Deborah Pritchard
PGDip, BSc, RGN, is infection control nurse, Tameside and Glossop Acute Services NHS Trust, Ashton-under-Lyne, Lancashire
Abstract Pritchard, D. (2007) Hepatitis C: occupational exposure for healthcare workers. www.nursingtimes.net
Abstract Pritchard, D. (2007) Hepatitis C: occupational exposure for healthcare workers. www.nursingtimes.net
This article analyses hepatitis C from the perspective of occupational exposure and examines health and safety regulations.
Introduction
Work should ideally be a contributing factor to the general overall good health and well-being of an individual's life. This may not always be the case, especially for healthcare workers who are often exposed to hazards that have the potential to affect their health. Blood-borne viruses, which include hepatitis C, are one such hazard (Watterson, 2003).
Occupational health and safety and Infection control standard precautions form a good practice guide to prevent transmission of such hazards in primary and secondary care settings, and the Advisory Committee on Dangerous Pathogens (2003) identified that infection control departments have a major role to play in communicating such hazards and precautions to employees.
Standard infection control precautions (formerly known as universal precautions) can protect both staff and patients if applied at all times without discrimination. They include: hand hygiene; use of personal protective equipment; management of sharps, clinical waste and linen; and care of the environment (RCN, 2005).
Clinical features
The hepatitis C virus was first identified in 1989 (Department of Health, 2004b). Prior to this it was classed as, and accounted for, most cases of non-A and non-B hepatitis (Rogers and Campbell, 2003). The virus itself is a blood-borne single stranded RNA virus with a lipid envelope, from the flaviviridae family (McCreaddie and Neilson, 2001).
There are six major genotypes or groups of the hepatitis C virus and within each genotype there are subtypes (Shiffman, 1998). Approximately 40%-50% of patients in the UK have genotype one and about 40%-50% have genotypes two and three (NICE, 2004).
Patients are most commonly infected with only one genotype (Rogers and Campbell, 2003). Type one variants are more likely to be associated with hepatocellular carcinoma, while types one and four respond less well than types two or three to treatment with interferon (Bagg, 2003).
The hepatitis C virus appears to evade the immune system much more easily than its counterpart, hepatitis B, because it mutates more rapidly. This has made vaccine development very difficult and it is still unavailable (Berger, 1998).
Acute symptomatic hepatitis C virus infection is rare and symptoms will include nausea, vomiting, fatigue, jaundice and anorexia. Most patients who acquire the virus are asymptomatic until chronic infection occurs (Davis, 2001).
Gungabissoon (2003) assessed that approximately 80%-85% of those who do acquire the virus will become chronically infected. The virus rarely causes symptoms on either initial exposure or during the disease progression and it can take between 10 and 30 years before clinical symptoms become apparent (Nadel, 1999).
This can mean that many people will not be aware that they have the hepatitis C virus, or know how or when they were infected (Gungabissoon, 2003).
For this reason it is sometimes referred to as a 'hidden epidemic' (DH, 2002b). This can cause great problems in that, by the time symptoms manifest, the liver damage will be irreparable (Nadel, 1999). Approximately 20% of patients with chronic hepatitis C will develop liver cirrhosis within 20 years (Lawrence, 2000).
Liver cirrhosis caused by the hepatitis C virus is the leading reason for liver transplantation in the UK and the US (Poynard, 2002).
Hepatitis C virus infection does not have a great impact on mortality in the first decade of infection (Copley, 2003; Harris et al, 2002).
Over the next 10-20 years, chronic hepatitis C virus infection is predicted to become a burden on the healthcare system as patients who are now asymptomatic with mild disease progress to end-stage liver disease and develop hepatocellular carcinoma (Nadel, 1999). This means that hepatitis C infections acquired in the 1970s and 1980s will start becoming chronic conditions in this decade.
Therefore early treatment and eradication of the hepatitis C virus infection is desirable in order to prevent the spread and to reduce the risk of progression of the disease (Davis, 2001).
Since hepatitis C was first classified in 1989, it has emerged as a significant public health problem (DH, 2004b). An estimated 200,000 people in the UK are infected with the virus (DH, 2004b) and it is a major cause of liver disease (Copley, 2003).
Most information about the clinical course of hepatitis C virus has come largely from retrospective studies of patients with established liver disease (Tong et al, 1995).
Hepatitis C virus is found in most body fluids but sufficient quantities to cause infection are found only in blood, vaginal secretions and semen (McCreaddie, 2001b). It has been reported that an infected mother could potentially pass on the infection via the placental barrier in the womb (Nadel, 1999).
Occupational and public health regulations
In 1982 the Health and Safety Executive published a booklet that gave practical guidance including statutory requirements for health surveillance to all employers with established occupational health facilities (Kloss, 2000). At this time, many employers had not established departments for occupational health so the infrastructure was inadequate to carry out any health surveillance.
Since 1990, there have been two major developments which have led to a strengthened occupational health service. In 1992, the Department of Health produced a white paper The Health of the Nation, which outlined the government's 'commitment' to preventative medicine and also selected key areas as national targets, one of which was cancer (DH, 1992).
It emphasised the importance of a healthy workplace (Kloss, 2000). The DH then formed a taskforce to review how the NHS promoted the health of its own employees.
In 1998 the DH produced the green paper Our Healthier Nation, which included a 10-year strategy for occupational health (DH, 1998a). As a consequence the Occupational Health Strategy Unit, which was formed in 1996, was charged with developing a national vision for occupational health, which was to include issues such as the availability of a service.
At the same time, there were a number of changes occurring around the regulations governing health and safety at work.
