SHEA Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus -Page 1 of 2

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> FULL TEXT: http://www.journals.uchicago.edu/doi/full/10.1086/650298

>

> Infect Control Hosp Epidemiol 2010;31:203–232

> © 2010 by The Society for Healthcare Epidemiology of America. All rights

reserved.

> DOI: 10.1086/650298

>

> SHEA Guideline

> SHEA Guideline for Management of Healthcare Workers Who Are Infected with

Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus

>

> K. , MD;

> Louise Dembry, MD, MS, MBA;

> Neil O. Fishman, MD;

> Grady, RN, PhD;

> Tammy Lundstrom, MD, JD;

> Tara N. Palmore, MD;

> Kent A. Sepkowitz, MD;

> J. Weber, MD, MPH; for the

> Society for Healthcare Epidemiology of America

>

> From the National Institutes of Health Clinical Center, Bethesda, land

(D.H.), the Department of Quality Improvement Support Services, Yale–New Haven

Hospital, New Haven, Connecticut (L.D.), the Division of Infectious Diseases,

University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

(N.F.), the Department of Bioethics, National Institutes of Health Clinical

Center, Bethesda, land (C.G.), the Section of Infectious Diseases,

Providence Hospital and Medical Center, Southfield, Detroit, Michigan (T.L.),

the Infectious Disease Fellowship Training Program, National Institutes of

Health Clinical Center, Bethesda, land (T.P.), Infectious Diseases Service,

Memorial Sloanâ€Kettering Cancer Center, New York, New York (K.S.), and the

Division of Infectious Diseases, University of North Carolina, Chapel Hill,

North Carolina (D.W.).

>

> Note: A statement about authorship appears at the end of the text.

>

> Received November 10, 2009; accepted November 23, 2009; electronically

published January 20, 2010.

>

> Address correspondence to K. , MD, Deputy Director for Clinical

Care, Clinical Center, National Institutes of Health, Bldg. 10, Rm. 6â€1480, 10

Center Dr., MSC 1504, Bethesda, MD 20892â€1504 (dkh@...).

>

> Executive Summary

>

> This guideline provides the updated recommendations of the Society for

Healthcare Epidemiology of America (SHEA) regarding the management of healthcare

providers who are infected with hepatitis B virus (HBV), hepatitis C virus

(HCV), and/or the human immunodeficiency virus (HIV). For the reasons cited in

the guideline, SHEA continues to recommend that, although some aspects of the

approach to and administrative management of each of these infectious syndromes

in healthcare providers are similar, separate management strategies for

healthcare workers who are infected with these unrelated viruses remain

appropriate. As we did in both prior iterations of this document, SHEA

emphasizes the use of appropriate infection control procedures to minimize

exposure of patients or providers to blood, emphasizes that transfers of blood

from patients to providers and from providers to patients should be avoided, and

recommends that infected healthcare providers should not be totally prohibited

from participating in patientâ€care activities solely on the basis of a

bloodborne pathogen infection. The types of procedures assessed by the panel as

associated with an increased risk for providerâ€toâ€patient transmission of

these pathogens are discussed in detail. For each pathogen, recommendations are

graduated according to the relative viral load level of the infected provider

(Tables 1 and 2). However, SHEA emphasizes that, because of the complexity of

these cases, each such case will be slightly different from the next, and each

should be independently considered in context.

>

> Table 1.

> Summary Recommendations for Managing Healthcare Providers Infected with

Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and/or Human Immunodeficiency

Virus (HIV)

>

--------------------------------------------------------------------------------\

------------------------------------

> Table 2.

> Categorization of Healthcareâ€Associated Procedures According to Level of

Risk for Bloodborne Pathogen Transmission

>

> Category I: Procedures with de minimis risk of bloodborne virus transmission

>

> • Regular historyâ€taking and/or physical or dental examinations, including

gloved oral examination with a mirror and/or tongue depressor and/or dental

explorer and periodontal probe

> • Routine dental preventive procedures (eg, application of sealants or

topical fluoride or administration of prophylaxisa), diagnostic procedures,

orthodontic procedures, prosthetic procedures (eg, denture fabrication),

cosmetic procedures (eg, bleaching) not requiring local anesthesia

> • Routine rectal or vaginal examination

> • Minor surface suturing

> • Elective peripheral phlebotomyb

> • Lower gastrointestinal tract endoscopic examinations and procedures, such

as sigmoidoscopy and colonoscopy

> • Handsâ€off supervision during surgical procedures and computerâ€aided

remote or robotic surgical procedures

> • Psychiatric evaluationsc

>

> Category II: Procedures for which bloodborne virus transmission is

theoretically possible but unlikely

>

> • Locally anesthetized ophthalmologic surgery

> • Locally anesthetized operative, prosthetic, and endodontic dental

procedures

> • Periodontal scaling and root planingd

> • Minor oral surgical procedures (eg, simple tooth extraction [ie, not

requiring excess force], soft tissue flap or sectioning, minor soft tissue

biopsy, or incision and drainage of an accessible abscess)

> • Minor local procedures (eg, skin excision, abscess drainage, biopsy, and

use of laser) under local anesthesia (often under bloodless conditions)

