PROTECTION OF WORKERS FROM HEPATITIS B IN THE WORKPLACE


Produced by:
Occupational Health and Safety Branch,
Ministry of Labour,
ISSN 1201-1452

1.0  WHAT IS HEPATITIS B?

     Hepatitis B is an infection that attacks the liver.  It is 
     caused by the hepatitis B virus (HBV), and is perhaps the 
     major infectious occupational disease.  For health care 
     workers, the risk of getting hepatitis B from a needle 
     puncture injury is greater than that of getting AIDS in this 
     way. 

     Infection with HBV may be acute or chronic. 

     In acute hepatitis B, about one-third of patients have no 
     symptoms and often don't know they are infected.  About one-
     third suffer a mild flu-like illness.  The remaining third 
     will have a much more severe case, including jaundice (a 
     yellowing of the eyes and skin), fatigue, nausea and 
     abdominal pain.  These patients may require hospitalization 
     and will often lose a great deal of time from work.  About 
     one to two per cent of reported cases develop fulminant 
     (i.e., sudden, fast-moving and severe) hepatitis, which is 
     fatal in about 85 per cent of cases. 

     About six to 10 per cent of newly-infected adults develop a 
     chronic, or long-lasting, HBV infection.  These people are 
     unable to clear the virus from their liver cells and become 
     chronic HBV carriers, with the virus staying in their blood 
     for months, years or even a lifetime.  Although most chronic 
     HBV carriers become healthy again after an acute infection, 
     they still carry the virus in their blood and can transmit 
     the virus to others.  Many chronic HBV carriers go on to 
     suffer liver disease, which can lead to cirrhosis and liver 
     cancer. 

2.0  HOW IS HBV (HEPATITIS B VIRUS) TRANSMITTED?

     The virus is found in the blood and certain body fluids of 
     people with hepatitis B.  These body fluids may include 
     semen, vaginal secretions, saliva and breast milk.  The 
     virus can be passed on to another person through contact 
     with contaminated blood and other body fluids.  For example, 
     HBV may be spread through sexual contact, the sharing of 
     infected needles and from an infected mother to her baby. 

     Examples of workplace exposure are: 

     -  puncture wounds or cuts caused by needles, scalpels or 
        lancets contaminated with blood;
     -  contaminated blood splashing into an open wound in the 
        skin or even onto a mild rash (i.e., dermatitis);
     -  contaminated blood splashing into the mouth or the eye 
        (however, the risk in these cases is much less than with 
        puncture wounds); and
     -  biting, which can happen in an "acting out" situation, 
        such as with children or aggressive patients or when, for 
        example, a patient bites a dentist. 

     HBV may be transmitted to persons within a household or 
     family-like setting.  It is not completely understood why 
     the virus from the saliva or blood of infected persons 
     infects fellow family members.  It may be because of the 
     frequent physical contact with the small cuts or skin rashes 
     that family members develop.  In any case, transmission by 
     close contact in household or family-like settings is a 
     concern for employees who work in such environments.  For 
     example, studies have shown that facilities for the 
     developmentally challenged pose an increased risk of 
     hepatitis B transmission. 

3.0  WHO IS AT RISK IN THE WORKPLACE?

     Workers who may come into contact with potentially 
     contaminated blood and body fluids through their work 
     include: 

     -  hospital and other health care workers; 
     -  medical laboratory workers; 
     -  emergency and rescue workers such as police officers, 
        firefighters, ambulance attendants and paramedics; 
     -  correctional workers; 
     -  dental professionals; 
     -  embalmers; 
     -  staff working in facilities for the developmentally 
        challenged; 
     -  housekeeping staff, cleaners and waste disposal workers 
        in health care facilities such as hospitals, medical 
        laboratories, medical/dental clinics and offices; and 
     -  workers handling dirty laundry from health care 
        facilities. 

     When trying to determine which workers may be at risk, you 
     must look beyond the job titles and identify the actual job 
     tasks through which a worker may come into contact with 
     blood and body fluids.  The most important factor in 
     determining level of risk is the frequency of exposure to 
     blood in the workplace.  For example, studies have shown 
     that before HBV vaccination became available, health care 
     workers had a three to five times greater risk of becoming 
     infected with HBV than the general population. 

