Changing times, changing landscapes: comparing the Society for Healthcare Epidemiology of America's infected provider guidelines with the Centers for Disease Control and Prevention's Guidelines for managing providers INFECTED with hepatitis B virus.

In March 2010, the Society for Healthcare Epidemiology of America (SHEA) published revised and updated guidelines for the management of healthcare workers infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV); in July 2012, the Centers for Disease Control and Prevention (CDC) published updated recommendations for managing HBV-infected healthcare providers and students. The purpose of this commentary is both to underscore the significance of the major modifications of recommendations in the CDC and SHEA revised guidelines and to highlight points of similarities and differences between them. The optimal management of healthcare providers infected with bloodborne pathogens has long been the focus of controversy. In 1991, the CDC issued guidelines recommending that healthcare workers who are infected with HBV and have circulating hepatitis B e antigen (HBeAg) who perform the types of invasive surgical and dental procedures that previously had been implicated in the transmission of HBV from healthcare workers to patients (referred to as “exposure-prone invasive procedures”) can conduct such procedures only after both notifying the patient of the healthcare provider’s infection and consulting an expert review panel. These guidelines make similar recommendations for providers infected with HIV. Once the expert review panel has evaluated the provider and his or her clinical performance and planned procedures, the panel could grant permission for the provider to conduct the procedures. Specifically, the guidelines state, “Healthcare workers who are infected with HIV or HBV and are ‘e’ antigen positive should not perform exposure-prone procedures unless they have sought the counsel of an expert review panel and have been advised under what circumstances, if any, they may continue to perform these procedures. Such circumstances would include notifying prospective patients of the healthcare worker’s seropositivity before they undergo exposure-prone invasive procedures.” These guidelines were issued as an immediate response to a cluster of 6 patients whose HIV infections were linked epidemiologically as well as through DNA sequencing to a dentist who had AIDS. The precise mechanisms by which HIV was transmitted in this dentist’s practice were never defined, and the extraordinarily high rate of transmission in the dentist’s practice remains unexplained. Several instances of iatrogenic transmission of HBV had been documented in the 1980s (summarized in Bell et al). Similarly, provider-to-patient transmission of HCV, although uncommon, has been subsequently documented definitively. Nonetheless, the landscape of management strategies for bloodborne pathogen infections in the healthcare setting has been altered dramatically in the more than 20 years that have intervened since the 1991 CDC guidelines were issued. Numerous strategies have been introduced into the healthcare workplace to decrease occupational risks for parenteral exposures (and, therefore, for infections, both from patient to provider and from provider to patient). For example, the introductions of universal/standard precautions, safer medical and surgical devices, modifications of intrinsically risky work practices, routine double-gloving for invasive procedures, and use of blunt-tipped surgical needles have all contributed to a reduction in risk for occupational exposures. Another major change in the past 2 decades is the fact that HCV has emerged as an increasingly important bloodborne pathogen that also has been associated with iatrogenic risks. In the intervening 2 decades, other countries and professional societies have issued more contemporaneous guidelines about the management of providers infected with bloodborne pathogens. Perhaps most significantly, substantial