Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus Infections in Obstetrician - Gynecologists

Experts agree that the risk of transmission of the hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) from an infected health care provider to a patient during the provision of routine health care that does not involve invasive procedures, and with the institution of universal precautions, is negligible (1). With invasive procedures, these risks remain quite small but are clearly increased when compared with routine patient care activities. Therefore, clinical activities of infected health care providers should include risk assessment based on these factors. To prevent transmission of bloodborne pathogens, it is important that health care workers adhere to standard precautions, follow fundamental infection control principles, and use appropriate procedural techniques. The Society for Healthcare Epidemiology of America has established guidelines for the management of health care providers who are infected with HBV, HCV, or HIV (1). This Committee Opinion focuses on these recommendations as they may relate to the practicing obstetrician–gynecologist. Categorization of representative obstetric and gynecologic procedures according to level of risk of bloodborne pathogen transmission is shown in Box 1. Recommendations for health care provider clinical activities, based on these categories and viral burden, are summarized in Table 1. It is important to note that when no restrictions are recommended, careful supervision should be carried out as highlighted in the footnoted section of Table 1. These recommendations provide a framework within which to consider such cases; however, each case should be independently considered in context by the expert review panel.

Expert Review Panel

The creation of an expert review panel is an important component of the Society for Healthcare Epidemiology of America's recommendations (1). The expert review panel counsels infected clinicians about continued practice, advising health care providers under what circumstances, if any, they may continue to perform procedures. According to the Society for Healthcare Epidemiology of America's guidelines, the expert review panel should be a locally convened panel of experts representing a variety of perspectives and may include the following: the obstetrician–gynecologist's personal physician, an infectious disease specialist with expertise in disease transmission, a health care professional with expertise in the procedures performed by the obstetrician–gynecologist, state or local public health official(s), and a hospital epidemiologist orother member of the infection-control committee of the hospital (1). The panel follows up on the health care provider's clinical status, via sanctioned communication with his or her personal physician; and outlines the health care provider's responsibilities in a contract or letter that is to be signed by the health care provider (1). See Box 2 for additional information on the establishment and functions of the expert review panel.

Hepatitis B Virus All obstetrician–gynecologists who provide clinical care should receive the HBV vaccine series. Postvaccination testing for the antibody to hepatitis B surface antigen 1–2 months after completing the vaccine series is recommended by the U.S. Centers for Disease Control and Prevention (2). Individuals who do not respond to the primary vaccine series (anti-hepatitis B surface antigen titers of less than 10 mIU/mL) should complete a second three-dose series or be evaluated to determine if they test positive for the hepatitis B surface antigen. Revaccinated individuals should be retested at the completion of the second vaccine series (3). Referral to a specialist may be necessary in cases involving individuals who do not respond serologically after completing a second series of HBV vaccination. Obstetrician–gynecologists who test positive for the hepatitis B surface antigen also should know their hepatitis B e antigen status, which indicates the presence of high-viral concentrations. If this latter test result is negative, viral load DNA testing should be done to establish the viral genome equivalents per milliliter of blood. Because high-viral load concentrations have been associated with an increased risk of transmission, obstetrician–gynecologists whose test results are Hepatitis B e antigen positive or who have a circulating Hepatits B viral load of at least 10⁴ genome equivalents per milliliter of blood should not perform procedures with a high risk of bloodborne pathogen transmission until they have sought counsel from an expert review panel (see “Expert Review Panel”) and have been advised under what circumstances, if any, they may continue to perform these procedures (see Box 1 and Table 1) (1).

Recent advances have been made in the development of treatment strategies that offer some hope of reducing viral load in patients chronically infected with HBV(4). There are now a number of antiviral agents that are approved by the U.S. Food and Drug Administration or are under investigation for such interventions. Of patients receiving monotherapy for 1 year, it can be anticipated that between 14% and 30% will have a negative test result for hepatitis B e antigen, and 21–67% will have undetectable viral DNA levels (4). The use of combination therapies may be even more beneficial. However, despite these advances, the role of therapy, its impact on transmission, and its place in modifying practice restrictions have not been adequately investigated to make a recommendation (1).

Hepatitis C Virus Although there is currently no vaccine available to prevent infection with HCV, the risk of acquiring HCV infection appears lower than the risk of acquiring HBV (an average of 1.8% after a percutaneous exposure to a source patient who is infected with HCV compared with 20–60% after percutaneous exposure to a source patient who is infected with HBV and is hepatitis B e antigen positive) (3). This is presumably because most individuals chronically infected with HCV have circulating viral loads that are an order of magnitude lower than those of HBV carriers. Routine HCV testing is not recommended for health care workers. However, after an occupational exposure, such as a needle stick, the exposed health care worker, as well as the source patient, should be tested for the antibody to HCV. Postexposure prophylaxis against HCV is not effective and not recommended. However, early antiviral therapy of the infected individual may be effective in reducing the risk of progression to chronic HCV infection (5, 6). Individuals who are chronically infected and have detectable levels of HCV RNA in their serum should be offered therapy assuming there are no contraindications to such antiviral therapeutic intervention. As with HBV-infected individuals, health care providers with circulating HCV viral loads of at least 10⁴ genome equivalents per milliliter should routinely use double gloving for all invasive procedures, for all contact with mucous membranes or nonintact skin, and for all instances in patient care in which gloving is routinely recommended (1) (see Box 1). As noted in Table 1, these infected individuals should not perform any Category III activities. Human Immunodeficiency Virus Since the original publication in 1991 of guidelines for the management of HIV-infected health care providers, much progress has been made in HIV detection, monitoring, and drug prophylaxis and treatment (7). The American College of Obstetricians and Gynecologists has a more detailed Committee Opinion on general issues pertaining to the approach to the HIV-infected patient and health care provider (8). In the most recent Society for Healthcare Epidemiology of America's guidelines, specific viral load cutoffs have been recommended to determine health care provider practice activity (Table 1). These viral load parameters are different than those for HBV and HCV. The same general recommendations apply regarding infection-control measures, supervision, and periodic testing.

References

1. Henderson DK, Dembry L, Fishman NO, Grady C, Lundstrom T, Palmore TN, et al. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2010;31:203–32.
2. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 1997;46(RR-18):1–42.
3. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. U.S. Public Health Service. MMWR Recomm Rep 2001;50:1–52.
4. Hoofnagle JH, Doo E, Liang TJ, Fleischer R, Lok AS. Management of hepatitis B: summary of a clinical research workshop. Hepatology 2007;45:1056–75.
5. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 1997;46:603–6.
6. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Centers for Disease Control and Prevention. MMWR Recomm Rep 1998;47(RR-19):1–39.
7. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR Recomm Rep 1991;40(RR-8):1–9.
8. Human immunodeficiency virus. ACOG Committee Opinion No. 389. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1473–8.