Back to 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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