Review and special articleThe risk of acquiring hepatitis B or C among public safety workers: A systematic review1
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)
- et al.
Seroprevalence of hepatitis B and hepatitis C among rural emergency medical care personnel
Am J Emerg Med
(1997) - et al.
Hepatitis B exposure in emergency medical personnel. Prevalence of serologic markers and need for immunization
Am J Med
(1983) - et al.
Prevalence of antibody to hepatitis B virus surface antigen in emergency medical personnel in Salt Lake City, Utah
Ann Emerg Med
(1986) - et al.
Viral hepatitis risk in urban emergency medical services personnel
Ann Emerg Med
(1986) - et al.
Epidemiology of needlestick injury in emergency medical service personnel
J Emerg Med
(1988) - et al.
Needlestick injuries and hepatitis B immunization in Florida paramedicsa statewide survey
Ann Emerg Med
(1991) - et al.
Occupational blood contact among prehospital providers
Ann Emerg Med
(1995) - et al.
Occupational infectious disease exposures in EMS personnel
J Emerg Med
(1993) - et al.
Epidemiology of accidental needle-puncture wounds in hospital workers
Am J Med Sci
(1983) - et al.
Incidence of needlestick injuries in hospital personnelimplications for prevention
Am J Infect Control
(1984)
Epidemiology of needle-stick injuries in hospital personnel
Am J Med
Risk of human immunodeficiency virus infection among emergency department workers
Am J Med
Absence of hepatitis C viral RNA from saliva and semen of patients with chronic hepatitis C
Gastroenterology
Hepatitis infection among adolescents resident in Melbourne Juvenile Justice Centrerisk factors and challenges
J Adolesc Health
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
Acquisition of hepatitis C by a conjunctival splash
Am J Infect Control
Blood exposure and the risk of hepatitis B virus infection in firefighters
J Occup Med
Occupational exposure to hepatitis B in paramedics
Arch Intern Med
Hepatitis B markers in Gloucestershire firemen
Occup Med
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
Slaying the hepatitis dragon. A study of fire department vaccinations for hepatitis B and C
J Emerg Med Serv JEMS
Hepatitis B markers in West Yorkshire firemen
Epidemiol Infect
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