Hepatitis B and Med School

[doireallyhaveto]

So here is my story:

I contracted HBV as a new born and was an active chronic carrier until I received interferon treatment when I was about 13. At that time I cleared the HBeAg and developed anti-HBeAg and became an inactive carrier (I still remain HBsAg +). My quant. DNA levels have remained between 10,000 and 30,000 which is considered very low and stable. The levels are so low that my physician (who is the head of the liver disease clinic at NIH) said that anything short of a blood transfusion would unlikely cause infection.


Now I told him that I would be attending medical school this coming fall. He approved and told me point blank: "DO NOT tell anyone that you have Hep B unless you are required to. There is a lot of prejudice and ignorance surrounding Hep B. It is VERY treatable so dont worry."


My Question:
My school, like most schools, requires Hep B Vaccination. Do I go through the series and write down that I am vaccinated or do I try to avoid getting vaccinated via "religious exemption" (my religion does not support unnecessary vaccinations ) or something else?


My concern is that although the CDC does not recommend any precautions for an individual in my condition, some one might throw a hissy-fit that I have a touch of the hepatitis.

Thanks in advance for your advice!

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[decafplease]

I would follow your doctor's advice. Have you asked him the question you are asking us, specifically?

 

[MattD]

So here is my story:

I contracted HBV as a new born and was an active chronic carrier until I received interferon treatment when I was about 13. At that time I cleared the HBeAg and developed anti-HBeAg and became an inactive carrier (I still remain HBsAg +). My quant. DNA levels have remained between 10,000 and 30,000 which is considered very low and stable. The levels are so low that my physician (who is the head of the liver disease clinic at NIH) said that anything short of a blood transfusion would unlikely cause infection.


Now I told him that I would be attending medical school this coming fall. He approved and told me point blank: "DO NOT tell anyone that you have Hep B unless you are required to. There is a lot of prejudice and ignorance surrounding Hep B. It is VERY treatable so dont worry."


My Question:
My school, like most schools, requires Hep B Vaccination. Do I go through the series and write down that I am vaccinated or do I try to avoid getting vaccinated via "religious exemption" (my religion does not support unnecessary vaccinations ) or something else?


My concern is that although the CDC does not recommend any precautions for an individual in my condition, some one might throw a hissy-fit that I have a touch of the hepatitis.

Thanks in advance for your advice!

You could just get a titer done. Of course, when your titer shows antibodies but you have no record of vaccination, they'll probably figure it out...

I don't know that they would give you a 'religious exemption' as it's an issue of patient protection as well as protection of yourself. Also, you'd have to find clergy to write a letter enumerating your 'faith's' beliefs and why you can't get vaccinated. I don't think you could scam your way through that one Good luck to you at any rate!

 

[doireallyhaveto]

I plan to the next time I see him, but want multiple opinions... perhaps some personal experience

 

[Law2Doc]

Now I told him that I would be attending medical school this coming fall. He approved and told me point blank: "DO NOT tell anyone that you have Hep B unless you are required to. There is a lot of prejudice and ignorance surrounding Hep B. It is VERY treatable so dont worry."


My Question:
My school, like most schools, requires Hep B Vaccination. Do I go through the series and write down that I am vaccinated or do I try to avoid getting vaccinated via "religious exemption" (my religion does not support unnecessary vaccinations ) or something else?


My concern is that although the CDC does not recommend any precautions for an individual in my condition, some one might throw a hissy-fit that I have a touch of the hepatitis.

Thanks in advance for your advice!

Since pretty much all med schools require proof of Hep B vaccination/immunity, I think it's fair to say you are not permitted not to reveal this condition.

 

[MattD]

Since pretty much all med schools require proof of Hep B vaccination/immunity, I think it's fair to say you are not permitted not to reveal this condition.

Well technically, he has immunity to future infection

 

[Law2Doc]

and write down that I am vaccinated or do I try to avoid getting vaccinated via "religious exemption" (my religion does not support unnecessary vaccinations )

I promise you that more adcoms would take issue to a future doctor who is opposed to vaccination than they would to one with hepatitis. You are going to be expected to counsel your patients to get vaccines as a doctor. If you have a religious issue with them, some folks would see that as problematic.

