from the medical register the name of Dr Patrick Ngosa for serious professional misconduct. He was a gynaecologist who feared that he had acquired HIV from a woman with whom he had an affair, but refused to have a test and continued to work for some time until eventually agreeing to a test which proved positive. Dr Gaud, a London surgeon who, realising that he was hepatitis B e‐antigen positive, substituted another person’s blood for his own for the purposes of a blood test. He continued to operate, infecting several patients. He was convicted of a crime, imprisoned and struck off the medical register (R v. Gaud (1995)).
Employers should promote a climate that encourages confidential disclosure. Those who perform, or who may perform, EPPs must obtain further expert advice about modification or limitation of their working practices to avoid EPPs until they meet the appropriate criteria to recommence EPPs. Procedures which are thought to be exposure prone must not be performed while expert advice is sought.
Blood‐borne virus health clearance
At first there was resistance from the health care professions to the compulsory testing of HCWs performing EPPs. Some surgeons called for the mandatory testing of patients since they considered that they were equally at risk of transmission of a virus from an infected patient. There was, of course, a fear that successful careers would be destroyed since for several years HCWs with BBVs were excluded from performing EPPs. A compromise was to introduce testing only for students and new entrants who would be likely to perform EPPs. A new HCW is defined as an individual who has direct clinical contact with patients in the NHS or independent sector for the first time. Existing HCWs who are moving to a post, or undergoing training that involves EPPs for the first time in their career, are also considered as new. So too are returning HCWs, depending on what activities they have been engaged in while away from the NHS, for example if they have worked abroad or been involved in research which may have exposed them to a blood‐borne virus.
Originally, all students training as doctors had to undertake EPPs at some time in their training but it is now possible to qualify as a doctor without performing EPPs so that BBV testing is not mandatory for medical students. Psychiatrists do not need training in surgery. Additional health clearance is not necessary for nursing students, as performance of EPPs is not a requirement of the curriculum for pre‐registration student nurse training. However, since most of the tasks performed by dentists and some of those performed by midwives are EPP, dental and midwifery students need BBV health clearance from the start of their training.
Hepatitis B
Hepatitis B presents different problems from HIV. There is a reliable vaccine, and medical treatment results in most cases having a happy outcome, though it is still a serious disease. There is less social stigma attached to hepatitis B infection than to HIV infection. Nevertheless, it is far more likely that hepatitis B will be transmitted in the course of medical, dental or nursing practice because it is ten times more infectious than HIV. Up until 2015 there were nine episodes of documented transmission of HBV from infected surgeons to patients in the UK since 1991. It is recommended that all HCWs, including students, who have direct contact with blood, blood‐stained body fluids or patients’ tissues are offered immunisation against hepatitis B and tests to check their response to immunisation, including investigation of non‐response.
Hepatitis B is a notifiable disease and a prescribed industrial disease under the Industrial Injuries Disablement Benefit Scheme for HCWs.
Hepatitis C
Hepatitis C is giving rise to increasing cause for concern. There is no preventive vaccine and infection can cause serious liver damage, sometimes many years later. The risk of transmission to the patient from the HCW, especially in the course of major surgery, is far higher than the risk of HIV transmission. There is no post exposure prophylaxis available for hepatitis C. However, treatment is available for hepatitis C infection and those who have responded successfully to treatment with anti‐viral therapy may be allowed to resume EPPs or to start professional training for a career that relies upon the performance of EPPs.
Hepatitis C is a notifiable disease, and falls within the Industrial Injuries Disablement Benefit Scheme.
Asymptomatic infection with HIV counts as a disability under the Equality Act from seroconversion, but this does not apply to hepatitis.
Clearance of infected HCWs to perform EPPs
For many years infection with HIV was a complete bar to working in any specialty that involved EPPs. However, the absence of evidence of transmission from HCW to patient in the UK, using data from patient notification exercises (PNEs) over 20 years during which over 10,000 patients were tested, and the development of effective anti‐retroviral therapy, led to a change of policy in 2014, allowing those HCWs whose condition is well controlled to perform EPPs. They must submit to regular viral load monitoring (every 12 weeks) by a consultant OH physician and consent to their names being registered on the UKAP‐OHR, a central confidential register managed by Public Health England on behalf of Health Protection Scotland, Public Health Wales and the Public Health Agency for Northern Ireland. HIV infected HCWs with a plasma viral load >200 copies/ml should be restricted from performing EPPs or commencing training for careers that rely upon performing EPPs.
HCWs who intend to perform EPPs should be tested for hepatitis B surface antigen first, which indicates current HBV infection. If negative they should be offered vaccination (unless already vaccinated) and have their response checked. If there is evidence that they may have acquired natural immunity, advice should be sought from a virologist or clinical microbiologist as to whether immunisation is necessary. HCWs for whom vaccination is contra‐indicated, who decline vaccination or who are non‐responders to vaccine, should be restricted from performing EPPs unless shown to be non‐infectious. They should be tested annually for surface antigen. HCWs shown to be hepatitis B e antigen positive will not be permitted to perform EPPs or undertake clinical duties in renal units. Treatment is available. An HB e antigen positive HCW who has been successfully treated and whose e antigen negative status is sustained 12 months after cessation of therapy, may be allowed to resume EPPs. Infected HCWs undergoing treatment must be regularly monitored. If they fail to attend for testing, or refuse to be tested, the occupational physician should warn the employer that they are no longer cleared to perform EPPs, until it has been established that the HCW has an up‐to‐date viral load which does not exceed the cut‐off of less than 200. In 2019 it was decided to include HCWs being monitored for HBV infection on the confidential register already set up for HIV positive HCWs.
HCWs infected with hepatitis C who are RNA positive should be restricted from performing EPPs or commencing training for careers that rely upon performing EPPs, unless they have responded successfully to treatment. If they have been treated with antiviral therapy and have remained HCV RNA negative for at least six calendar months after cessation of treatment, they can return to performing EPPs, but should be checked again six calendar months later.
Apart from these restrictions there is no bar to a HCW infected with a blood‐borne virus being employed in the care of patients which does not involve EPPs, but they should remain under regular medical and OH supervision in accordance with good practice.
Confidentiality concerning the infected health care worker
There is a general duty to preserve the confidentiality of medical information and records (Chapter 3). OH records are kept separately from other hospital records and are not accessible to managers without the consent of the worker, other than in the public interest where patients or others may be at risk. Disclosure
