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Volume: 24S4 - July 1998

Proceedings of the Consensus Conference on Infected Health Care Workers:
Risk for Transmission of Bloodborne Pathogens

DEFINITIONS

Exposure-prone procedures⁺ (Canadian definition)

The term 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 includes the following:

1. digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs⁽⁵⁾) 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

2. repair of major traumatic injuries, or

3. major cutting, or removal of any oral or perioral tissue, including tooth structures++
   

during which blood from an injured HCW may be exposed to the patient's open tissues.

It is recognized that it is difficult to determine every situation in which there is a significant risk of transmission of a bloodborne pathogen, and therefore this definition is meant to guide the practitioner and/or expert panel in making an informed decision about the factors in a specific case.

Significant injury

An injury during which one person's blood or other high-risk body fluid comes in contact with someone else's body cavity; subcutaneous tissue; or non-intact, chapped or abraded skin or mucous membrane⁽¹⁾. In the context of an infected HCW, an instrument contaminated with the HCW's blood or the dripping of blood from the HCW to a patient's body cavity may be the mechanism by which a significant exposure occurs.

"Hands free" technique

A procedure that ensures that "the surgeon and surgical nurse do not touch the same instrument at the same time. This is achieved by placing the sharp instrument in a so-called neutral zone that is cleared of other instruments"⁽³³⁾.

Look-back

If a HCW has been identified as infected with HBV, HCV or HIV and has performed exposure-prone procedures that could have put patients at risk of exposure to an infection, then the agency employing the HCW or the local public health agency contacts patients at risk to give advice about testing and potential treatment and to discuss methods of preventing further transmission with those found to be infected.

"No touch" technique

The use of an extension such as a sponge forcep, rather than hands, to handle or touch contaminated items or to handle or touch sterile items⁽⁴³⁾.

Non-responder

A HCW who has had two complete series (three doses) of hepatitis B vaccine and has tested anti-HBs negative (< 10 IU/L) 4-8 weeks after each hepatitis B immunization series⁽⁴¹⁾.

Trace-back

If a patient has been identified as infected with HBV, HCV or HIV and has no identifiable risk of infection from that pathogen, as assessed by the physician or local public health agency, but has undergone an exposure-prone procedure within the appropriate incubation period, then the local public health agency seeks to identify the HCW who has performed exposure-prone procedures and other infected or potentially infected patients in order to provide treatment and counselling on preventing further transmission.

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REFERENCES

1. Health Canada, LCDC. Bloodborne pathogens in the health care setting: risk for transmission. CCDR 1992;18:177-84.

2. CDC. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone procedures. MMWR 1991;40:1-9.

3. Joint Working Party of the Hospital Infection Society and the Surgical Infection Study Group. Risks to surgeons and patients from HIV and hepatitis: guidelines on precautions and management of exposure to blood or body fluids. BMJ 1992;305:1337-43.

4. PHLS. Hepatitis C virus transmission from HCW to patient. CDR Review 1995;5(26):R121.

5. Dorland's illustrated medical dictionary. 27th edition. Philadelphia: W.B. Saunders Co., 1988.

6. Bell DM, Shapiro CN, Culver DH et al. Risk of hepatitis B and human immunodeficiency virus transmission to a patient from an infected surgeon due to percutaneous injury during an invasive procedure: estimates based on a model. Infect Agents Dis 1992; 263-69.

7. Bell D. Human immunodeficiency virus transmission in health care settings: risk and risk reduction. Am J Med 1991;3B-294S-3B-300S.

8. Bell DM, Shapiro CN, Ciesielski CA, Chamberland ME. Preventing bloodborne pathogen transmission from health-care workers to patients. Surg Clin North Am 1995;75:1189-1203.

9. Health Canada, LCDC. Nosocomial hepatitis B associated with orthopedic surgery - Nova Scotia. CCDR 1992;18:89-90.

10. Johnson BL, Langille DB, LeBlanc JC et al. Transmission of hepatitis B related to orthopedic surgery. Infect Control Hosp Epidemiol 1994;15:352.

11. Johnson I. Hepatitis B - EEG clinics outbreak investigation. Toronto: Ontario Ministry of Health. 1997. Final report.

