In the United States as of 2015, an estimated 1.1 million individuals were living with human immunodeficiency virus (HIV)1 and ~850,000 were living with hepatitis B virus (HBV),Reference Schillie, Vellozzi and Reingold2 and healthcare personnel (HCP) are among them. Since the early 1990 s, the Centers for Disease Control and Prevention (CDC)Reference Polder, Bell and Curran3,Reference Holmberg, Suryaprasad and Ward4 and the Society for Healthcare Epidemiology of AmericaReference Henderson, Dembry and Fishman5 have recommended that HCP living with HIV/HBV who perform exposure-prone procedures seek counsel from a panel of experts to assess the risk to patients and to receive guidance to prevent transmission.
In 1992, the NC Commission for Public Health adopted an administrative code rule, hereafter referred to as “the rule,” requiring all HCP living with HIV/HBV and performing surgical, obstetric, or dental procedures, to notify the State Health Director or designee and to undergo review of their practices and clinical condition (Appendix A online). The rule requires the State Health Director to appoint an ad hoc expert panel if there may be “a significant risk of transmission … to patients” and to issue an isolation order detailing measures necessary to prevent transmission. Expert panels generally include experts in infectious disease, infection prevention, public health, a provider of the same profession, a licensing board representative (if applicable), and the HCP’s physician.
Beginning in 1994, all isolation orders issued pursuant to the rule required HCP to complete a state-approved course in infection prevention (https://spice.unc.edu/0206spice/). Additional requirements could include specific measures to prevent transmission (eg, double gloving); restrictions on practice; assessment of professional practice and infection prevention compliance by a designated practice monitor; and routine monitoring of the HCP’s clinical status by their personal physician (physician monitor). Patient notification is not required unless a significant risk for transmission occurs (eg, injury resulting in exposure to HCP’s blood). Here we review implementation of the rule in North Carolina with >25 years of data.
Methods
We evaluated data for all NC HCP living with HIV/HBV who self-reported their status to the NC Division of Public Health (NC DPH) from January 1992 through August 2018.
We manually abstracted data from secure paper records housed at the NC DPH, including correspondence, notes from expert panel reviews, and isolation orders. We performed descriptive analyses on a discrete set of variables including infecting pathogen (HIV/HBV), profession, level of training, year of isolation order (or self-report if none issued), need for an expert panel, and official State Health Director recommendations. We categorized professions as dental, obstetrical, surgical, or student. HCP in a profession not specified above are not required by the rule to notify the State Health Director and were excluded from further analyses. Levels of training included student, postgraduate, professional, and unknown (additional details in Table 1). Unclear records were reviewed by 2 adjudicators independently, and discrepancies were reconciled.
Table 1. North Carolina Healthcare Personnel Performing Invasive Procedures Who Self-Reported Living With Hepatitis B or HIV to the North Carolina Division of Public Health (NC DPH) From January 1992 Through August 2018 and Summary of Recommendations for Prevention of Healthcare Provider to Patient Transmission
Note. HIV, human immunodeficiency virus; HCP, healthcare personnel.
a Coinfection of Hepatitis B and HIV occurred in 2 HCP; thus, some categories may not sum to equal overall values.
b Year corresponds to official decision letter date from the NC DPH, most decisions occurred within the same calendar year as receipt of the HCP’s self-reported notice.
c Student profession designations: 5 dental, 2 surgical (operating room technician), 2 medical.
d Student, currently enrolled a degree program (eg, MD, RN); postgraduate, resident or fellow; professional, licensed independent practitioner; unknown, training status unknown.
e Two records were excluded from the total: the first due to missing data on infection prevention measures (attributed to the paper record keeping process), the second due to a rescinded isolation order directly following expert panel conclusion that the nature of procedures practiced by the HCP did not qualify under the rule.
f The physician monitor and providers’ personal physician could be the same person.
Results
From 1992 through 2018, the NC DPH has documentation of self-reports from 68 HCP living with HIV/HBV. Of these HCP, 51 (75%) reported performing dental, obstetrical, or surgical procedures as defined by the Rule or were students with the potential to engage in these procedures; only these 51 HCP were included in further analyses.
The most common qualifying profession was dentistry (37%). HCP at student and postgraduate levels of training comprised 18% and 22% of reports respectively (Table 1). Among the study population, 34 (67%) were living with HBV, 19 (37%) were living with HIV, and 2 were coinfected.
