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Advice to the Profession: Blood Borne Viruses

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Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.

Hepatitis B virus, hepatitis C virus and human immunodeficiency virus cause significant disease and can be transmitted between a physician and a patient during the course of treatment. The risk of transmitting infectious diseases is a concern shared by both physicians and patients.

The risk of transmitting blood borne viruses (BBV) to a patient is greater when a physician’s blood borne infection is unrecognized and untreated. Therefore, it is important for a physician to know his or her status in regard to whether they are carriers of a blood borne virus. This information is essential not only to safeguard physicians’ health and that of their patients, but also to ensure public trust in the profession.

The College’s Blood Borne Viruses policy sets expectations for:

  • reducing the risk of acquiring or transmitting a blood borne virus
  • physicians who are exposed to a blood borne virus, and
  • physicians who become infected with a blood borne virus.

This advice document is intended to help physicians interpret their obligations as set out in the Blood Borne Viruses policy and provide guidance around how these obligations may be effectively discharged.

Does the Blood Borne Viruses policy apply to all physicians?

No. The policy only applies to physicians including postgraduate residents and fellows who perform exposure prone procedures (EPPs) or who assist in performing these procedures, since there is a higher risk of transmission of BBVs during an EPP. This policy applies  not only to physicians who perform or assist in performing procedures that may become exposure-prone (for example, a laparoscopic procedure that may convert to an open procedure) but also includes physicians who have the potential to perform or assist in performing exposure prone procedures in the course of providing day-to-day care even though they may not be currently performing them, for example, emergency physicians.

Why does the policy apply to physicians who assist in performing exposure prone procedures?

The policy applies to physicians who assist in performing exposure prone procedures because we recognize that physicians assisting with these procedures may be subject to similar risks as physicians who perform the procedures.

Why does the policy apply to physicians who have the potential to perform or assist in performing exposure prone procedures?

In summary, this policy applies to physicians who have the potential to perform or assist in performing exposure prone procedures, for example, emergency physicians, because we want to ensure that both patients and physicians are protected. Performing or assisting in performing exposure prone procedures is within an emergency physician’s scope of practice. A patient who requires an exposure prone procedure could come to the emergency department. Although this may not happen every day or even often, if it does the emergency physician would need to perform the exposure prone procedure.

How do I know if I am performing exposure prone procedures?

The College has adopted the following definition of “exposure prone” procedures from the Centre for Disease Control (1998):

  1. digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs) or the simultaneous presence of the health-care worker’s fingers and a needle or other sharp instrument or object in a blind or highly confined anatomic site (e.g., during major abdominal, cardiothoracic, vaginal and/or orthopaedic operations1);
  2. repair of major traumatic injuries; or
  3. manipulation, cutting or removal of any oral or perioral tissue, including tooth structures, during which blood from a health-care worker has the potential to expose the patient’s open tissue to a blood borne pathogen.

The College has adapted the list of procedures for which there is definite risk of blood borne virus transmission according to the SHEA Guideline for Management of Healthcare Workers who are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus. Examples of procedures that are classified as ‘exposure-prone’ are set out in Appendix B of the Blood Borne Viruses policy.  Examples of procedures that are not EPPs can be found in the SHEA Guideline.

What are the blood borne viruses?

The policy applies to Hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) which are the relevant blood borne viruses.

How often must I be tested for blood borne viruses?

The frequency with which physicians must be tested for BBVs will vary, depending on the applicable circumstances.

  1. Physicians who perform or who assist in performing EPPs or who have the potential to perform or assist in performing EPPs are to be tested for HCV and HIV every three years.
  2. Physicians who perform or assist in performing exposure prone procedures must be tested annually for HBV unless the physician has been confirmed immune to HBV.
  3. Physicians who want to perform or assist in performing EPPs must be tested for HCV, HIV and HBV (if they haven’t been confirmed immune to HBV) before they commence performing or assisting in performing EPPs in Ontario. This applies to new registrants, residents and fellows in training programs who will begin performing or assisting in performing exposure prone procedures as part of their education program, and physicians who are changing their scope of practice or re-entering practice.
  4. Physicians who have been exposed to bodily fluids of unknown status through a specific incident, such as a needle prick, or splash onto a mucous membrane or non-intact skin, must seek appropriate expert advice regarding the frequency of testing that is required to determine if they have been infected with one or more blood borne viruses.

Why do you require periodic testing for BBVs?

In the absence of a firm testing requirement, we found that physicians were not routinely being tested despite their ethical obligation to know their serologic status. Testing allows physicians to monitor and safeguard their own health. As well, periodic testing will reassure the public that the profession is doing everything possible to ensure public and physician safety.

I have never been immunized for HBV. I understand that the policy recommends that I do.

Yes. HBV immunization is widely regarded as an important safety precaution, and the policy strongly recommends that physicians be immunized unless a contraindication exists or they already have immunity. Post-immunization testing is required to demonstrate immunity through the demonstration of an effective antibody response.

Physicians who do not respond to the vaccine (do not seroconvert as evidence of immunity) are advised to seek expert advice on alternative vaccination protocols in order to confirm the presence of an effective antibody response.

Why have you chosen the interval of three years for HCV and HIV testing?

Although any interval for testing is arbitrary as the literature does not provide any direction with respect to a testing interval, a three-year testing interval is a reasonable compromise amongst possible options.

What should I do in addition to testing, following an exposure?

The College encourages physicians to consult the Blood Borne Diseases Surveillance Protocol for Ontario Hospitals2 and their own hospital’s protocols and/or policies for detailed information about post-exposure protocols, including post-exposure prophylaxis.

How do I make a report to the College if I test positive for a blood borne virus?

