CDC Updates HBV Recommendations for RNs and Other Healthcare Workers

July 11th, 2012

By Jennifer Olin, BSN, RN

For the first time in over 20 years the US Centers for Disease Control and Prevention (CDC) has updated its recommendations for the management of hepatitis B virus (HBV) for infected healthcare providers and students to prevent HBV transmission. They were published on July 6 in the CDC's Morbidity and Mortality Weekly Report.

"The primary goal of this report is to promote patient safety while providing risk management and practice guidance to HBV-infected health-care providers and students, particularly those performing exposure-prone procedures such as certain types of surgery," writes Scott D. Holmberg, MD and colleagues.

What is Hepatitis

HBV is just one strain of hepatitis, which is an inflammation of the liver, most commonly caused by a viral infection. HBV is one of the five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread.

Hepatitis types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.

Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C, and D usually occur as a result of parenteral contact with infected body fluids.

The most common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact.

Acute infections may occur with limited or no symptoms, or may include symptoms such as jaundice, dark urine, extreme fatigue, nausea, vomiting, and abdominal pain.

For a closer look:

• Hepatitis A virus (HAV) is present in the feces of infected persons and is most often transmitted through consumption of contaminated water or food. Certain sex practices can also spread HAV. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Safe and effective vaccines are available to prevent HAV.
• Hepatitis B virus (HBV) is transmitted through exposure to infective blood, semen, and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth or from family member to infant in early childhood. Transmission may also occur through transfusions of HBV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. HBV also poses a risk to healthcare workers who sustain accidental needle stick injuries while caring for infected-HBV patients. A safe and effective vaccine is available to prevent HBV.
• Hepatitis C virus (HCV) is also transmitted through exposure to infective blood. This may happen through transfusions of HCV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. Sexual transmission is also possible, but is much less common. There is no vaccine for HCV.
• Hepatitis D virus (HDV) infections occur only in those who are infected with HBV. The dual infection of HDV and HBV can result in a more serious disease and worse outcome. Safe and effective hepatitis B vaccines provide protection from HDV infection.
• Hepatitis E virus (HEV), like HAV, is transmitted through consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognized as an important cause of disease in developed countries. Safe and effective vaccines to prevent HEV infection have been developed but are not widely available.

Hepatitis B and Healthcare Workers

Back in the 1980s, 17,000 healthcare workers a year would contract HBV and up to 300 each year would die from the infection. In fact, the nickname for Hepatitis B during this era was the "healthcare workers" disease.

In 1991 the Occupational Safety and Health Administration’s Bloodborne Pathogen Standard (BBP) was passed requiring employers to provide the vaccine free of charge to all workers with the possibility of exposure during the course of their work. The incidence of occupational hepatitis B infections declined dramatically, from more than 17,000 cases in 1983, before the availability of the vaccine, to 400 in 1995 — a 95% decline and an amazing example of an OSHA success.

As of 2007, an estimated 75% of healthcare workers in the US have been vaccinated against hepatitis B. The vaccination process includes a course of three injections given with the second injection at least one month after the first dose and the third injection given six months after the first dose.

However, those guidelines have not eliminated the disease, only made us safer in caring for patients and ourselves when it comes to exposure to the virus.

According to the authors of the new CDC recommendations, as with the previous 1991 guidelines, HBV infection should not disqualify individuals from practicing in healthcare fields.

"Because percutaneous injuries sustained by health-care personnel during certain surgical, obstetrical, and dental procedures provide a potential route of HBV transmission to patients as well as providers, this report emphasizes prevention of operator injuries and blood exposures…” they added.

Changes to the previous recommendations include:

• No requirement is now needed to pre-notify patients of a healthcare provider's HBV status.
• For most providers and students with chronic hepatitis B who conform to current standards for infection control, HBV infection status alone does not require any curtailing of their practices or supervised learning experiences.
• Guidance on management of health-care personnel and students with chronic hepatitis B infection, including practice assessments and monitoring through laboratory testing.

• Ethical considerations and confidentiality of health-care workers’ HBV status.
• Prevention strategies including use of Standard Precautions and work practices to prevent percutaneous injuries.
• Recommendations for hepatitis B vaccinations and testing for susceptible personnel, previously provided in 2011 by the Advisory Committee on Immunization Practices.

As nurses we are taught to use Universal Precautions with every patient. This doesn’t mean being standoffish or not touching our patients with our bare hands it just means being careful and using common sense. That combined with the right vaccines will keep you working in healthcare for as long as you choose.