Overall, 32 (63%) reports required expert panel review (Table 1); reasons for not convening a panel are summarized in Table 2. Isolation orders were issued for all 32 cases. Recommendations for infection prevention were available for 30 cases. Reasons for missing data include incomplete documentation and isolation order retraction following panel evaluation. Of the 30 isolation orders with infection prevention recommendations, 26 (87%) included a requirement for a practice monitor; only 13 (43%) required HCP to limit or change their clinical practice. The most common practice limitations were prohibition of “blind” (ie, nonvisualized) procedures (n = 6) and required use of blunt-tip suture needles during surgery (n = 3).6 In 2 cases, restrictions limited the ability of the HCP to perform routine duties of their profession: prohibition of vaginal deliveries and cesarean sections for an obstetrician, and prohibition against placing hands over or within body cavities or open wounds for a surgical technician. Duties considered noninvasive (ie, outpatient care and nonsurgical procedures) were unaffected. Due to missing records, one practice limitation was unspecified. All isolation orders required the completion of a state-approved infection prevention course with the exception of 2 cases that occurred prior to the addition of this requirement to the rule in 1994. A practice monitor is a healthcare professional working with the infected HCP who is asked to oversee compliance with infection prevention techniques and any required limitations. The NC DPH has received no notifications of HCP noncompliance from practice monitors. Changes in employment for 1 HCP and 2 practice monitors were reported via communication from the HCP and/or their practice monitor; in these situations, a new practice monitor was selected. Notification by a physician monitor of HCP treatment noncompliance occurred in 1 case and an isolation order was reissued promptly; upon the HCP’s return to care, the order was amended. Also, 3 additional isolation orders were amended based on self-reported information about HCP clinical status or practices, and 1 isolation order was rescinded based on clinical evidence of HBV clearance.
Table 2. Reasons for Not Convening an Expert Panel to Evaluate Risk of HIV or Hepatitis B Transmission for the 19 HCP Without a Panel
Note. NC DPH, North Carolina Department of Public Health; HCP, healthcare personnel; HIV, human immunodeficiency virus.
Discussion
For more than 25 years, North Carolina has effectively implemented state-level review of self-reported HCP living with HIV/HBV. Expert panel review was required for fewer than two-thirds of HCP who self-reported living with HIV/HBV from 1992 to 2018. All reviewed HCP were permitted to continue with their practice, although many were required to implement measures to avoid risk of transmission to patients. The rule does not require HCP living with hepatitis C virus (HCV) to self-report. Although instances of provider-to-patient HCV transmission have occurred in the United States,Reference Henderson, Dembry and Fishman5 North Carolina has not yet revised its rule to include this bloodborne pathogen.
The self-reporting rule was designed to ensure that HCP across the state are held to uniform standards, to protect the safety of patients, and to maintain provider confidentiality. Implementation occurred amid widespread public fear concerning provider-to-patient transmission of HIV in the United States, largely instigated by the 1990 incident of a Florida dentist living with HIV who transmitted it to several patients.7 Inconsistent management of HCP living with HIV in the early 1990 s was a primary impetus for North Carolina’s adoption of the rule. Prior to implementation, some NC practitioners with HIV were fired or experienced breaches of confidentiality through unwarranted patient notification and retrospective record reviews to test patients for HIV infection.8,Reference Kanigel9
Although provider-to-patient transmission of HIV/HBV is of grave concern, such transmission has rarely been reported.Reference Polder, Bell and Curran3-Reference Henderson, Dembry and Fishman5,Reference Lewis, Enfield and Sifri10 In the United States, there has been 1 documented instance of HIV transmission from a provider to patients, with no known occurrences since then,7 and only 2 instances of HBV transmission to patients have been documented since 1991.Reference Lewis, Enfield and Sifri10 This rarity has been attributed to widespread adoption of standard infection prevention precautions, improved HBV vaccination among HCP, and HIV/HBV status awareness among HCPReference Henderson, Dembry and Fishman5,Reference Lewis, Enfield and Sifri10 as recommended by CDC guidelines.Reference Polder, Bell and Curran3,Reference Holmberg, Suryaprasad and Ward4
Implementation of this rule has successfully standardized management of HCP living with HIV/HBV. We are unaware of any loss of employment by an HCP due to their HIV/HBV status or inappropriate requirements for patient notification since its implementation. Rules of similar constitution have been implemented in other states according to an informal query of the Council of State and Territorial Epidemiologists, but to our knowledge no previous publications have described their implementation history or success.
Based on our analysis, we conclude that the NC DPH’s process for investigating and mitigating risk of transmission from HCPs living with HIV or HBV to patients has provided a reasonable balance between protecting the public health and maintaining the privacy and livelihood of HCP. However, this process will require continuous re-evaluation as our understanding of HIV and HBV transmission risk evolves.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2019.372
Acknowledgments
We thank all past State Health Directors or designees at the NC DPH who have reviewed HCP self-reports over the years, as well as all those who volunteered their time and expertise serving as a member of an expert panel.
Financial support
No financial support was provided relevant to this article.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
