Clinical and occupational health management of healthcare workers living with chronic hepatitis B: UK policy and international comparisons

Hepatitis B virus (HBV) is a highly infectious bloodborne virus, which remains endemic in large geographic areas and represents a major global healthcare challenge. HBV transmission from healthcare workers, who perform exposure prone procedures (EPP), to patients is a recognized transmission risk, which varies widely globally. Although the risk is small in developed countries, it increases significantly in high‐prevalent, low‐resource countries, representing a major challenge to these healthcare systems and underlining the necessity for robust guidance to be in place. The HBV landscape has evolved as a result of global vaccination programs, implementation of standard precautions and the advent of new generation antiviral agents (3rd generation nucleos(t)ide analogues). In light of the progress in the field, the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP) recently issued updated guidance, which essentially removes past barriers, restricting healthcare workers from performing EPPs solely on the basis of HBV DNA level, regardless of hepatitis B ‘e’ antigen and/or treatment status. Although the current recommendations remain conservative compared to those of other developed healthcare systems, UK practice is now in line with other high‐income countries, while ensuring patient safety remains paramount, without unduly restricting HCWs from clinical practice. The current article presents the latest UKAP guidance, considers its implications for HCWs and compares it with the guidance from major international scientific societies and governing bodies.


| INTRODUC TI ON
Hepatitis B virus (HBV) is a highly infectious bloodborne virus that remains endemic in large geographic areas, with a third of the global population estimated to have been exposed to the infection at some point in their lives. For a healthcare worker (HCW) to transmit HBV to a patient, it is accepted the HCW must be sufficiently viraemic and there must be direct contact between the HCWs body fluids and/or blood and the patient's tissues or mucous membranes. At a population level, risk of transmission in the context of healthcare will depend upon the population prevalence of HBV, the use of standard precautions during procedures and the provision of an occupational health policy for HCWs. The risk of transmission to patients in a developed, low-prevalence nation is low. Nonetheless, minimizing this risk to patients is an important role for occupational health physicians, and an ethical duty for all healthcare workers to ensure their patients is not put at undue risk. In areas with high HBV prevalence, often coupled with limited healthcare resources and challenging environments to maintain appropriate infection prevention and control, the problem of transmission from HCW to patient and vice versa as well as patientpatient transmission constitutes an area of public health concern.
Guidance and support for the management of healthcare workers living with blood-borne viruses in the United Kingdom are provided by an independent advisory committee called the UK Advisory Panel for Healthcare Workers infected with Bloodborne Viruses (UKAP). In 2020, UKAP issued updated guidance on the management of HCWs living with bloodborne viral infections. Importantly, a significant change was made to the guidance, in light of the availability of more effective treatments for HBV infection that removed restrictions on practice, provided the HCW living with HBV is compliant with certain clearance conditions. 1 The recent UKAP's key recommendations are summarized in Table 1.

| CURRENT UK CLINI C AL AND O CCUPATI ONAL HE ALTH G U IDAN CE FOR HE ALTH C ARE WORK ER S LIVING WITH HEPATITIS B
Healthcare workers in the UK are offered screening for HBV serology as part of occupational health clearance. Testing for hepatitis B surface antigen (HBsAg) is mandatory for those wishing to perform exposure prone procedures (EPPs). Individuals that are negative for HBsAg are offered immunization with subsequent assessment of hepatitis B surface antibody (anti-HBs) titre. HCW for whom HBV vaccination is contra-indicated, who decline vaccination, or who are non-responders to vaccination (i.e. anti-HBs <10 mIU/mL) is restricted from performing EPPs unless shown to be non-infectious with regular ongoing the centre of UK policy and the latest guidance maintains this, while simultaneously removing unnecessary restrictions for HCWs. In view of the UK's revered track record in public health policy, we believe the present article may act as a springboard for health policymakers to consider issuing relevant guidance, especially in low-resource countries where recommendations are lacking.

Hepatitis B serology UKAP recommendations
HBsAg negative -offer vaccination, unless already vaccinated or acquired natural immunity through past HBV infection -assess response to vaccination (anti-HBs) -in case vaccination is contra-indicated, HCWs decline vaccination or are non-responders (anti-HBs <10 mIU/mL), annual HBsAg assessment is required in order to give clearance for performance of relevant duties  While patient safety must remain the paramount concern of any public health guidance, policy makers are obligated to consider developments in the field to ensure the delivery of a safe service and concurrently minimize restrictions on HCWs. With the recom-

| THE IMPAC T OF PRE VENTIVE ME A SURE S ON REDUCING RIS K OF HBV TR ANS MISS ION FROM HE ALTH C ARE WORK ER S TO PATIENTS
Over the last two decades, there has been significant progress in implementing 'Standard Precautions' to minimize the risk of bloodborne virus transmission in clinical practice, including but not limited to the use of protective equipment, double-gloving, wider use of single-use equipment and more effective cleaning standards. 8 and not on HBeAg status, and adopts a cut-off level of equal to or higher than 1,000 IU/mL. This is in recognition that HBV DNA is a more sensitive marker of infectivity than the presence or absence of HBeAg. 13 As previously discussed, UK-based HCWs with CHB are restricted from performing EPP if HBV DNA level is equal to or exceeds 200 IU/mL. This is more cautious than the 1,000 IU/mL SHEA cut-off, the cut-off of 10 4 geq/mL (2,000 IU/mL) proposed by the European Consensus Group and the cut-off of 10 5 geq/mL in the Netherlands. 4,13,14 According to data published in 2008, it was estimated that this lower threshold would have restricted practice of 58% of HBV-positive HCWs in the UK and >94% in the Netherlands, if adopted. 15 Notably, guidelines from the United States and the European Association for the Study of the Liver (EASL) do not restrict HCW on antiviral therapy from performing EPP based on the pre-treatment viral load. 5 The UK with its longstanding track record in patient safety and occupational health has always sought to adopt the most stringent guidance with patient safety being paramount. The HBV field is now on the cusp of major change with multiple new therapeutic agents to achieve functional cure (sustained HBsAg loss) in the developmental pipeline. Therefore, these are timely changes to the UK guidance to ensure patients are protected from viral transmission through EPP, which in some cases could be catastrophic.
Combined with the drive to eliminate HBV, the latest guidance will protect patients, but will not be overly restrictive on HCWs who can still make a major contribution to the NHS. Importantly, given the relatively small numbers of HBV-infected HCWs in the UK, the changes in policy have not overburdened occupational health departments.
In areas of high population prevalence of HBV, the risk of transmission from patient to HCW is significant and possibly even greater than the risk to the patient, given that the risk of infection from patient to HCW is not limited to the context of EPP and percutaneous exposure is common. 12

ACK N OWLED G EM ENTS
The current article is written on behalf of the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP). Fortune Ncube for their input, support and commitment to undertaking this review.

CO N FLI C T S O F I NTE R E S T
None declared for this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analysed in this study.