Hepatitis B in healthcare workers: Transmission events and guidance for management

Table 3 Categories of exposure-prone procedures

CDC

Category I. Procedures known or likely to pose an increased risk of percutaneous injury to a healthcare provider that have resulted in provider- to-patient transmission of HBV. These procedures are limited to major abdominal, cardiothoracic, and orthopedic surgery, repair of major traumatic injuries, abdominal and vaginal hysterectomy, caesarean section, vaginal deliveries, and major oral or maxillofacial surgery. Techniques that have been demonstrated to increase the risk for healthcare provider percutaneous injury and provider-to-patient blood exposure include: digital palpation of a needle tip in a body cavity and/or the simultaneous presence of a health care provider’s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site

Category II. These procedures pose low or no risk for percutaneous injury to a HCW or, if a percutaneous injury occurs, it usually happens outside of a patient’s body and generally does not pose a risk for provider-to-patient blood exposure. These include: surgical and obstetrical/gynecologic procedures that do not involve the techniques listed for Category I, the use of needles or other sharp devices when the HCW’s hands are outside a body cavity, dental procedures other than major oral or maxillofacial surgery, insertion of tubes, endoscopic or bronchoscopic procedures, internal examination with a gloved hand that does not involve the use of sharp devices, and procedures that involve external physical touch

SHEA

Category I. Procedures with de minimis risk of bloodborne virus transmission: regular history-taking and/or physical or dental examinations; routine dental preventive procedures, diagnostic procedures, orthodontic procedures, prosthetic procedures, cosmetic procedures not requiring local anesthesia; routine rectal or vaginal examination; minor surface suturing; elective peripheral phlebotomy; lower gastrointestinal tract endoscopic examinations and procedures; hands-off supervision during surgical procedures and computer-aided remote or robotic surgical procedures; and psychiatric evaluations

Category II. Procedures for which bloodborne virus transmission is theoretically possible but unlikely: locally anesthetized ophthalmologic surgery; locally anesthetized operative, prosthetic, and endodontic dental procedures; periodontal scaling and root planing; minor oral surgical procedures; minor local procedures under local anesthesia; percutaneous cardiac procedures; percutaneous and other minor orthopedic procedures; subcutaneous pacemaker implantation; bronchoscopy; insertion and maintenance of epidural and spinal anesthesia lines; minor gynecological procedures; male urological procedures; upper gastrointestinal tract endoscopic procedures; minor vascular procedures; amputations; breast augmentation or reduction; minimum-exposure plastic surgical procedures; total and subtotal thyroidectomy and/or biopsy; endoscopic ear, nose, and throat surgery and simple ear and nasal procedures; ophthalmic surgery; assistance with an uncomplicated vaginal delivery; laparoscopic procedures; thorascopic procedures; nasal endoscopic procedures; routine arthroscopic procedures; plastic surgery; insertion of, maintenance of, and drug administration into arterial and central venous lines; endotracheal intubation and use of laryngeal mask; and obtainment and use of venous and arterial access devices that occur under complete antiseptic technique, using universal precautions, “no-sharp” technique, and newly gloved hands

Category III. Procedures for which there is definite risk of bloodborne virus transmission or that have been classified previously as “exposure-prone:” general surgery; general oral surgery; cardiothoracic surgery; open extensive head and neck surgery involving bones; neurosurgery, other intracranial procedures, and open-spine surgery; nonelective procedures performed in the emergency department; obstetrical/gynecological surgery; orthopedic procedures; extensive plastic surgery; transplantation surgery except skin and corneal transplantation; trauma surgery; interactions with patients in situations during which the risk of the patient biting the physician is significant; and any open surgical procedure with a duration of more than 3 h, probably necessitating glove change

ACS

Not provided

Canada

Procedures during which transmission of HBV, HCV, or HIV from a HCW to patients is most likely to occur and includes the following: (1) digital palpation of a needle tip in a body cavity 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; (2) repair of major traumatic injuries; or (3) major cutting or removal of any oral or perioral tissue, including tooth structures, during which there is potential for the patient’s open tissues to be exposed to the blood of an injured HCW

UK

Exposure-prone procedures are those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker. These include procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside a patient’s open body cavity, wound, or confined anatomical space where the hands or fingertips may not be completely visible at all times

Europe

Exposure-prone procedures are invasive procedures where there is potential for contact between the skin of the HCW and sharp surgical instruments, needles, or sharp tissues in body cavities or poorly visualized/confined body sites

Australia

Category 1: A procedure where the hands and fingertips of the HCW are visible and outside of the body most of the time and the possibility of injury to the worker’s gloved hands from sharp instruments and/or tissues is slight

Category 2: A procedure where the fingertips of the HCW may not be visible at all times but injury to the worker’s gloved hands from sharp instruments and/or tissues is unlikely. If injury occurs it is likely to be noticed and acted upon quickly to avoid the HCW’s blood contaminating a patient’s open tissues

Category 3: A procedure where the fingertips are out of sight for a significant part of the procedure, or during certain critical stages, and in which there is a distinct risk of injury to the worker’s gloved hands from sharp instruments and/or tissues. In such circumstances it is possible that exposure of the patient’s open tissues to the HCW’s blood may go unnoticed or would not be noticed immediately

CDC: Centers for Disease Control and Prevention, United States; SHEA: Society for Healthcare Epidemiology of America, United States; ACS: American College of Surgeons, United States; Canada: Laboratory Centre for Disease Control of Health Canada; UK: Department of Health, United Kingdom; Europe: European Consensus Group; Australia: Australian Government, Department of Health and Aging; HCW: Healthcare worker; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HIV: Human immunodeficiency virus.