Blood-borne Pathogens - Issues in Ontario 2010

Tracy L. Wilson, MSc, M.D., FRCSC
Thunder Bay, ON

Over the past year, much discussion within our medical communities across the country has focused on the issues around blood-borne pathogens (BBP) and mandatory testing thereof. Ontario has led these controversial discussions, as the College of Physicians and Surgeons in Ontario (CPSO) license renewal/application already incorporates questions regarding the BBP status of physicians performing exposure prone procedures (EPP), regarding mandatory testing and reporting of seroconversions. When this was first implemented two years ago, the medical community became concerned with issues around seroconversion and associated practice restrictions, professional and personal discrimination and protection of private medical information. Most wondered what their ethical and legal obligations were to report a seroconversion and what options were available for treatment and financial support or retraining in the face of permanent practice restrictions. Very quickly it became clear that most of us don't know the answers to these critical questions!

 

The OMA and its surgical assembly began working with the CPSO in order to ensure a safe, fair and supportive environment for physicians who seroconvert and face practice restrictions. The CPSO promised to develop an independent, arm's length expert panel that would oversee all such cases. To date, no such arm's length expert panel has been created. At present, seroconverted physicians who perform EPP are ethically and legally obliged to report their BBP status to the CPSO, who report the physician to the Inquiries, Complaints and Reports Committee (ICRC), a CPSO committee. The chair of the ICRC then refers the physician to a panel of the ICRC to determine what, if any, practice restrictions are necessary. The ICRC panel may choose to refer appropriate select cases to an outside panel of experts, for advice. The ICRC is not arm's length from the CPSO, nor is there a standardized, guaranteed manner in which all cases are handled. There remains an unfulfilled need to develop an arm's length expert panel, designed to follow seroconverted physicians, help with treatment options and guide them in making safe, ethical, evidence-based decisions in restricting their practices. Unfortunately, until more recently the CPSO has taken a 'no tolerance' approach, recommending that all seroconverted physicians permanently avoid doing EPP, with no exceptions.

Disgruntled and concerned Ontario physicians began calling the CMPA for advice in remitting their license renewals, wondering about their legal rights to refuse disclosure of their blood-borne virus (BBV) status and their options after seroconversion. Despite the fact that the risk of a physician transmitting BBP to their patient is exceptionally low, a growing number of provincial medical colleges have begun requesting the BBP status of physicians during licensing. In the face of this development, the CMPA decided that the issues, surrounding individual physician privacy and public safety concerning the collection, use and safeguarding of physicians' personal health information, required further investigation. The CMPA's plan was to provide recommendations to policy makers, hospitals, regulatory and medical bodies, and physicians, maintaining an appropriate balance between the physician's right to privacy and the safety of the public. The CMPA commissioned an Expert Panel to review the body of scientific research regarding the risks of transmission of BBV from health care workers to patients and to find a constructive, evidence-based approach to this difficult issue. Last summer, six experts, from four relevant specialties, were named independently to the panel and began an 'information gathering' process. The panel produced two papers:

"The Physician with blood-borne viral infection: What are the risks to patients and what is an appropriate approach to the physician"1

 

"Physician personal health information: Supporting public safety and individual privacy"2

Both articles are very comprehensive, well-researched summaries of current evidence regarding BBV. I would highly recommend a thorough read and review of this literature for each physician and their medical association. (www.cmpa-acpm.ca)

The panel outlined 11 recommendations regarding the testing of physicians for BBV and practice recommendations once seroconverted. In brief, they recommended an evidence-based approach to the screening of physicians and the management of BBV-infected physicians. Safe work environments, including access to universal precautions and protective equipment should be available and occupational exposures should always be reported. Additional financial resources should be made available to seroconverted physicians permanently restricted in their practices. In those physicians performing EPP, they recommend testing for HBV immunity (presence of anti-HBs). The data is inconclusive regarding HCV screening, but if done requires the detection of HCV RNA for positivity. Mandatory HIV testing is not recommended even in physicians performing EPP, but known HIV-infected physicians should avoid EPPs until, with antiretroviral therapy, their HIV RNA level is undetectable. At that point, the physician can return to EPPs while using double gloving and universal precautions. HBV-infected physicians should avoid EPPs if their HBV DNA is greater than 2000 IU/ml, except on patients who are HBV-immune or HBV-infected already. Once the physician's HBV DNA level drops consistently below 2000 IU/ml, he or she can return to doing EPPs using universal precautions. A personal physician should monitor the infected physician's viral DNA/RNA levels every three-four months. Finally, HCV-infected physicians should refrain from performing EPPs until HCV RNA levels are undetectable while on anti-HCV therapy. More than 55% of those HCV-infected individuals given anti-HCV therapy have a 'sustained virological response' at greater than 12 weeks post-treatment. These individuals are essentially 'cured' and can resume EPPs. Non-responders must either continue on anti-HCV therapy or permanently avoid EPPS1,2.

In August 2010, the Expert Panel presented these recommendations at the CMPA Annual General Meeting. The CPSO, having agreed to work with the CMPA, has softened its approach to those seroconverted physicians practicing EPPs. Whereas practice restrictions were, until now, permanent and irrevocable, the CPSO has begun considering temporary restrictions while monitoring viral RNA/DNA loads. This will however require a more standardized, reproducible approach with an independent panel following and monitoring the physician's health and infectivity. As treatment and potential cures evolve, so must the monitoring schedule for infected individuals.

Focused medical education must be available to practitioners regarding the benefits of appropriate exposure-based testing for BBV and the merits of post exposure prophylaxis and potentially curative treatments, such as in many HCV cases. One such CME event run by the chair of the OMA section of Ontario surgical assistants, Dr. David Esser, Oct 2010, reviewed surgical safety tips to prevent BBV exposure, testing and treatment for BBV, what to do if a patient won't agree to be tested, and life of a physician after seroconversion. During this CME event, a case was discussed where a physician OR assistant was refused testing and treatment at the hospital following a significant BBV exposure because they were not a hospital employee. Subsequently, a motion was brought to and passed by the OMA Council in Nov 2010:

"That the OMA advocate that hospitals should provide any physicians, who suffer exposure to blood-borne pathogens (BBP) while providing care in a hospital setting, immediate testing and treatment for BBPs."

Motherhood statement? Perhaps, but similar legislative issues are arising across Canada. Orthopaedic surgeons, as health care advocates, need to direct our hospitals, medical associations and colleges to implement regulations and policies that protect the rights of patients to have safe treatment without discrimination, while considering the rights of physicians to a safe work environment allowing privacy, health, livelihood and career protection.

For those of you practicing outside of Ontario, you may feel that none of this applies to you... you are wrong! Colleges across Canada are implementing questions on medical license applications/renewals regarding the physician's BBP status and others will take Ontario's lead in the near future. Already in Alberta, physicians must know their HBV and HCV status, but do not require HIV testing. If HBV positive, their practice is restricted only if Hep B eAg is positive. In British Colombia, physician BBP testing is requested, and medical practice will be restricted if the physician is HIV positive or if the HCV RNA is positive, or if HBV viral loads are high. It is certainly easier to exact change proactively, while educating and leading our colleges and medical facilities as they implement reasonable, equitable, evidence-based, safe guidelines for physicians and our patients regarding BBP.

References
  1. 'The Physician with blood-borne viral infection: What are the risks to patients and what is an appropriate approach to the physician', Shafran, D. et al., presented at CMPA AGM, Aug 2010
  2. 'Physician personal health information: Supporting public safety and individual privacy', Shafran D. et al., presented at CMPA AGM, 2010

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