidelines and excerpts pertaining to management of HIV and HCV in the health care setting. 
   Individuals who are found to be infected with HBV shall be counseled by the Student Health Service director or Occupational Medicine/Employee Health Service director in accordance with current guidelines from the CDC. (See Attachments B and C)
4. In accordance with University policy, RowanSOM shall not make any inquiries of applicants for admission regarding the existence, nature or severity of disabilities prior to acceptance, but may inquire about the ability of applicants to meet the published Essential Functions of the educational program, with or without reasonable accommodations. In evaluating applicants to RowanSOM educational programs, an applicant's limitations or impairments due to HIV, HBV and/or HCV infection may be considered on a case-by-case basis, as with other medical illnesses and disabling conditions, to determine the applicant's ability to perform the essential functions and curricular requirements of the academic program. In no case shall information or inference about HIV, HBV or HCV status be used as the basis for denying an applicant full and complete consideration in the admissions process. Evaluation for admission should focus on whether the individual in his or her current state of health, with reasonable accommodation by the University, will be able to successfully complete the essential functions and curricular requirements of the academic program.

ATTACHMENT 2

CDC classification of exposure-prone patient care procedures

A. Category I. Procedures known or likely to pose an increased risk of percutaneous injury to a health-care provider that have resulted in provider-to-patient transmission of hepatitis B virus (HBV) 

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These and similar procedures are not included in Category I as they pose low or no risk for percutaneous injury to a health-care provider or, if a percutaneous injury occurs, it usually happens outside a patient's body and generally does not pose a risk for provider-to-patient blood exposure. These include surgical and obstetrical/gynecologic procedures that do not involve the techniques listed for Category I; the use of needles or other sharp devices when the health-care provider's hands are outside a body cavity (e.g., phlebotomy, placing and maintaining peripheral and central intravascular lines, administering medication by injection, performing needle biopsies, or lumbar puncture); dental procedures other than major oral or maxillofacial surgery; insertion of tubes (e.g., nasogastric, endotracheal, rectal, or urinary catheters); endoscopic or bronchoscopic procedures; internal examination with a gloved hand that does not involve the use of sharp devices (e.g., vaginal, oral, and rectal examination; and procedures that involve external physical touch (e.g., general physical or eye examinations or blood pressure checks).

Attachment 3
Table: Follow-up Plan for UMDNJ Individuals with Hepatitis B Virus Infection

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ATTACHMENT 4
Example Student Health/Occupational Medicine counseling letter for HBV positive UMDNJ individuals receiving no HBV Committee review (HBV<1,000 IU/ml, and Category I procedures not required, but reasonable expected. See Attachment C)

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I have read and understood the contents of this letter and the attached policy, and I agree to any requirements expressed in this letter in all respects. I understand that if I do not comply with the requirements in this letter and/or the attached policy, I may be subject to [discipline, up to including dismissal/termination].



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Student /Employee Name (Print)


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Student/Employee Signature


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Date

ATTACHMENT 5

CDC Recommendation -
Notification of Patients of HBV-Infected Health-Care Providers

There is no clear justification for or benefit from routine notification of the HBV infection status of a health-care provider to his or her patient with the exception of instances in which an infected provider transmits HBV to one or more patients or documented instances in which a provider exposes a patient to a bloodborne infection. Routine mandatory disclosure might actually be counterproductive to public health, as providers and students might perceive that a positive test would lead to loss of practice or educational opportunities. This misperception might lead to avoidance of HBV testing, of hepatitis B vaccination (if susceptible), of treatment and management (if infected), or of compliance with practice oversight from an expert panel (if infected and practicing exposure-prone procedures). In general, a requirement for disclosure is accepted to be an insurmountable barrier to practice and might limit patient and community access to quality medical care.

ATTACHMENT 6

Excerpt from: SHEA Guideline for Management of Healthcare Workers
Who Are Infected with Hepatitis B Virus, Hepatitis C Virus,
and/or Human Immunodeficiency Virus

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 see: http://www.shea-online.org/Assets/files/guidelines/BBPathogen_GL.pdf

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1. HIV
   SHEA recommends that HIV-infected providers who have circulating HIV viral burdens of greater than or equal to 5 x 102 GE/mL routinely use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for all instances in patient care for which gloving is recommended, and that they not perform those Category III activities identified as associated with a risk for provider-to-patient transmission of bloodborne pathogen infection despite the use of appropriate infection control procedures (Tables 1 and 2). SHEA recommends that an HIV-infected provider who has a viral burden of less than 5 x 102 GE/mL not be excluded from any aspect of patient care, including the performance of Category III procedures, so long as the infected provider (1) is not detected as having transmitted infection to patients; (2) obtains advice from an Expert Review Panel about continued practice; (3) undergoes follow-up routinely by Occupational Medicine (or an appropriate public health official), who tests the provider twice annually to demonstrate the maintenance of a viral burden of less than 5 x 102 GE/mL; (4) also receives follow-up by a personal physician who has expertise in the management of HIV infection and who is allowed by the provider to communicate with the Expert Review Panel about the provider's clinical status; (5) consults with an expert about optimal infection control procedures (and strictly adheres to the recommended procedures, including the routine use of double-gloving for Category II and Category III procedures and frequent glove changes during procedures, particularly if performing technical tasks known to compromise glove integrity [eg, placing sterna wires]); and (6) agrees to the information in and signs a contract or letter from the Expert Review Panel that characterizes her or his responsibilities (discussed in more detail in Recommendation 8, below).
2. General Recommendations
   The rationale for these recommendations is presented below (in the section Background and Rationale). SHEA argues for comprehensive education concerning bloodborne pathogens for all healthcare providers and trainees. SHEA recommends managing infected providers in the context of comprehensive approach to the management of all impaired providers. SHEA emphasizes the importance of patient safety as well as provider privacy and medical confidentiality. The society also emphasizes the importance of offering employees who have disabilities reasonable accommodation for their disabilities. The guideline discusses exposure management in detail and, in general, recommends adherence to existing guidelines for managing exposures to these viruses. SHEA underscores that practitioners who are institutionally based and who develop one of these bloodborne pathogen infections are ethically bound to report their infections to their institutions' occupational medicine providers and to engage in the process outlined below. Further, practitioners who are not institutionally based and who develop one of these bloodborne pathogen infections are ethically bound to engage their public health departments (consonant with state and local laws), as described below. Finally, the society encourages routine voluntary, confidential testing of providers, emphasizing that providers who conduct Category III procedures should know their immune status with respect to each of these 3 bloodborne pathogens. Specific details and the rationale for these recommendations are included in the body of the guideline.