 

[doireallyhaveto]

I dont actually have an religious issue with the vaccine per se, just I want to find a way around this potentially messy issue (and that was a little bit of a joke)

 

[Law2Doc]

Well technically, he has immunity to future infection

Sure, but by asking for proof of vaccination or immunity they are asking the question he doesn't want to answer. If they didn't ask about Hepatitis B at all, I would agree with you (eg if they don't ask about Hep C, then you probably will never have to mention it). But they do ask specifically about Hep B and want you to take steps to protect yourself and others from it. To not mention it in the face of that would be deceptive, at a minimum.

 

[MattD]

I dont actually have an religious issue with the vaccine per se, just I want to find a way around this potentially messy issue

What he's saying is that the lie would backfire on you..

Sure, but by asking for proof of vaccination or immunity they are asking the question he doesn't want to answer. If they didn't ask about Hepatitis B at all, I would agree with you (eg if they don't ask about Hep C, then you probably will never have to mention it). But they do ask specifically about Hep B and want you to take steps to protect yourself and others from it. To not mention it in the face of that would be deceptive, at a minimum.

Hence the smiley "I'm being a smartass" emoticon

 

[doireallyhaveto]

my doctor did at one point say "I guess we _could_ give you the vaccine... not that it would do anything, but it would give you a record of vaccination..."

And as I said before, concern of spread to others is minimal to non-existent, sexual contact wouldnt even spread the disease.

 

[Quix]

Well technically, he has immunity to future infection

Maybe. I'll confess my overall ignorance (I may be confusing HepB and C), but aren't there multiple strains of HepB, which could produce superinfection?

 

[doireallyhaveto]

Maybe. I'll confess my overall ignorance (I may be confusing HepB and C), but aren't there multiple strains of HepB, which could produce superinfection?

There is Hep D (??) co-infection but that generally only affects imuno-compromised individuals and is very rare... and of the other genotypes of hep b you are stuck with the one you got and mine isnt the super HBV genotype

 

[Jolie South]

wow, that's a tough situation. it seems like the only way to know the answer would be to ask a school, but then you'd be letting the cat out of the bag, wouldn't you?

i hope you get this figured out.

 

[QuantumMechanic]

Your medical information is supposed to be confidential so I don't know how this would be a problem. Its not like its Hep C or HIV anyway.

 

[Law2Doc]

Your medical information is supposed to be confidential so I don't know how this would be a problem.

Your record of vaccinations, titers and history of having this handful of illnesses isn't really confidential -- the school asks you point blank to provide them with this information as a condition to matriculation. It's not like a school can ask for evidence of immunity and you can say none of your business.

 

[0Complications]

I think the best advice hand down is to talk to your doctor about it. Ask what he recommends doing. Then go from there.

 

[nhtreehugger]

I think that you need to provide proof of immunity against Hep B, not proof of immunization. So contracting it at birth would make you immune in a sense. It's sort of like how people who always test positive for the skin TB test present their chest xrays as proof that they "are immune" (even though their not). ok, that wasn't a very clear explanation but I can't figure out how to make it better. If anyone more eloquent knows what I'm talking about, feel free to jump in

 

[Jolie South]

I think that you need to provide proof of immunity against Hep B, not proof of immunization. So contracting it at birth would make you immune in a sense. It's sort of like how people who always test positive for the skin TB test present their chest xrays as proof that they "are immune" (even though their not). ok, that wasn't a very clear explanation but I can't figure out how to make it better. If anyone more eloquent knows what I'm talking about, feel free to jump in

i thought that they did chest x-rays to show that there weren't any lesions/active infection.

 

[Bacchus]

i thought that they did chest x-rays to show that there weren't any lesions/active infection.

To show their is no active infection. You will still see the lesions but the immune system is keeping any tubercles from releasing microbacterium.

When it becomes extrapulmonary is when its alllllllllllll downhill.

 

[nhtreehugger]

i guess, i'll cross off pulmonologist from my potential career fields

anyways, back to the op, for hep B, you need to demonstrate immunity, so that the hospital doesn't have to worry about you suing their pants off when you get stuck with a needle. I don't think it's a matter of potentially infecting the patient w/ ur disease (even if it's hiv or hep c as a previous poster mentioned). Maybe I should have used chicken pox as an example. I work w/ kids and have to demonstrate immunity to chicken pox. I never got the vaccine, but I got chickenpox when I was little, so I demonstrate immunity. But like everyone else said, listen to ur doctor.

