Occupational Exposure

NOTE: The following information is excerpted from the document, "Immunization of Health-Care Workers: Recommendations of the Advisory Committee of Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC)." For cited references and additional information, please refer to the MMWR: Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC).

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Hepatitis B
  Immunization is strongly recommended
  Needlestick or other percutaneous exposures
Hepatitis C and other parenterally transmitted non-A, non-B hepatitis
Hepatitis A

Hepatitis B

Hepatitis B virus (HBV) infection is the major infectious hazard for health-care personnel. During 1993, an estimated 1,450 workers became infected through exposure to blood and serum-derived body fluids, a 90% decrease from the number estimated to have been thus infected during 1985 (18-20). Data indicate that 5%-10% of HBV-infected workers become chronically infected. Persons with chronic HBV infection are at risk for chronic liver disease (i.e., chronic active hepatitis, cirrhosis, and primary hepatocellular carcinoma) and are potentially infectious throughout their lifetimes. An estimated 100-200 health-care personnel have died annually during the past decade because of the chronic consequences of HBV infection (CDC, unpublished data).

The risk for acquiring HBV infection from occupational exposures is dependent on the frequency of percutaneous and permucosal exposures to blood or body fluids containing blood (21-25). Depending on the tasks he or she performs, any health-care or public safety worker may be at high risk for HBV exposure. Workers performing tasks involving exposure to blood or blood-contaminated body fluids should be vaccinated. For public safety workers whose exposure to blood is infrequent, timely postexposure prophylaxis may be considered, rather than routine preexposure vaccination.

In 1987, the Departments of Labor and Health and Human Services issued a Joint Advisory Notice regarding protection of employees against workplace exposure to HBV and human immunodeficiency virus (HIV), and began the process of rulemaking to regulate such exposures (26). The Federal Standard issued in December, 1991 under the Occupational Safety and Health Act mandates that hepatitis B vaccine be made available at the employer's expense to all health-care personnel who are occupationally exposed to blood or other potentially infectious materials (27). Occupational exposure is defined as "...reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties (27)." The Occupational Safety and Health Administration (OSHA) follows current ACIP recommendations for its immunization practices requirements (e.g., preexposure and postexposure antibody testing). These regulations have accelerated and broadened the use of hepatitis B vaccine in health-care workers (HCWs) and have ensured maximal efforts to prevent this occupational disease (23).

Prevaccination serologic screening for prior infection is not indicated for persons being vaccinated because of occupational risk. Postvaccination testing for antibody to hepatitis B surface antigen (anti-HBs) response is indicated for HCWs who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks (e.g., physicians, nurses, dentists, phlebotomists, medical technicians and students of these professions). Knowledge of antibody response aids in determining appropriate postexposure prophylaxis.

Vaccine-induced antibodies to HBV decline gradually over time, and less than or equal to 60% of persons who initially respond to vaccination will lose detectable antibodies over 12 years (28; CDC, unpublished data). Studies among adults have demonstrated that, despite declining serum levels of antibody, vaccine-induced immunity continues to prevent clinical disease or detectable viremic HBV infection (29). Therefore, booster doses are not considered necessary (1). Periodic serologic testing to monitor antibody concentrations after completion of the three-dose series is not recommended. The possible need for booster doses will be assessed as additional data become available.

Asymptomatic HBV infections have been detected in vaccinated persons by means of serologic testing for antibody to hepatitis B core antigen (anti-HBc) (1). However, these infections also provide lasting immunity and are not associated with HBV-related chronic liver disease.

Immunization Is Strongly Recommended

ACIP strongly recommends that all HCWs be vaccinated against (or have documented immunity to) hepatitis B. Specific recommendations for use of vaccines and other immunobiologics to prevent this disease among HCWs follow.

Any HCW who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated. Hepatitis B vaccine should always be administered by the intramuscular route in the deltoid muscle with a needle 1-1.5 inches long.

Among health-care professionals, risks for percutaneous and permucosal exposures to blood vary during the training and working career of each person but are often highest during the professional training period. Therefore, vaccination should be completed during training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions, before trainees have contact with blood. In addition, the OSHA Federal Standard requires employers to offer hepatitis B vaccine free of charge to employees who are occupationally exposed to blood or other potentially infectious materials (27).

