This case study involves pre-employment health clearance by occupational health of a healthcare worker applying for a post involving exposure-prone procedures. Cherry Feliciano and Anne Harriss discuss an evidence-based approach.
Healthcare professionals are regularly exposed to a range of biological hazards as a result of their clinical role. Those undertaking invasive surgical procedures are at a heightened risk.
Conversely, there is the potential that those infected with blood-borne viruses, including the human immunodeficiency virus (HIV), and those undertaking surgical interventions, could be putting their patients at risk of HIV infection and, consequently, of developing acquired immune deficiency syndrome (AIDS).
HIV is transmitted through bodily fluids. It infects and damages the host’s CD4 lymphocytes, also known as T lymphocytes, the white blood cells associated with the immune response (Porth, 2015).
On infecting the CD4 cells, the virus hijacks the cell’s normal functioning, forcing it to become a “factory” producing more viruses, which then infect further cells. The CD4 count then depletes as HIV infection progresses.
Without effective treatment, the immune system becomes compromised and the individual eventually develops the symptoms of AIDS. These include severe weight loss, night sweats, enlarged lymph nodes and opportunistic infections (Marieb and Hoehn, 2016).
Data published on the World Health Organisation (WHO) web-site indicates that since the beginning of the HIV epidemic, more than 70 million people have been infected with HIV, and about 35 million have died of HIV-related conditions (WHO, 2017).
In 2014, there were roughly 37 million of people globally living with HIV, two million being newly infected, and 1.2 million having died through an AIDS-related illness. Since 2000, early access to anti-retroviral drugs has resulted in AIDS-related deaths falling by 42% (UNAIDS, 2016).
The Department of Health (DoH) (2005) highlights that, up to the point of publication, there were only three reported cases worldwide of HIV transmission from a health professional to patient resulting from clinical tasks involving exposure-prone procedures (EPPs).
EPPs are clinical procedures whereby during a surgical procedure the healthcare worker (HCW) inserts their gloved hands inside a patient’s open body cavity, wound or confined anatomical space, with the clinicians fingertips not being visible at all times.
These are high-risk activities as their hands may encounter sharp instruments, needles or body tissues, such as bone fragments, leading to puncture wounds or lacerations. Such incidents expose patients to the blood of the HCW. Screening for HIV is therefore paramount for patient and worker safety (Palmer et al, 2013).
The DoH (2007) requires all HCWs changing their role to incorporate EPPs and newly employed practitioners with roles involving EPPs to agree to be tested for the presence of HIV antibodies.
Initially, HIV-positive HCWs were considered permanently unfit to perform EPP duties. Currently, revised Public Health England guidelines (PHE, 2014) allow them to undertake EPPs provided they receive appropriate treatment and their care is well managed and they have a DNA plasma viral load level of less than 200 copies/ml.
This case study details aspects of the effects of HIV infection to John (pseudonym), an applicant for a post as a theatre scrub nurse. It highlights details of HIV infection and OH mechanisms enabling safe performance at work.
HIV infection
HIV is one of a group of retroviruses. Each virus consists of two, single chains of ribonucleic acid (RNA), which can only replicate within a host cell.
HIV RNA (Ribonucleic Acid) and HIV DNA (Deoxyribonucleic Acid) are the viral genetic materials that can be used to determine the HIV viral load (Porth, 2015).
Viral load is an important parameter when deciding whether or not HIV-positive clinical staff whose job requirements incorporate high-risk interventions such as surgery, are able to continue undertaking these procedures.
Transmission is via bodily fluids (Marieb and Hoehn, 2016). Within the clinical setting, this includes blood-to-blood contact, particularly as a consequence of direct inoculation (Tokars et al, 1992).
John declared that he was HIV positive. Although he could not confirm the origin of his infection, he suspected, but could not confirm, that this resulted from an unreported work-related inoculation.
There are two distinct forms of HIV virus: HIV type 1 (HIV-1) and HIV type 2 (HIV-2). Globally, the predominant type is HIV-1, and generally this is the form when HIV is referred to without specifying the type of virus. HIV-1 is more infectious and progresses more rapidly than HIV-2.
John’s initial HIV status indicated that he was HIV-1 positive, negative to HIV-2 but p24 antigen positive. The p24 antigen is a viral protein that makes up most of the capsid – the viral core. As serum concentrations of p24 antigen are high in the first few weeks after infection, tests sensitive to p24 antigen are useful for diagnosing very early infection when antibody levels are still low. Serum concentrations of p24 antigen are detectable a few weeks after infection. Consequently, the presence of the p24 antigen is useful for identifying that the person has been infected by HIV-1 before antibodies are produced (PHE, 2017).
