Hepatitis B and exposure prone proceduresBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6947.73 (Published 09 July 1994) Cite this as: BMJ 1994;309:73
- Tony Delamothe
New guidelines should be implemented this month
By this month all of Britain's surgeons undertaking exposure prone procedures should be immune to hepatitis B—either through natural immunity or after a course of immunisation.*RF 1-3* Government guidelines make exceptions for staff who fail to respond to the vaccine and those who are positive for hepatitis B surface antigen—provided that they are negative for hepatitis B e antigen. The guidelines' aim is to identify and exclude any health care worker who is positive for hepatitis B e antigen from performing procedures in which injury to the worker could result in blood contaminating the patient's open tissue.
Two short papers in this week's journal suggest that implementing these guidelines has not been without problems. Poole and colleagues report that four surgeons needed six or nine doses of vaccine (instead of the usual three) to develop adequate immunity; two consultant surgeons refused either to be vaccinated or to provide evidence of immunity (p 94).4 In another report Hassan and Oldham describe one health care worker who developed Reiter's syndrome after the second dose of vaccine and another who developed arthritis after the first (p 94).5 Revaccination was not attempted as more severe adverse effects may follow.
The guidelines take account of these and similar problems. People without evidence of previous infection who do not respond to the vaccine may continue to perform exposure prone procedures provided that inoculation incidents are followed up according to the guidelines; so may “health care workers…in whom completion of the course is deemed inadvisable because of a severe reaction to vaccine.” On the other hand, those who refuse to provide evidence of immunity face the same restrictions as those imposed on staff who are positive for hepatitis B e antigen—that is, not being allowed to perform exposure prone procedures (and the offer of alternative work).
Before refusal doctors should be aware that they will be treading a lonely path. Some employers might regard refusal to supply information as failure to comply with a reasonable managerial request and consider disciplinary action. The NHS Executive recommends that employers should take legal advice regarding their responsibility for retraining or redeploying staff whose work is restricted because of refusal to comply with the guidelines.
Defence bodies can defend a doctor only if they can identify experts to support the doctor's case. So far no convincing arguments have emerged to support doctors who put their “rights” to remain ignorant of their hepatitis B status above their responsibilities to patients. Both the Central Consultants and Specialists Committee of the BMA and the Royal College of Surgeons suggest compliance with the guidelines.
The college has, however, emphasised two further points.6 The first is that surgeons found to be positive for hepatitis B e antigen should insist on further virological assessment of their antigen status and not rely on a single assay from one department. This conforms with recent advice given by the chairman of the British health departments' advisory group on hepatitis that tests of infectivity should be repeated, preferably by various laboratories using different techniques.7
The college's second point is that surgeons who are concerned about the test's outcome should, before the test, seek a written undertaking from their employer that it will follow the recommendations of the advisory group on hepatitis. “In particular, they should agree to the individual injury benefits which would be available to them under the conditions laid down in the NHS Injury Benefits Scheme, were they to be found to be e antigen positive.”
But strict compliance with the terms of the injury benefits scheme may not be enough: doctors must show that they were infected during work— which may be impossible. And for those having to give up work the scheme guarantees inflation proofed income “of up to 85% of preinjury NHS earnings.” The “up to” seems too vague. The quid pro quo for doctors complying with the guidelines should be that the financial sting should be removed for the very few who will remain positive for hepatitis B e antigen after their initial infection or treatment with interferon.
Employers are responsible for offering vaccine to all relevant staff, and the guidelines point out that the costs of immunisation and follow up should be set against the possible legal costs if health care workers infect patients. But if patients infect health care workers (which is statistically more likely) employers may be liable for damages under health and safety legislation if they have failed to immunise them.
Faced with this double liability, some employers have apparently gone beyond the recommendations that they should make compliance with the guidelines a condition of service for new staff and that they should determine applicants' immune status before confirming employment. For example, excluding applicants who cannot demonstrate immunity to hepatitis B (among whom non-infected non-responders to the vaccine predominate8) is not the intention of the carefully worded guidelines.
The NHS Executive is not monitoring the implementation (or misimplementation) of the guidelines and expects that the financial disincentives of non-compliance will ensure that they are followed. Including compliance with the guidelines in contracts between purchasers and providers is meant to provide further encouragement. Nevertheless, anecdotal reports suggest that employers have adopted a wide variety of schemes, with widely varying rates of success. Some employers may have gone over the top; others seem to have only the haziest notion of what their responsibilities and liabilities are. The problem is that the NHS is not a single employer that can adopt a uniform policy about this issue or health and safety issues generally. Much of the failure to interpret and implement the new guidelines correctly comes from inadequately funded and staffed occupational health services.
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