Prevaccination serologic screening for previous infection is not indicated for persons being vaccinated because of occupational risk unless the hospital or health-care organization considers screening cost-effective. Postexposure prophylaxis with hepatitis B immune globulin (HBIG) (passive immunization) and/or vaccine (active immunization) should be used when indicated (e.g., after percutaneous or mucous membrane exposure to blood known or suspected to be HBsAg-positive {See Table 3 below}).

Needlestick or other percutaneous exposures of unvaccinated persons should lead to initiation of the hepatitis B vaccine series. Postexposure prophylaxis should be considered for any percutaneous, ocular, or mucous membrane exposure to blood in the workplace and is determined by the HBsAg status of the source and the vaccination and vaccine-response status of the exposed person (See Table 3 below)(1,18).

If the source of exposure is HBsAg-positive and the exposed person is unvaccinated, HBIG also should be administered as soon as possible after exposure (preferably within 24 hours) and the vaccine series started. The effectiveness of HBIG when administered greater than 7 days after percutaneous or permucosal exposures is unknown. If the exposed person had an adequate antibody response (greater than or equal to 10 mIU/mL) documented after vaccination, no testing or treatment is needed, although administration of a booster dose of vaccine can be considered.

One to 2 months after completion of the 3-dose vaccination series, HCWs who have contact with patients or blood and are at ongoing risk for injuries with sharp instruments or needlesticks should be tested for antibody to hepatitis B surface antigen (anti-HBs). Persons who do not respond to the primary vaccine series should complete a second three-dose vaccine series or be evaluated to determine if they are HBsAg-positive. Revaccinated persons should be retested at the completion of the second vaccine series. Persons who prove to be HBsAg-positive should be counseled accordingly (1,16,121,173). Primary non-responders to vaccination who are HBsAg-negative should be considered susceptible to HBV infection and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood (See Table 3 below). Booster doses of hepatitis B vaccine are not considered necessary, and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series is not recommended.

TABLE 3. Recommended postexposure prophylaxis for percutaneous or permucosal exposure to hepatitis B virus, United States

Vaccination and antibody response status of exposed person
Treatment when source is

HBsAG * positive HBsAg negative

Source not tested or status unknown

Unvaccinated HBIG † x 1; initiate HB vaccine series § Initiate HB vaccine series Initiate HB vaccine series
Previously vaccinated: Known responder ¶ No treatment No treatment No treatment
Known non-responder

HBIG x 2 or
HBIG x 1 and initiate revaccination

No treatment If known high-risk source, treat as if source were HBsAg positive
Antibody response unknown

Test exposed person for anti-HBs **
1. If adequate ¶, no treatment
2. If inadequate ¶, HBIG x 1 and vaccine booster

No treatment

Test exposed person for anti-HBs
1. If adequate ¶, no treatment
2. If inadequate ¶, initiate revaccination

* Hepatitis B surface antigen.
† Hepatitis B immune globulin; dose 0.06 mL/kg intramuscularly.
§ Hepatitis B vaccine.
¶ Responder is defined as a person with adequate levels of serum antibody to hepatitis B surface antigen (i.e., anti-HBs_>= 10 mIU/mL); inadequate response to vaccination defined as serum anti-HBs<10 mIU/mL.
** Antibody to hepatitis B surface antigen.

Hepatitis C and other parenterally transmitted non-A, non-B hepatitis

Hepatitis C virus (HCV) is the etiologic agent in most cases of parenterally transmitted non-A, non-B hepatitis in the United States (117,118). CDC estimates that the annual number of newly acquired HCV infections has ranged from 180,000 in 1984 to 28,000 in 1995. Of these, an estimated 2%-4% occurred among health-care personnel who were occupationally exposed to blood. At least 85% of persons who contract HCV infection become chronically infected, and chronic hepatitis develops in an average of 70% of all HCV-infected persons (117-119). Up to 10% of parenterally transmitted non-A, non-B hepatitis may be caused by other bloodborne viral agents not yet characterized (non-ABCDE hepatitis) (117,120).

