Hepatitis B and C: a current problem in the group of infectious diseases in the nursing/midwifery profession

Introduction

Viral hepatitis was one of the leading causes of death among infectious diseases worldwide in 2022, with the number of deaths rising from 1.1 million in 2019 to 1.3 million [1, 2]. Hepatitis B caused 83% of these deaths, and hepatitis C caused 17% [1, 3].
The increase in deaths underscores the challenge of achieving the World Health Organization (WHO) goal of eliminating viral hepatitis as a public health threat by 2030 [4].
To this end, new action plans are being developed and implemented by various countries, as well as the European Union (EU), on the basis of their reports, with the aim of eliminating viral hepatitis infections and treating the disease [5].
Medical personnel are the occupational group most at risk of microbial infections, including hepatitis B and C virus [6]. Diverse efforts to eliminate viral hepatitis in many countries around the world include a range of screening and prevention activities, which include targeting occupational risk groups.
Despite a reduction in the risk of exposure to hepatitis B in healthcare facilities in the United States, the risk of infection among medical and allied health students is increasing. It is therefore recommended that they be vaccinated, even in cases where immunity has not been demonstrated [7]. Hence, students should have a documented hepatitis B vaccination regimen before entering clinical practice [8].
The safety of the hepatitis B vaccine is overseen by the World Advisory Committee on Vaccine Safety, which is an advisory body to the WHO. It is worth noting that this is a vaccine that can be taken by pregnant women or people with autoimmune diseases such as rheumatoid arthritis [9].
Contraindications to the vaccine include allergic reactions to yeast or any of its components. The current need is to spread reliable information about hepatitis prophylaxis to eliminate misconceptions about contraindications [10].
Unverified information and opinions, as well as misinformation, available through social media creates confusion and promotes the spread of anti-vaccine movements [11]. The literature review by Khan et al. also identified confusion as a characteristic factor affecting vaccination. Of the 28 articles included in the review, as many as 11 addressed the topic of confusion with vaccinations through the social network Twitter. The authors concluded that misinformation spread through mass media ultimately influences vaccination behavior [12]. Social media platforms such as Facebook, Twitter and Instagram can be used as tools for spreading news about anti-vaccine movements [13]. Therefore, it remains in the hands of governing authorities and health professionals to use these platforms to correct misinformation related to vaccine safety [11, 13].
Notably, Bianchi and Tafuri point to the positive impact of the Internet, citing a study by Porreca et al., who investigated the sentiments of users of the website YouTube on vaccine-related topics, following an intensive vaccine promotion campaign by healthcare professionals, among others. Thanks to the efforts of healthcare professionals through this platform, a change in the frequency of negative opinions on vaccination was observed from 52% in 2017 to 54% positive opinions in 2018 [11].
Vaccination against hepatitis B is the most effective form of protection against this virus. A doubling of the vaccination rate against this virus can be considered a success in public health, which has contributed to a 90% reduction in new infections [14].
The aim of this paper is to highlight the issues surrounding infectious diseases in the nursing/midwifery profession, using hepatitis B and C as an example, in the context of the available hepatitis B vaccine.

Incidence and occupational diseases due to hepatitis and vaccination against hepatitis in 2018-2022 in Poland and selected countries

