NBDS Guidelines on members with Bloodborne Viruses

The NBDS is committed to protecting and maintaining the rights of patients and Dental Health Care Providers (DHCP`S) and the integrity of the dental profession.

Some clinical treatments will require exposure-prone procedures. These exposure-prone procedures have been determined to pose an increased risk of bloodborne disease transmission due to their nature and the type of instruments and devices typically used for exposure-prone procedures.

Therefore, dental health care providers and clinical support staff cannot avoid involvement in the provision of patient care activities that involve exposure-prone procedures. The NBDS has determined that the performance of exposure-prone procedures places patients at increased risk. Entry into the health care professions is a privilege offered to those who are prepared for a lifetime of service to the public.

All dental health care providers have a fundamental responsibility to provide care to all patients assigned to them without prejudice and to ensure that care is delivered competently and safely. A failure to accept this responsibility violates a basic tenet of the dental profession – to place the patient’s interest and welfare first. Dental Health Care Providers have an ethical obligation to their patients to know their own infectious disease status (especially with respect to HBV, HCV and HIV). If negative to HBV, HCV and HIV, testing should be performed on a schedule based on the individual’s level of risk and whenever an exposure occurs.

Dental Health care providers are at risk of contracting infectious diseases during patient care activities. A policy of immunizations and Routine Practices (Standard Precautions) can protect DHCPs from some of these infectious diseases. Percutaneous injuries can place a HCW at risk to occupational exposure to HBV, HCV and HIV. Therefore, training and education on the prevention of injuries is an absolute necessity for all DHCPs.

To minimize the risk of transmission of bloodborne viruses (BBV) from DHCPs to patients, the DHCPs must adhere to Routine Practices, including proper handwashing, use of PPE as required and adherence to the proper management of sharps. When the DHCPs follow these guidelines, the risk of transmission of a BBV from DHCPs to patients is negligible.

If exposure-prone procedures (EPPs) are performed, the risk of transmission is slightly higher but is still minimal. Although impossible to attain zero risk of BBV transmission from a DHCPs to a patient, the risk can be made negligible due to the efficacy of the HB vaccine and effective drug regimens to suppress HCV and HIV.

The NBDS Recommendation for Dental Health Care providers that are infected will follow the Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Settings from the Public Health Agency of Canada.

RISK OF TRANSMISSION OF HIV

Studies have estimated the risk of HIV transmission from patients to DHCPs after percutaneous injury to range from about 0% to 3%

All HCWs who perform EPPs have ethical and professional obligations to know their HIV status.

If negative, those performing EPPs should be tested at appropriate intervals as determined by their level of risk and whenever an exposure has occurred

HCWs infected with HIV should seek medical care from a physician with expertise in HIV management for optimal health maintenance and should be managed according to current recommendations with regular monitoring of HIV RNA levels

HCWs infected with HIV should be restricted from performing EPPs until: a) the HCW is under the care of a physician with expertise in HIV management; and b) the HCW is either on effective combination antiretroviral therapy or has been identified as an elite controller; and c) the HCW’s viral load is undetectable

HCWs infected with HIV who are on effective combination antiretroviral therapy (or are elite controllers), and have an undetectable viral load should have no restrictions on practice based on HIV status alone.

HCWs infected with HIV who do not perform EPPs do not need any restrictions on practice based on HIV status alone.

If a HCW-to-patient transmission of HIV occurs, the HCW should cease clinical practice immediately until determination for fitness to return to practice is made Elite controllers are defined as individuals infected with HIV who are not receiving therapy and have maintained undetectable viral load in the blood (HIV RNA < 50 copies/mL) for at least one year, based on three separate viral load assessments). This spontaneous control of viral replication in the absence of therapy is estimated to occur in approximately 1 in 300 individuals infected with HIV.

RISK OF TRANSMISSION OF HCV

Studies have estimated the risk of HCV transmission from patients to DHCPs after percutaneous injury to range from about 2%

• All HCWs who perform EPPs have ethical and professional obligations to know their HCV status.
• If negative, those performing EPPs should be tested at appropriate intervals as determined by their level of risk and whenever an exposure has occurred.
• Confirmation of active HCV infection should be done using HCV RNA testing. HCWs infected with HCV should seek medical care from a physician with expertise in HCV management for optimal health maintenance and should be managed according to current recommendations
• HCWs testing positive for HCV RNA should be restricted from performing EPPs until: a) the HCW is under the care of a physician with expertise in HCV management; and b) the HCW has completed effective therapy c) the HCW has tested negative for HCV RNA at least 12 weeks post-treatment.

Note: Expert Review Panels may individualize practice restrictions to allow a HCW to perform EPPs while on effective therapy provided the virus is undetectable; the HCW’s practice should then be restricted post treatment until a sustained virologic response (SVR) is confirmed.

• HCWs testing negative for HCV RNA 12 weeks post-treatment can be considered to have SVR and should have no restrictions on practice based on HCV status alone.
• HCWs infected with HCV who do not perform EPPs do not need any restrictions on practice based on HCV status alone.
• If a HCW-to-patient transmission of HCV occurs, the HCW should cease clinical practice immediately until determination for fitness to return to practice is made.

RISK OF TRANSMISSION OF HBV

Studies have estimated the risk of HBV transmission from patients to DHCPs after percutaneous injury to range from about 5 to 30%

• All HCWs who perform EPPs have ethical and professional obligations to know their HBV status.
• HCWs who remain susceptible to HBV should be tested at appropriate intervals as determined by their level of risk and whenever an exposure has occurred.
• HCWs born or previously residing in high HBV endemic countries should be tested for both antiHBc and HBsAg to fully define HBV status.
• HCWs infected with HBV should seek medical care from a physician with expertise in HBV management for optimal health maintenance and should be managed according to current recommendations with regular monitoring of HBV DNA level.
• HCWs infected with HBV should be restricted from performing EPPs until: a) the HCW is under the care of a physician with expertise in HBV management; and b) the HCW’s HBV DNA level is below 103 IU/mL (5 x 103 GE/mL)F or equivalent and monitored regularly (every 3 to 6 months)
• HCWs infected with HBV who have HBV DNA levels less than or equal to 103 IU/mL (5 x 103 GE/mL)E or equivalent should have no restrictions on practice based on HBV status alone.
• HCWs infected with HBV who do not perform EPPs do not need restrictions on practice based on HBV status alone.
• If a HCW-to-patient transmission of HBV occurs, the HCW should cease clinical practice immediately until determination for fitness to return to practice is made