12. PHLS. Lessons from two linked clusters of acute hepatitis B in cardiothoracic surgery patients. CDR Rev 1996;6:R119-R125.

13. PHLS. Response to the discovery of two practicing surgeons infected with hepatitis B. CDR Rev 1996;6:R126-R128.

14. The Incident Investigation Team and Others. Transmission of hepatitis B to patients from four infected surgeons without hepatitis B e antigen. N Engl J Med 1997;336:178-84.

15. Heptonstall J. Presentation at the Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens. Ottawa: November 19, 1996.

16. Mast E. Presentation at the Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens. Ottawa: November 19, 1996.

17. Esteban JI, Gomez J, Martell M et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;334:555-60.

18. CDC. Transmission of HIV infection during an invasive dental procedure, Florida. MMWR 1991;40:21-27,33.

19. CDC. Update: investigations of persons treated by HIV-infected health care workers - United States. MMWR 1993;42:329-31.

20. Dorozynski A. French patient contracts AIDS from surgeon. BMJ 1997;314:250.

21. Robert L, Chamberland ME, Cleveland J et al. Investigations of patients of health care workers  infected with HIV: CDC database. Ann Intern Med 1995;122:653-57.

22. Robillard P. Presentation at the Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens. Ottawa: November 19, 1996.

23. Gerberding  JL. Procedure-specific infection control for preventing intraoperative blood exposures. Am J Infect Control 1993;21:364-7.

24. Harpaz R, Von Seidlein L, Averhoff FM et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996;334:549-54.

25. Tokars JI, Bell DM, Culver DH et al. Percutaneous injuries during surgical procedures. JAMA 1992;267:2899-904.

26. Short LJ, Bell DM. Risk of occupational infection with blood-borne pathogens in operating and delivery room settings. Am J Infect Control 1993;21:343-50.

27. Lanphear BP. Trends and patterns in the transmission of bloodborne pathogens to HCW. Epidemiol Rev 1994;6:437-50.

28. Shapiro CN.  Occupational risk of infection with hepatitis B and hepatitis C virus. Surg Clin North Am 1995;75:1047-56.

29. Pugliese G. Should blood exposures in the operating room be considered part of the job? Am J Infect Control 1993;21:337-42.

30. Paltiel D. Perception of risk. Presentation at the Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens. Ottawa: November 19, 1996.

31. National Safety Council. Plog B, ed: Fundamentals of industrial hygiene. 3rd edition. Chicago: National Safety Council, 1988;457-474.

32. CDC. Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures - New York City, March 1993-June 1994. MMWR 1997;46:25-9.

33. Raahave D. Operative precautions in HIV and other bloodborne virus diseases. Infect Control Hosp Epidemiol 1996;17:529-31.

34. Gerberding JL, Lewis FR, Schecter WP. Are universal precautions realistic? Surg Clin North Am 1995;75:1091-104.

35. Kelen GD, Green GB, Hexter DA et al. Substantial improvement in compliance with universal precautions in an emergency department following institution of policy. Arch Intern Med 1991;151:2015-56.

36. Courington KR, Patterson SL, Howard RJ. Universal precautions are not universally followed. Arch Surg 1991;126:93-6.

37. Wright JG,Young NL, Stephens D. Reported use of strategies by surgeons to prevent transmission of bloodborne diseases. Can Med Assoc J 1995;152:1089-95.

38. Osterman JW. Beyond universal precautions. Can Med Assoc J 1995;152:1051-95.

39. Schaffner W, Mishu-Allos B. Protecting patients when their surgeon or dentist is infected with a blood-borne virus. J Hosp Infect 1995;30S:156-62.

40. Hersey JC, Martin LS. Use of infection control guideline by workers in healthcare facilities to prevent occupational transmission of HBV and HIV: results from a national survey. Infect Control Hosp Epidemiol 1994;15:243-52.

41. Health Canada, LCDC. An integrated protocol to manage health care workers exposed to bloodborne pathogens. CCDR 1997;23S2:1-14.

42. Mast EE, Alter MJ. Prevention of hepatitis B virus infection among HCW. In: Ellis RW, ed. Hepatitis B vaccines in clinical practice. New York: Dekker, 1993:295-307.

