CMA says no to mandatory hepatitis B vaccination, screening for MDs
Barbara Sibbald is CMAJ's Associate Editor of News and Features.
© 1998 Canadian Medical Association (full text / en bref)
Should vaccination of physicians against hepatitis B, as well as subsequent screening for the virus, be mandatory? The CMA says no: the voluntary route is the way to go. But Health Canada disagrees. Its new guidelines call for mandatory vaccination and subsequent screening of exposure-prone physicians for the virus.
La vaccination des médecins contre l'hépatite B et le dépistage ultérieur du virus devraient-ils être obligatoires? L'AMC répond que non : ces interventions doivent demeurer facultatives. Santé Canada n'est toutefois pas de cet avis. Ses nouvelles directives prescrivent la vaccination et le dépistage obligatoires pour les médecins risquant l'exposition au virus.
The CMA disagrees with new Health Canada guidelines that call for mandatory vaccination against hepatitis B and postvaccination screening of all "exposure-prone" health care workers. Instead, the CMA advocates a concerted push for voluntary vaccination and, eventually, universal vaccination against hepatitis B.
The CMA says Health Canada's guidelines, although laudable in their objective of trying to prevent transmission of hepatitis B virus (HBV) from infected health care workers to patients, fail to guarantee the rights of privacy, confidentiality and autonomy for these same workers. Moreover, the guidelines are almost completely silent on the question of just how a massive mandatory program would operate and who would cover the huge costs involved. The relatively low risk of transmission of bloodborne pathogens and the absence of studies on the feasibility and cost of mandatory screening does not justify implementation at this time, argues CMA President Victor Dirnfeld.
The new guidelines are part of the "Proceedings of the Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens," which emerged from a November 1996 conference organized by Health Canada's Laboratory Centre for Disease Control (LCDC). They are published as a supplement to the July 15 issue of the Canada Communicable Disease Report (1998;24[suppl 4]) and will also be available on the Web on July 15 at www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr.
The guidelines represent the policy approved by the majority of the 80 experts attending the 1996 conference, but they have no legal clout it's up to individual regulatory bodies to decide whether to adopt them.
Dirnfeld says the CMA chose the voluntary route because the evidence does not warrant measures any more intrusive than those recommended by the LCDC in 1992. "The board concluded that voluntary measures were reasonable, given the risk and benefit," says Dirnfeld, who has been tested for both HIV and HBV. In addition, the CMA says voluntary vaccination and testing wasn't given a fair trial after being recommended in 1992; postvaccination testing wasn't even suggested then.
Dirnfeld says that physicians are very willing to participate in screening programs to reduce the likelihood that they will, if infected, transmit hepatitis B to their patients. The problem is that launching a massive mandatory screening program without adequate provision for resources to make it work and without any discussion of financial compensation for physicians and other health care workers who will be put out of work is unwise and unfair. Most physicians who have been infected with hepatitis B acquired the infection while providing care for infected patients. To ensure the cooperation of health care workers, the program needs to reassure them that by coming forward for testing they will not suffer undue discrimination and hardship. This is a reasonable expectation, says Dirnfeld, but one that is largely glossed over in the Health Canada document.
Despite the relatively low risk, Dr. Ian Gemmill, who participated in the 1996 consensus conference, argues in favour of mandatory vaccination for physicians. "Where there is a small but real risk that can be avoided by immunization and testing, it's hard to argue against doing it," says Gemmill, the acting medical officer of health for the Kingston, Frontenac, Lennox and Addington Health Unit. "The demonstrated scientific evidence is absolutely clear."
Gemmill, who "strongly supports" the guidelines, says there is a "moral" imperative to follow the recommendations. "The public doesn't want to hear that it is difficult or inconvenient to get immunization. The patient wants to hear it's been done." Gemmill thinks the LCDC "is trying to avoid another hepatitis C fiasco. Because of [the] Krever [inquiry], we have to do the right thing and be seen to be doing the right thing."
For its part, the CMA is calling for a widespread education campaign and universal vaccination instead of a narrow focus on occupational risk groups. Currently, school-children across Canada (except in Manitoba) are being vaccinated, as are most residents and health care students.
The CMA also argues that the "consensus recommendations" weren't even the result of a consensus, since one-third of the 80 participants later said they shouldn't be published. Shirley Paton, chief of the Division of Nosocomial and Occupational Infection at the LCDC, says consensus at these conferences is always in the 70% to 80% range "providing no one says they can't live with the recommendations." According to Paton, "no one could visualize why health care workers wouldn't agree with mandatory immunization."
Physicians who test positive for the hepatitis B e antigen won't automatically lose their hospital privileges, she says. They will be suspended from practice for a week at most until an expert advisory panel of their peers meets to decide what to do. "We're not saying people can't practise," she says. "They may have to change or restrict their practice."
The CMA notes that changing a practice is easier said than done because there are few positions available for physicians seeking retraining almost all of these spots are reserved for new medical school graduates. Restricting a practice is difficult, too, particularly for surgeons with a very defined set of skills.
The guidelines only apply to health care workers who are "exposure prone," including those doing procedures that require blind palpation of a needle tip in a body cavity or repairs of major traumatic injuries, or those operating in the oral cavity.
Dentists aren't happy either
The CMA is far from alone in its opposition. The Canadian Dental Association (CDA) also opposes mandatory testing, arguing that it is impractical and potentially illegal. In its official response to the LCDC report, the CDA says that mandatory testing and the requirement to provide proof of seroconversion could be challenged under Canada's Charter of Rights and Freedoms. In addition, postvaccination testing is not recommended due to the cost and the high number of seroconversions.
The CDA says its voluntary program has been very successful. A recent survey of 6444 dentists by Dr. Gillian McCarthy of the University of Western Ontario revealed that 91% had been vaccinated against hepatitis B and 3% had acquired natural immunity. The results of a similar study of Canadian surgeons will be available in August. A pilot survey of London surgeons revealed that 86.5% had been vaccinated and 3.8% reported naturally acquired immunity. The HBV vaccination series of 3 doses (at 0, 1 and 6 months) costs $60.
Dr. Bill Pollett, a surgeon at St. Clare's Mercy Hospital in St. John's, has a personal interest in the issue because he contracted hepatitis B from a patient a decade ago. As in most cases, he acquired immunity to hepatitis B as a result of the infection and is not contagious. President-elect of the Canadian Association of General Surgeons, Pollett personally supports voluntary testing and vaccination. He is "uneasy" about a mandatory system, but he "strongly urges" his colleagues to get vaccinated. "I'm not sure that the risk is so great to warrant the sacrifice of the rights of health care workers. But on the other hand, is it that big a deal [to get immunized]?"
In the end, though, he supports the CMA position that the voluntary approach should be given a fair trial first. "Why was there this sudden shift from voluntary to mandatory?" he asks. "Those programs from 1992 were never implemented."
He says he regrets not being vaccinated, and believes if vaccination was readily available, people would accept it.