Review and special article
The risk of acquiring hepatitis B or C among public safety workers: A systematic review1

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Abstract

Context: Determination of the occupational risk of hepatitis B and C to public safety workers is important in identifying prevention opportunities and has significant legal and policy implications.

Objectives: Characterize the risk of occupationally acquired infection: (1) risk of exposure to blood and body fluids, (2) seroprevalence of hepatitis B and C in the source population, and (3) risk of infection after exposure.

Data Sources: Electronic search of MEDLINE (1991–1999), HealthStar (1982–1999), and CINAHL (1975–1999) supplemented by selected reference citations and correspondence with authors of relevant articles.

Study Selection: Peer-reviewed journal articles (N=702) that addressed the transmission of hepatitis B and C in law enforcement, correctional, fire, emergency medical services, and healthcare personnel were identified. One hundred five (15.0%) articles were selected for full-text retrieval; 72 (68.6%) were selected for inclusion.

Data Abstraction: Articles selected for inclusion were abstracted by two reviewers and checked by a third reviewer, using a standard reporting form.

Data Synthesis: Evidence tables were constructed, using the standardized abstracts. The tables were designed to summarize data for the key elements of the risk analysis.

Conclusions: Data suggest that emergency medical service (EMS) providers are at increased risk of contracting hepatitis B, but data have failed to show an increased prevalence of hepatitis C. EMS providers have exposure risks similar to those of hospital-based healthcare workers. Other public safety workers appear to have lower rates of exposure. Urban areas have much higher prevalence of disease, and public safety workers in those areas are likely to experience a higher incidence of exposure events.

Introduction

Reports of an “epidemic” of viral hepatitis among firefighters and other public safety workers, including emergency medical service (EMS) personnel, police, and corrections officers, have attracted the attention of labor organizations, state and municipal governments, legislators, and public health officials. This perceived epidemic is based on media reports, suggesting that public safety workers are experiencing an increased prevalence of infection as a result of occupational exposure.1, 2, 3, 4 It is unclear whether these perceptions reflect a true increase in occupational risk or an increased awareness and media attention.

To reassess the risk in this population of employees, we conducted an extensive and systematic review of the literature on the occupational risk of viral hepatitis for public safety workers (law enforcement, correctional, fire, and EMS personnel). The literature was reviewed to identify published reports on the prevalence of hepatitis B and hepatitis C in public safety workers to ascertain if there were epidemiologic data to suggest that public safety workers are at greater risk than the general public.

Additionally, the literature was reviewed to better characterize the risk of occupationally acquired infection on the basis of the key elements of the risk, namely the risk of experiencing an incident that involved an occupational exposure to blood and other body fluids, the risk that those materials contain hepatitis B virus (HBV) or hepatitis C virus (HCV), and the risk of infection after an exposure.

The availability of a safe and effective vaccine to prevent HBV infection, and its widespread adoption among healthcare and public safety workers, has lessened the occupational risk of acquiring HBV infection. Unfortunately, unimmunized or incompletely protected workers may still be at risk of infection. Overall, the occupational risk of HBV infection is dramatically declining in healthcare workers. In 1995, an estimated 800 healthcare workers became infected with HBV, a 95% decline from the estimated 17,000 new cases in 1983.5

Since the identification of hepatitis C as the causative agent for what was previously known as “non-A non-B” hepatitis, there has been growing interest in assessing the risk of occupational transmission. A screening blood test has been available since 1991, but earlier methods were not as reliable as current testing methods. Unfortunately, there has been little research on the distribution of hepatitis C in public safety workers since reliable methods have become available.

Occupational transmission of HBV or HCV occurs primarily as a result of percutaneous exposure to infected blood or body fluids, most commonly from a needlestick injury (NSI). Each year, an estimated 600,000 to 800,000 such injuries occur among the approximately 8 million healthcare workers nationally.5 The economic and public health implications of these exposure incidents cannot be overstated.

Similarly, public safety workers perform job tasks that may result in exposure to blood and body fluids. These activities include care of open wounds, insertion of intravenous catheters, and rescue or extrication of the severely injured from hazardous environments. Characterization of the infection risk to public safety workers is important in identifying opportunities for prevention and has significant legal and policy implications for workers’ compensation and occupational health and safety protection programs.

Section snippets

Objectives

  • 1.

    Describe the epidemiology of hepatitis B and C in public safety workers compared with that of reference populations.

  • 2.

    Describe the risk of exposure to blood, body fluids, and other potentially infectious materials in public safety workers.

  • 3.

    Describe the risk of exposure of public safety workers to blood or body fluids that contain HBV or HCV.

  • 4.

    Describe the risk of infection after exposure to hepatitis B or C in public safety workers.

