Infectious Diseases & Immunization (Policy for Students)
The following policies pertain to all students of the Faculty of Medicine working in a health care setting or in an education or research environment. All postgraduate matched candidates are required to show proof of Immunization or immunity for diphtheria, tetanus, pertussis (whooping cough), polio, measles, mumps, rubella, chicken pox, hepatitis B (must include immune status from blood test). Immunization against influenza is recommended. A 2-step TB Skin Test must be completed prior to starting residency. If the 2-step TB test is more than 2 years old a 1-step TB test must be completed. An immunization status form will be sent to accepted candidates for completion. If this form is fully completed by a physician or public health facility, documentation/titres are not required. If the matched candidate completes the form, it must be accompanied by documentation/titres of the immunizations.
Universal Precautions
All students are expected to understand universal precautions and to practice these precautions in all health care and relevant educational and research settings as the minimum standard for prevention of transmission of blood borne pathogens.
The following policies pertain to all students of the Faculty of
Medicine working in a health care setting or in an education or research
environment. All medical students accepted for study at Dalhousie
Medical School are required to show proof of immunization for tetanus,
diphtheria, polio, measles, mumps, rubella, mantoux (TB), chicken pox
and Hepatitis B (sero conversion). Proof of immunization must be written
documentation obtained from a physician and/or public health facility.
This documentation must include the date of immunization. Immunization
against influenza is recommended. An immunization card for recording
immunizations is sent to all residents, on their acceptance to Dalhousie
University, from the Postgraduate Office with instructions to have it
satisfactorily completed prior to beginning their studies. Students
should have hepatitis B immunization as well as tuberculin testing
carried out by Student Health Services after the school term begins,
with the results recorded on their immunization card and with positive
reactions appropriately followed up. As hepatitis B immunization is
given in a series of three injections, it is necessary to document that
all injections have been carried out. Undergraduate students who will
receive their three immunizations through student health services,
should have their immunizations recorded on their medical school
immunization card by Student Health. Post-graduate students who are not
from Dalhousie University are required to submit their completed medical
school immunization card, demonstrating appropriate immunization
including three injections for hepatitis B by December 31st of the year
they begin their training program.
HIV Testing
All students who have personal risk factors for HIV are encouraged to seek voluntary HIV testing.
HBV Vaccination
- All students must be vaccinated against HBV unless contraindicated by a physician's order.
- Following vaccination, all students must be tested for their HBV antibody status and counselled regarding the results.
Occupational Exposures
1. All students who have had a significant exposure to blood or other high risk body fluids in a health care or relevant educational or research setting are recommended to seek voluntary testing for HIV, HBV and HCV, where indicated, through the appropriate health services facility of the University or hospital. Situations of particular risk for transmission of blood borne viruses are where:
a. The source individual is known to be infected with HIV, HBV or HCV
b. The source individual suggest a risk of infectivity (high risk sexual practices, IV drug abuse)
2. All students have an ethical obligation to report to their supervising physician a significant exposure of their blood to a patient.
Risk of Infection
- All students with an infection that could put a patient or a volunteer (eg: research subject, simulated patient) at risk are encouraged to seek advice through the appropriate health service of the University or the hospital with respect to the potential for transmission of the infection to patients or volunteers and of the appropriate precautions.
- Students known to be infected with HIV, HBV or HCV who are involved with invasive procedures in a health care setting should be knowledgeable of and adhere to policies governing such practice in the health care institution in which these activities take place.
- If a student is aware that a patient or volunteer has been exposed to the blood of an individual infected with a blood borne pathogen, the student should inform the supervising physician of the situation. The supervising physician will undertake to inform the occupational health service of the institution which will arrange counselling regarding the risk and advisability of testing and prophylaxis. It is not appropriate that the identity of the source individual be disclosed to the patient or volunteer.
Policy for Applicants and Postgraduate Residents with a Communicable Infection
(Approved by Faculty Council October 9, 2007)
Objective:
To outline the course of action to be taken when postgraduate resident in the Faculty of Medicine has a communicable infection.
