University of Illinois

College of Medicine at Urbana-Champaign

  Internal Medicine Residency Program

  Program Policy

Subject: Infectious Disease Prevention

Category: 
           
Scope:  All Services

Effective Date: 7/30/2001

Revised:

Approved by REC:

Purpose:  To outline the guidelines and procedures for infectious disease prevention for residents' exposure to blood and body fluids and risks related to Human Immunodeficiency Virus (HIV), and Hepatitis B Virus.

Policy:            

Due to possible risks of acquiring infectious diseases during the postgraduate medical education such as HIV (Human Immunodeficiency Virus), HBV (Hepatitis B Virus), residents should be informed of universal precautions, exposure procedures, and treatment available at each of the residency teaching hospitals (Carle, Covenant, and Department of Veterans' Affairs Medical Center, Danville). Residents should also become familiar with provisions and limitations of their personal health insurance plan. The following policy applies to all University of Illinois College of Medicine at Urbana-Champaign postgraduate medical residents, referred to hereinafter as the subject group.

  1. Residency programs sponsored by the University of Illinois College of Medicine at Urbana-Champaign endorse the precepts and recommendations as they apply to the subject group that are contained in the Association of Program Directors in Internal Medicine position paper on AIDS (July 14,1989). Attachment #1 contains a summary of the precepts and recommendations contained in this position paper.
  2. As part of the educational program the subject group will receive and familiarize themselves with information about HIV and viral hepatitis, specifically about methods by which these agents may be transmitted in the educational setting and how to prevent such transmission. They shall also be provided and familiarize themselves with each affiliated institution's blood and body fluids exposure policy and procedures to be taken if exposed. As part of the postgraduate medical curriculum, residents will receive a series of informational and practical sessions regarding preventive measures before exposure and follow up procedures after exposure to these agents. The associate residency directors at each teaching hospital site will monitor their affiliated institution's policy, will identify procedures for individuals to take after exposure that will include providing immediate treatment and counseling, and will keep records of all subject groups exposures.
  3. Routine or mandatory HIV testing of the subject group is not recommended. All residents are encouraged to undergo personal assessment to determine their need for HIV testing. Testing must be on a voluntary basis. This assessment should include known high-risk behaviors as well as risks associated with health care related occupational exposure. If individuals in the subject group are at risk they should learn their HIV status in order to protect and improve their health and to receive appropriate counseling. All persons in the subject group who are infected with HIV or HBV should report that information to the Residency Director, who will regard the information as confidential and privileged. In such circumstances, the Residency Director should ascertain that the seropositive resident has ready access to consultants with expertise in management of AIDS or HBV. All confidentiality laws shall be followed to protect the identity of HIV infected residents.
  4. All persons in the subject group who are potentially exposed to HIV and viral hepatitis in the course of their medical education should follow the routine teaching site defined reporting procedures and shall also report the exposure incident on a U of I Employee Injury Report Form. Medical care and counseling will be provided on site as per site policy (attached).
  5. Exposed individuals will be able to receive on site primary injury treatment and management. This should include, but not be limited to: wound care; tetanus prophylaxis, if indicated; follow guidelines for hepatitis B exposure; obtain a reference serum sample from all exposed individuals, if possible; assessment of the degree the individual is at risk from the type of exposure; arrangement for counseling; and information and recommendations for antiretroviral prophylaxis (protocol, dosage, duration, side effects, potential long-term effects, and pros versus cons of prophylaxis). Antiretroviral medications will be made available if recommended and desired (written consent given) to the subject group at all affiliated institutions for prophylaxis after blood/body fluid exposure.* If the exposure risk warrants, counseling is provided, and the resident signs the voluntary consent form, the resident will be able to receive sufficient dosage of antiretroviral medications (if desired and within four hours of exposure, if possible) until source testing can be completed. The University of Illinois will be responsible for only initial and immediate associated expenses (those not covered by insurance or by the hospital where the exposure occurs) incurred during primary injury management including the primary injury management itself, appropriate immunizations, and serologic procedures of the source and exposed individuals, antiretroviral medications, and physician consultation. The faculty infectious disease subspecialist on call will be available as a resource in cases where policy implementation is questioned.
  6. The established University long-term disability program shall apply to employees. COM-UC will inform the subject group of the current coverage provided. (Current policy provides coverage only for employees with two years service.) The COM-UC will encourage its residents who are at risk for exposure to purchase appropriate additional insurance.
  7. The UICOM-UC will distribute this policy to the subject group and to each affiliated institution where a subject group may be at risk. The Residency Director will be responsible for the development of specific site procedures and the distribution of those procedures to the subject group.
  8. This policy will be reviewed on a periodic basis by the Section of Infectious Diseases and a report submitted to the Graduate and Continuing Medical Education Committee. Reviews will include a review of adherence to each recommendation and the circumstances, management, and results of each policy, relevant to exposure and recommendations for policy revision as appropriate.

