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I thought I was immune to hepatitis B.

I thought I was immune to hepatitis B

Concern about AIDS in laboratory conversations and journals eclipses the danger of hepatitis B, which is far more likely to threaten lab workers. Among those who handle blood products, the lifetime risk of contracting hepatitis B is 15 to 30 per cent, compared with just 5 per cent in the general population.

While the mortality rate is much lower for hepatitis B than for AIDS, investigators believe the hepatitis virus is more easily spread and more difficult to destroy. And transmission of the disease does not require direct host-to-host contact. The hepatitis B virus has been known to survive for months on pens and pencils, laboratory equipment, counter tops, and many other inanimate objects.

None of that really mattered to me. After more than 20 years as a medical technologist, I imagined (like many laboratorians) that I had grown immune to hepatitis B. So when I developed malaise, anorexia, and abdominal pain, I assumed it was a lingering case of the flu.

The symptoms lingered 10 days. That moved me finally to run a hepatitis screen and face the truth: a positive result for hepatitis B surface antigen. I hadn't had a needlestick injury and could not recall any other kind of laboratory accident in at least six months. Yet within two weeks, my bilirubin jumped to more than 17 mg/dl, and my ALT climbed to more than 4,500 IU.

Studies of health care workers who have contracted hepatitis show that the majority cannot trace the infection to a specific incidient. In the laboratory, hepatitis B and non-A, non-B can be transmitted through small cuts as well as needlesticks. Transmission also occurs across mucosal surfaces, such as in pipetting accidents when hand bulbs are not used. Other means of transmission include splashes to the eyes; touching the mouth, nose, or eyes with contaminated hands or gloves; and placing contaminated pens or pencils in the mouth. While serum or plasma are most likely to cause infection, spinal fluid, saliva, semen and other body secretions can also transmit the disease.

Laboratorians know hepatitis B can strike them, but few are familiar with the symptoms, the course of the disease, and the markers now available for lab testing. I learned all of that the hard way.

The risk of developing hepatitis B depends on whether the individual has been previously infected or immunized, the virulence of the strain, the amount of virus, and the number of exposures. Malaise is usually the first symptom to appear and the last to be resolved. Patients feel generally ill and lack energy. They do not like the tast of food, nor can they tolerate strong odors. The anorexia, of course, leads to weight loss. Some pateints experience abdominal pain, low-grade fever, vomiting, and diarrhea; a few are afflicted by itching, with or without rashes, and many have joint pains.

My own first clue was eye pain--it hurt to look to the right or the left. My physician told me this is now deemed a classic early sympton of hepatitis B.

Clinical symptoms intensify as jaundice develops along with dark urine and light stools. In self-limited cases, the symptoms subside and liver function tests reach maximum levels at about the time the jaundice peaks. Such patients usually make a rapid recovery and regain lost weight, but the lack of energy may persist for months.

I was lucky to be out of the laboratory for only two months. Even in self-limited cases, other technologists have had to stay out four months or more.

After weathering several weeks of extreme illness, I spent most of my time at home resting, reading, and regaining the weight I had lost. I felt somewhat guilty during the last two weeks of convalescence, riding my horse every day though I hadn't been cleared to go back to work. But I still needed 10 hours of sleep each night, and relaxation was part of the healing process. Warning about the possibility of a relapse, my doctor said I should let my body recover in its own time.

Not all who are exposed to the virus manifest clinical symptoms. In fact, most cases are completely asymptomatic and are diagnosed only when the antibody is found--as might happen when testing prior to vaccination. Despite the absence of symptoms, lasting immunity develops.

Chronic carriage develops in approximately 10 per cent of all cases of hepatitis B. Most of these patients have had subclinical, anicteric episodes.

The diagnosis of chronic hepatitis B is established when a person is positive for HBsAg in two tests performed six months apart. Chronic hepatitis B can persist for years or decades and can be very mild or severe.