Changes in Europe gave considerable impetus to health and safety law (Kloss, 2000). A framework of five directives was agreed in 1989 and 1990. These were enacted into UK law as regulations under the auspices of the Health and Safety at Work Act (1974). The framework included:
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Management of Health and Safety at Work Regulations 1992 (1999, 2nd ed);
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The Workplace Regulations 1992;
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Provision and Use of Work Equipment Regulations 1992;
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Personal Protective Equipment Regulations 1992.
The most important of these was the Management of Health and Safety at Work Regulations (1999), which was the spearhead for the European Community Framework Directive. This essentially obliged all employers, with very few exceptions, to make an assessment of the risks to the health and safety of their employees.
Employers were also to ensure that their employees were provided with such health surveillance as appropriate to the job.
The introduction of the Control of Substances Hazardous to Health Regulations (updated in 1999 and 2002) also obliged employers to assess the hazards of all substances with which their employees have contact at work.
This entailed the introduction of health surveillance if there was a reasonable likelihood that an identifiable disease or adverse health effect could occur from the exposure (Kloss, 2000). From the perspective of a healthcare worker, this would include body substances with the associated risks of exposure to blood-borne viruses.
The Public Health (Control of Disease) Act 1984 involved the reporting of notifiable infectious diseases (which include viral hepatitis), to the consultant in communicable disease control at the local health authority now superceded by the notifications officer at the area Health Protection Agency.
Notification of accidents and dangerous occurrences at work and of work related to disease must be formally reported under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (HSE, 1995)).
This placed the duty to 'report' on the employer or other responsible person, and includes a section on industrially-linked diseases. Hepatitis has been classed under RIDDOR as one such disease. However, reporting hepatitis under RIDDOR does not necessarily signify that it was caused by a work-related activity (Kloss, 2000).
In 2001 the Hepatitis C Strategy Committee was formed, which aimed to enhance surveillance in order to estimate the size of the future 'disease burden'. They recommended methods of infection control and, in conjunction with NICE, recommended a consistent approach to the management and treatment of infected individuals.
These principles featured in Getting Ahead of the Curve, the government's first infectious diseases strategy for England (DH, 2002d).
Getting Ahead of the Curve set out 12 proposals for improvements to existing systems, the first of which was the creation of the Health Protection Agency. This was established on 1 April 2003. Concerning infectious diseases, it brought together the main functions of the Public Health Laboratory Service, consultants in communicable disease control and regional epidemiologists, while also incorporating chemical and radiological risks. In relation to hepatitis C, their remit was to link in on the public health protection side.
Getting Ahead of the Curve also highlighted hepatitis C as one of the long-term 'burdens' for the NHS.
While the costs of not treating during the acute phase of the illness are low, as the disease progresses, many people develop decompensated cirrhosis, where the treatment costs (which may include liver transplantation) increase enormously (DH, 2002a)., Getting Ahead of the Curve became the government's flagship document to launch an action plan for hepatitis C to counter this.
The Hepatitis C Action Plan for England (DH, 2004c) is based on best practice and serves as a broad framework for implementation of Hepatitis C: Strategy for England (DH, 2002c). There are also links with the government's 10-year strategy for addressing drug misuse (DH, 1998c).
Infectivity and occupational exposure
The DH (2002a) made an assessment that healthcare workers may be at risk of acquiring hepatitis C virus infection from occupational injuries. Gungabissoon (2003) reported that healthcare workers are at greater risk of exposure to the hepatitis C virus than the rest of the general population.
Further studies have shown that the overall prevalence of hepatitis C among healthcare workers had been estimated to be 0.23%, rising to 0.28% for those who have occupational contact with blood and body fluids (Thorburn, 2001; Ramsay, 1999).
Thorburn (2001) undertook anonymous testing of healthcare workers in Glasgow between 1994 and 1997. Of the 10,654 healthcare workers who gave blood at their occupational health departments during that period, 30 tested positive. This equates to 0.28%, which is identical to Ramsay's findings.
Figures presented by Sulkowski et al (2002) showed a dramatically increased prevalence in that transmission rates from hepatitis C virus-infected patients to healthcare workers can be as much as 10%. It should be noted however that Sulkowski et al (2002) tested patients with known infection rather than the general patient population and therefore it must be concluded that these figures would be higher.
The accepted average of the risk of transmission from a hepatitis C antibody positive source to a healthcare worker is probably between 1.2% and 3% (Department of Health, 2004b). There have not been any reported cases of transmission via intact skin (Sulkowski et al, 2002) - transmission is more likely to occur following exposure to blood via hollow-bore instruments (Bagg, 2003).
Standard infection control precautions will minimise the risk of transmission of all blood-borne viruses including hepatitis C (Gungabissoon, 2003). The Department of Health (1998b) provided guidance on protecting healthcare workers against occupational exposure to blood-borne viruses and this guidance recommended that employers draw up their own local policies on the management of blood exposure incidents for both staff and patients.
Exposure to blood and body fluids remains an important concern for healthcare workers, especially those who sustain a percutaneous injury. The risk of acquiring hepatitis C infection following a needlestick injury is estimated at approximately 3% while hepatitis B is 30% and HIV is 0.3% (Tarantola et al, 2003).
It is therefore extremely important that the local reporting mechanisms and follow-up protocols are adhered to (McCreaddie, 2001a). The increasing availability of safety devices and compliance with standard precautions can also help to reduce the risks (Bagg, 2003).
Standard infection control measures should apply to all situations, with all body substances treated as potentially infectious. This means that healthcare workers must consistently adhere to current evidence-based guidelines in order to prevent healthcare-associated infections and transmission from patient to patient and patient to staff (Gungabissoon, 2003; Pratt, 2003).
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