Physicians must report to the College if they are seropositive with respect to HBV, HCV, and/or HIV through the completion of the Annual Renewal Survey. If physicians find out their status prior to the annual renewal survey, they must make their report to the College as soon as is reasonably practical after learning of their status. Physicians must not wait to report their status on the next Annual Renewal Survey. To make a report to the College, physicians are advised to contact the College’s Physicians Advisory Service at 416-967-2606 or toll-free at 1-800-268-7096 ext. 606.

In order to comply with the policy and the annual renewal requirements, physicians may have to share with the College very confidential and private information. How does the College protect physician privacy?

We understand and respect that physicians are asked to share with us very personal, sensitive information and may be anxious about doing so. The College respects the confidentiality and privacy of all the information that we receive; this includes physician information about BBVs and their health. To help reassure physicians, we have outlined our practices regarding confidentiality and the management of seropositive physicians below. No personal health information is made public. 

What will happen if I do not answer the questions on the Annual Renewal Form?

Successful renewal of your certificate of registration is dependent on:

  1. completion of the annual renewal form, and
  2. full payment of all fee amounts due.

If you do not understand the questions on the renewal form or have any other questions, please contact the College’s Physician Advisory Service at 416-967-2606 or 1-800-268-7096 ext. 606 for clarification.

I know the policy is directed at physicians, but is there any way for physicians to know if a patient they are treating has a BBV?

Yes, physicians may be able to find out a patient’s status under the Mandatory Blood Testing Act, 2006. This is an Ontario law, and it allows physicians and other care providers to get confirmation of a patient’s serological status in some circumstances. Physicians should inquire with their institution, or seek independent legal advice from legal counsel or the Canadian Medical Protective Association, as to whether this statute is applicable in the circumstances.3

College Practices: Blood Borne Viruses

What if I have tested positive for a blood borne virus and do exposure prone procedures?

Physicians who have tested positive for HBV, HCV, and/or HIV will be expected to undergo such regular testing as is recommended by their treating physician and approved by the College for the purposes of monitoring their health, including their viral loads. There are effective management regimes for these viral infections and the expectation is that physicians will be followed by an appropriate treating physician with expertise in viral infections.

In determining whether seropositive physicians will be able to continue performing or assisting in performing EPPs, the College’s priority is to ensuring patient safety while permitting a physician to practice safely. The College will evaluate each situation based on the specific facts, including the physician’s practice and viral loads, and will consider the best available evidence and where applicable, the recommendations of the Expert Panel. An Expert Panel is a panel struck to evaluate the health information and practices of seropositive physicians for the purpose of recommending to the College what restrictions, if any, will be required on the seropositive physician’s practice. It is comprised of experts, external to the College, in surgery, public health, infectious diseases, occupational medicine, along with a chief of staff, and other experts, including those from the member’s own specialty, as appropriate.

If the College has determined that a seropositive physician can safely perform or assist in performing EPPs, the physician must take such precautions (in addition to Routine Practices defined in Appendix B of the policy) that are required or recommended by the College. The College’s recommendations regarding additional precautions will be consistent with the SHEA Guideline.

The following contains further detail on College practices with respect to the Evaluation of Practice and Practice Restrictions.

Seropositive Physicians: Evaluation of Practice and Practice Restrictions

When a physician is seropositive and wishes to continue performing and assisting in performing exposure prone procedures, the College will evaluate the physician’s practice and health information to determine what restrictions, if any, are required to safeguard patient health.

The College will take steps to gather relevant information about the physician’s health and whether the physician’s scope of practice involves or potentially involves exposure prone procedures. The College will evaluate each situation based on the specific facts, including the physician’s practice and viral loads.

If a Seropositive Physician’s viral load for HBV and HCV is below 1x10E4 GE/ml4, and below 2xE2 GE/ml for HIV and they agree to participate in ongoing health monitoring, they may continue to perform EPPs. 

In the event a Seropositive Physician’s viral load exceeds the acceptable threshold they will be required to enter into an undertaking restricting their practice such that they will not perform EPPs until their viral load is below the threshold.  

Restricting physicians from doing exposure prone procedures is resorted to only when a physician’s viral load exceeds the acceptable threshold. If the College does impose restrictions on a physician’s practice, it will ensure that the institution(s) at which the physician works are aware of the restrictions.  The College generally does not make institutions aware of the details when a physician poses no increased risk and is subject only to health monitoring to ensure the risk level stays the same. Whether broader notification of the practice restrictions is required will depend on the circumstances of each case. When evaluating whether broader notification is required, the College will strive to protect physician privacy to the greatest extent possible, while not compromising patient safety.

Any advice provided by the College to the physician or where necessary, restrictions imposed on a physician’s practice, will be informed by evidence and the recommendations of the Expert Panel if one is struck. 

Confidentiality and Privacy

As set out in the Privacy Code, the College respects the confidentiality and privacy of all information it receives or creates in the course of fulfilling its regulatory functions. This includes information about blood borne viruses and physician health.

To do so, the College ensures that information about physicians’ serological status and physicians’ practices is only made available to College Committees or the Expert Panel, if it is struck, for the purpose of evaluating seropositive physicians’ practices and making decisions regarding any practice restrictions if necessary. All those who have access to this information know and understand their obligations regarding confidentiality and privacy. The Expert Panel is not advised of a physician’s name. Your BBV status will not be posted on the CPSO public register. If you are restricted from performing certain procedures, that may be on the register.

Endnotes

1. Pelvic operations, as per the SHEA Guideline, are another example.

2. This document is available at: https://www.oha.com/Documents/Blood%20Borne%20Diseases%20Protocol%20(November%202018).pdf

3. The Ministry of Community Safety and Correctional Services and local public health units may also have information regarding the Mandatory Blood Testing Act, 2006.

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