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The Hepatitis B Vaccination Series as well as Post Exposure Prophylaxis recommendations are described below.

I. Hepatitis B Vaccination Series

A stick with a needle with Hepatitis B positive blood results in seroconversion in approximately 30% of unvaccinated personnel. In 1986, recombinant vaccines that consist of highly purified HBsAg particles expressed in yeast were licensed in the U.S.  It was not until the Bloodborne Pathogens standard became effective in 1992 that federal OSHA mandated that the hepatitis B vaccine be made available to all health care workers who were at risk. Prior to1982, 6000 to 8000 US healthcare workers contracted the hepatitis B virus annually due to occupational exposure, resulting in two hundred deaths annually and additional hundreds open to cirrhosis and liver cancer in years to come.

A titer evaluation is not a prerequisite for receiving the hepatitis B vaccination series.

II. Reporting of Needlestick Injuries and Post-Exposure Prophylaxis

Post-exposure prophylaxis is available for HIV and HBV. However, this control measure is low on the hierarchy because many health care workers, especially physicians, do not report their exposures and therefore do not get the prophylaxis. The reason for this under-reporting is varied. Many physicians believe the risk to be very low and not worth the time and aggravation of going through the post-exposure procedures. Some health care providers are concerned about the negative consequences if they seroconvert.

In a Notice to Readers (MMWR Vol. 50,  6/29/01) entitled Updated Recommendations for Follow-Up of Health-Care Workers After Occupational Exposure to Hepatitis C Virus, the CDC notes that no vaccine is available to prevent hepatitis C, and immune globulin is not recommended for postexposure prophylaxis. However, CDC does recommend a postexposure follow-up protocol which includes counseling and:

• for the source, baseline testing for antibody to HCV (anti-HCV);
• for the person exposed to an anti-HCV-positive source, baseline and follow-up (e.g., 6-month) testing for anti-HCV and alanine aminotransferase activity; confirmation by supplemental anti-HCV testing of all anti-HCV results reported as repeatedly reactive by enzyme immunoassay (EIA);
• recommending against postexposure prophylaxis with immune globulin or anti-viral agents (e.g., interferon); and
• education of HCWs about the risk for and prevention of bloodborne infections, including hepatitis C, in occupational settings, with the information routinely updated to ensure accuracy.

Patient Notification of Health Care Worker HIV Status

The incident whereby six patients contracted HIV from a Florida dentist, led to development of a series of conflicting national and state policies that some believe unfairly penalizes health care workers with HIV. Public health and medical experts agree that the chance of an HIV-infected health care worker spreading the virus to patients is remote. In 1991, however. the CDC responded to the public's alarm about this incident by adopting guidelines published in the 7/12/1991 MMWR 40(RR08);1-9 entitled "Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures." The guidelines say that HIV-infected health care workers should avoid any "exposure-prone" procedures not explicitly approved by an expert panel that has reviewed their case. Exposure-prone procedures are described as those which could bring the worker's blood in contact with the patient's body cavity, subcutaneous tissues or mucous membranes. A provision was also included, at the behest of Congress, over the scientific objections of CDC officials, which recommends that HIV-positive health care workers who perform exposure-prone procedures notify prospective patients of their seropositivity.

Congress also directed the states to adopt guidelines "equivalent" to the CDC's, but the CDC publicly announced that it would allow the states leeway to deviate from its provisions. As a result, most state guidelines, including New Jersey, do not include the patient notification provision. 

However, in 1991, the New Jersey Superior Court in the Behringer case upheld a hospital's right to require a surgeon to disclose his HIV status to a patient prior to obtaining consent for an invasive procedure. The court's ruling focused on whether a patient gave "informed consent" if the patient was not informed as to the risk from an HIV positive surgeon. Although the court did not address, the surgeon's independent obligation to inform the patient, it is not unlikely that in the future, the courts would look to the legal reasoning in Behringer as the basis for an obligation on the part of a physician to inform his/her patients.

As to other communicable diseases, besides HIV, the Behringer case also gives guidance on what must be disclosed. The court weighed the likelihood (or risk) of infection and the gravity of the potential resulting disease. As AIDS is fatal, the court found a compelling need to disclose the information. Similarly, if the illness (or virus) of the physician is treatable and non-fatal, the court may decide that there is no need to disclose.

HIV and Workers Compensation

Not reporting an exposure to blood or body fluids can have serious consequences for health care workers who develop a disease. New Jersey health care workers who seroconvert for HIV or Hepatitis are not automatically presumed to have acquired the infection at their job. An investigation may be conducted to determine if the infection could have been acquired outside of the job. Personnel in these situations who develop illness have a better chance of getting workers compensation if they have documented their injury. Still, even if an exposure was documented, if the illness occurs more than 2 years after the exposure, the statute of limitations for obtaining workers compensation and disability may have been exceeded.

A discussion of the risk of transmission of HBV, HCV, and HIV following an occupational exposure is included below. Recommended prophylaxis measures for each virus and efficacy information is also reviewed.

a. HBV

The risk of transmission of HBV to a non-immune health care worker ranges from 2% if the source patient is Hepatitis B antigen negative to 40% if the patient is positive. HBV hyper-immune globulin and/or recombinant HBV vaccine is recommended for health care workers exposed to HBV who have anti-HBsAg titer less than 10 mIU per millilitre.

Source: Gerberding J L. Management of Occupation exposures to blood-borne viruses. N Engl J Med 1995: 332;444-51.

The current post-exposure prophylaxis for protection against Hepatitis B in both vaccinated and unvaccinated health care employees is described by the CDC. (Use your browser's back key to return to this page)

b. HCV

The risk associated with occupational exposure to HCV is not well established but is estimated to range between 3 and 10%. Available data do not support the use of immunoglobulin, interferon-or anti-viral agents for prophylaxis against HCV. However it is important to document infection because chronic hepatitis will develop in more than 50% of infected adults. These patients may respond to treatment with interferon.

Gerberding J L. Management of Occupation exposures to blood-borne viruses. N Engl J Med1995: 332;444-51

A discussion concerning post-exposure prophylaxis for Hepatitis C is included in April 1996 CDC Report Number 56 entitled, Hepatitis Surveillance Issues and Answers: " What is the risk of acquiring hepatitis C for health care workers and what are the recommendations for prophylaxis and follow-up after occupational exposure to hepatitis C virus?"

c. HIV

The average risk for HIV infection from percutaneous exposures to HIV infected blood is 0.3%. In a case-control study among health care workers exposed to HIV infected blood the risk was increased for exposures involving 1) a deep injury, 2) visible blood on the device, 3) a device previously placed in the source patient's vein or artery or 4) a source or patient who died as a result of AIDS within 60 days post exposure. In the same case-control study zidovudine post-exposure prophylaxis (PEP) was associated with a decrease of approximately 79% in the risk for HIV seroconversion. In HIV infected patients combination therapy with zidovudine and lamivudine (3TC) has greater anti-retroviral activity than zidovudine alone and adding a protease inhibitor such as indinavir provides even greater anti-retroviral activity.

Source: CDC. Case-Control Study of HIV seroconversion in health-care workers after percutaneous exposure to HIV infected blood-France, United Kingdom, and United States, January1988-August 1994, MMWR 1995;44:929-33. )

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