HIV-1 is the most common and known to cause AIDS in the US, Europe and central Africa. It is faster to progress than the HIV-2 virus. John tested positive for HIV-1 antibody with presence of the primary protein of HIV found during the initial stage of HIV infection (Porth, 2015). His results confirmed that he was infected with HIV-1 and at the initial stage of infection.
The virus targets white blood cells, specifically the T- cell, multiplying within it and leading to cell destruction. A few weeks post-infection, the immune system becomes compromised and the infected person feels unwell, developing pyrexia and sweating.
Once replication of the virus becomes uncontrollable, severe immune deficiency results as T- cells die and are replaced with the HIV virus, which infect the organs. Symptom severity and manifestation depends on the organs involved. AIDS, the final stage of the disease, is fatal due to multiple complications, including organ damage failure.
Viral load reflects the amount of HIV in the blood represented by viral RNA and is “proportional” to infectivity – a low viral load of less than 200 copies/ml means the individual is less infective (PHE, 2014).
The employer is responsible for disseminating their policy for HIV-infected HCWs to their employees and the OH service is responsible for the coordination of health issues relating to the employment of HIV-infected HCWs.
For HCWs who undertake EPPs, the DoH requires screening for blood-borne viruses (DoH, 2007). The OH service can only confirm that HCWs wishing to perform EPP are fit for those tasks provided they are taking an effective combination anti-retroviral drug therapy (cART), have a viral load less than 200 copies/ml and are subject to plasma viral load monitoring every 12 weeks. They must also be under joint supervision of a consultant occupational physician and the physician responsible for their treatment.
To assess fitness to perform contracted duties, without risk to themselves or others, prospective employees submit a completed health declaration. This process also ascertains whether or not supportive modifications are required for those with long-term health conditions (Litchfield and Becker, 2012).
During his pre-employment health assessment, John indicated that although well, he had been receiving anti-retroviral medication since 2015 after testing HIV positive. Following discussion of the DoH guidelines for those undertaking EPPs, John provided informed consent for blood screening on an identified validated sample.
John was contacted upon receipt of serology results and he was asked to attend an OH meeting to discuss them as they indicated current infectivity with HIV.
John was aware of his condition prior to serology testing and was fully aware of the mechanism of the virus. It was important that the information he required regarding the management of HIV was discussed and the necessary follow-up and support instigated.
John confirmed that he remained asymptomatic and was compliant with his current treatment. He was not cleared to undertake EPP at that point as further tests were necessary to determine whether or not his viral load and status of HIV infection were compatible with Public Health England (2014) requirements for health professionals undertaking EPP tasks.
Since 2007, the DoH has required applicants new to, or moving into, NHS posts involving EPP to be cleared as fit to undertake those tasks. The HCW must provide an identified validated sample (IVS) for EPP serology from an accredited UK laboratory including hepatitis B antibody, hepatitis B surface antigen, hepatitis C antibody and HIV (DoH, 2007).
The 2014 DoH guidance on the management of HIV-infected HCWs allows EPP to be undertaken by those on effective cART, with a plasma viral load below 200 copies/ml. Being infected with HIV does not preclude healthcare duties other than those involving EPPs (DoH, 2005).
HIV-infected HCWs can be considered fit for EPPs subject to satisfactory three-monthly viral load testing, which is monitored by both OH and their treating doctor (PHE, 2014). HCWs may commence employment and continue EPP duties dependant on their HIV viral load stability, with levels below 200 copies/ml following two IVS tests no less than three months apart, with further three-monthly viral load testing (PHE 2014). John was advised of these requirements and consented for testing and a follow-up OH review was arranged.
John was cleared for non-EPP responsibilities advising a temporary alternative placement while waiting the serology results for EPP clearance. Should HIV treatment be discontinued EPP duties must cease (PHE, 2014).
The role of the OH adviser (OHA) is a “multi-faceted and multi-disciplinary activity concerned with prevention of employees’ ill-health in an employed population” (Aw et al, 2007), taking into consideration the health and safety of others involved (Palmer et al, 2007).
Therefore, it is important to guarantee that the functions such as assessment, review and providing advice are undertaken to ensure health and safety at workplace (WHO, 2002).
Organisational policy on pre-placement assessment for those undertaking EPPs requires consideration of the possibility of passing on blood-borne viruses.
