Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice.

A growing body of literature defends the efficacy of seasonal influenza vaccination for health care workers in reducing the mortality of hospitalized patients. I review the evidence concerning influenza vaccination, concluding that universal vaccination of health care workers against influenza should be considered standard patient care and that nonvaccination represents maleficent care. I further argue that the ethical responsibility to ensure universal vaccination of staff against seasonal influenza lies not only with individual health care providers but with each individual health care institution.

Updated CDC recommendations for the management of hepatitis B virus-infected health-care providers and students.

This report updates the 1991 CDC recommendations for the management of hepatitis B virus (HBV)-infected health-care providers and students to reduce risk for transmitting HBV to patients during the conduct of exposure-prone invasive procedures (CDC. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991;40[No. RR-8]). This update reflects changes in the epidemiology of HBV infection in the United States and advances in the medical management of chronic HBV infection and policy directives issued by health authorities since 1991. The primary goal of this report is to promote patient safety while providing risk management and practice guidance to HBV-infected health-care providers and students, particularly those performing exposure-prone procedures such as certain types of surgery. Because percutaneous injuries sustained by health-care personnel during certain surgical, obstetrical, and dental procedures provide a potential route of HBV transmission to patients as well as providers, this report emphasizes prevention of operator injuries and blood exposures during exposure-prone surgical, obstetrical, and dental procedures. These updated recommendations reaffirm the 1991 CDC recommendation that HBV infection alone should not disqualify infected persons from the practice or study of surgery, dentistry, medicine, or allied health fields. The previous recommendations have been updated to include the following changes: no prenotification of patients of a health-care provider's or student's HBV status; use of HBV DNA serum levels rather than hepatitis B e-antigen status to monitor infectivity; and, for those health-care professionals requiring oversight, specific suggestions for composition of expert review panels and threshold value of serum HBV DNA considered "safe" for practice (<1,000 IU/ml). These recommendations also explicitly address the issue of medical and dental students who are discovered to have chronic HBV infection. For most chronically HBV-infected providers and students who conform to current standards for infection control, HBV infection status alone does not require any curtailing of their practices or supervised learning experiences. These updated recommendations outline the criteria for safe clinical practice of HBV-infected providers and students that can be used by the appropriate occupational or student health authorities to develop their own institutional policies. These recommendations also can be used by an institutional expert panel that monitors providers who perform exposure-prone procedures.

[Does patient safety justify mandatory vaccinations?]. / Rechtfertigt der Patientenschutz verpflichtende Impfungen?

BACKGROUND AND OBJECTIVES: Medical and dental students belong to a group of health care workers (HCWs) who are frequently exposed to patients with occupationally transmissible infectious diseases. Vaccinations are the most effective interventions to protect HCWs and patients from vaccine-preventable infectious diseases. Despite decades of effort to encourage HCWs to be immunized, vaccination levels (e. g. influenza) remain insufficient. METHODS: To assess the attitudes of German medical and dental students towards mandatory immunizations, an anonymous questionnaire was offered to medical and dental students of the University of Frankfurt/Main, Germany. Overall, 56.9 % (1823/3200) of all medical and dental students attended to the study. RESULTS: This study - so far the largest study done on this issue - showed that almost 88.5 % of the responding medical and dental students would accept mandatory vaccinations for HCWs. CONCLUSION: Contrary to the widespread concern that a vaccination requirement would cause resistance, our data support that mandatory vaccinations (at least for HCWs who care for immunocompromised patients) might be widely accepted.

Presenteeism: a public health hazard.

"Presenteeism" occurs when an employee goes to work despite a medical illness that will prevent him or her from fully functioning at work. This problem has been well studied in the business and social science literature, and carries increased importance in the health care setting due to the risk of infectious disease transmission in vulnerable patient populations. In this manuscript, we discuss an outbreak of viral gastroenteritis in a long-term care facility and the role presenteeism played in disease transmission and extension of the outbreak. We use existing literature to point out the hazards of presenteeism in the health care sector. We will also discuss factors that may be involved in the decision to work while ill and propose policy changes that may reduce the incidence of presenteeism in health care organizations.