> • Percutaneous cardiac procedures (eg, angiography and catheterization)

> • Percutaneous and other minor orthopedic procedures

> • Subcutaneous pacemaker implantation

> • Bronchoscopy

> • Insertion and maintenance of epidural and spinal anesthesia lines

> • Minor gynecological procedures (eg, dilatation and curettage, suction

abortion, colposcopy, insertion and removal of contraceptive devices and

implants, and collection of ova)

> • Male urological procedures (excluding transabdominal intrapelvic

procedures)

> • Upper gastrointestinal tract endoscopic procedures

> • Minor vascular procedures (eg, embolectomy and vein stripping)

> • Amputations, including major limbs (eg, hemipelvectomy and amputation of

legs or arms) and minor amputations (eg, amputations of fingers, toes, hands, or

feet)

> • Breast augmentation or reduction

> • Minimumâ€exposure plastic surgical procedures (eg, liposuction, minor

skin resection for reshaping, face lift, brow lift, blepharoplasty, and

otoplasty)

> • Total and subtotal thyroidectomy and/or biopsy

> • Endoscopic ear, nose, and throat surgery and simple ear and nasal

procedures (eg, stapedectomy or stapedotomy, and insertion of tympanostomy

tubes)

> • Ophthalmic surgery

> • Assistance with an uncomplicated vaginal deliverye

> • Laparoscopic procedures

> • Thoracoscopic proceduresf

> • Nasal endoscopic proceduresg

> • Routine arthroscopic proceduresh

> • Plastic surgeryi

> • Insertion of, maintenance of, and drug administration into arterial and

central venous lines

> • Endotracheal intubation and use of laryngeal mask

> • Obtainment and use of venous and arterial access devices that occur under

complete antiseptic technique, using universal precautions, “noâ€sharpâ€

technique, and newly gloved hands

>

> Category III: Procedures for which there is definite risk of bloodborne virus

transmission or that have been classified previously as “exposureâ€proneâ€

>

> • General surgery, including nephrectomy, small bowel resection,

cholecystectomy, subtotal thyroidectomy other elective open abdominal surgery

> • General oral surgery, including surgical extractions,j hard and soft

tissue biopsy (if more extensive and/or having difficult access for suturing),

apicoectomy, root amputation, gingivectomy, periodontal curettage, mucogingival

and osseous surgery, alveoplasty or alveoectomy, and endosseous implant surgery

> • Cardiothoracic surgery, including valve replacement, coronary artery

bypass grafting, other bypass surgery, heart transplantation, repair of

congenital heart defects, thymectomy, and openâ€lung biopsy

> • Open extensive head and neck surgery involving bones, including

oncological procedures

> • Neurosurgery, including craniotomy, other intracranial procedures, and

openâ€spine surgery

> • Nonelective procedures performed in the emergency department, including

open resuscitation efforts, deep suturing to arrest hemorrhage, and internal

cardiac massage

> • Obstetrical/gynecological surgery, including cesarean delivery,

hysterectomy, forceps delivery, episiotomy, cone biopsy, and ovarian cyst

removal, and other transvaginal obstetrical and gynecological procedures

involving handâ€guided sharps

> • Orthopedic procedures, including total knee arthroplasty, total hip

arthroplasty, major joint replacement surgery, open spine surgery, and open

pelvic surgery

> • Extensive plastic surgery, including extensive cosmetic procedures (eg,

abdominoplasty and thoracoplasty)

> • Transplantation surgery (except skin and corneal transplantation)

> • Trauma surgery, including open head injuries, facial and jaw fracture

reductions, extensive softâ€tissue trauma, and ophthalmic trauma

> • Interactions with patients in situations during which the risk of the

patient biting the physician is significant; for example, interactions with

violent patients or patients experiencing an epileptic seizure

> • Any open surgical procedure with a duration of more than 3 hours, probably

necessitating glove change

> Note.Modified from Reitsma et al.1

>

> a Does not include subgingival scaling with hand instrumentation.

> b If done emergently (eg, during acute trauma or resuscitation efforts),

peripheral phlebotomy is classified as Category III.

> c If there is no risk present of biting or of otherwise violent patients.

> d Use of an ultrasonic device for scaling and root planing would greatly

reduce or eliminate the risk for percutaneous injury to the provider. If

significant physical force with hand instrumentation is anticipated to be

necessary, scaling and root planing and other Class II procedures could be

reasonably classified as Category III.

> e Making and suturing an episiotomy is classified as Category III.

> f If unexpected circumstances require moving to an open procedure (eg,

laparotomy or thoracotomy), some of these procedures will be classified as

Category III.

> g If moving to an open procedure is required, these procedures will be

classified as Category III.

> h If opening a joint is indicated and/or use of power instruments (eg, drills)

is necessary, then this procedure is classified as Category III.

> i A procedure involving bones, major vasculature, and/or deep body cavities

will be classified as Category III.

> j Removal of an erupted or nonerupted tooth requiring elevation of a

mucoperiosteal flap, removal of bone, or sectioning of tooth and suturing if

needed.2

>