Blood-Borne Pathogen Infection Policy for Medical Students
This policy closely complies with the most current evidence contained within the SHEA (Society for Healthcare Epidemiology of America) guideline and CDC (Centers for Disease Control) Recommendations for Management of Medical Students who are Infected with Hepatitis B Virus (2012). This policy also discusses policy for students with other blood-borne pathogens, including hepatitis C virus and human immunodeficiency virus.
To promote patient safety while providing risk management and practice guidance to blood-borne pathogen infected medical students.
- Required to comply with College of Medicine blood-borne pathogen policies and requirements.
- Aware that they will be required to participate in the care of patients with various communicable diseases or infections including hepatitis B, hepatitis C and HIV.
- Ethically and professionally responsible for knowing their serological status with respect to blood-borne pathogens and to inform Student Health and the Associate Dean for Medical Education if they are positive for a blood-borne pathogen infection. Confidentiality concerning the student’s state of health will be maintained to the greatest extent possible. An Expert Review Panel may be consulted for guidance, keeping the name of the student confidential if possible. Disclosure may be necessary if there is reason to believe that the infected individual has declined or has failed to follow the provisions of this policy in regards to personal notification of appropriate personnel or fails to respond within a reasonable amount of time to a recommendation that they personally notify the person in charge of a particular clinic or department.
- Expected to be in a state of health such that they may participate in the academic programs, including patient care, without posing a risk to themselves of others.
- Obligated to comply with hepatitis B immunization policies and requirements as outlined by the College of Medicine and Student Health. This policy requires that all students receive the hepatitis B vaccine and test positive on the subsequent quantitative serology titer. Further testing is provided for those students who still do not respond to a second series of the vaccine.
- Mandated to comply with the Communicable Disease Protocol as outlined by the College of Medicine according to the most current CDC recommendations.
- Required to use standard precautions and additional practices in order to prevent the spread of blood-borne pathogens and other infections. These practices are reviewed annually with all students under the Infection Control Procedures.
- Required to disclose, as per school policy, if they are potentially exposed to a blood-borne pathogen in a clinical setting and provide a blood specimen if indicated. This information is reviewed annually under the Sharp Injury/Blood and Body Fluid Exposure Policy.
The medical school faculty will:
- Provide education and training to all students in appropriate methods to prevent the transmission of communicable diseases, including blood-borne pathogens, that is consistent with the CDC’s guidelines for standard and additional precautions. This infection control training will be reviewed during the student’s initial orientation and on entry to Phase II (clerkships).
- 2. Maintain confidentiality to the greatest extent possible regarding information disclosed by students concerning their serological status and disclose relevant information only with appropriate consent.
The Expert Review Panel will:
- Advise the student to apply for ADA (disability) status based on their medical condition which then allows the panel to design accommodations to prevent these students from participating in exposure-prone procedures (EPPs), such as those encountered in surgery or OB/GYN, without jeopardizing their medical education.
- Designate contact personnel in departments that perform EPPs. Such personnel will be notified by the student of their disease status, if appropriate, and any applicable restrictions that may apply as recommended by the Expert Review Panel according to the CDC guidelines.
- Develop a plan of counseling and advice to assist the student regarding clinical practice and career choices. This information will be discussed with the student by the Associate Dean of Medical Education and/or the Director of Student Health.
- Evaluate the student’s status and continued testing and/or treatment as indicated in the guidelines outlined in this policy.
Medical students infected with blood-borne pathogens:
- Are professionally and ethically obligated to inform Student Health and the Associate Dean for Medical Education of any blood-borne infection.
- May pursue their studies only as long as their continued involvement does not pose a health or safety hazard to themselves or others. It is expected that all students can be accommodated as needed with some modification to their program of study to reduce the risks of blood-borne pathogen transmission.
- Will have their condition reviewed and monitored by an Expert Review Panel at the request of the Associate Dean for Medical Education. The members of the Expert Review Panel may be selected from, but not necessarily limited to, the Associate Dean, an infectious disease and hospital epidemiology specialist, liver disease specialist (gastroenterologist/hematologist) with expertise in blood-borne pathogens and their infectivity, the Student Health director, a person with bioethics experience and legal counsel. The student is responsible for ensuring the receipt of requested lab results and any pertinent physician notes (including those obtained from facilities outside the Penn State Health system) by the director of Student Health.
- May have clinical duties or clinical exposure modified, limited or abbreviated based on recommendations from an Expert Review Panel as outlined in the CDC guidelines – particularly as it relates to the performance of exposure prone procedures and the status of the blood borne infection (e.g. viral loads etc.).
- Required to immediately disclose if they accidentally expose a patient to their blood-borne pathogen in a clinical setting. Pre-notification to patients is neither suggested nor required.
- Must be offered advice and counseling that will assist them regarding clinical practice and career choices.
- Have the right to appeal decisions made by the Associate Dean or Expert Panel by submitting, in writing or in person, a proposed amendment to the decision and the rationale supporting such amendment. The student may submit additional documentation from their personal physician or other health care provider in support of their appeal. In the case where the student’s appeal is denied by the Associate Dean of Medical Education or Expert Panel, the student may engage in the Student Appeal Procedure of their University to submit any additional appeals.