Dentistry and the ethics of infection.

Currently, any dentist in the UK who is HIV-seropositive must stop treating patients. This is despite the fact that hepatitis B-infected dentists with a low viral load can continue to practise, and the fact that HIV is 100 times less infectious than hepatitis B. Dentists are obliged to treat HIV-positive patients, but are obliged not to treat any patients if they themselves are HIV-positive. Furthermore, prospective dental students are now screened for hepatitis B and C and HIV, and are not allowed to enrol on Bachelor of Dental Surgery degrees if they are infectious carriers of these diseases. This paper will argue that: (i) the current restriction on HIV-positive dentists is unethical, and unfair; (ii) dentists are more likely to contract HIV from patients than vice versa, and this is not reflected by the current system; (iii) the screening of dental students for HIV is also unethical; (iv) the fact that dentists can continue to practise despite hepatitis B infection, but infected prospective students are denied matriculation, is unethical; and (v) that the current Department of Health protocols, as well as being intrinsically unfair, have further unethical effects, such as the waste of valuable resources on 'lookback' exercises and the even more damaging loss of present and future dentists. Regulation in this area seems to have been driven by institutional fear of public fear of infection, rather than any scientific evidence or ethical reasoning.

'This was something that happened to someone else'--an HIV positive dentist explains.

In this article, prompted by the Editorial and Opinion piece in the October 21 issue of the BDJ (BDJ 2006; 201: 485, 497-499), the writer, an HIV positive GDP of 28 years experience, expresses graphically and cogently his experiences following his diagnosis in 2004 and the subsequent loss of his chosen occupation. In general the BDJ does not publish anonymous contributions, but in this case, for obvious reasons of confidentiality, we have chosen to do so, also in deference to the courage of this colleague in sharing his harrowing story.

HIV-positive status among surgeons - an ethical dilemma.

HIV/AIDS is a manageable disease with a reasonable expectation that affected individuals might be able to experience both reduced mortality and morbidity. Within the socio-political context of the illness there has been a very strong emphasis on human rights issues, especially in relation to discrimination, which has seemingly been influenced more by emotion than science. This article explores and addresses the potential risk of an HIV-positive surgeon transmitting the virus to a patient. We argue that the Centers for Disease Control (CDC) and Health Professions Council of South Africa (HPCSA) guidelines are too restrictive, especially against a background of limited transmission risk, and hence that these guidelines could be more harmful than beneficial to our health systems.

Dental students with Hepatitis B: issues to be considered when defining policies.

Carriers of the Hepatitis B virus represent a significant proportion of the world's population. Since the existing policies on how to manage infected dental students lack clarity, the issues related to Hepatitis B and a set of recommendations for the adoption of a new policy will be presented here. After considering the virology, epidemiology, prevention, and treatment of Hepatitis B, the current health management policies will be reviewed, and ethical considerations, including the issue of disclosure, will be explored. The recommendations presented here for a new Canadian policy on infected health care workers include universal immunization, assessment of infectivity by measuring Hepatitis B DNA levels, and disclosure to patients on the basis of scientific evidence. These recommendations are intended to aid Canadian dental schools, and dental schools in other nations, with students who are carriers of Hepatitis B.

Patient care and the health-impaired practitioner.

The risk of HIV-infected or otherwise impaired practitioners infecting or injuring their patients is very low, but is of proper concern to patients, practitioners and healthcare facilities. Practitioners' general legal and ethical duties to protect patients includes protection against their own liability to present risk of harm. Healthcare facilities have similar duties of care to protect patients, for instance by proper selection and management of personnel, but may also bear indirect or vicarious ('no fault') legal liability for injuries due to the negligence of the personnel they engage. Impaired practitioners should disclose their status to licensing and health facility authorities. They are entitled to non-discriminatory employment opportunities, but may be licensed and approved to practice under conditions that appropriately protect patients. When impaired practitioners practice within such approved conditions, modern courts hold that they have no legal duty to volunteer disclosure of their status to their patients.