Importance of Hepatitis B Screening for Health Care Workers in Primary Health Care

¶ … Hepatitis B screening for health care workers in primary health care

The cause for Hepatitis B is a DNA virus and the complete virus has the name 'Dane particle'. The virus contains three major antigens in structure: The surface antigen, the core antigen and e antigen. Hepatitis B is more prevalent among certain population groups and this group contains the health care workers also. (Hepatitis B Seronegative Commonalties in Health Care Workers. Seronegative Commonalties). The susceptibility for health care workers exists for a variety of infections due to the nature of their work. All workers for health care like physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers and even administrative staff are at risk due to their regular contact with patients and their infected material. These diseases are preventable with suitable vaccines. It is thus very important to maintain immunity for the control of infection and the maintenance of immunity for these workers of health care. The best use of agents for immunization protects the health of the workers and also stops the further infection of other workers from the infected workers. The regular use of tests for screening and programs for immunization are helpful in the reduction of numbers of susceptible workers for health care in the hospitals and other institutions. It also reduces further onward transmission of the diseases. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, MMWR, 1997, p. 3)

Hepatitis B exists all over the world, and as many as 2 billion persons have been infected all over the world. The estimate of chronic carriers of Hepatitis B is 350 million and that is 5% of the population of the world. (Mac Arthur, 2001, p. 38) Among Americans, about 5% of the population are estimated to be carrying evidence in their antibodies that they have been infected earlier by hepatitis B virus, and of them 0.1 to 0.5% are chronic carriers. The recent years have shown a case of slow decline of these carriers among the general population. The sequence of infection with hepatitis B is well-known. Out of the population who has been infected, a proportion between 5 and 10% develop chronic hepatitis with persistent infectivity. Among the chronically infected individuals, 15 to 25% finally end up with cirrhosis or hepatocellular cancer. (Swinker, 1997, p. 2294) The battle against hepatitis B is being led by the healthcare professionals. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, MMWR, 1997, p. 5) At the same time, this is the major hazard for infection for the health care personnel. (Swinker, 1997, p. 2296) The risks arise from acquiring infection from accidental blood exposure. Once they are infected themselves, they also may cause infection to the patients. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, MMWR, 1997, p. 5) Among the American health care workers, as many as 12,000 get hepatitis B due to occupational injuries like a needle stick or splash of mucous membrane. From the lot, about 200 develop fulminant hepatitis and that may even result in their death. (Hepatitis B Seronegative Commonalties in Health Care Workers. Running Head: Seronegative Commonalties)

For stopping the spread of hepatitis B it is essential that all health care personnel are vaccinated. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, MMWR, 1997, p. 7) This was a very serious hazard earlier, when as much as 30% of all health care workers in high risk specialty areas were infected with it. (Swinker, 1997, p. 2298) Studies among the personnel now show that 10 to 40% workers in health care or dental areas have or had infection of HBV. The costs of health care for hepatitis B, non -- A and non-B hepatitis among these workers are between $10 and $12 million a year now. The ratio of reported clinical hepatitis B has been increasing - from 6.9 per 100,000 in 1978 to 9.2 per 100,000 in 1981, and on to 11.5 per 100,000 by 1985. This leads to the annual hospitalization of about 500 health care workers who are exposed to blood. Among this group, there are over 200 deaths and the cause is fulminant hepatitis in 12 to 15 cases, cirrhosis in 170 to 200 cases and liver cancer in 40 to 50 cases. (Joint Advisory Notice, 1987) During 1993, there was an infection of 1,450 workers through exposure to blood and serum derived body fluids. This is a drop of 90% from the estimated number of infections in 1985. At the same time, there is chronic infection of 5 to 10% of the workers infected by HBV. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, MMWR, 1997, p. 10) The total number of cases of health workers who have been infected has however fallen remarkably in the last decade - from 12,000 cases in 1990 to 5,100 cases in 1995. The reason for this drop is felt to be the wider use of preventive immunization, increased use of protective equipment by the health care workers and the regular adherence to general precautions. (Swinker, 1997, p. 2300)

The occupational hazard from hepatitis B is well documented. In the general population the prevalence of serological markers for this disease is lower than 5%. The figure is higher in medical and dental workers. It is 16% in general dentists, 28% in surgeons, 23% in anesthesia personnel and 30% among nurses of emergency departments. (Hepatitis B Seronegative Commonalties in Health Care Workers- Running Head: Seronegative Commonalties) Blood, saliva, semen, vaginal fluids, and any substance from the body showing visible contamination with blood and laboratory materials that are infected as also concentrated virus may cause the transmission of HBV to health workers. The infection occurs through open wounds, mucous membrane or non-intact skin touching infected blood or similar infected material. Non-intact skin is chapped, abraded or weeping skin or with dermatitis. The chances of HBV infection after parenteral exposure to blood depends on the probability of the supposedly infected material containing hepatitis B virus antigen (HBsAg), the immune status of the infected individual, the amount of blood that is passed on and the method of exposure. (Taylor, 1996, p. 1)

HBsAg alone may not have as high infectivity than if hepatitis B e antigen (HBeAg) is also present along with high levels of circulating virus. The danger of HBV transmission to a worker in danger due to a percutaneous exposure to HBsAg positive blood is between 6 and 30%, and the danger of transmission increases to 30% when the blood is HBeAg positive. In the place of work, blood is the greatest single source for the transmission of hepatitis B Thus the blood and body substances of all patients have to be treated like sources of infection for HBV and similar blood transmitted pathogens. (Taylor, 1996, p. 1) When the blood is collected several serological tests are carried out on the blood for prevention of hepatitis being passed on to the recipient of the blood. (General Health Encyclopedia: Hepatitis B) The staff in charge of exposure prone procedures has to know their hepatitis B status. Health care workers with HBeAg or HBV DNA positive indications should not be involved in procedures that risk exposure. (Taylor, 1996, p. 2)