Once the OHA had identified that John was being treated for HIV, it was important to consider the potential impact on his ability to carry out the post without putting others at risk. John was apprehensive regarding his HIV status and employment. The OHA explained the available psychological support mechanisms, including confidential HIV counselling.
With John’s consent, the OH nurse liaised with the HIV specialist managing his case. The impact of HIV-positive status on John’s resistance to infection was an important consideration when advising suitability for a post, particularly with regard to exposure to known or undiagnosed TB.
The DoH (2007) highlights the risk of contracting TB for HIV-positive HCWs, requiring John to be “assessed” for TB risk.
HIV-associated immuno-suppression could render him at risk of acquiring infection from patients (Cox et al, 2007).
The OHA discussed TB symptoms with John, stressing the importance of reporting possible exposure to this disease. Although TB asymptomatic, he declared that he had been taking prophylactic Isoniazid over the previous six months.
In compliance with hospital policy and DoH guidance (DoH, 2007), a TB symptoms enquiry was required six months after completion of Isoniazid treatment. If John had been symptomatic at that point, he would have been referred to the chest clinic for further management.
The OH service uses an accredited laboratory to carry out EPP blood testing. Two samples of blood were taken one week apart.
The results were available four weeks from testing date. They confirmed a plasma viral load below 200 copies/ml.
As John had a viral load below 200 copies/ml and was taking anti-retroviral therapy, he was cleared as fit for employment to an EPP post.
He remained subject to three-monthly OH reviews and the necessary on-going clearance for an HIV-infected HCW performing EPP, to confirm the stability of his condition (PHE, 2014). John’s manager and HR were informed of his clearance to undertake EPPs.
From the point of diagnosis, HIV meets the definition of disability under the Equality Act 2010.
It is paramount for the employer to make reasonable adjustments from the onset of the employment process (Lewis and Thornbory, 2010). Whether or not the Equality Act applies is generally a judicial matter (Kloss and Ballard, 2012). However, in John’s case, the Act applies due to his condition resulting from HIV infection.
Consent from John was needed to disclose the implications of his condition, but not the diagnosis, to facilitate appropriate adjustment and support by his employer. John’s ability to undertake his role as well as the implications of his disability were considered in conjunction with his duties and work environment (Murugiah et al, 2002).
The OH service arranges the recall for retesting and maintains confidential records of HCWs who have been tested for HIV viral load.
Particular vigilance is required in the event of inoculation or other untoward related incidents where others could have been put at risk. Under such circumstances, contact will be made with the UK Advisory Panel (UKAP) to discuss any further actions (PHE, 2014).
John was advised of the importance of safe systems of work. To ensure patient safety and in compliance with DoH guidance (PHE, 2014), John continued to be monitored jointly by both his treating doctor and occupational health.
As part of the process of obtaining clearance to practise EPPs, details of his treatment and his current viral load are returned to UKAP for inclusion on a confidential register maintained by PHE.
Conclusion
John started his new post, initially working within theatre recovery as this did not involve EPPs.
On receipt of two serology results confirming viral load results of less than 200 copies/ml and with continuous compliance with his anti-retroviral treatment, he was cleared to practice EPP for three months, with the proviso that he agreed to a three-monthly assessment to confirm that his HIV viral load was stable.
John remains asymptomatic, is compliant with his treatment and attends all OH appointments, including the HIV counselling services. He has a positive outlook regarding both his condition and his ongoing employment prospects for posts involving EPPs.
He has appropriate health management provided by his healthcare providers, from an occupational perspective he is supported by the hospital OH team and there is appropriate follow-up in place to ensure the safety of all concerned.
This case highlights the importance of health assessment, and the vital role the OHA plays in upholding good practice by facilitating excellent support, advice and maintenance of fitness of the HCW with HIV.
In 2013 the DoH amended its policy with regard to EPPs. Those HIV-positive HCWs with low viral loads are now allowed to undertake such work tasks. This evidence-informed change brings the UK into line with most other western countries (PHE, 2014).
Currently, there is no known definite cure for HIV, however with the ongoing global awareness, good health support and available anti-retroviral therapy, HIV-infected people are able to enjoy a good quality of life (UNAIDS, 2015).
Cherry Feliciano BSN RN, BSc (Hons) SCPHN is a specialist occupational health adviser at Ashford and St. Peter’s Hospitals NHS Foundation Trust. Professor Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, NTFHEA, PFHEA, FRCN is OH lead at London South Bank University.
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