Method: This was an observational descriptive study. Records of the HBV immune status of all doctors who reported an occupational injury (OI) to the occupational health clinic between June 2010 and May 2011 were reviewed. A structured questionnaire was then distributed to all laboratory personnel and senior doctors employed at the hospital.

Results: Of the 67 doctors who reported an OI, 39% (26 out of 67) had no HBV immunity and only 19% (5 out of 26) had received Hepatitis B immunoglobulin. Of the 78 doctors who completed the questionnaire, 65% (51 out of 78) reported at least one OI during their career. Fifty-six percent of the respondents were unaware of their HBV immune status and only 31% had received a booster within the previous 5 years.

Conclusion: Poor compliance of HCWs to HBV vaccination and post-exposure prophylaxis is a concern. In-service training is needed to inform staff of the efficacy of HBV vaccination and immunoglobulin therapy.

Contexte: L’infection par le virus de l’hépatite B (VHB) est l’agent pathogène transmis par le sang qui se transmet le plus facile. Ceci constitue un risque du métier pour les professionnels de la santé (PS). Malgré le fait que l’infection puisse être évitée par la vaccination et l’administration post-expositionnelle d’immunoglobulines, beaucoup de PS n’ont pas conscience des risques d’infection par le VHB et des mesures préventives appropriées. Cette étude est unique dans le contexte sud-africain car elle se concentre sur l’exposition, l’attitude et la connaissance par les médecins de l’infection par le VHB.

Méthodologie: Il s’agit d’une étude descriptive observationnelle. Les historiques relatifs au statut immunitaire vis-à-vis du VHB de tous les médecins ayant signalé un accident du travail (AT) à l’établissement de santé qui les employait entre juin 2010 et mai 2011 ont été examinés. Un questionnaire structuré a ensuite été distribué à tout le personnel de laboratoire et aux chefs de service employés par l’hôpital.

Résultats: Parmi les soixante-sept médecins qui ont signalé un AT, 39% (26 de 67) n’étaient pas immunisés contre le virus de l’hépatite B et seulement 19% (5 de 26) avaient reçu des immunoglobulines de l’hépatite B. Parmi les 78 médecins qui ont répondu au questionnaire, 65% (51 de 78) ont signalé au moins un AT au cours de leur carrière. Cinquante-six pour cent des personnes interrogées ne connaissaient pas leur statut immunitaire vis-à-vis du VHB et seulement 31% avaient reçu un vaccin de rappel au cours des cinq dernières années.

Conclusion: La mauvaise observance par le personnel de santé de la vaccination contre le VHB et la prophylaxie post-expositionnelle est inquiétante. Une formation interne est nécessaire pour informer le personnel de l’efficacité de la vaccination contre le VHB et de l’administration d’immunoglobulines.

The aim of the study was to investigate the validity of these observations and to make recommendations, based on the findings, to the hospital management to enhance HCWs’ protection.

According to South African legislation,² every employer must have a system in place to ensure that all staff are immunised against HBV infection and that exposures to HBV and other blood-borne pathogens are reported and appropriately managed. HBV infection in the workplace is a preventable disease provided all at risk personnel are immunised with the HBV vaccine and develop immunity. The development of such immunity can be determined by testing for hepatitis B surface antibodies (HepBsAb).⁶ The KwaZulu-Natal DOH has made provision for hepatitis immunisation to be made available through OHCs to all staff members who have not previously been immunised and for those who need booster immunisation.³

In the occupational health setting HBV is the most easily transmitted blood-borne pathogen, followed by Hepatitis C virus, and then HIV.⁷ The risk of a HCW acquiring HBV infection after a needle stick injury is one hundred times greater than the risk of acquiring HIV infection. The non-immune HCW has a 27% to 37% risk of contracting hepatitis B if the source patient is HBeAg negative. The risk increases to 62% if the source patient is HBeAg positive.⁸

The HBV vaccine is safe and effective.³ Pre-exposure vaccination is freely available in all government institutions, including universities and hospitals. It is best administered when the HCW is undergoing training. Immunisation involves three intramuscular injections followed by post-vaccination testing one to two months after the last dose to assess immunity.³ A HBV surface antibody titre of >10muIU per mL indicates the presence of immunity.³