43. AORN. Standards, recommended practices, and guidelines. 1997:303.

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RESPONSE FROM THE CANADIAN MEDICAL ASSOCIATION

The prevention of the occupational transmission of bloodborne pathogens is a very important policy objective. The Canadian Medical Association (CMA) shares Health Canada's goal of continuing to protect the public. CMA commends Health Canada and the Laboratory Centre for Disease Control (LCDC) for being vigilant about this problem and for convening the conference from which these recommendations emerged.

However, CMA believes that the claim to consensus coming out of the conference is misleading. Although there was consultative discussion, no consensus was reached. More than one third of the participants recently polled did not support publishing these recommendations in light of the dissent of CMA and others.

The recommendations in these proceedings supersede the ones published by LCDC from a similar consensus conference in 1992 and diverge from them in important respects. CMA does not support the new recommendations. In the move from a voluntary system of immunization and screening to a mandatory one in the case of hepatitis B, and by the introduction of a new system of management for all health care workers known to be infected with hepatitis B virus (HBV), hepatitis C virus or human immunodeficiency virus, important rights of privacy, confidentiality and autonomy will be infringed upon, and new burdens and responsibilities imposed. The revised recommendations are not explicit about why it is thought that these changes are necessary or justified. CMA does not believe they are.

CMA's main concerns about the new recommendations are as follows:

• the proposed mandatory system, particularly its emphasis on the concept of "exposure-prone procedures", may afford even less protection to the public than would a carefully implemented voluntary program;

• the recommendations focus too narrowly on a particular risk group, and the narrowly targeted measures will do little to prevent transmission compared with other, more comprehensive measures, such as universal immunization;  

• the evidence does not warrant measures any more intrusive on privacy and autonomy than those in the previous recommendations;  

• with respect to HBV, the proposed mandatory regimen is unlikely to provide significant additional gains in risk reduction over the 1992 recommendations; such minimal gains as may be achieved under the proposed mandatory regimen do not, on balance, outweigh the costs in moral, social and financial terms;

• the rationale underlying the recommendations is not clear, particularly with regard to the principles upon which they are based;

• respect for autonomy and for privacy are not given adequate consideration;

• the approach to risk assessment and management is at best unclear, and at worst confused.

If health authorities are serious about protecting the public they should consider the following:

• universal hepatitis B immunization;

• enhanced voluntary testing of health professionals;

• universal precautions;

• an educational campaign directed at the public and health professionals.

CMA believes that a properly implemented voluntary system, enhanced by an educational program, would afford greater protection than would the conference recommendations, and in addition would have the merit of being less intrusive on privacy and autonomy.

In the case of HBV, immunization is certainly important in preventing transmission from health care worker to patient (and is also a prudent measure to be taken for the health care worker's own protection). It would be good to immunize as many health care workers who are capable of transmitting HBV as possible. However, CMA believes this goal could be achieved by less restrictive means, such as encouraging vaccination in the context of better education of health care workers, or more convenient access to the vaccine. Medical, nursing, and dental students in particular, and other health care professionals in training, should have access to hepatitis B vaccination through their programs.

CMA holds that a voluntary system for both immunization and testing has never been adequately attempted. If immunization for health care workers has not reached desired levels, this is not because the voluntary approach taken after the 1992 recommendations cannot work. Rather, it is because a voluntary system was never properly implemented to begin with.

With regard to mandatory testing for HBV, it is important to note that in the 1992 recommendations post-vaccination testing was not even recommended. This being so, the abrupt decision to move to mandatory testing in the revised recommendations is unwarranted. Before consideration of a mandatory system, there should be a trial in which vaccination and post-vaccination follow-up testing is strongly recommended to health care professionals and set in the context of an educational campaign in which the risks and benefits of vaccination and knowledge of personal serologic status are clearly laid out.

