These guidelines were developed and adopted by the ACFD to serve as a resource to assist ACFD Member Institutions in the development of their institutional policies.
Entry into the healthcare professions is a privilege that carries a responsibility to do no harm.
Direct patient care, including invasive procedures, is required during the educational programs of dental professionals (1-4). This places patients and healthcare workers (HCWs) at increased risk of transmission of infections including airborne diseases, and bloodborne pathogens (BBPs) – HIV/AIDS, hepatitis B virus (HBV) and hepatitis C virus (HCV) (5-7). Faculty and students should have the appropriate immunizations and the necessary training in infection control and Standard Precautions to minimize the potential for cross infection and the risk to patients, clinical students, faculty and staff (5-8).
Many HCWs including dental workers are reluctant to treat patients with BBPs – especially HIV/AIDS (9-13).
The Calendars of Faculties/Schools of Dentistry should inform potential applicants that:
- students will be required to treat patients with infectious diseases (including HIV, HBV and HCV) should they be assigned to them;
- applicants need to fulfil requirements related to health status – including infection with HBV, HCV and HIV – and immunizations (see below).
- it is not possible to complete the DDS clinical program necessary for graduation without performing invasive / exposure-prone procedures.
- students and applicants with HIV-related health problems, hepatitis B or other infections may be unable to practice dentistry safely and competently.
HCWs including dentists and hygienists are at risk for exposure to blood-borne pathogens (7, 14, 15). Healthcare students are also vulnerable to exposures (16-20) especially those in dentistry (21, 22). Dental students are at higher risk for needle-stick injuries than are experienced practitioners (23). As such, this should be considered in the development of institutional infectious disease policies. There are vaccines to protect against HBV and other infections and a policy of mandatory immunizations and screening of HCWs and trainees protect patients, students and HCWs.
HCWs, including dental workers, who do invasive procedures have an ethical obligation to know their own infectious disease status and to be medically assessed for risk of transmission of any infection (5). Despite this, less than 60% of HCWs report knowing that they are immune to HBV (24).
Acceptance into a dental program should be contingent upon completion of appropriate immunization and screening.
Policies for international and Canadian applicants should be the same.
Recommended Immunization Guidelines (6, 25-31):
Faculties or schools should have an immunization policy in place for students and student applicants. It is recommended that students seeking entrance into any healthcare programs provide the following information:
Diphtheria and tetanus
Completion of a primary series of at least 3 doses of a combined tetanus, pertussis and diphtheria preparation and booster within the last 10 years is required.
Completion of a primary series of at least 3 doses of oral polio vaccine or inactivated polio vaccine is required.
Completion of two doses of measles vaccine or documented proof of disease (i.e. presence of measles IgG) is required as evidence of protection. Adults born after 1970 without a history of the disease require at least 1 dose of MMR (measles-mumps-rubella) vaccine.
Completion of at least one dose of mumps vaccine or documented proof of disease (i.e. presence of mumps IgG) is required. If non-immune, 1 dose of MMR vaccine is required.
Completion of at least one dose of rubella vaccine or documented proof of disease (i.e. presence of rubella IgG) is required. If non-immune, 1 dose of MMR vaccine is required.
Completion of 1 dose (before age 13) or 2 doses (if given after age 13) of varicella vaccine, or proof of the disease (i.e. history of varicella or presence of varicella zoster virus IgG) is required.
Negative two step tuberculin skin test (TST) within the last 12 months is required. If there is a previously documented positive TST, previous treatment for active TB or treatment for latent TB, medical evaluation is needed to deem the person non-contagious.
Completion of a HBV-containing (hepatitis B virus) vaccine series and documented seroconversion with antibodies to hepatitis B surface antigen (anti-HBs) is required. Testing should be done at least one month (but no later than six months) after the final immunization in the series. Lack of seroconversion requires revaccination and reassessment for immunity. If a healthcare worker never before tested is found not to have protective antibody, re-immunization with a full series of hepatitis B containing vaccine is indicated (27).
HBV immunization is not required if there is evidence of immunity due to prior infection (anti-HBs positive and/or antibodies to hepatitis B core antigen [anti HBc] positive).
Recommended Guidelines for Student and Student Applicants with Infectious Diseases
Compared with HCV or HIV, transmission of HBV is the greatest hazard in healthcare settings to those who are not immune (5, 32-35). The presence of HBeAg indicates a high risk of infectivity (5, 34, 36, 37). Among HCWs who sustained injuries from needles contaminated with blood containing HBV, the risk of developing clinical hepatitis if the blood was both HBsAg-positive and HBeAg-positive was 22%-31%. By comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive, HBeAg-negative blood was 1%-6% (34). Estimates of the risk of disease transmission after needlestick injuries contaminated with HCV or HIV are approximately 2% and 0.3% respectively (34, 38, 39). Healthcare workers, including students, who are infected with HCV, HIV, or HBV with no evidence of HBe antigen or a high viral load (>103 genome equivalents/mL) are considered low risk for transmission (5, 38, 40-48).
Applicants who are HBsAg-positive and HBeAg-positive or who have a viral load greater than 103 genome equivalents/mL should NOT be accepted into clinical programs.
Applicants who are HBsAg-positive but HBeAg-negative can be accepted, but should receive counselling before beginning the clinical program
Non-responders (non-immune) to the hepatitis B vaccine should be tested on a regular basis for the presence of HBeAg and viral DNA and be removed from direct patient care activities if found to be positive for HBeAg or if they exceed a viral load greater than 103 genome equivalents/mL.
Current recommendations should be followed in the event of exposure to a non-responder (27).
Applicants who are carriers of Hepatitis C can be accepted, but should receive counselling before beginning the clinical program
Human Immunodeficiency Virus (HIV)
Applicants who are HIV positive can be accepted but should be counselled before admission to clinical programs. Students with risk factors for HIV should be counselled to seek HIV testing on a volunteer basis.
Communicable Disease Status
Any student or student applicant with an infectious disease (6) has a moral and ethical obligation to inform the appropriate authority in their educational institution to receive appropriate counselling and recommendations. This is consistent with the Canadian Dental Association’s Code of Ethics (49). In addition, there may be further specific reporting requirements in the various provincial jurisdictions (5).
The confidentiality of the infected student should be maintained. The name of the infected student requiring counselling cannot be divulged without permission of the student.
HCWs exposed to HIV, HBV or HCV should be advised to follow current recommendations for postexposure prophylaxis (34).
2006 Ad Hoc Committee on Infectious Diseases and Health Care Workers
Blaine M Cleghorn, Chair
2009 Ad Hoc Committee on Infectious Diseases and Health Care Workers
Blaine M Cleghorn, Chair
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Adopted Feb 2010 – To be Revised 2014