 

[doireallyhaveto]

agreed, I will ask my doctor... but he just put his fear into me with the "DONT TELL ANYONE!" comment

It is good to know that I have NIH behind me though, I think being on NIH's bad side will scare med schools more than any liability I may incur

 

[LadyWolverine]

OP,
I received the HepB vaccination when I was in high school. By the time I started graduate school (almost 10 years later), I had misplaced the original paperwork, and the doctor that I had visited as an adolescent for my vaccination had since retired. Since the school required proof of HepB vaccination before they enrolled me, I had no choice but to get an antibody titer. They drew some blood, sent it off to a lab, and voila - a few weeks later I got a piece of paper in the mail saying that I had antibodies to HepB. No more questions were asked, and I was enrolled in school.
Now, I don't remember if I had to sign any kind of forms stating whether or not I have ever had or been exposed to HepB. I just remember going to the school clinic with my immunization records, they asked if I had my HepB records, and I told them that I didn't. That's when they told me that they could simply test the antibody titer in my blood.
I don't condone lying, misguiding your school's administration, or hiding the truth, but I think that you may not have to disclose your HepB status as long as you can demonstrate that you have an antibody titer above a predetermined threshold.
However, my memory of the entire process is fuzzy at best, and there may have been some sort of form that I had to sign, where you had to check boxes saying that you had either 1. had the HepB vax, or 2. been infected with/exposed to the virus.
Hope that helps.

 

[doireallyhaveto]

well that wont work as the titer test is for surface antibodies which I dont have since I have surface antigen floating around

 

[LadyWolverine]

Aha. Forgot you mentioned the HBsAg + part in the initial post. Guess you're SOL then. Sorry, I got nothin.

 

[doireallyhaveto]

odds are that the sAg will go away eventually since I converted the eAg and maintain a low DNA count but I wish it would just go away now

 

[mmag]

My med school currently requires proof of vaccination and a titer documenting immunity. Unlike for TB, the form doesn't ask if you have the disease.
Might you consider getting the vaccine just so you have the vaccine on record?

 

[Jolie South]

just out of curiosity. . .

is it possible to clear the infection or will you always be a carrier?

 

[doireallyhaveto]

just out of curiosity. . .

is it possible to clear the infection or will you always be a carrier?

yes, odds are for some one in my condition to clear it

 

[Amino Acid]

Your medical information is supposed to be confidential so I don't know how this would be a problem. Its not like its Hep C or HIV anyway.

uh and what's the problem with Hep C; are those who were unfortunate to innocently be infected by it now considered like they're not worthy of med school or something?

 

[Crixivan]

I think we were given the option to decline the vaccination if we signed a waiver.

Having a titer drawn is probably the easiest solution.

 

[kronickm]

Why don't you just call a school confidentially and ask them the question of what you should do. All of this crap to try to "fool" the titer/vaccination requirements seems foolish. I do not think being a chronic hep B carrier would prevent a school from accepting you as I don't think it interferes with your medical lisence. I would not, however, disclose this to any patients.

 

[CTtarheel]

most schools will require you to give them serological evidence of vaccination and immunity (HBsAb), and I don't think it's routine to do the full Hep B panel when testing that, so as long as you'll test HBsAb+ you should be ok.

Whether or not hospitals will ask you for this info later down the road I don't know.

 

[CTtarheel]

Your medical information is supposed to be confidential so I don't know how this would be a problem. Its not like its Hep C or HIV anyway.

Actually it's much much worse. HBV is much more easily transmitted than HCV or HIV and there are many documented transmissions from patient to physician and physician to patient. I don't believe there are any documented cases of HIV transmission from physician to patient.

 

[Despina]

Sure, but by asking for proof of vaccination or immunity they are asking the question he doesn't want to answer. If they didn't ask about Hepatitis B at all, I would agree with you (eg if they don't ask about Hep C, then you probably will never have to mention it). But they do ask specifically about Hep B and want you to take steps to protect yourself and others from it. To not mention it in the face of that would be deceptive, at a minimum.