There is good reason to believe that a voluntary approach, intensely pursued, could prove as effective in preventing occupational transmission of HBV as the screening and management regimen proposed in the current recommendations. CMA has recently developed a detailed policy along these lines and urges health professionals, health institutions, public health officials and governments to give serious considerations to its proposal for an effective voluntary system. Given the improvements that have been made in the treatment of HBV there is considerably more benefit in learning one's serologic status today than there was in the past. In addition, CMA considers that health care workers have a responsibility to know their serologic status if they put patients at significant risk. This responsibility is grounded in the principle of medical ethics, "do no harm". The health care system does and must rely to a considerable extent upon the moral integrity of health care workers. A voluntary approach incorporating an explicit appeal to professional responsibility would draw on the individual moral integrity of every health care worker.

Further gains in risk reduction could be made if an intensive voluntary approach were coupled with improved use of universal precautions or the use of other prophylactic measures.  Programs to vaccinate patients pre-operatively where feasible would also substantially reduce the risk of occupational transmission.

Finally, CMA has serious concerns about the recommendations' narrow focus on the occupational transmission of HBV. The evidence clearly shows that the risks of occupational transmission are minuscule compared with other sources of infection, such as sexually transmitted disease and intravenous drug use. Targeting health care workers for mandatory vaccination and testing will do little to address the serious public health problems posed by HBV. A more intensive public health initiative to immunize the entire population, for example, would produce substantial gains in reducing the risk of transmission without singling out and stigmatizing one particular group in society.

CMA recognizes that such an initiative would be costly. However, the mandatory regime proposed in the recommendations would be costly in social and moral terms as well as economic ones. The occupational transmission of bloodborne pathogens is a small, albeit important, part of a much larger public health problem. It is questionable whether some or all of the various new measures in the revised recommendations are cost-effective (given how the money could otherwise be used to prevent transmission). CMA believes that universal immunization for HBV would probably be more cost-effective. Issues of cost aside, there can be no doubt that if we want to address the problem of HBV in a serious and comprehensive way, universal immunization would be the most effective way to proceed.

CMA is committed to the goal of protecting the public from the hazards of disease and will continue its work on behalf of its members and the public.

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RESPONSE FROM THE CANADIAN DENTAL ASSOCIATION

The Canadian Dental Association (CDA) supports the general intent of the proceedings of the LCDC Consensus Conference on Infected Health Care Workers to bring about further emphasis on preventive measures and reduce the risks of transmission of bloodborne pathogens by practitioners. However, CDA notes that the recommendations for mandatory testing of practitioners and related requirements for practitioners to show proof of seroconversion are impractical because of potential legal challenges and other serious difficulties that would follow implementation. CDA believes that the overall goal of the report and the specific objectives of its recommendations can be more efficiently and effectively met by seeking further emphasis on preventive measures within a voluntary system administered by professional regulatory authorities.

CDA currently encourages dental health professionals to be immunized (voluntarily) against hepatitis B. The success of this policy is reflected in a study conducted in 1994 and 1995 by G.M. McCarthy and J.K. MacDonald which reports that 93% to 94% of Ontario dentists have been so immunized and that an additional 1% have acquired natural immunity⁽¹⁾. A more recent study of dentists across Canada by the same authors, which was supported by a Health Canada grant, indicates that 94% of those dentists responding reported receiving HBV vaccination.

There are no reported cases of transmission of hepatitis B from dentist to patient since 1986. It is difficult to justify mandatory immunization of dentists when it is apparent that voluntary approaches are practical and can work.

CDA's Code of Ethics, which is referenced by several provincial dental licensing authorities, currently states, under Article 2, Competency:

A practitioner should inform the dental licensing authority when a serious injury, dependency, infection or other condition has either immediately affected, or may affect over time, his or her ability to practice safely and competently.

The intent of such a provision is to encourage a voluntary process, administered by the dental regulatory authority, to work with practitioners who have identified limitations (and to determine an appropriate range of practice through a consultative process).

Mandatory approaches will introduce rather than solve problems. CDA has obtained a preliminary legal opinion suggesting that provisions for mandatory testing or proof of seroconversion could be challenged under Canada's Charter of Individual Rights and Freedoms. Professional regulatory authorities will accordingly be faced with the LCDC report's recommendations on the one hand, and on the other the possibility of legal challenges if they choose to follow them.