Principles:
The Faculty of Medicine at Dalhousie University is committed to protecting and maintaining the rights of patients and health care workers as well as the integrity of the educational process of Medical professionals.
To study or work in the health care professions is a privilege offered to those who are prepared for a lifetime of service to the public. Students, residents, faculty, and health care workers (HCW) have a fundamental responsibility to provide care to all patients assigned to them. A failure to accept this responsibility violates a basic tenet of the medical profession – to place the patient’s interest and welfare first. Thus, health care workers have an ethical obligation to their patients to know their own infectious disease status where that may impact on the health of the patient.
The requirements of each residency training program are set according to the standards of the credentialing agency (the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada). A communicable infection may prevent a resident from achieving the requirements of some programs, and thus make that person unable to complete the program.
Residents in health care professions are at risk of contracting infectious diseases during the course of providing patient care1-5. A policy of mandatory immunizations combined with consistent application of infection prevention and control practices helps to protect residents from some of these infectious diseases. A patient’s right to informed consent may outweigh the worker’s right to privacy when a recognized risk of disease transmission is present.
Terms
“Communicable Infections Committee” means the committee described in Section 2.0;
“Exposure-prone procedures” is used for the purpose of managing the risk of bloodborne pathogens transmitted in Canada. They are procedures during which transmission of HBV, HCV or HIV from a HCW to patients is most likely to occur and include the following: digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs) or the simultaneous presence of the HCW's fingers and a needle or other sharp instrument or object in a blind or highly confined anatomic site, e.g. during major abdominal, cardiothoracic, vaginal and/or orthopedic operations, or repair of major traumatic injuries, or major cutting or removal of any oral or perioral tissue, including tooth structures”… (Note: from the Public Health Agency of Canada’s consensus report on infected health care workers6 which further states that this definition is quite broad in its scope and recommends that an expert panel make an informed decision based on factors in a specific case).
“Program” means the Faculty of resident training programs.
1. Hepatitis B (HBV) Immunization and Immune status of residents registered in the Program.
Applicants to a residency training program must be able to meet the core requirements outlined by the program. All Dalhousie University training programs are accredited through the RCPS and CFPC, and must meet the standards of these accrediting agencies that permit trainees to apply for certification exams. The Faculty of Medicine may refuse acceptance to the Program on the basis of disease status. The HBV status of all residents admitted to the Program is required so as to assess whether modification to the residents’ training in the Program is necessary to ensure patient and resident safety.
2. The Communicable Infections Committee
There shall be a Communicable Infections Committee that shall comprise the Assistant Dean of Admissions and Student Affairs, the Associate Dean of Postgraduate Medical Education, and a faculty member who is an infectious disease specialist who is appointed by the Department Head for the Department of Medicine. The latter member shall be appointed for a three (3) year term. The function of this Committee is to assist the Associate Dean of Postgraduate Medical Education in counseling residents, and in evaluating and structuring modifications to the Program as may be required by theresident’s disease or immune status, as more particularly set out in this Policy.
3. HBV immunization
HBV immunization is required of all residents registered in the Program prior to joining their training program. Residents shall provide results of post-immunization HBV antibody (HBsAb) testing to the Assistant Dean, Admissions and Student Affairs. Residents who test negative for HBsAb following HBV immunization will be required to provide results of hepatitis B surface antigen (HBsAg) testing (see 3.2). The course of action to be followed based on the hepatitis B serological results 7,8 are summarized below:
3.1 HBsAg positive:
Residents whose serologic profile indicates that they are HBsAg positive will be evaluated by the Communicable Infections Committee to determine whether their clinical experiences require modification to allow them to complete Program requirements while at the same time ensuring patient and resident safety or whether they may continue in the training program. The Communicable Infections Committee shall assist in developing any such modifications and will provide counseling to the residents as may be required. Every reasonable attempt will be made to ensure that the learning objectives of the curriculum are met, but this may not be possible in all cases.