The Immunisation Action Coalition recommends that HCWs with a normal immune status who demonstrate an adequate hepatitis B surface antibody titre response of at least 10mIU per mL following their vaccination series do not need a booster or periodic HepBsAb testing. This recommendation is based on the fact that although HepBsAb titre levels decline with time, the immune memory in the form of the anamnestic anti-HBs response remains intact indefinitely. Therefore the HCW with HepBsAb levels <10mIUper mL remains protected.⁹ However, the South African National Department of Health (DOH) guidelines advocate administration of a HBV booster every five years with no need for further immunity testing, unless the HCW has sustained a percutaneous or mucosal injury.¹⁰ This recommendation is based on the high prevalence of HIV infection in South Africa and the assumption that the immune status of HCWs may be challenged by HIV.¹⁰

Post-exposure prophylaxis (PEP) with HBV immunoglobulin provides substantial protection following exposure to blood and blood products for HCWs who have no immunity against HBV infection.¹¹

The current DOH HBV PEP recommendations following exposure to blood or blood products (see Table 1).¹²

It is estimated that 5.9% of HCWs are exposed annually to HBV. This equates to approximately 66 000 HBV infections worldwide.¹³

A number of international studies carried out in Kenya in 2006¹⁴ and in Albania in 2007¹⁵ have shown a high prevalence of HBV infection amongst the general population and low vaccination coverage amongst HCWs. These studies are consistent with South African studies.⁶ In 2002 Vardas et al.¹⁶ showed that only 30.6 percent of HCWs were immune to HBV infection and in 2007 in Bloemfontein De Villiers⁸ showed that in 67.5% of cases the HCWs’ HBV status was unknown following an occupational exposure. There is a paucity of data regarding the true extent of immunity against HBV infection amongst doctors in South Africa in general and in KwaZulu-Natal in particular and this study sought to fill this gap.

Informed consent was obtained from all those who participated in the study. Patient information leaflets and consent forms were given to all participants in the study.

Data was protected by storing it in a lock-up safe that was only accessible to the researcher and the occupational health unit manager.

In addition to the record review all laboratory personnel and senior doctors were asked to complete a self-administered questionnaire. Senior doctors were targeted as they presented a more stable doctor population; they are often asked by colleagues to explain the correct procedure following a NSI or other accidental exposure and are expected to set an example to junior colleagues. Over and above this, a brief review of the records at the OHC suggested that this group of HCWs generally did not attend the OHC for HBV immunisation or booster immunisation.

The questionnaire asked about previous sharps injury or mucosal exposure to blood or blood products and whether the HIV and the HBV status of the source patient had been checked at the time of injury. It aimed to discover whether or not the HCW was aware of his or her HBV immune status and assessed their knowledge and attitude regarding HBV infection.

Records from the occupational health clinic register showed that 67 doctors had reported a percutaneous or mucosal injury between June 2010 and June 2011. There were no records from laboratory personnel as they no longer access care at the OHC. Twernty-three of those who had sustained an occupational injury were men and 44 were women. The average number of years of service was 5 (range 1–8 years). The largest numbers of those with needle stick injuries were working in the department of surgery. This was followed by paediatrics and the least number of injuries were reported in the department of obstetrics and gynaecology (see Table 2).

In response to the questionnaire, 51 doctors reported at least one percutaneous or mucosal injury during their career. The HIV status of the source patient had been checked in 73% (37 out of 51) of the injuries whilest the HBV status of the source patient had been checked in only 4% (2 out of 51) cases.

Fifty-six percent of HCWs were not aware of their immune status. Furthermore only 22% had received a booster within 5 years of their last immunisation and 78% had received their booster after five years or not at all. Fifty-four percent of participants were not aware that the HBV booster should be administed every 5 years (see Table 4).

Their knowledge regarding HBV was weak. Only 33% of the participants knew the true risk of HBV transmission whilst 67% underestimated the risk.

Fifty-seven percent of staff correctly indicated that HBV infection was most easily transmitted after a needle stick injury. Thirty-five percent of staff incorrectly thought that HIV was more easily transmitted after an NSI than HBV.

