Blood Borne Viruses – Update: New Policy Approved

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    Stakeholder feedback

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    View the comments posted to our online discussion page

    Our Process

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    The College’s Blood Borne Viruses policy received final approval from Council on December 3, 2015, and is now an official policy of the College of Physicians and Surgeons of Ontario.

    We would like to thank all those who submitted their feedback and contributed to this policy review. While not every comment or suggested edit was incorporated into the final policy, all comments were carefully considered in light of current practice issues, the values and duties of medical professionalism, and the College’s mandate to protect the public.

    Below is a brief summary of the policy review process, including an overview of the feedback received and revisions undertaken:



    Who we heard from

    • 42 submissions were received in response to this consultation.
    • While the majority of feedback was received from individual physicians (32 responses), we also heard from a number of other important stakeholders, including other Canadian medical regulators, Public Health Ontario and the Professional Association of Residents of Ontario and 4 members of the public.
    View the feedback: Survey reportWritten Comments

    What we heard

    Other important considerations

    • The majority of feedback received during the consultation was supportive of most of the provisions in the draft policy, the one exception being the provision regarding periodic testing for HCV and HIV.
    • Of those respondents who had concerns with the draft policy, the following comments were made:
        • Scope section: needs to be clarified; remove emergency physicians from the scope section.
        • Include a requirement for patients to be tested.
        • It is unnecessary to test for blood borne viruses before a physician begins performing or assisting in performing exposure prone procedures.
        • College processes for seropositive physicians should be made clearer.
    • There were polarized views with respect to the section of the draft policy that requires testing for HCV and HIV every 3 years.
        • Some respondents were supportive of the new provision and stated that this is an improvement over the current policy’s requirement for annual testing.
        • Some respondents advocated maintaining the current position of annual testing.
        • Some respondents were opposed to the testing requirements and had the following comments: the requirements contradict the SHEA guideline; initial testing and testing post-exposure should be sufficient; there should not be any testing.
        • Some respondents asked why was a three year testing interval was chosen and whether it was based on evidence.
    • In addition to the feedback, we considered a wide range of other information while developing the final policy. This included:
        • Policies and guidelines of other organizations, including other Canadian medical regulators.
        • A review of the literature on the transmission of blood borne viruses.
        • Data obtained from the results of the Annual Renewal Survey from 2013 and 2014.

    How we responded to your feedback

    • The main policy positions were retained; however, revisions were made to the draft policy to enhance clarity and comprehensiveness. These revisions are highlighted below:
    • The Scope section has been clarified to explain why the policy only applies to procedures that are exposure-prone and that post-graduate trainees are included in the policy.
    • Wording has been added to the section on Testing Post-Exposure which encourages physicians to consult their hospital’s protocols and/or policies (in addition to the Blood-Borne Diseases Surveillance Protocol for Ontario Hospitals) for information on post-exposure protocols. As well, we clarify that expert advice must be sought regarding prophylaxis treatment in addition to advice regarding frequency of testing.
    • Wording has been added to clarify that physicians must comply with precautionary measures recommended by public health authorities.
    • Most of the revisions are found in Appendix A of the draft policy which sets out College Practices regarding blood borne viruses. It has been revised to clarify and make more transparent the current processes at the College regarding confidentiality and privacy of physician information pertaining to blood borne viruses as well as the College’s processes regarding evaluation of seropositive physicians’ practices and imposition of practice restrictions.

    The final policy

    • The Blood Borne Viruses policy received final approval from CPSO Council on December 3, 2015. It is now a formal policy of the College of Physicians and Surgeons of Ontario.

    Read the Final Policy

    Key messages of the final policy:

    • It is important for a physician who performs or assists in performing exposure prone procedures or who has the potential to perform or assist in performing exposure prone procedures to know his or her status in regards to whether they are infected with a blood borne virus not only to safeguard physicians’ health and that of their patients, but also to ensure that patient and public trust in the profession is maintained.
    • The policy sets out a number of expectations including testing and reporting requirements in order to meet this goal.
    • The testing requirements include: being tested for HCV and HIV every 3 years; being tested for HBV annually if a physician has not been confirmed immune to HBV; and testing for HCV, HIV and HBV, if they haven’t been confirmed immune to HBV, before they commence performing or assisting in performing exposure prone procedures in Ontario.
    • The policy sets out the College processes regarding confidentiality and privacy as well as the processes regarding the evaluation of seropositive physicians’ practices.