7/30/01

Summary of the Position Paper on AIDS by The Association of Program Directors

in Internal Medicine (APDIM)

General Educational Program

Counseling Services for residents should be available from individuals with the expertise to address the emotional and psychological stresses embodied in the care of patients with HIV-related diseases. Special attention should be given to the resident who expresses reluctance to participate in patient care and in educational programs concerned with HIV-related individuals. Residents must understand that the obligation to provide care to all patients, regardless of personal risks, whether real or perceived, is deeply rooted in medical history and medical ethics. Open discussion with the reluctant resident by the residency director or other senior faculty members adept at counseling is often helpful and reduces resident fear.

Special Features of the Educational Process

Residents should learn to incorporate into their practices, procedures for taking complete sexual histories of their patients. Residents must discuss the sexual preference and partners of their patients. They should understand the terminology of specific groups of whom they are dealing, whether these be heterosexual, homosexual, or bisexual. Residents should not make assumptions about the patients sexual orientation without appropriate questions. Residency directors should encourage residents to participate in public education programs and community-wide efforts intended to eliminate general misconceptions about AIDS and to diminish public and professional anxiety about the disease.

Confidentiality

Residency directors must impart to all residents, the concept of patient confidentiality and emphasize the individual patient's right to privacy. Residents have an obligation to maintain the confidentiality of their patient's records and should never disclose information to outside sources.

In those circumstances where the health and welfare of individuals supersedes responsibility to maintain confidentiality, the resident under the supervision of the attending physician. should inform present or recent sexual contacts, persons with whom an HIV-positive has shared needles. or other persons likely to have contact with the infected person's blood or body fluids. Since the conflicts that exist between the obligation of confidentiality and the obligation to warn potentially exposed individuals are troublesome, input from the institution's Ethics Committee might be beneficial. Residents who convert or arc found to be sero-positive deserve the same respect for confidentiality and individuals rights of privacy as non-health care workers. While the residency director or department head should be advised of the resident's serologic status, that information must be regarded as confidential and privileged and never disseminated. In such circumstances, the residency directors should ascertain that the sero-positive resident has ready access to consultants with expertise and management of AIDS and to an appropriate counselor.

Special Considerations: Testing of Residents For HIV Antibody

Mandatory or routine testing of residents is not recommended. All residents should have available on a voluntary basis the right to be tested for WV-infection. If a resident has exposure to blood or certain other body fluids through percutaneous inoculations or contact with non-intact skin or mucous membrane, prompt evaluation and follow-up should be arranged. Current public health service guidelines should be reviewed. Baseline testing for the resident for HIV-antibodies and serologic testing is advised. Exposed individuals should follow precautions to prevent transmission of HIV to others pending results of follow-up testing. An ethical dilemma arises when a resident sustains exposure to a known patient source and the patient refuses to consent to an HIV-antibody test. The APDIM agrees with the American College of Physicians and the Infectious Diseases Society of America that in situations of accidental exposure, the patient's blood may ethically be tested for HIV antibody without the individuals informed consent. The patient should be informed and counseled if this is deemed necessary. State laws on testing for antibodies without the individuals informed consent are variable, so residency directors must be informed on the legality of such action in their state.

Sero-positive Resident

Confidentiality is essential. The sero-positive resident should be treated as any sero-positive patient. If otherwise able to care for patients, the HIV-infected resident should be permitted to do so. Residents present virtually no risk of HIV transmission to patients provided they observe the principles of universal precautions regarding blood and body fluids advocated for all health care workers. When an HIV-positive resident begins to manifest physical or cognitive impairment that interferes with assigned responsibilities, the residency director or counsellor should advise against further continuance of study.

Exposure to HIV-positive Material

Any resident who sustains accidental percutaneous or mucus membrane exposure to infected blood, secretions or other body fluids should be encouraged to test voluntarily for HIV-antibody. Testing of the exposed resident should be done at the time of exposure and then 6 weeks, 12 weeks, and 6 months later. The department head and/or residency director should be informed of any documented or perceived exposure by the resident and appropriate counseling should begin even before test results are available. Exposed individuals should follow precautions to prevent transmission of HIV pending test results.

