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What Are the Occupational Risks of Hepatitis B?

Christine M. Kukka
HBV Project Manager;

Many people infected with the hepatitis B virus (HBV) wonder if their bloodborne infection poses a health risk to others in workplace settings, such as offices, factories, health care facilities, schools or daycare centers. They wonder if it is necessary to disclose their infection to protect coworkers, students or patients.

Federal and state laws in the United States have examined this topic in-depth and have overwhelmingly concluded that any workers who might conceivably come into contact with blood or body fluids in the course of their jobs be immunized against hepatitis B and trained in standard precautions.

Standard precautions, mandated by the Occupational Safety and Health Administration (OSHA), require every worker to keep a barrier between them and anyone’s blood or body fluids. This practice must be applied to everyone, not just to those who have a diagnosed bloodborne infection such as hepatitis B or C or HIV.

Why must they be used with everyone?

Because one out of every four people infected with HIV doesn’t know s/he is infected, and only 30 percent of adults with hepatitis C know they are infected. There are many adults and children with hepatitis B who are also unaware of their infections.

With so many undiagnosed infections around, health officials require standard precautions to be used with everyone at all times. Employers must also design blood and body fluid exposure policies as if everyone was infected with HIV or hepatitis.

Because all employers, supervisors, police, teachers and daycare providers must practice standard precautions, the Centers for Disease Control and Prevention (CDC) and other agencies have stated that neither adults nor students have to disclose their infections in most workplaces, schools or daycare centers.

Standard precautions have been very successful in safeguarding everyone’s health. For example, one CDC study of police, firefighters and prison guards found their HBV infection rate was no higher than the general population, despite their increased chances of exposure to blood through accidents, fights and bites.

But what about medical settings, where accidental needle sticks and surgery and other procedures involving sharp instruments increase the odds that a patient might be exposed to the blood of an HBV-infected doctor or nurse? Does this mean HBV-infected people can’t become doctors or nurses?

Can Hepatitis B Sideline a Health Care Career?

Hepatitis B is 100-times more transmissible than HIV or hepatitis C because of the high volume of hepatitis B viruses in the blood of infected people, compared to the lower viral load in people infected with HIV or hepatitis C. A safe and effective vaccine does exist that prevents HBV infection, but unfortunately, not all patients have been immunized.

Even when health care workers practice standard precautions and are as careful as possible, there is still a chance that a doctor or nurse could cut him or herself during an “exposure-prone” medical procedure, such as surgery, and infect a patient who has not been vaccinated.

While there is no clear national policy on this topic, many medical organizations and hospitals require health care workers who perform exposure-prone procedures to be tested for HIV and hepatitis B and C. HBV-infected people who have high viral loads and the “e” antigen (HBeAg) have been restricted from performing surgery and other high-risk procedures.

But these policies vary widely between hospitals, creating much confusion and anxiety among infected health care workers. The ethics of these regulations, and their varying interpretations, continue to be hotly debated.

The CDC currently recommends that healthcare workers who are infected with HIV or HBV (and are “HBeAg” positive with high viral loads) not perform exposure-prone procedures unless they have sought “counsel from an expert review panel.”

To avoid discrimination and invasion of healthcare providers’ privacy, a number of medical ethicists have made alternate recommendations that are now under consideration. They propose that:

• Hospitals should provide hepatitis B vaccination to patients undergoing elective procedures to reduce HBV transmission risk.

• HBV-infected health care workers should practice without restrictions on patients who have already been infected with, or have been vaccinated against hepatitis B. This would avoid discrimination against infected health care workers.

• If health care workers had the option to disclose their HBV infections to susceptible patients, this could provide an opportunity for patients to choose what risks they were willing to accept in the course of their health care. Doctors and nurses could educate their patients about infectious diseases, such as HBV. Infected health care workers could then perform more exposure-prone procedures if patients agreed.

However, these policies may be of limited help to HBV-infected medical students. It would be difficult to keep their infection confidential as they rotate frequently through different departments during their training. A large number of people would need to know their practice restrictions in order to avoid putting non-immune patients at risk of contracting hepatitis B, which would violate the medical student’s privacy.

Disclosure opportunities to patients would be more difficult, because students are often requested to assist in procedures with minimal advance notice, and students do not have the same type of relationship with patients as doctors and nurses on staff.

Ironically, this same dilemma confronts medical personnel and health care students who fail to respond to a hepatitis B immunization. A small percentage of people fail to create sufficient antibodies to protect them against hepatitis B, even after two rounds of vaccination. These people remain vulnerable to infection from HBV-infected patients. In some cases, these people are discouraged from practicing medicine because of their risk.

Debate on this issue will continue, and many hope the CDC will re-examine this ethical dilemma and issue new guidelines.

More articles about this topic are available at:

Hepatitis B Virus-Infected Physicians and Disclosure of Transmission Risks to Patients: A Critical Analysis, published in the BMC Medical Ethics Journal
http://www.pubmedcentral.nih.gov/
rticlerender.fcgi?tool=pubmed&pubmedid
=11716796

CDC Report: Recommendations for Preventing Transmission of Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures
http://www.cdc.gov/mmwr/preview/
mmwrhtml/00014845.htm

For more information about hepatitis B, contact the following organizations:

Hepatitis B Foundation
1-215-489-4900, www.hepb.org

Hepatitis B Support List
www.hblist.org

Hepatitis Foundation International
1-800-891-0707, www.hepfi.org

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