Serologic enzyme immunoassays (EIA) licensed for the detection of antibody to HCV (anti-HCV) have evolved since their introduction in 1990 and a third version is now available which detects anti-HCV in greater than or equal to 95% of patients with HCV infection. Interpretation of EIA results is limited by several factors. These assays do not detect anti-HCV in all infected persons and do not distinguish among acute, chronic, or resolved infection. In 80% to 90% of HCV-infected persons, seroconversion occurs an average of 10-12 weeks after exposure to HCV. These screening assays also yield a high proportion (up to 50%) of falsely positive results when they are used in populations with a low prevalence of HCV infection (118,121). Although no true confirmatory test has been developed, supplemental tests for specificity are available (such as the licensed Recombinant Immunoblot Assay {RIBA™}), and should always be used to verify repeatedly reactive results obtained with screening assays.

The diagnosis of HCV infection also is possible by detecting HCV RNA with polymerase chain reaction (PCR) techniques. Although PCR assays for HCV RNA are available from several commercial laboratories on a research-use basis, results vary considerably between laboratories. In a recent study in which a reference panel containing known HCV RNA-positive and -negative sera was provided to 86 laboratories worldwide (122), only 50% were considered to have performed adequately (i.e., by failing to detect one weak positive sample), and only 16% reported faultless results. Both false-positive and false-negative results can occur from improper collection, handling, and storage of the test samples. In addition, because HCV RNA may be detectable only intermittently during the course of infection, a single negative PCR test result should not be regarded as conclusive. Tests also have been developed to quantitate HCV RNA in serum; however, the applicability of these tests in the clinical setting has not been determined.

Most HCV transmission is associated with direct percutaneous exposure to blood, and HCWs are at occupational risk for acquiring this viral infection (123-131). The prevalence of anti-HCV among hospital-based HCWs and surgeons is about 1% (125-128) and 2% among oral surgeons (129,130). In follow-up studies of HCWs who sustained percutaneous exposures to blood from anti-HCV positive patients through unintentional needlesticks or sharps injuries, the average incidence of anti-HCV seroconversion was 1.8% (range: 0%-7%) (132-137). In the only study that used PCR to measure HCV infection by detecting HCV RNA, the incidence of postinjury infection was 10% (136). Although these follow-up studies have not documented transmission associated with mucous membrane or nonintact skin exposures, one case report describes the transmission of HCV from a blood splash to the conjunctiva (138).

Several studies have examined the effectiveness of prophylaxis with immune globulins (IGs) in preventing posttransfusion non-A, non-B hepatitis (139-141). The findings of these studies are difficult to compare and interpret, because of lack of uniformity in diagnostic criteria, mixed sources of donors (volunteer and commercial), and differing study designs (some studies lacked blinding and placebo controls). In some of these studies, IGs appeared to reduce the rate of clinical disease but not overall infection rates. In one study, data indicated that chronic hepatitis was less likely to develop in patients who received IG (139). None of these data have been reanalyzed since anti-HCV testing became available. In only one study was the first dose of IG administered after, rather than before, the exposure; the value of IG for postexposure prophylaxis is thus difficult to assess. The heterogeneous nature of HCV and its ability to undergo rapid mutation, however, appear to prevent development of an effective neutralizing immune response (142), suggesting that postexposure prophylaxis using IG is likely to be ineffective. Furthermore, IG is now manufactured from plasma that has been screened for anti-HCV. In an experimental study in which IG manufactured from anti-HCV negative plasma was administered to chimpanzees one hour after exposure to HCV, the IG did not prevent infection or disease (143).

The prevention of HCV infection with antiviral agents (e.g., alpha interferon) has not been studied. Although alpha interferon therapy is safe and effective for the treatment of chronic hepatitis C (144), the mechanisms of the effect are poorly understood. Interferon may be effective only in the presence of an established infection (145). Interferon must be administered by injection and may cause side effects. Based on these considerations, antiviral agents are not recommended for postexposure prophylaxis of HCV infection.