The risk for HBV exposure for any health care or public safety worker depends on the tasks performed by the individual. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, MMWR, 1997, p. 10) From 1982, there has been a safe, immunogenic and effective vaccine for prevention of hepatitis B For health care workers exposed to blood and body fluids, this has been recommended by CDC. (Joint Advisory Notice, 1987) Health care workers go through exposure prone procedures and must know their infectious situation for hepatitis. This is to prevent exposure prone procedures when it is known that there are proven risks of the passing of infection from health care worker to the patient. Some health care workers still have to engage in exposure prone procedures and they should seek routine testing if they feel that they have had risks of exposures. (Duties of Care, 1998) Vaccination programs for health care workers reduce the transmission of HBV infection. (U.S. Preventive Services Task Force, 2004, p.4) For minimizing HBV exposure and prevention of infection the critical factors are engineering controls, work practices and protective equipment. The assurance of adequate protection comes only from proper controls and provision of equipment. (Joint Advisory Notice, 1987)

It is important for workers to know applicable practices of work, and correct methods of using required controls and protective equipment. This makes it essential that a detailed work practices program be established. This should have standard operating procedures for all tasks or work areas that have a chance for exposure to fluids or tissues. The worker education program should familiarize the workers with work practices and teach them to properly use the controls and equipment to be used. (Joint Advisory Notice, 1987) The diagnosis of the disease is in stages. At the start is the checking of Hepatitis B surface antigen presence in blood tests of the infected individual as the first viral marker. This stays in the only for a period of 1 or 2 months. The next stage, after the appearance of hepatitis B surface antigen is the detection of hepatitis B core antibody or Anti-HBc. This happens within one or two weeks. (Hepatitis B: cancer-symptoms.org) For evaluation of patients at high risk for hepatitis B infection, there is a single test called HBcAb, or Hepatitis B core antibody that is the best. When the results of the test are negative, the patient should receive the vaccination for hepatitis B A positive result indicates the conducting of HBsAg or hepatitis B surface antigen test. If the test for HBsAg is positive, then the patient is infectious. (Hepatitis B: (www.cpmc.org)

The third stage is the finding of hepatitis B surface antibody (Anti-HBs). This is present in both of those who have been immunized and those who have recovered from an infection of hepatitis. The fourth stage is the finding of both hepatitis B surface antibody and core antibody. These stay on indefinitely in blood of patients who have recovered from an attack of hepatitis B The fifth stage is the high levels of liver enzyme or transminase in blood due to liver damage. The sixth stage is low levels of albumin and prolonged time for prothombin due to failure of liver. (Hepatitis B: cancer-symptoms.org) All patients infected with HBV should go through ALT test. This is for measuring the level of alanine aminotransferase, a liver enzyme in the blood. A high level of ALT indicates inflammation of liver. Liver function tests are for albumin, bilirubin, INR or a coagulation test, liver biopsy, HBV DNA QUANTIFICATION, HBeAg or hepatitis B e antigen, anti-HBe or hepatitis B e antibody, anti-HDV or hepatitis delta virus antibody for adults getting HBV, estimation of time or age of acquiring HBV, etc. (Hepatitis B vaccination in public service current: Scientific Working Group on Viral Hepatitis Prevention, 1996)

Other important tests are for HBV Core and PreCore mutant; HBV Genotype; and YMDD mutant in patients on lamivudine if HBV DNA is elevated. (Hepatitis B: (www.cpmc.org) Exposure prone procedures should not be done by health care workers when they are HBV DNA or hepatitis B e antigen (HBeAg) positive. These persons have greater risks in exposure prone procedures as individuals who have 'e' antigen face a greater risk from infection than others who are HBsAg positive but HBeAg negative. (Duties of Care, 1998) Patients with hemophilia and thalassaemia major, and require a blood transfusion can get hepatitis B vaccination with effect from 1 January 1992 by appointment. They can be referred to VHPS. Like health care workers they are also to get pre-vaccination screening and post vaccination tests. (Hepatitis B vaccination in public service current: Scientific Working Group on Viral Hepatitis Prevention, 1996)

Health departments and health care providers face two important challenges in the maintenance of high screening rates among pregnant women for HBsAg, and giving immunoprophylaxis to new born infants. (Prevention of Perinatal Hepatitis B through Enhanced Case Management -- Connecticut, 1994-95, and United States, 1994) Routine screening for hepatitis B is now done for pregnant women as it is a reportable disease and this has led to more accurate figures coming out. It is now known that one in a thousand pregnant women is chronic carriers of hepatitis B (General Health Encyclopedia: Hepatitis B) Pregnant women are now being screened at a high enough rate, but the present efforts of determining and tracking infants born to HBsAg positive mothers are not enough. The progress in prevention of pre-natal HBV transmission will succeed only on improved health department identification and tracking. (Prevention of Perinatal Hepatitis B through Enhanced Case Management -- Connecticut, 1994-95, and United States, 1994: MMWR Weekly 1996, p. 585) According to OSHA, employers have to offer hepatitis B vaccine free of charge to workers regularly exposed to blood and similar infectious materials in their duties. The regular serologic testing, for checking of antibody concentrations when the series of three doses is complete, has not been recommended by OSHA. (Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices, 1997)