Emergency workers exposed to bodily fluids have better protections: Kendall.
By Andrew MacLeod, Yesterday, TheTyee.ca
Provincial Health Officer Perry Kendall has sent a letter to all British Columbia MLAs advising them against voting for a bill aimed at helping people who respond to emergencies.
The bill won't succeed at preventing any infections as it intended to, and it may well increase the risk, he said.
The Emergency Intervention Disclosure Act would allow police, firefighters and paramedics to use a court order to force someone to give a blood sample if they've been exposed to that person's bodily fluids during the course of their work.
Labour, Citizens' Services and Open Government Minister Margaret MacDiarmid, who worked as a family physician before entering politics, introduced the bill on April 30. Both government and opposition MLAs have expressed support for the bill, while noting the concerns raised by Kendall and Information and Privacy Commissioner Elizabeth Denham.
"I fully recognize that elected officials have the final authority over what they choose to enact legislatively," Kendall wrote in his May 1 letter. "But I respectfully submit that there are some substantive public health and policy issues that may not have been fully appreciated in discussions so far. I am setting out my concerns in order to ensure that your decisions may be fully informed."
No infection reduction
Kendall began by saying he has "nothing but respect" for first responders and that he recognizes the risk their work brings of exposure to blood and bodily fluids that may contain pathogens, and the anxiety those exposures can bring.
But after four pages bringing a medical perspective to the question, he concluded, "It should be apparent that the actions available under this proposed Act will in no way reduce the risk of infection or result in any fewer episodes of occupational disease transmission."
Moreover, he said, "A case could be made that passage of the Act could result in increasing such risk if an exposed First Responder relied upon knowing the infection status of the source prior to initiating post-exposure prophylaxis."
The main concerns are HIV, hepatitis B and hepatitis C, he said. "There is an alternative resolution to these concerns that obviates the need to seek a court order overruling an individual's right to refuse to submit to diagnostic testing, and alternative that has a lower likelihood of unwanted adverse consequences."
There is a vaccine for hepatitis B that all first responders should have, he said. If they are exposed, they should take immune globulin, which "virtually guarantees 100 per cent protection from recent and future exposures."
Better options for treatment
In the case of HIV, the treatment should start much quicker than the time it would take to force and get a blood test, Kendall said.
"Post-exposure prophylaxis is highly effective and with newer medications, well-tolerated, should be started within two hours, and is recommended to continue for 28 days," he said. "Waiting for test results from a source person could result in a preventable HIV infection occurring, and even a negative test result of a high risk source does not guarantee that the source is not infected due to the possibility of false negative tests."
As for hepatitis C, there is no vaccine or prophylaxis available. "Post-exposure management recommends follow up to ascertain whether infection has occurred and to institute antiviral therapy if so confirmed," Kendall wrote.
The letter notes that WorkSafeBC figures show that since 1987 there have been 47 cases the agency has followed where first responders have been exposed to blood.
"There is thus a statistically small, but very real risk, and that must be taken seriously," said Kendall. "I suggest that addressing this risk can better be done by ensuring that first responders are educated about, have access to, and utilize universal precautions, pre-exposure prophylaxis where applicable, the most up-to-date diagnostic testing technologies and evidence-based post-exposure follow up."
With the most recent testing technology, known as Polymerase Chain Reaction, an infection can be found within the first responders' own blood within two weeks, Kendall said in a May 4 interview.
Forcing a person to give a sample through a court order under the proposed law would require would likely take longer, he said. "It's hard to imagine this happening in a period of time that's less than two weeks."
Practice won't change: MacDiarmid
A new generation of testing that will give results quicker is on its way, but is not yet commonly available, said Minister MacDiarmid. "We're not there at this point."
The new law will not replace the current practice, she said. "They still take all the precautionary steps."
First responders do take precautions to prevent exposure to people's bodily fluids, but it's not always possible, she said, giving the example of a paramedic arriving at a car wreck who cuts himself badly while reaching in to help someone in the vehicle.
It's also standard to go on a prophylactic treatment right away when there's been an exposure, she said.
But first responders have said they want the peace of mind a law like the one B.C. is debating would bring, she said. "I think it's really hard to dismiss that... To say there's no benefit at all, I find that quite difficult."
In most cases people will give a sample willingly, but for those rare times when they won't first responders would like to be able to compel them, she said. In Alberta, which has a similar law, it has only been used twice, she said.
"We do recognize if someone doesn't want to reveal that information, there's a privacy element to it," she said. "It's a place where we've tried to find a balance."
The majority of the MLAs support passing the bill, she said.
Support for first responders, says NDP
Indeed, when the bill came up for second reading debate on the morning of May 3, three NDP MLAs acknowledged the concerns outlined in Kendall's letter, but said they would support the bill regardless.
They included Michelle Mungall from Nelson-Creston, Jagrup Brar from Surrey-Fleetwood and health critic Mike Farnworth.
"I think it's important that we do address some of the issues [Kendall] has raised in committee stage of the bill," said Farnworth, according to Hansard. "But I think, on balance, this is a bill that strikes just that -- the right balance between the needs of our first responders in this province and the issues around privacy. I think this bill does achieve that balance, and that's why I'm pleased to support it."
The bill sends a "strong message to first responders" in the province, he said, "that members of this House have been listening to their concerns and have put forward a piece of legislation that I think meets those needs. At the end of the day, that should be what governing is about."
Certainly the bill has the support of first responders. At least a dozen, in uniform, were in MacDiarmid's office the day she introduced the bill, and reporters received printed testimonials from 14 across the province who had been exposed to bodily fluids while on the job.
One, for example, was from Lee DePellegrin, the president of the Trail Fire Fighters, who told of a colleague who while at the station had a man spit "blood and bodily fluids" in his unprotected face. The fire fighter got treatment, but didn't have peace of mind, he said. "Although the prophylactic treatment was the responsible course of action in this case, there was and is always a doubt etched in the back of the fire fighter's mind about whether he was actually exposed to a communicable disease or not."
If the person who spat at the fire fighter had been confirmed to have an infection, "then the appropriate specific treatment for the type of exposure could have been administered, as opposed to the general prophylactic cocktail," DePellegrin said.
Had the person tested negative, "a treatment may very well have happened anyway, but the big difference is the fire fighter would have confidence that after the treatment and subsequent tests, they could live a life without doubts and fear."
Provincial Health Officer Kendall, however, pointed out that sense of reassurance may be misplaced. "It won't reduce infection," he said. "The only benefit of the knowledge would be if you could get it in time and you trusted it."
In the case of HIV, for example, knowing a person didn't have it might allow the first responder to stop taking the drug therapy sooner or to return to having sex without a condom with a regular partner. However, there's a "window period" where an infected person won't test positive, so it would not be advisable to trust that first test, he said.
The government's bill is well intentioned, he said. "For all its good intentions, it may well have negative side effects that outweigh those good intentions."
Kendall in his letter also said the bill also "carries with it the spectre of possible re-exacerbation of AIDS phobia, and the further stigmatization of certain classes of individuals."
Information and Privacy Commissioner Elizabeth Denham last week wrote to MacDiarmid saying the small benefit from the bill does not outweigh the privacy invasion of requiring a medical test, The Tyee reported. "[It] subjects individuals to a process of looking for disease that is highly privacy invasive while providing little to no demonstrable benefit to the emergency responder," she said.