Hepatitis B Discrimination Alive and Well in the United States
Hepatitis B discrimination occurs not only in China but in the United States as well.
Should people with chronic hepatitis B infection be prevented from working in health care? Should they be barred from training in health care professions? The answer to both is no, according to official recommendations from the Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America (SHEA).
Despite these national recommendations, the Hepatitis B Foundation (HBF) has fielded calls over the years from health care workers infected with hepatitis B. In 2011 the HBF was galvanized into action after receiving four calls within six months from distraught students who were either denied admission to medical and dental schools, or threatened with dismissal from their training program because of a hepatitis B infection.
“It was a painful wake-up call to realize that hepatitis B-related discrimination occurs not only in China, but also right here in the United States,” says Joan Block, executive director of the HBF. “In an era of universal vaccination and effective antiviral therapies, there is absolutely no reason that hepatitis B should prevent anyone from pursuing their dreams.”
The HBF quickly mobilized support from national thought leaders and the CDC then convened a meeting on June 4, 2011, in Atlanta. The goal was to update the CDC’s 1991 hepatitis B recommendations for health care workers and students. Since most medical and dental schools look to the CDC for guidance, it is essential that their recommendations accurately reflect advances in the field and clearly state that hepatitis B is not a reason to deny or dismiss a person from studying or practicing a health care profession.
With the full support of John Ward, MD, director of the CDC’s Division of Viral Hepatitis (DVH), the June meeting was productive and reaffirmed agreement on key updates of the recommendations. Under the leadership of Scott Holmberg, MD, MPH, chief, epidemiology and surveillance branch of the DVH, the recommendations were written within a few months and reviewed extensively by outside experts and organizations, including HBF, as well as within the CDC and the CDC director’s office. The updated recommendations will be published in the CDC’s Morbidity and Mortality Weekly Review in early summer 2012.
Although the CDC and SHEA guidelines, which are based on scientific evidence, have consistently stated that most HBV-infected health care workers pose little risk to patients, some medical and dental schools and hospitals have not fully adopted these recommendations.
And public opinion is not always aligned with the science either. In a 2005 survey of the general public, only 38 percent of respondents thought that infected providers should be allowed to provide patient care of any kind. And 82 percent believed health care providers with hepatitis B or C infections must inform their patients.
Clearly, misperceptions about how HBV is spread, and lack of knowledge about the current antiviral drugs that reduce transmission risk to almost zero, have unnecessarily shut out many students from health care training programs (read Speaking Personally in this issue).
Transmission Risk Now Negligible
During the June 2011 meeting convened by CDC, the group noted that dismissal of HBV-infected individuals not only goes against the 1991 CDC recommendations but also is unwarranted. Over the past 20 years, the risk of transmission has become negligible, thanks to greater use of the HBV vaccine to prevent infection and widespread adoption of universal precautions in the workplace. Improved detection and monitoring of HBV DNA (or viral load) have also helped reduce transmission risk. “Most importantly,” emphasizes Anna Lok, MD, a renowned hepatologist at the University of Michigan, “we now have seven approved treatments for hepatitis B, [whereas there were] none in 1991,” when the CDC last issued recommendations.
“The new antiviral drugs are highly effective in suppressing the hepatitis B virus,” helping to reduce the already low risk of transmission to patients. Moreover, denying HBV-positive students admission to medical school “is unfounded because students can complete necessary training without being involved in exposure-prone procedures,” Dr. Lok added.
Rationale for New CDC Recommendations
The CDC has found no documented instance of medical or dental student transmission of HBV to patients, none from dentists to patients since 1987, and only one instance of surgeon-to-patient transmission since 1994. Thus, the CDC and the group it convened reaffirmed that HBV should not be cause for stopping providers from training or practicing in health care professions. To prevent unwarranted actions, institutional expert panels should evaluate HBV-positive health care students and providers on a case-by-case basis to ensure patient safety and the individuals’ confidentiality.
According to Dr. Lok, students can be counseled early on to avoid careers in health care fields that involve significant exposure-prone procedures, such as surgery. And medical, dental and allied health schools and hospitals should follow reasonable monitoring and treatment recommendations for HBV-infected health care workers and students. These recommendations should be based on the SHEA guidelines and others published by medical societies such as the American Association for the Study for Liver Diseases.
Greater awareness of current advances in HBV prevention and control is clearly needed. With the CDC aiming to screen and vaccinate 90 percent of U.S. health care providers, more HBV-infected students and providers will be identified. Therefore, schools and hospitals need to know how to appropriately handle such cases to prevent unwarranted denial or dismissal of affected individuals from their institutions.
“These [updated CDC] recommendations … will have a beneficial impact on the public and providers,” says the CDC’s Dr. Holmberg. Both the Hepatitis B Foundation and CDC believe that the updated CDC recommendations will help put the risk of transmission into proper perspective and be consistent with the advances made in the prevention and control of HBV infection.
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