The recommendations present practical as well as legal problems. A major concern centres on the "new Canadian definition" for the term "exposure-prone procedures" as related to dentistry. With the lack of evidence of transmission of disease to dental patients, it is technically impossible to identify one dental procedure as being more "at risk" than any other. The definition, however, attempts to equate risk in dental procedures with "degree of invasiveness", although no direct evidence-based foundation for this equivalency can be provided.

A second practical concern relates to the proposed requirement for practitioners to provide evidence of seroconversion. The biology of HBV vaccination is such that, after immunization, blood levels of antibodies, as tested in serology, decline. Despite the gradual reduction in blood antibody level, there is no need - as is true for many childhood immunizations - for booster immunization. In fact, booster immunizations are not recommended. Post-immunization testing is currently not recommended because of the cost and the high number of seroconversions experienced, particularly among younger individuals. If related recommendations in the LCDC report cannot be changed, such issues will need to be addressed and clarified.

Although the publication of these recommendationsis not equivalent to the introduction of new policy by the federal government, it stands as a medical legal reference that may be considered on its own merits. CDA's concerns are presented to assist evaluation of the report and its recommendations.

Despite the concerns noted, CDA views these proceedings of the LCDC Consensus Conference as an indication of a need for re-emphasis upon voluntary approaches, directed by professional regulatory authorities, to the prevention of transmission of disease from practitioner to patient. CDA pledges its support in this regard, to include immediate objectives such as the following:

• further encouragement of dentists to be voluntarily immunized, and special encouragement to ensure that allied dental personnel working with patients are immunized;

• encouragement of the recognition of a professional responsibility to be aware of the results of immunization;

• professional awareness initiatives to publicize the above and their relationship to Article 2, CDA Code of Ethics (and related provisions in the codes of individual provinces);

• professional awareness initiatives to publicize the continuing importance of universal precautions and their complete and consistent application.

Reference

1. McCarthy GM, MacDonald JK. Improved compliance with recommended infection control practices in the dental office between 1994 and 1995. Am J Infect Control 1998;26:24-8.

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Appendix I

LIST OF PARTICIPANTS

Abbott, Dr. Lewis
Queen Elizabeth Hospital

Amos, Ms. Anita
Canadian Association of Nephrology Nurses
& Technologist

Archibald, Dr. Chris
Division of HIV/Epidemiology Research

*Armstrong, Ms. Nicole
Bureau of Infectious Diseases

Baines, Dr. Andrew
Faculty of Medecine/University of Toronto

Beaty, Mr. Jeremy
Hepatitis C Survivors' Society

Bertolini, Mr. Renzo
Canadian Centre for Occupational Health
and Safety

Blaney, Ms. Sharon
Canadian Occupational Health Nurses Association

Bouchard, Mme Françoise
Association pour la santé et la sécurité du travail

Bragg, Ms. Dorothy
National Federation of Nurses' Unions

Brazeau, Dr. Michel
Fédération des médecins spécialistes du Québec

Chadsey, Dr. Don
College of Physicians & Surgeons of Alberta

Chartrand, Ms. Valerie
Northside Harbor View Hospital

Cheung, Dr. Lily
Occupational & Environmental Medical
Association of Canada

Clottey, Dr. Clarence
Saskatchewan Health Department

Cogan, Ms. Patricia
The Montreal General Hospital Patients'
Committee

Conly, Dr. John
Toronto Hospital

Coshan, Ms. Rita
Occupational Health and Safety Association,
Regina

Demshar, Dr. Helen
Ontario Ministry of Health, Laboratory
Services Branch

*Deschamps, Ms. Linda
Division of HIV/Epidemiology Research

Douville-Fradet, Dr. Monique
Ministère de la santé et des services sociaux

Ellis, Ms. Cathy
Canadian Confederation of Midwives

Fast, Dr. Margaret
College of Physicians and Surgeons of Manitoba

Galvon, Dr. Fran
Nova Scotia, Northern Regions

Garber, Dr. Gary
Ottawa General Hospital

Gemmill, Dr. Ian
Kingston, Frontenac and Lennox &
Addington Health

*⁺Gill, Dr. John
Southern Alberta Clinic

Gilmore, Dr. Norbert
McGill Centre for Medicine, Ethics and Law

*⁺Godsoe, Dale Advisory Committee on Blood Regulation

Gray, Ms. Shelley
Nova Scotia Department of Labour

Grimsrud, Dr. Karen
Alberta Health

*Gully, Dr. Paul
LCDC

*Gumpert, Ms. Suzanne
Canadian Nurses Association

Hamilton, Mr. Rod
College of Physicians and Surgeons of Ontario

Hart, Dr. Brom
Dentist, Halifax

Hay, Ms. Vija
Operating Room Nurses Association of Canada

Heptonstall, Dr. Julia
Communicable Disease Surveillance Center, U.K.