In the absence of effective prophylaxis, persons who have been exposed to HCV may benefit from knowing their infection status so they can seek evaluation for chronic liver disease and treatment. Sustained response rates to alpha interferon therapy generally are low (10%-20% in the United States). The occurrence of mild to moderate side effects in most patients has required discontinuation of therapy in up to 15% of patients. No clinical, demographic, serum biochemical, serologic, or histologic features have been identified that reliably predict which patients will sustain a long-term remission in response to alpha interferon therapy.

Several studies indicate that interferon treatment begun early in the course of HCV infection is associated with an increased rate of resolved infection. Onset of HCV infection among HCWs after exposure could be detected earlier by using PCR to detect HCV RNA than by using EIA to measure anti-HCV. However, PCR is not a licensed assay and its accuracy is highly variable. In addition, no data are available which indicate that treatment begun early in the course of chronic HCV infection is less effective than treatment begun during the acute phase of infection. Furthermore, alpha interferon is approved for the treatment of chronic hepatitis C only.

IG or antiviral agents are not recommended for postexposure prophylaxis of hepatitis C. No vaccine against hepatitis C is available. Health-care institutions should consider implementing policies and procedures to monitor HCWs for HCV infection after percutaneous or permucosal exposures to blood (146). At a minimum, such policies should include:

  • For the source, baseline serologic testing for anti-HCV;

  • For the person exposed to an anti-HCV positive source, baseline and follow-up (e.g., 6 months) serologic testing for anti-HCV and alanine aminotransferase activity;

  • Confirmation by supplemental anti-HCV testing of all anti-HCV results reported as repeatedly reactive by EIA;

  • Education of HCWs about the risk for and prevention of occupational transmission of all blood borne pathogens, including hepatitis C, using up-to-date and accurate information.

Hepatitis A

Occupational exposure generally does not increase HCWs' risk for hepatitis A virus (HAV) infection. When proper infection control practices are followed, nosocomial HAV transmission is rare. Outbreaks caused by transmission of HAV to neonatal intensive care unit staff by infants infected through transfused blood have occasionally been observed (147-149). Transmission of HAV from adult patients to HCWs is usually associated with fecal incontinence in the patients. However, most patients hospitalized with hepatitis A are admitted after onset of jaundice, when they are beyond the point of peak infectivity (150). Serologic surveys among many types of HCWs have not identified an elevated prevalence of HAV infection compared with other occupational populations (151-153).

Two specific prophylactic measures are available for protection against hepatitis A -- administration of immune globulin (IG) and hepatitis A vaccine. When administered within 2 weeks after an exposure, IG is greater than 85% effective in preventing hepatitis A (2). Two inactivated hepatitis A vaccines, which can provide long-term preexposure protection, were recently licensed in the United States: HAVRIX® (manufactured by SmithKline Beecham Biologicals) and VAQTA® (manufactured by Merck & Company, Inc.) (2). The efficacy of these vaccines in preventing clinical disease ranges from 94% to 100%. Data indicate that the duration of clinical protection conferred by VAQTA® is at least 3 years, and that conferred by HAVRIX® at least 4 years. Mathematical models of antibody decay indicate that protection conferred by vaccination may last up to 20 years (2).

Routine preexposure hepatitis A vaccination of HCWs and routine IG prophylaxis for hospital personnel providing care to patients with hepatitis A are not indicated. Rather, sound hygienic practices should be emphasized. Staff education should emphasize precautions regarding direct contact with potentially infective materials (e.g., hand washing).

In documented outbreaks of hepatitis A, administration of IG to persons who have close contact with infected patients (e.g., HCWs, other patients) is recommended. A single intramuscular dose (0.02 mL per kg) of IG is recommended as soon as possible and less than or equal to 2 weeks after exposure (2). The usefulness of hepatitis A vaccine in controlling outbreaks in health-care settings has not been investigated.

The following vaccination schedules are recommended for the vaccines available in the United States:

  • HAVRIX®: for persons aged greater than 18 years, two doses, the second administered 6-12 months after the first.

  • VAQTA®: for persons aged greater than 17 years, two doses, the second administered 6 months after the first.