     Workers at risk must remember they cannot always identify 
     persons with a hepatitis B infection.  Many people appear to 
     be healthy while their blood may still carry the virus.  For 
     this reason, workers at risk should treat all blood and body 
     fluids as being possibly contaminated with HBV. 

4.0  HOW CAN HEPATITIS B BE PREVENTED IN THE WORKPLACE? 

     Prevention is the only protection against hepatitis B since 
     there is no specific treatment for the infection.  After the 
     workers and activities at risk have been identified, a 
     hepatitis B prevention program should be established.  It 
     may include a number of strategies, such as: 

     -  immunizations against hepatitis B ;
     -  universal precautions;
     -  control measures;
     -  education; and
     -  reporting and follow-up of exposure.

     4.1  IMMUNIZATION AGAINST HEPATITIS B

          -  The hepatitis B vaccine is over 90 per cent 
             effective in preventing HBV infection. 
          -  The vaccine is safe and has no serious side effects 
             since it is made from synthetic material and not 
             from human tissue. 
          -  To be protected, you need three doses of the 
             vaccine.  You get the second dose one month after 
             the first and the third five months later. 
          -  Studies have shown that you do not need a booster 
             shot of the vaccine after getting the initial three-
             dose vaccine schedule. 

     4.2  UNIVERSAL PRECAUTIONS

          It is recommended that the following precautions be 
          practised when contact with blood and body fluids is 
          anticipated. 

          Barrier precautions:
          -  Wear gloves, aprons, lab coats and other protective 
             clothing as needed.
          -  Wear goggles or face shields to protect against 
             splashing of blood or body fluids into eyes or mouth 
             or onto broken skin or skin rashes. 
          -  Use mouthpieces for resuscitation.

          Other precautions:
          -  Wash hands before and after all contact with 
             patients or their blood/body fluids.
          -  Wash all body surfaces exposed to blood or body 
             fluids with soap and water as soon as possible after 
             contact. 
          -  Avoid recapping used needles.
          -  Dispose of used needles and other contaminated sharp 
             instruments and tools in puncture-resistant 
             containers. 
          -  Place materials soiled with blood or body fluids in 
             leak-proof, appropriately labelled waste 
             bags/containers. 

     4.3  CONTROL MEASURES

          -  Use biological safety cabinets in procedures 
             involving aerosol production.
          -  Clean all potentially contaminated or contaminated 
             surfaces, such as floors, walls, beds and large 
             equipment, with a 1:10 solution of household bleach. 
          -  Use routine autoclaving when sterilizing 
             contaminated instruments that can tolerate moisture 
             and heat. 
          -  Where routine autoclaving is not appropriate or 
             possible, use other sterilization procedures such as 
             exposing the contaminated instruments to dry heat at 
             160 degrees Celsius for one to one and a half hours, 
             treating them with 10 per cent ethylene oxide in CO2 
             at 55 to 69 degrees Celsius for 10 hours, or soaking 
             the contaminated instruments in two per cent 
             formaldehyde or glutaraldehyde solution for three 
             hours. 

     4.4  EDUCATION

          All at-risk workers should receive training in:
          -  how and when they are likely to come into contact 
             with blood and body fluids in their particular work; 
          -  which procedures and protective equipment to use to 
             prevent contact with blood and body fluids during 
             their work; and 
          -  what to do if they are exposed to blood or body 
             fluids. 

     4.5  REPORTING AND FOLLOW-UP OF EXPOSURE

          Workers must report all incidents of exposure to 
          contaminated or potentially contaminated blood or body 
          fluids to their supervisors, their employee health 
          departments and their physicians.  Employers must keep 
          appropriate records of workers' exposures. 

5.0  WHAT SHOULD BE DONE IF A WORKER IS EXPOSED TO HBV?

     The following initial measures should be taken:

     -  Allow any wound to bleed freely.
     -  Cleanse with soap and water.
     -  Apply an appropriate antiseptic to any wound.