Career counseling to such residents will be provided by the Associate Dean, Postgraduate Medicine, and consultation with a Committee for Career Options. This committee will be comprised of representatives from each specialty who will review and advise the Assistant Dean in matter of alternative career options for residents.
The Associate Dean of Postgraduate Medicine Affairs shall notify the Advisory Committee on Blood Borne Pathogens of the College of Physicians and Surgeons of Nova Scotia of the resident’s serologic status.
Note: The purpose of excluding HBsAg positive residents with an increased likelihood of transmitting HBV from surgical procedures and surgical training is to protect patients from acquiring HBV. There is precedence for such a policy of exclusion in Canada 9, 10, 11, the United States 12,13 and outside North America 14-16. The Public Health Agency of Canada also supports a policy of exclusion 5.
Note: Not all HBsAg positive residents need to be excluded; HBV viral load is an important determinant.
3.2 Non-responders to Hepatitis B vaccine:
Individuals who have been vaccinated but are either non-responders or have inadequate antibody titres after completing two series (three doses /series) of HBV vaccine are not considered immune16. These residents will be required to sign the Agreement Form for HBsAg testing (Appendix 1) and to undergo serologic testing on an annual basis.
The resident's HBsAb and HBsAg status must be reported to the Communicable Infections Committee annually or after an exposure incident, until graduation from the Program.
The Communicable Infections Committee shall provide counseling to such residents relative to their training and health status. Career counseling will be provided to such residents by the Assistant Dean of Postgradaute Medical Education.
3.3 Declination of Hepatitis B vaccine:
Residents declining to be immunized against HBV on religious or similar grounds or for medical reasons are to be counseled by the Communicable Infections Committee. Their request for a waiver of the immunization requirements set out in this policy will be assessed on a case-by-case basis.
Such residents must sign The Agreement Form for HBsAb and HBsAg Testing (Appendix 1) and the Hepatitis B Vaccine Declination Statement (Appendix 2) and to undergo annual serologic testing as specified in 3.2 in order to be allowed to continue their studies.
4. HIV Testing
Residents with risk factors for HIV and who are involved in exposure-prone procedures have a moral and ethical obligation to undergo HIV testing on a voluntary basis. HIV-infected residents will be counseled by the Communicable Infections Committee. The Associate Dean of Postgraduate Medicine will notify the Advisory Committee on Blood Borne Pathogens of the College of Physicians and Surgeons of Nova Scotia of the resident’s serologic status.
5. Hepatitis C (HCV) Testing
Residents with risk factors for HCV and who are involved in exposure-prone procedures have a moral and ethical obligation to undergo HCV testing on a voluntary basis. HCV-infected residents will be counseled by the Communicable Infections Committee. The Associate Dean of Postgraduate Medicine will notify the Advisory Committee on Blood Borne Pathogens of the College of Physicians and Surgeons of Nova Scotia of the resident’s serologic status.
6. Other Communicable Infections and Residents
Any resident who has or develops a communicable infection is required to inform the Associate Dean of Postgraduate Medicine in order to discuss whether this condition could impact on his or her ability to participate fully in the Program. The Associate Dean of Postgraduate Medicine may engage in counseling the resident, in evaluating the need for modification to the resident’s participation in the Program and in structuring any required modifications.
Residents who have acute or chronic medical conditions that render them susceptible to infection should discuss with their personal physicians and the Associate Dean of Postgraduate Medicine whether the condition might affect their ability to safely perform their duties.
This policy is consistent with the Canadian Medical Association’s Code of Ethics which states, under “Responsibilities to Oneself”:17
“Seek help from colleagues and appropriately qualified professionals for personal problems that might adversely affect your service to patients, society or the profession.”
The reporting obligations will be consistent with the requirements of the Nova Scotia government. This policy document should be reviewed biannually or more frequently as needed by the Communicable Infections Committee to ensure that it reflects current knowledge and opinion.