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Hepatitis B and admission to medical school: an audit of British medical school policy

^a Centre for Occupational Health, School of Epidemiology and Health Sciences, The University of Manchester, Manchester M13 9PT

Correspondence to: Dr Parker.

In 1993 the health departments in the United Kingdom issued guidance on hepatitis B,¹ requiring all healthcare workers (including medical students) who perform exposure prone procedures to be vaccinated against hepatitis B and to have their serological response to the vaccine checked. Healthcare workers who perform invasive procedures and who do not respond to vaccination must be tested for hepatitis B carrier status. Those who are found to be positive for surface antigen without "e" markers (HBsAg positive) need not be excluded from any work. Workers who have "e" markers (HBeAg positive) should be excluded from invasive procedures.

In 1994 the Committee of Vice Chancellors and Principals agreed guidelines for universities on the fitness of students to practise medicine.² They recommended that "all successful applicants for entry into medical school should produce satisfactory evidence of non-infectivity and immunisation against hepatitis B by the time of registration as a medical student." The advice was expanded to say: "All applicants should be screened for hepatitis B virus and antibody, and subsequently immunised if necessary, before entry to medical school."

These guidelines do not specify which tests should be performed or what antigenic status is incompatible with medical school entry.

Subjects, methods, and results

To ascertain how British medical schools interpreted the guidance, we sent a questionnaire to all 27 medical school deans in Britain in October 1995. The questionnaire asked what policy the medical school adopted for the 1995 student entry and the requirements of the policy.

Valid replies were received from 23 medical schools (85%). Two deans replied but declined to answer any of the questions, and no reply was received from two medical schools.

All respondents had a policy on hepatitis screening and vaccination for prospective students. Twelve medical schools expected students to have started a course of vaccination, but only four expected them to have completed the course by registration. A variety of hepatitis screening tests were sought (table 1), but only two medical schools adopted the conventional approach of looking for surface antigen and "e" markers only in students who fail to seroconvert after hepatitis B vaccine. Two medical schools are asking for tests for hepatitis C, ahead of anticipated guidance.

Table 1--Combinations of hepatitis B screening tests
specifically requested by 23 medical schools in Britain
before registering a new student
------------------------------------------------------------
                                           No (%) of medical
Tests                                           schools
------------------------------------------------------------
Hepatitis B surface antibody only                0
Hepatitis B surface antigen only                 8 (35)
Hepatitis B anticore antibody only               2 (9)
Hepatitis B surface antigen and "e" markers
 Regardless of vaccination status                3 (13)
 Only if antibody negative after vaccination     2 (9)
All of the above tests                           3 (13)
No tests specified                               5 (21)
Markers for infection with hepatitis C virus     2 (9)

Deans were asked: "Under what circumstances would you refuse a student, or remove one from your degree course?" Two medical schools seemed to confuse hepatitis B surface antibody and antigen, and would refuse a student who was antibody positive. Five medical schools are prepared to reject students who are positive for hepatitis B surface antigen, without consideration of "e" markers. Twelve schools would refuse or remove a student who was positive for "e" marker, two said they would not remove any students, and two did not answer the question.

Careers counselling of a hepatitis positive student would involve a specialist occupational physician in only 12 of the 23 medical schools and a virologist in six.

Comment

Testing prospective medical students for hepatitis B carrier status--particularly before entry and before the results of vaccination are known--has been criticised as an expensive exercise with limited benefit to patient care.^{3 4} There have been criticisms of the screening tests used.⁵

At the start of the 1995-6 academic year, British medical schools had interpreted the available guidelines in various ways. Policies may have changed in respect of the 1996 intake, but no clarification has been issued by the Committee of Vice Chancellors and Principals.

The setting of a consistent and achievable policy on the screening of medical and dental students before entry is vital to avoid inappropriate testing, inappropriate exclusion of potential students, and inconsistencies between medical schools.

Funding: University of Manchester.

Conflict of interest: None.

1. UK Health Departments Advisory Group on Hepatitis. Protecting health care workers and patients from hepatitis B. London: HMSO, 1993.
2. Committee of Vice Chancellors and Principals of the Universities of the United Kingdom. Fitness to practice medicine and dentistry in relation to hepatitis B. London: CVCP, 1994.
3. Lever AM. Hepatitis B and medical student admission. BMJ 1994;308:870-1. [Free Full Text]
4. Poland GA. Vetting medical school applicants on basis of potential hepatitis B transmission. Lancet 1994;343:1162.
5. Gerlich W, Caspari G. Hepatitis B immunisation before entry into medical school. Lancet 1994;343:1572-3.

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