I don't know if the med school physical is the same as when you get hired for a hospital, but my physical was pretty confidential. I had a chronic condition, and the doc who said, "As long as you bring in evidence that shows that its being managed, I'll clear you for work and this information will be kept confidential" Why not just call a few medical schools and ask without revealing who you are.

 

[BurnEmUpBears]

.

 

[BurnEmUpBears]

Actually it's much much worse. HBV is much more easily transmitted than HCV or HIV and there are many documented transmissions from patient to physician and physician to patient. I don't believe there are any documented cases of HIV transmission from physician to patient.

It's true that HBV is more infectious (and common) than HCV or HIV, but I would hardly say it's worse. It's far less deadly, we have better drugs to treat it, we have a vaccine, and chronic infection with HBV is far less devastating than HIV.

The chances of infection after a needlestick with blood containing those agents are:

HBV - 30%
HCV - 3%
HIV - 0.3%

 

[Tachymeter]

Maybe you could just make an anonymous email account and email the school about it. Tell them you are someone whose been accepted but you have this concern and you would like to know. Or even say you are a prospective student and you are wondering about this.

 

[TMP-SMX]

The major reason they want these titers/vaccinations done is to make sure that if you are shown to have been exposes to the virus that it was not while you were in school. This is why they need a baseline titer or proof of vaccination (especially for Hep C as there is no vaccine).

 

[edfig99]

Proof of immunity to hepatitis B is demonstrated by the presence of Hepatitis B surface antibody. As a chronic carrier (Hep BsAg+) the OP will not have HepBsAb. Whether or not s/he receives the vaccine or keeps it hidden by not saying anything, the hospital where he will rotate through will undoubtedly require titers and it will be picked up. Most hospitals routinely screen all healthcare workers (including students) for HBV and HCV as part of pre-employment screening, in addition to MMR and varicella immunity. Some hospitals limit patient care responsibilities and privileges for people with HBV or HCV, which is probably why the NIH doctor makes the recommendation to not say anything (but there's actually no way NOT to say anything).

Most places will require you to get titers. If Hep BsAb is negative, they'd order a Hep BsAg and if that is positive, check anti-eAg. If you are antieAg ab, then your infectivity is very low (more on the order of 6% with a needlestick), as opposed to if you had no antieAg Ab (where infectivity is something like 30%) They'd then recommend seeing some consultants and then basically provide appropriate career counseling. (For example, someone with HCV or Hep B with eAg probably will not be able to pursue a surgical career).

Of course, this all varies by school, hospital and state.
At my school and hospital there is no way to avoid it.
And NYS does not allow religious exemptions to vaccination for any healthcare workers or professional students.

 

[edfig99]

-removed- duplicate post.

 

[doireallyhaveto]

Thanks Edfig99, very helpful post...

I was a little confused there at the end of your post: some one who is sAg+ and eAg- would or would not be advised against a surgical career?

 

[gbennett]

if youre concerned about your legal obligations, i would contact a lawyer in the field who would actually know the answer. (your school might have law students available for no cost for consultations about anything, mine does)

 

[edfig99]

Thanks Edfig99, very helpful post...

I was a little confused there at the end of your post: some one who is sAg+ and eAg- would or would not be advised against a surgical career?

well...it's not a black and white thing.

the issue is that if someone is sAg+ and eAg-, they are potentially infectious if they perform certain high-risk, exposure-prone procedures (for example, imagine an oral surgeon working with a scalpel or needle in the tight space of the mouth under poor visualization). At the attending physician level, at hospitals where there are screening programs in place, if someone is found to have this pattern of tests, they will likely undergo some expert review to determine what procedures and under what circumstances that person will be able to perform. There will also need to be determinations made about disclosing that status to patients, and other related issues...This is all done on a case by case basis. so it gets messy.

When i've discussed this issue with hospital occupational health physicians who oversee this responsibility for their attending staff, they recommend that students who know early on their status can and probably should be warned about this. it doesn't mean they can't pursue surgical training, but know that they may encounter multiple obstacles along the way and even potentially limitations in practice. and while the CDC has their own recommendations (for example, http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm) hospitals set up their own bylaws and guidance and generally are allowed to set up stricter policies.