Hepatitis-B: Preventive Medicine for Emergency Responders
HEALTH
When firefighter and emergency medical technicians aid an injured person, it’s the injuries they’re looking for— not signs of infectious disease. However, if the victim has a break in the skin or requires mouth-to-mouth resuscitation, the emergency responder becomes susceptible to contracting hepatitis.
Three viruses cause the disease: hepatitis-A, hepatitis-B, and hepatitis non-A, non-B. Hepatitis-A victims almost always recover and are not chronic carriers. Sixty percent of hepatitis non-A, non-B victims will continue to be infected and can transmit the virus through blood transfusions. While hepatitis-A can be prevented by taking globulin before exposure, there is no vaccine or cure for either A or non-A, non-B once you’ve been infected.
There is a vaccine for hepatitis-B virus (HBV). In fact, it’s the only way to prevent emergency personnel who’ve been exposed to the virus from contracting the disease, because there’s no cure for HBV, either, once a person’s been infected. That’s why the San Jose (Calif.) Fire Department has designed a program to inform fire department members how HBV is transmitted, what symptoms it produces, and what the vaccination procedures are. As part of the program, the fire department is working closely with the Santa Clara County Office of Emergency Medical Services and disseminating information through seminars at local community colleges.
HBV infection may or may not cause clinical symptoms, and the only way to tell HBV from the other hepatitis viruses is through blood tests. About 60 percent of the individuals who contract HBV don’t develop any major signs of the disease. These asymptomatic victims experience rather mild, flulike symptoms that last only a few days. Their bodies then develop HBV antibodies that will protect them from redeveloping the disease, should they be exposed to the virus in the future.
The second group—the remaining 40 percent of those who contract the disease—are symptomatic victims. They experience various combinations of anorexia, malaise, nausea, vomiting, abdominal pain, and jaundice. Skin rashes, joint pain, and arthritis can also occur. These symptoms range from mild to debilitating. Approximately five percent of the victims in this group may have to be hospitalized.
A firefighter or EMT in this category may be out of work for weeks or even months. Because the course of the HBV infection is so erratic, there’s no way to predict how long the hepatitis will persist.
In about one to two percent of HBV victims, the disease will come on suddenly and with great severity. This fulminating infection, as it’s called, can be fatal within days of the onset of symptoms.
With or without symptoms, an HBV victim can become a chronic carrier who is infected with the disease for a long time. This happens in about 10 percent of the cases. The other 90 percent of victims are acutely infected. They have the virus in their blood for one to six weeks, and then it goes away. You can contract the disease from either a chronic carrier or an acutely infected person. Unfortunately, chronic carriers from the asymptomatic group are unaware of their condition. That makes them more likely to infect others.
About one fourth of chronic carriers develop cirrhosis of the liver. This puts them at a much higher risk of developing liver cancer than noncarriers. These two potential problems usually occur years after the person initially contracts HBV.
Transmission
HBV is usually contracted by exposure to the blood of an infected person. It’s also possible to contract the virus through infected body fluids (urine, saliva, and semen), but this is much less likely because these body fluids don’t contain a lage number of viral particles.
About one half of all fire-related incidents require the emergency responder to administer immediate medical assistance to injured or bleeding accident victims. This often necessitates close personal contact and increases the risk of transmitting infectious diseases.
Emergency workers in San Jose are at a particularly high risk of contracting HBV because of the area’s large Asian population. Fifteen to 20 percent of all Asian refugees are chronic carriers of HBV, according to the June 5, 1985, issue of Morbidity and Mortality Weekly Report, published by the federal Centers for Disease Control in Atlanta. Because the virus can be passed on at childbirth, descen dents of chronic carriers are also considered chronic carriers.
The CDC also reports that 70 to 85 percent of these Asian refugees and their descendents are acutely infected with HBV.
If you are exposed to an HBV carrier, it will probably be to one who doesn’t exhibit symptoms, both because asymptomatic victims are in the majority and because they’re unaware of their infection. This, in turn, will leave you unaware of the need to protect yourself.