PEP against HBV infection is accessible in the form of the hepatitis B immunoglobulin. An injured HCW qualifies for this if he or she has not been immunised previously and the source patient is infected. Fifty-seven percent of doctors reported at least one sharp injury or mucosal exposure during their employment at the hospital, but only two of the source patients’ hepatitis B status had been checked. In 96% of cases their HBV status had not been checked. This is worse than the findings of De Villiers⁸ in Bloemfontein in 2007 which showed that the HBV status of 67.5% of patients remained unknown following occupational exposure by a HCW. In comparison the HIV status of the source patient is often known or actively sought and is considered the most important issue for the injured HCW, despite the fact that the risk of contracting HBV infection is 100 times higher than that of contracting HIV infection following a needle stick injury. Thirty-five percent of the participants incorrectly believed that HIV was more easily transmitted than HBV and this could explain why the HBV status of the source patient is not actively tested.

Although occupationally acquired HBV infection is preventable by vaccination, 56% of the participants were not aware of their immune status and 54% were not aware that the HBV booster dose should be administered every five years. After immunisation with the vaccine series it is vital to have an immunity test performed to determine if the HCW is protected against HBV. If the HCW does not develop an antibody response a second vaccine series needs to be given and the HCW rechecked to determine whether he or she is a responder or a non-responder.¹³ Every HCW should be aware of their immune status so that Hep B PEP can be managed appropriately. Human hepatitis B immunoglobulin is available in the public sector. Hepatitis B immunoglobulin should be administered within 48 hours to those HCWs who are not immune; however, it can be given up to seven days after exposure. At the hospital where the study was conducted, and in many other public sector hospitals in South Africa, it unfortunately takes more than seven days to obtain the results of the HepBsAb titre. This may limit the opportunity to access PEP. If the HCW in this hospital is unaware of his or her immune status, however, hepatitis B immunoglobulin must be given. In this study the immunoglobulin had been administered to only five HCWs between June 2010 and May 2011. This is a great concern as twenty-six doctors had not been immune at the time of the injury and as all should have been given the hepatitis B immunoglobulin in line with current policy. A further concern is that in 50% of injuries doctors had not returned to review their baseline blood results, including their HepBsAb titre, thus missing the opportunity to receive appropriate follow-up and immunisation.

More than 80% of participants acknowledged that HBV infection was important, yet 56% were not aware of their immune status. There may be a number of reasons for this, including the low profile of HBV infection, the pervasive nature of HIV infection and the emphasis that has been placed on HIV PEP. It may also be because 80% of the participants thought that the Hepatitis B immunisation programme at the hospital was neither well organised nor accessible.

These findings are comparable with a study carried out by Maha Talaat in Egypt which noted that only 15.8% of their HCWs completed the three doses of the hepatitis B vaccine.¹⁷

The majority of the injuries were reported by surgeons and by paediatricians. A study by Kent and Sepkowitz in 2004 showed that in prevaccine surveys the incidence of HBV infection was more than ten times higher in surgeons and laboratory workers exposed to blood and blood products than amongst other categories of HCWs.¹⁸ The least number of injuries were reported by doctors working in Obstetrics and Gynaecology. This finding was surprising as Obstetrics is a hands-on procedural discipline where needle stick injuries and mucosal exposure might be expected to occur.

Laboratory personnel have been employed by the National Health Laboratory Service since 2009 and they no longer access the service at the OHC. Results on exposure to blood or blood products were therefore not available. 80% were aware of their HBV immune status, but the majority had poor knowledge regarding the risk of acquiring HBV. The majority also believed that HIV was more easily transmitted than HBV after an injury. No injuries were reported in this group.

South Africa has a high prevalence of HBV infection, more than 75% of adults having serological evidence of previous hepatitis exposure and carrier rates between 10% – 25%.¹⁴ HCWs are therefore susceptible to and at risk of acquiring this preventable disease. The onus is on HCWs to take responsibility for their own health. The National DOH can assist by introducing legislation similar to legislation in Britain,¹⁹ requiring all HCWs to submit proof of their HBV immunity prior to being employed.

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