Medical students who are potentially exposed to a blood-borne pathogen are:
- Required to seek medical attention immediately after the event as per the school’s policy for HIV rapid testing and post-exposure prophylaxis if indicated.
- Required to report and document occurrence as per the Student Health Policy.
- Required to follow post-exposure testing and treatment. This information, including testing of the source patient, is outlined in the Sharps Injury/Blood and Body Fluid Exposure POlicy and reviewed at Penn State College of Medicine orientation and at the start of Phase II with students.
Blood-borne disease: A disease caused by a microbial agent capable of being transmitted via contact with the blood of an infected individual. Most notably, this includes the human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV).
Category I. Procedures known or likely to pose an increased risk of percutaneous injury to a health care provider that have resulted in provider-to-patient transmission of hepatitis B virus (HBV): These procedures are limited to major abdominal, cardiothoracic and orthopedic surgery, repair of major traumatic injuries, abdominal and vaginal hysterectomy, caesarean section, vaginal deliveries and major oral or maxillofacial surgery (e.g. fracture reductions). Techniques that have been demonstrated to increase the risk for health-care provider percutaneous injury and provider-to-patient blood exposure include:
- digital palpation of a needle tip in a body cavity and/or
- the simultaneous presence of a health care provider’s fingers and a needle or other sharp instrument or object (e.g., bone spicule) in a poorly visualized or highly confined anatomic site.
Category I procedures, especially those that have been implicated in HBV transmission, are not ordinarily performed by students fulfilling the essential functions of a medical or dental school education.
Category II. All other invasive and noninvasive procedures: These and similar procedures are not included in Category I as they pose low or no risk for percutaneous injury to a health care provider or, if a percutaneous injury occurs, it usually happens outside a patient’s body and generally does not pose a risk for provider-to-patient blood exposure. These include:
- surgical and obstetrical/gynecologic procedures that do not involve the techniques listed for Category I;
- the use of needles or other sharp devices when the health care provider’s hands are outside a body cavity (e.g., phlebotomy, placing and maintaining peripheral and central intravascular lines, administering medication by injection, performing needle biopsies or lumbar puncture);
- dental procedures other than major oral or maxillofacial surgery;
- insertion of tubes (e.g., nasogastric, endotracheal, rectal, or urinary catheters);
- endoscopic or bronchoscopic procedures;
- internal examination with a gloved hand that does not involve the use of sharp devices (e.g., vaginal, oral and rectal examination; and
- procedures that involve external physical touch (e.g., general physical or eye examinations or blood-pressure checks).
- Students should not be prohibited from participating in patient care activities solely on the basis of their blood-borne pathogen infection. Viral load burden may determine if a student should be restricted from performing certain exposure-prone procedures.
- Using standard precautions, the infected student may perform routine physical examinations provided there is no evidence of open or healing wounds, or eczema on the student’s hands.
- If the skin of the hands is intact, and there are no wounds or skin lesions, then in examining a body orifice, whether oral, vaginal or rectal, the student must wear gloves as per standard precautions.
- If the skin of the hands is not intact, whether from a healing laceration, or from any skin condition interfering with the normal protection afforded by intact skin, or cannot be covered with an appropriate barrier, then the affected student should not provide direct contact until they have received effective treatment and the condition is resolved.
- A decision as to whether an affected student should continue to perform a procedure which in itself is not exposure-prone should take into consideration the risk of complications arising that might necessitate the performance of an exposure-prone procedure.
- It is recognized that infection control precautions are not perfect. However, based on the guidelines outlined in this document, it is expected that the risk of transmission event occurring is low and if an event were to occur, remedial action can further minimize the risk to the patient.
Summary of recommendations for managing medical students infected with hepatitis B (HBV) as indicated by current CDC recommendations
Anonymous viral load testing results should be submitted to the Expert Review Panel by the director of Student Health in order to ensure confidentiality for the student. Restrictions and subsequent monitoring, if warranted, will be recommended by the Expert Review Panel in accordance with the guidelines outlined in this policy and the information will be conveyed to the student by the Associate Dean and/or the director of Student Health.
The summary for managing students infected with hepatitis B applies to hepatitis B blood-borne pathogens. In 2021, the state of the art is that every effort should be made to eradicate hepatitis C and/or completely suppress HIV viral levels through the use of antiretroviral therapy. Achievement of these goals for hepatitis C and/or HIV should mitigate the risk of transmission during exposure-prone procedures. The student with hepatitis C and/or HIV will be evaluated on a case-by-case basis by the Expert Review Panel.
The above summary of management of hepatitis B, hepatitis C and HIV provides a framework within which to consider such cases. However, each case is sufficiently complex that each should be independently considered in context by the Expert Review Panel.
- CDC recommendations for the Management of Hepatitis B Virus Infected Health Care Providers and Students. MMWR, Vol. 61, No. 3. July 6. 2012.
- Updated U.S. PHS Guidelines for Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Post-Exposure Prophylaxis. MMWR, Vol. 50 (RR-11), pages 1 to 42. June 29, 2001.
- Henderson et al. SHEA Guideline for Management of Healthcare Workers Who are Infected with Hepatitis B Virus, Hepatitis C Virus and/or HIV Virus. Infection Control and Hospital Epidemiology, Vol. 31, No. 3, pages 203-232. March 2010.
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