     Medical advice should be sought for instituting the 
     following measures and for follow-up:

     -  In the case of a puncture wound, assess the person's 
        tetanus immunization status and provide anti-tetanus 
        toxoid as required. 
     -  If the exposed worker has not received the hepatitis B 
        vaccine, she/he should be given the first dose of the 
        vaccine, and arrangement should be made for the second 
        and third doses. 
     -  Depending on the circumstances, it may be appropriate for 
        the person to receive Hepatitis B Immune Globulin (HBIG) 
        As well as a full course of the vaccine.  HBIG is a 
        preparation containing antibodies specifically designed 
        to attack HBV and should be given within 48 hours of 
        exposure. 

6.0  IS THERE ANY TREATMENT FOR HEPATTIS B?

     There is no specific treatment for hepatitis B.  
     Immunization is the most effective tool in preventing the 
     occurrence of the disease.  Hospitalization may be required 
     for some patients. 

7.0  ARE THERE ANY LEGAL REQUIREMENTS TO ASSIST IN THE PREVENTION 
     OF HEPATITIS B IN THE WORKPLACE?

     7.1  THE OCCUPATIONAL HEALTH AND SAFETY ACT

          Under the Occupational Health and Safety Act, employers 
          must protect their workers from the health and safety 
          hazards found in their workplaces and in the tasks the 
          workers perform. 

          In this guideline, the Ministry of Labour has 
          identified hepatitis B as a potential health hazard to 
          workers in certain kinds of workplaces and occupations. 

          Therefore, employers in such workplaces must protect 
          their workers from possible hepatitis B infection. 

          More specifically, section 25(2) of the Act obligates 
          employers to:
          "(a) provide information, instruction and supervision 
               to a worker to protect the health or safety of the 
               worker; 
          (d)  acquaint a worker or a person in authority over a 
               worker with any hazard in the work and in the 
               handling, storage, use, disposal and transport of 
               any article, device, equipment or a biological, 
               chemical or physical agent; 
          (h)  take every precaution reasonable in the 
               circumstances for the protection of a worker; 
               [and] 
          (j)  prepare and review at least annually a written 
               occupational health and safety policy and develop 
               and maintain a program to implement that policy." 

     7.2  THE HEALTH CARE AND RESIDENTIAL FACILITIES REGULATION

          Section 8 of the Health Care and Residential Facilities 
          Regulations (O. Reg. 67/93, made under the Occupational 
          Health and Safety Act) imposes a general duty on 
          employers to develop, establish and put into effect 
          measures and procedures for the health and safety of 
          workers.  This duty could include, for example, 
          developing measures to protect workers against the 
          identified hazard of HBV infection.  In developing 
          these measures, the employer must consult with the 
          joint health and safety committee or health and safety 
          representative. 

          Section 9 outlines more specific measures that should 
          be considered when addressing the hazard of HBV 
          infection, such as: 

          -  safe work practices,
          -  safe working conditions,
          -  control of infections,
          -  immunization against infectious diseases, and
          -  handling, cleaning and disposal of soiled linen, 
             sharp objects and waste. 

    7.3  REGULATION 965

         Under clause 4(e) of Regulation 965 (R.R.O. 965/90, made 
         under the Public Hospitals Act), each hospital must 
         establish and provide for the operation of a 
         communicable disease surveillance program.  Under this 
         program, the hospital must adopt the Blood-borne 
         Diseases Surveillance Protocol for Ontario Hospitals, 
         published jointly by the Ontario Hospital Association 
         and the Ontario Medical Association and approved by the 
         Minister of Health. 

         The Blood-borne Diseases Surveillance Protocol presently 
         states that hepatitis B vaccine is to be offered, at the 
         expense of the hospital, to any permanent full-time or 
         part-time employees who are at risk of exposure to 
         blood-borne illnesses due to the nature of their 
         activities in the hospital, through potential exposures 
         to blood, body fluids or wounds from contaminated 
         sharps. 

For further information on protection of workers from hepatitis 
B, please contact the medical or nurse consultant at your local 
Ministry of Labour office.