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Purpose and Preamble
To propose recommendations and minimum regulatory standards to FMRAC’s members regarding medical professionals1 who participate in exposure prone procedures (EPPs) or who have tested positive for blood borne pathogens (BBPs), i.e., hepatitis B virus (HBV), hepatitis C virus (HCV) or human immunodeficiency virus (HIV), to reduce the risk of transmission of infection for the benefit of public safety. The extent of risk varies and depends on a range of factors. It is incumbent on medical regulatory authorities (MRAs) to develop approaches to identify and monitor these individuals in order to mitigate the risk of transmission to the public through effective regulation.
It is expected that each MRA develop and implement policy that is informed by evidence and supported by an operational approach that addresses:
- the obligations of medical professionals to know their own infectious status;
- the reporting responsibilities of infected medical professionals;
- the reporting responsibilities of physicians treating infectious medical professionals;
- the definition of what constitutes EPPs;
- any requirement for vaccination;
- transparency and disclosure issues specifically outlining the circumstances and extent to which information will be shared2;
- the responsibilities of all medical professionals when a blood exposure occurs.
FMRAC recommends that the following be adopted by all MRAs in documents of professional guidance regarding blood borne pathogens:
- Medical professionals who participate in EPPs, or whose scope of practice has the potential to require them to participate in EPPs, must know their serologic status and be tested at appropriate intervals.
- All medical professionals who participate in EPPs and have tested positive must report immediately to their MRA.
- Treating physicians should be aware of the ethical obligation to report to the MRA those medical professionals who participate in EPPs in circumstances where there are reasonable grounds to expect a risk of infection to patients or the public. When risk is uncertain, treating physicians may wish to seek the advice of an Infectious Disease specialist. They should also be aware of the obligation to comply with any and all relevant provincial or territorial legislation.
- The preferred definition of EPP is indicated below3
- Medical professionals who participate in EPPs and who are not immune to HBV, and who have no contraindications to immunization, must be immunized against HBV4
- Medical regulatory authorities must remind medical professionals of their ethical, professional and legal responsibilities to follow facility or health authority5 protocols following body fluid exposures, and ensure that any patient or other person who may have been exposed to their body fluids through the provision of medical care is informed of the transmission risks and offered appropriate testing and follow-up medical care, without identifying the individual who may have been the source of transmission.
- Each MRA’s policies on this topic should be reviewed regularly to recognize evolving science and evidence.
1 This framework includes all potential categories of members (and registrants) of colleges of physicians and surgeons, recognizing that not all categories are members in all jurisdictions, e.g., undergraduate medical students are not members of the CPSO, and not every province has physician assistants regulated by medical regulatory authorities.
2 This may include but not be limited to public hospitals and surgical facilities.
3 Invasive procedures where there is a higher than average risk that injury to the HCW may result in the exposure of the patient’s open tissues to the blood or body fluid of the worker. For transmission of a BBP to occur during an EPP, three conditions are necessary:
- HCW must be sufficiently viremic;
- HCW must sustain an injury or have a condition that allows for exposure;
- HCW’s blood or infectious body fluid must come in contact with a patient’s wound, traumatized tissue, mucous membranes, or similar portal of entry. EPPs with documented risk of transmission include:
- Digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs) or the simultaneous presence of the HCW’s fingers and a needle or other sharp instrument or object in a blind or highly confined anatomic site, e.g., as may occur during major abdominal, cardiothoracic, trans vaginal, pelvic and/or orthopedic operations; or
- Repair of major traumatic injuries; or
- Major cutting, or removal of any oral or perioral tissue, including tooth structures during which the patient’s open tissues may be exposed to the blood of an injured HCW.
Reference: Public Health Agency of Canada. Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers (in development).
4 Canadian Immunization Guide. Part 3, Vaccination of Specific Populations−Immunization of Workers. Available at: http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-work-travail-eng.php#a1 and Centers for Disease Control. Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students. MMWR 2012; 61:1-16. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6103a1.htm.