Pregnant Resident

Provided the pregnant resident adheres to the principals of universal precaution regarding blood and body fluids, no special precautions are needed.

Reluctant Resident

The stressful, psychological, and emotional dimensions that caring for patients for HIV-related diseases and the fear of infection of the HIV virus are often the major reasons for resident's reluctance to care for such patients. Counseling with an experienced attending should be arranged.

Homosexual or Bisexual Residents

Confidentiality and individual privacy are principles that pertain for health care providers including residents as well as for patients. Such individuals should not be indiscriminately identified or singled out. Should a patient refuse care or attention by a resident because the patient questions the resident's sexual preference, the residency director or attending physician should intervene immediately and directly with the patient. In a diplomatic yet firm manner, the attending should use the occasion to educate the patient about HIV-related diseases and the public misconceptions that surround the disease.

Recommendations

  1. Residency directors should assume the responsibility to assist residents to address and cope with their fears and prejudices in treating HIV-infected patients. The residency director should articulate a clear policy which emphasizes the resident's responsibility to provide care to all patients without regard to the nature of their illness.
  2. Residency directors and faculty have the responsibility to provide information and educational programs for residents about HIV-infection. These should include:
    • Up-to-date information on the modes and risks of transmission of the virus.
    • Training in the universal precautions methods employed in clinical settings. and in the monitoring of compliance.
    • The policy to be followed in the event of potential exposure.
    • The appropriate facilities, equipment, and personnel needed to avoid unnecessary risks.
    • Counseling to those who express reluctance to participate in the education and patient care of HIV-infected individuals.

3. Residency directors and their institutions should articulate a policy on HIV-screening and on the HIV-positive trainee.

    1. Mandatory screening of residents should not be initiated.
    2. Residents and faculty at risk of HIV infection should be encouraged to seek testing and counseling.

4. Residency directors should insure that HIV-infected residents have access to:

    • Expert medical care and counseling.
    • A designated member of the faculty with whom to discuss, confidentially, career activities, and plans.
    • Support and individualized educational and career counseling.

5. Residency directors should establish policies and procedures to insure confidentiality and appropriate handling of information related to a person's HIV status.

    1. Clearly defined, confidential means of communication and information storage should be established.
    2. The rights and welfare of the individual patient are always of first concern so that information about a resident or HIV positive patient should be shared only to a degree necessary for the effective implementation of policies.

June 29, 2001

IMMUNIZATION REQUIREMENTS

      Trainees are expected to provide documentation of infection control requirements prior to entering the residency. To protect the health of trainees, patients and staff, the following documentation is required:

ANNUALLY:

      Tuberculosis: Skin test yearly. Chest x-ray if positive (baseline on file in C-U. Repeat x-ray for pulmonary symptoms).  Mask fit-testing is required yearly.

      Influenza: Yearly vaccination strongly recommended.

INITIALLY:

      Universal Precautions and Infection Control:  Each trainee will receive instruction and mask fit-testing.

      Rubella: Documentation of immunity or of live immunization after 1969 is required.

      (German Measles)

      Rubeola (Measles): 1) Two doses of live vaccine (can be MMR) separated by at least one month. First dose must have been given as of January 1, 1968 or later, and on or after the first birthday; or one of the following:
    1. report of immunity by titer presented to program office; or
    2. born before 1957; or
    3. disease confirmed by physician; or
    4. physician's statement of contraindication.

    Mumps: Immunization or proof of immunity required.

    Hepatitis B: Vaccine, or proof of immunity required. Hepatitis vaccine is available at program expense if obtained through Veterans' Hospital (program will not pay for immunization at other sites or location).

    Diphtheria Tetanus: Documentation of immunization every ten years required.

    Varicella: Titer to determine immune status.Varicella titer is available at program expense if obtained through Carle Laboratory via Employee Health Service (varicella titer). Varicella vaccine available at program expense for those without documented immunity.

If deficiencies exist, the trainee should contact his/her primary physician or the Danville Veterans Administration Illiana Health Care System (DVAIHS).

When planning return trips to native countries, residents should consider travel immunizations for themselves and family, treating self as any clinic patient who would be requesting travel to that country.

(7/30/01)