There are an estimated 200,000 to 400,000 carriers in the U.S., many of whom don't know they are and don't realize they can infect others. Carriers also are at increased risk for developing hepatic carcinoma.

Fulminant hepatic failure develops in a very small percentage of patients with hepatitis B and non-A, non-B. The disorder occurs mostly in those with hepatitis B; it is rare among hepatitis A patients.

Mortality rates run as high as 75 per cent, and the prognosis is age-dependent. Children usually survive, while patients over 40 usually do not.

There are six commonly used HBV markers at present: HBsAg, HBeAg, two for anti-HBc, anti-HBe, and anti-HBs. HBsAg is found during the acute phase of self-limited cases and in patients with chronic hepatitis B. HBeAg occurs briefly in self-limited cases. Its presence in the chronic stage indicates a high level of infectivity.

High levels of anti-HBs alone or anti-HBc together with anti-HBs signifies previous exposure to HBsAg and immunity against reinfection. All who are infected develop anti-HBc, and more than 90 percent also develop anti-HBs.

In the presence of HBsAg, anti-HBe indicates a marked reduction in the degree of infectivity. Anti-HBe, along with the other HBV antibodies, may also be found in recovered hepatitis patients.

In self-limited cases, after HBsAg disappears it may take weeks to many months before anti-HBs can be demonstrated. Anti-HBs is never identified at all in a small number of cases.

The Delta hepatitis agent was discovered in Italy in 1977. A "defective" virus, it requires the presence of HBsAg to survive. Delta infection may be transmitted simultaneously with hepatitis B or be superimposed on a chronic hepatitis B infection. In the latter instance, called superinfection, severe chronic liver disease is the rule. Delta hepatitis markers are under development and will probably be commercially available soon.

Workers' compensation should cover employees who contract hepatitis B on the job, including those of us in management. But my claim was initially denied. The hospital's risk management group had always been reluctant to approve compensation without clear-cut evidence of a needlestick. In talking to technologists, nurses, and other health care professionals, I learned that few claims had been approved. Nearly all who had been turned down decided not to fight for their legal benefits.

I filed an appeal and sought a hearing. What I was entitled to and what I wanted was to have my sick time restored, my health insurance carrier reimbursed, and any future medical bills paid by the hospital carrier. Although I had enough accumulated sick days to cover the period of recuperation, I felt it was unfair to deplete them for a work-related illness.

Laboratory management backed me up and was ready to testify if necessary. But the appeal was denied.

At that point, I hired an attorney who specialized in workers' compensation cases. He explained that we only had to prove that the chances were greater than 50-50 that I had contracted the hepatitis at my place of employment. Since hepatitis B is a known health hazard in the clinical laboratory, the attorney believed I had a strong case.

Some people asked why I wanted to fight my employer before the state industrial commission. After all, I wasn't asking for any money, and the dispute could have a long-term adverse effect on my career. My reply: It was a matter of principle.

True, hospitals and other medical facilities must cut costs, but the savings should not come at the expense of their employees. Any claim that appears to have a legitimate basis should at least be considered instead of automatically refused in the apparent hope that the employee will drop any further action, Morale takes a big drop when employees think the hospital doesn't care about their safety and won't compensate them for work-related illness or injuries.

The day before the hearing, my attorney called to say that the hospital's risk management group had decided not to dispute the claim. The sick time would be restored, my insurance carrier would be reimbursed, nad any future medical bills would be covered. This was good news--I certainly hadn't looked forward to battling the hospital. I hope it will now be easier for personnel who contract hepatitis on the job to obtain workers' compensation benefits.

A preventive measure that all laboratorians should seriously consider is vaccination against hepatitis B, which also protects against the deadly Delta hepatitis. Unfortunately, the vaccine has been coolly received. Health care workers are afraid of the side effects, which are minor, and some cost-conscious administrators balk at the expense--about $100 per employee for the series of three injections.

