Hepatitis B status must be known for medical school

BMJ 1994; 308 doi: (Published 02 April 1994) Cite this as: BMJ 1994;308:876
  1. S Kingman

    All students who are offered places at medical school will have to provide certificates to show they have been immunised against hepatitis B before they can start their courses. Those students who are infective carriers of hepatitis B virus will not be allowed to study medicine (see editorial on p 870).

    The Committee of Vice Chancellors and Principals (CVCP) issued guidance last week on immunisation to the Universities and Colleges Admissions Service (formerly UCCA) after receiving advice from the Council of Deans of United Kingdom Medical Schools and Faculties. The admissions service will include the information in its handbook for applicants.

    The guidance states that “medical schools are mindful of their overriding duty of care to the public with whom medical students come into close contact at an early stage of their studies.” It says that all the deans have agreed that successful applicants must have proof “of non-infectivity and immunisation against hepatitis B by the time of registration.” The guidance is likely to come into force by autumn 1996 and will also apply to dental students. Frank Harris, executive secretary of the council of deans, said, however, that medical schools were autonomous and that it was up to them to consider individual cases.

    Although the guidance does not spell out the definition of “infectious,” one dean said that it was likely to include students who carried the e antigen without carrying the antibodies to that antigen that would make them non- infective.

    The BMA's Medical Students Committee has criticised the CVCP's move as alarmist, unnecessary, and discriminatory. Some medical schools, which currently test students in their first year before they begin clinical work, say that the current system works well and does not need to be changed.

    The Medical Students Committee says that it firmly supports a universal and rigorously applied vaccination programme among medical students. But it believes that students who are infective carriers should be allowed to continue on a modified course that excluded procedures that could put patients at risk. They would still be able to follow careers in specialties such as psychiatry, epidemiology, pathology, microbiology, and public health. Rupert Gauntlett, BMA student representative at Leicester Medical School, said: “To do something as radical as completely closing the door to medical school represents a tremendous overreaction.”

    Until now medical schools have made special arrangements for students who are infective carriers of the hepatitis B virus, allowing them to follow modified courses. The council of deans has now said, however, in a letter to the Medical Students Committee, that “it is not generally accepted that the course can be suitably modified.” Yet a spokesperson for the General Medical Council, which has to approve all courses leading to a medical degree, said that such modifications are “under active consideration.”

    Vaccination against hepatitis B requires three injections. The second and third injections are usually given one month and six months after the first, although they can be given at one month and two months. Sixth formers who are interested in applying for medical school are advised to start a vaccination course in the lower sixth.

    Andy Hall, senior lecturer in epidemiology at the London School of Hygiene and Tropical Medicine, says that 95-98% of people will seroconvert after three doses and more after additional doses. But 1-2% will never seroconvert and therefore remain susceptible to infection.

    The prevalence of hepatitis B carriers among people born in Britain is 0.5% or less - and could be even lower among 17 to 18 year olds. But in many parts of the world, including much of Africa and Asia, the prevalence in the general population is as high as 10-20%. Although the guidance deals with infective carriers, some deans believe that the number of infective carriers is also higher in these parts of the world.

    Mark Bailey, chairman of the Medical Students Committee, said: “We see this policy as discriminating against people who have a problem which is quite likely no fault of their own, and which we think does not prevent their ability to follow a medical job in the future.”

    The ruling follows guidelines on hepatitis B vaccination of health care workers issued to health authorities and trusts last August by the NHS Management Executive. These say that health workers who are infective carriers of hepatitis B virus must not perform “exposure prone procedures” in which there is a risk that injury will result in their blood contaminating a patient's open tissues. It does not, however, exclude them from practising medicine.

    * A survey last year of senior medical students in the US showed that 97% had been immunised against hepatitis B, according to a spokesman for the American Association of Medical Colleges (AAMC). Since 1992 the AAMC and the medical school accrediting agency have insisted that schools should follow guidelines set out by the Centers for Disease Control and Prevention, which say that health care workers exposed to patients should be immunised. The AAMC's spokesman said that students were usually immunised just before they started their clinical studies in their third year of school.

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