Data sources

The search process began with a preliminary MEDLINE search from 1991 to September 1999 that combined the Medical Subject Heading (MeSH) terms “viral hepatitis, human” and “hepatitis.tw” with “occupational exposure,” “occupational disease,” and “occupational.tw.” Identification and retrieval of important reviews and key articles were followed by citation checking of those articles to identify and to retrieve other relevant articles.

A second, more comprehensive MEDLINE search was performed, based

Study selection

Articles published in peer-reviewed medical and scientific journals that described observational (cohort, case–control, or cross-sectional) studies that addressed the occupational transmission of hepatitis B and C in law enforcement, correctional, fire, or EMS personnel were selected. The primary reviewers (GR, JH, and LM) examined the abstracts and ranked them according to (A) likely to be helpful in addressing study questions, (B) may be helpful in addressing study questions, (C) not likely

Data extraction

Articles selected for inclusion were abstracted by two reviewers and checked by a third reviewer, using a standard reporting form. Study data were abstracted for potential meta-analysis.

Prevalence of viral hepatitis in public safety workers

Our search identified 12 articles about viral hepatitis risk in firefighters and emergency medical personnel and three studies about police officers. Earlier studies (pre-1991) generally addressed hepatitis B, whereas some later studies included hepatitis C (Table 1).

Of the 12 articles that addressed firefighters or emergency medical personnel, 10 were original studies,6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and one reviewed previously published data.16 Six original studies evaluated the prevalence

Conclusions

Data suggest that EMS personnel, including firefighters, may be at increased risk of contracting hepatitis B as a result of their work exposures to infected blood and body fluids. Available data do not demonstrate an increased risk for police officers, and no data are available that address correctional officers.

Data regarding the prevalence of HCV infection among public safety workers are sparse, but the small number of published studies does not show an increased prevalence of hepatitis C.

Acknowledgements

We thank The Oregon Health Services University Center for Research in Occupational and Environmental Toxicology for providing financial and administrative support for the preparation of this report; Peter Spencer, PhD, FRCPath, and Kent Anger, PhD, of The Oregon Health Services University Center for Research in Occupational and Environmental Toxicology for providing scientific and editorial advice in the preparation of this report; and Ann Thomas, MD, MPH, of The Oregon Health Division for

References (56)

  • R.D McCormick et al.

    Epidemiology of needle-stick injuries in hospital personnel

    Am J Med

    (1981)
  • R Marcus et al.

    Risk of human immunodeficiency virus infection among emergency department workers

    Am J Med

    (1993)
  • M.W Fried et al.

    Absence of hepatitis C viral RNA from saliva and semen of patients with chronic hepatitis C

    Gastroenterology

    (1992)
  • E.L Ogilvie et al.

    Hepatitis infection among adolescents resident in Melbourne Juvenile Justice Centrerisk factors and challenges

    J Adolesc Health

    (1999)
  • V Puro et al.

    Risk of hepatitis C seroconversion after occupational exposures in health care workers. Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections

    Am J Infect Control

    (1995)
  • H.R Rosen

    Acquisition of hepatitis C by a conjunctival splash

    Am J Infect Control

    (1997)
  • Brown JK. Firemen to march for Hep-C. Philadelphia Daily News 2000 Feb...
  • Brown JK. A hepatitis C crisis. Firehouse.com News; 2000 Mar 27. Available at: www.firehouse.com/news/2000/philly/....
  • Lin J. Firefighters’ hepatitis worries cast nationwide shadow; three times national rate in Philadelphia. Cincinnati...
  • Spielman F. Hepatitis C tests urged for firefighters, medics. Chicago Sun-Times 2000 Feb...
  • National Institute for Occupational Safety and Health (NIOSH). NIOSH Alert: preventing needlestick injuries in health...
  • B.A Woodruff et al.

    Blood exposure and the risk of hepatitis B virus infection in firefighters

    J Occup Med

    (1993)
  • T.D Valenzuela et al.

    Occupational exposure to hepatitis B in paramedics

    Arch Intern Med

    (1985)
  • R.J Springbett et al.

    Hepatitis B markers in Gloucestershire firemen

    Occup Med

    (1994)
  • C Spitters et al.

    Prevalence of antibodies to hepatitis B and C among fire department personnel prior to implementation of a hepatitis B vaccination program

    J Occup Environ Med

    (1995)
  • K.L Pardoe

    Slaying the hepatitis dragon. A study of fire department vaccinations for hepatitis B and C

    J Emerg Med Serv JEMS

    (1994)
  • B.A Crosse et al.

    Hepatitis B markers in West Yorkshire firemen

    Epidemiol Infect

    (1989)
  • Pardoe KL. Prevalence of antibodies to hepatitis B and C among fire department personnel prior to implementation of a...
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