Three health care unions--the Service Employees International Union, the National Union of Hospital and Healthcare Employees, and Local 1199, Drug, Hospital, and Healthcare Employees Union--recently petitioned the Occupational Safety and Health Administration to "immediately issue a clear policy directive stating that employers must offer hepatitis B vaccine free of charge to high-risk employees." The unions also asked OSHA to "promulgate standards and/or regulations to adequately protect health care employees from the hazard posed by occupational exposure to hepatitis B."

Regarding a specific exposure, report any accident or injury immediately if the date and time are known, and fill out any necessary forms. This documentation is essential if you subsequently develop symptoms of hepatitis B. (A friend of mine at another hospital could have used such supporting evidence. She was recently told by a risk management nurse that her hepatitis probably came from gardening!) Consult your hospital's infection control specialist or epidemiologist and follow the institution's protocol.

When you are under repeated or constant exposure and a specific incicent cannot be pinpointed, prepare a report as soon as symptoms of the disease appear. If you do contract hepatitis B, I suggest waiting until you are on the road to recovery before filing a claim for workers' compensation. (Check how much time you have to file; deadlines vary from state to state.) I did the paperwork at the height of my illness and wasn't up to the stress of dealing with the risk management and employee health departments as well as lawyers. Workers' compensation cases take months to process, so there's no real hurry.

Supervisors should alert new personnel to the danger of needlesticks and other exposures. This includes nontechnical staff members. The computer operator who occasionally helps process specimens must recognize the importance of proper hand washing and the use of gloves.

I devised a form that lists safety hazards and precautions (Figure I). The new employee and I discuss each item and sign the form, which then becomes part of the employee's permanent record.

Mouth pipetting cannot be tolerated. Also remind employees to keep pens, pencils, and hands away from their mouths and never to eat or drink in the labortory.

Clearly identify hepatitis B positive or suspected positive patient specimens, as well as AIDS, AIDS-related complex, and any other hazardous materials. (We occasionally receive polio and typhoid specimens.) Use appropriate markings and easily recognizable labels and spin these specimens in the centrifuges designed for this purpose.

Remember, however, that all specimens should be considred infectious. After all, the laboratory often gives clinicians the first clues--elevated bilirubin and enzymes--that hepatitis may be present.

Use gloves when processing hazardous specimens, and dispose of the gloves in appropriate receptacles. Discard used pipets in containers of 5 per cent bleach. These containers should be placed throughout the lab in convenient locations and should be able to withstand repeated autoclaving.

If a hazardous condition exists in your laboratory, report it to your supervisor or manager. If you are the manager, resolve the problem quickly. Work with others to improve safety conditions. Laboratory safety is everyone's concern.

Looking back, I'm pretty sure I was exposed to hepatitis B when I reached into our pneumatic transport system and retrieved a broken tube. My accident fell within the general incubation range of 45 days to six months. Once infected, I made two erroneous assumptions that delayed my diagnosis and recovery: I was sure I was immune and, even when I began feeling sick, I discounted the possibility of hepatitis because I wasn't jaundiced.

My institution has made some changes. Accident reports are filed routinely, and the employee health nurse follows up promptly. The laboratory manager has advised the floors that hazardous specimens must be hand-delivered. Specimens sent through the pneumatic tube have to be packaged well enough to avoid damage. Technologists are better about using gloves, even though this makes the transfer of labels from tube to tube a major chore.

I'm also happy to report that my illness prompted many colleagues, including other oldtimers, to get the vaccination. We are not complacent, but we are confident that the threat of hepatitis B has diminished in our laboratory.
COPYRIGHT 1987 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1987 Gale, Cengage Learning. All rights reserved.

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Title Annotation:personal narrative of infected laboratory worker
Author:Ramaley, Shirley A.
Publication:Medical Laboratory Observer
Date:Jan 1, 1987
Words:2248
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