At the San Jose seminars, doctors who specialize in infectious diseases instruct the emergency workers to be cautious when handling victims with open wounds and to wear rubber gloves for their own protection.
Vaccination
The CDC recommends that anyone at increased risk of contracting HBV be vaccinated. (There’s no danger of contracting the disease from the vaccine.) After a known exposure, you should definitely be vaccinated. After a bona fide percutaneous exposure, where blood has been splashed in your eyes or a needle has punctured your skin, you should also take hepatitis-Bspecific immune globulin.
The HBV vaccine is given in a three-shot series and doesn’t become fully effective until the third shot has been given six months later. The globulin provides antibodies immediately and prevents the virus from infecting you.
There are two HBV vaccines available. Both are produced by Merck, Sharp & Dohme, a division of Merck & Co. Inc., located in West Point, Pa.
The Heptavax-B vaccine is derived from the blood of HBV carriers. Before the blood is used in the vaccine, it’s checked for other communicable diseases.
Since 1982, when Heptavax-B became available, it’s been administered to one million people worldwide. According to the CDC, it provides immunity to 85 to 95 percent of those who receive the three-shot series, and the immunity lasts for about five years. Booster shots may be necessary, however, so after being vaccinated, you should have your antibody level checked periodically.
Side effects of this vaccine have been minimal; the patient may experience soreness at the site of injection and a low-grade fever.
The other vaccine, RecombivaxHB, is made through genetic engineering. Recombivax-HB has been available only since January, so there are no statistics on the number of people who’ve taken the vaccine, its duration of immunity, or whether there are side effects.
Both Heptavax-B and Recombivax-HB have the same safety level, according to a Merck, Sharp & Dohme representative. The only advantage of Recombivax-HB is that the vaccine is always available. Heptavax-B may be in short supply if there aren’t enough blood donors at a particular time.
The San Jose Fire Department’s vaccination program is paid for by its insurance company. The cost of the vaccination is $116 per person for the three-shot series. Although vaccination isn’t mandatory, about 90 percent of the department’s members have chosen to be inoculated. The remaining 10 percent refuse the vaccine—usually for religious reasons.
If you’re interested in starting a vaccination program in your department, consult your city or county public health department. You can also consult physicians in your community who specialize in infectious disease and gastroenterology.
To find out more about the vaccine, call Merck, Sharp & Dohme. The company has representatives in most cities and can provide information and the names of physicians who will come to your department to administer the shots.
Make sure you understand the HBV infection and the health risks involved if you or one of your department members contract it. Also make sure you understand how the vaccine should be administered, as well as its safety value and effectiveness.
Consider the cost of the vaccine. You’ll need one 3-milliliter vial for each patient. It’s most economical to buy 30 or more vials at a time. You can buy the vaccine in onethird installments to spread the cost over two fiscal years.
Find out if you’ll be able to get insurance that will pay for your vaccination program. In some cases, health maintenance organizations may provide a health care package at a reduced cost.
Consider whether screening for the presence of HBV antibodies is worthwhile. If every member were screened, only those with negative test results—individuals who have not been infected with HBV— would be vaccinated as a preventive measure. If results are positive, that person’s body is building up its own antibodies. San Jose Fire Department members aren’t tested first because the procedure costs $40 per person. It’s more cost-effective to vaccinate all members even if some of them have already been infected.
After you review all this information, you’ll probably decide that a physician who specializes in infectious diseases should visit the department and speak to all at-risk employees. The physician should supply written documentation on the hazards of HBV and give individuals a chance to ask specific questions and voice concerns.
Department members should then sign a statement indicating they have participated in the procedure, understand the information, and have decided to accept or refuse the vaccine.
Medical personnel will administer the vaccine, keep records, and reschedule follow-up visits.
Post-vaccination screening for antibodies usually is not done because the vaccine is so effective and screening is so expensive.
The threat of infectious disease is a serious risk for today’s fire service personnel. Developing an HBV vaccination program in your department is the best way to combat this growing problem.