Honish, Ms. Agnes
Community & Hospital Infectious Control
Association of Canada

Johnston, Dr. Lynn
Victoria General Hospital

Jorundson, Dr. Edward
Occupational & Environmental Health Services,
Health Canada

Kinch, Dr. Robert
Society of Obstetricians & Gyneacologists
of Canada

King, Dr. Susan
The Hospital for Sick Children

Knoppers, Me. Bartha
McMaster Meighen

Kolbinson, Dr. Dean
University of Saskatchewan

*Lapensée, Ms. Katherine
LCDC

Legault, Dr. Diane
Ordre des dentistes du Québec

Liss, Dr. Gary
Ontario Ministry of Labour

Losos, Dr. Joe
LCDC

Mah, Dr. Stephanie
Workers Compensation Board of B.C.

Malawski, Dr. Anna
Ottawa General Hospital

Mast, Dr. Eric
Centers for Disease Control & Prevention, USA

McCarthy, Major Anne
OSHI, Health Canada

McCarthy, Dr. Gillian
Association of Canadian Faculty of Dentistry

*McLaren, Ms. Ruth
Canadian Health Care Association

McLean, Ms. Patricia
Canadian Nurses Protective Society

McGinnis, Dr. Randall
Alberta Medical Association

Mestery, Ms. Kathy
Manitoba Health

Meyers, Ms. Jane
Hepatitis C

*Mindorff, Ms. Catherine
Community & Institutional Infection Prevention
& Control

*Muirhead, Mr. Paul
Williams, McEnery & Davis

Novik, Dr. Alvin
Yale University

*Onno, Ms. Sharon
LCDC

Paliotti, Mrs. Rosa
Canadian Healthcare Association

Paltiel, Dr. David
Yale School of Medicine

*Paton, Ms. Shirley
LCDC

Petty, Dr. Trey
Canadian Dental Association

Potkonjak, Mrs. Billie
Canadian Liver Foundation

Randall-Wood, Ms. Deborah
Canadian Association of Nurses in AIDS Care

Rebbeck, Dr. Patricia
College of Physicians and Surgeons of B.C.

Rebryna, Dr. Diane
Alberta Dental Association

Redekop, Dr. Ted
Manitoba Department of Labour

Ricketts, Dr. Maura
LCDC

Robertson, Mr. Gerald
University of Alberta

*Robillard, Dr. Pierre
Direction de la santé publique de Montréal

Rowand, Mr. Scott
Hamilton Health Sciences Corporation

Spika, Dr. John
LCDC

Stein, Dr. Minna
Royal College of Dental Surgeons of Ontario

Stone, Ms. Karen
I.W.K. Grace Health Centre

Stratton, Dr. Faith
Department of Health, St. John's

Stringer, Ms. Bernadette
Commission de contrôle de l'énergie atomique

Tepper, Dr. Martin
LCDC

Vogel, Dr. Anne
Vancouver Health Board

Wallace, Dr. Evelyn
Ministry of Ontario

Walters, Dr. David
Canadian Medical Association

White, Ms. Wanda
Department of Health and Social Services

Yeo, Mr. Michael
Canadian Medical Association

Zack, Ms. Elisse
Canadian AIDS Societ

* Steering committee member
⁺ Did not attend conference

⁺ The term "invasive procedures" was used during the Consensus Conference. It was changed following review by a subgroup, which stated that "exposure-prone procedures" are invasive procedures that also present the opportunity for the patient to be exposed to the blood of the HCW.

⁺⁺ It is not the intent to include all invasive dental procedures as exposure-prone, although this is theoretically possible; rather, the goal is to identify those procedures involving a major opening in the oral or perioral tissue.

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