A literature review and critique of the literature from 2008-2023 were conducted to identify scientific articles, reports and publications from occupational medicine and the broader health sciences related to hepatitis B vaccination in the workplace.
Articles on hepatitis B exposure with a focus on vaccine aversion and secondary exposure after receiving mandatory hepatitis B vaccination resulting from the workplace were evaluated. The database included articles published in English with the full text publicly available. A search of bibliographic databases was performed in the MEDLINE/PubMed database using MeSH criteria, AND descriptors and keywords in the search: reluctance to vaccinate, secondary exposure to hepatitis B after receiving mandatory vaccination, hepatitis B vaccination. Filters were used to narrow the search. The inclusion criterion was studies conducted within the last 5 years.
The analysis includes reports for 2018-2022 on: occupational diseases, issued by the Institute of Occupational Medicine (IMP) in Lodz entitled Occupational Diseases in Poland, hepatitis B and C incidence obtained from reports entitled Infectious Diseases and Poisons in Poland, and mandatory vaccinations against hepatitis B among health care personnel, from reports entitled Immunization in Poland. The latter two items are published by the National Institute of Public Health National Research Institute Department of Epidemiology. In addition, relevant statistical data obtained through the World Health Organization (WHO) on hepatitis-related prophylaxis or the National Institute of Public Health State Research Institute, among others, were also evaluated. The results of the search are presented in tabular form using absolute numbers.
The total number of hepatitis B cases in 2018-2022 was 11,090, and the number of hepatitis C cases was 11,512. Looking at the distribution of the number of cases, it is not possible to clearly determine an upward or downward trend [15-17].
The detection rate was 4.03/100,000 – 58% higher than the rate in 2020 and 53% lower than the median for 2015-2019 [18]. Both hepatitis B and hepatitis C have a predominantly chronic course of disease. The number of people vaccinated for hepatitis B has remained at a similar level since 2020.
A definite decrease in occupational cases of hepatitis B and C can be observed. The total number of cases of hepatitis B was 18, and of hepatitis C 36. It follows that occupational diseases of hepatitis C etiology have the highest prevalence. Taking into account the total number of occupational diseases of nurses of 1482, the total number of hepatitis B and hepatitis C cases (54) is small and accounts for 3.6% of the total incidence in this professional group [3, 15-17]. These results are presented in Table 1.
There is no comparative scale with the present years for the data presented in Table 2 on the number of hepatitis B vaccinations among pupils, students and medical professionals in Poland for 2018 only.
According to data from the Central Statistical Office, at the end of 2018, 33,403 people were studying nursing (bachelor’s and master’s degrees) in Poland [20]. On the other hand, the number of post-secondary students in the 2017/2018 school year in medical faculties was 55,600, of whom 44 200 were women [21].
The number of hepatitis B vaccinations of medical professionals exposed to the infection was 6582. In contrast, data obtained from the Supreme Chamber of Nurses and Midwives for 2018 show that the number of stated practicing rights in 2018 for nurses was 4618 and for midwives 869 (5487 in total). There is therefore a slight difference of 1095 resulting from the number of hepatitis B vaccinated health professionals and the above-mentioned nurses and midwives. This is assuming that 100% of those who obtained the title to practice their profession were vaccinated. However, these data are inaccurate due to the fact that the medical profession does not include only the professions of nurse and midwife. In Poland, there are no data on hepatitis B vaccination registers in relation to the number of people undergoing such vaccination [22].
Comparing the largest and smallest number of mandatory vaccinations among exposed people, it can be concluded that the largest number of mandatory vaccinations was shown among people aged 30+ (2019-2022: 21264, 15440, 18577, 18591, respectively), and the smallest in young people aged 0-19 (572, 509, 653, 806). The highest percentage was among people aged 30+ (250950, 143924, 127739, 129826), and the lowest among those aged 0-19 (1700, 1836, 1394, 1715) [16]. These results are presented in Table 3.
According to the National Institute of Public Health of the National Research Institute, the number of people evading mandatory immunization in Poland is increasing every year. In 2022, the number was 72,722, and in 2023 it was 87,344 [23]. According to the 2019 report on the survey of the implementation of Council Directive 2010/32/EU in Polish hospitals, in which nursing staff, among others, were addressed, it appears that the most common source of punctures is opening an ampoule (70.7% of respondents). This was followed by drawing blood (32.1% of respondents) and administering a drug by injection (27.8% of respondents). A surprisingly small number of stabbings were reported by respondents during an invasive procedure during resuscitation (7.4% of respondents). It is worth noting at this point that 75.6% of respondents indicated that they have sufficient access to safe needles for drawing blood, and 25.9% of people have access to safe needle-free ampoules. This is why there is such a high number of pricks when opening an ampoule [24].
According to an anonymous survey of a group of, among others, 50 nurses at a selected health care facility, the level of anti-HBS antibodies was checked in nurses once a year, most often among employees with seniority of 10-15 years (42.9%). Respondents with this length of service were also the smallest group of people in whom antibody levels were not checked (57.1%). In personnel with seniority of 15-20 years > 20, antibody levels were measured in 41.7% of respondents. Respondents with seniority of 5-10 years reported the lowest response. Among them, 25% of respondents had their antibody levels determined once a year. Employees with seniority of 5-10 years were the largest group of respondents, with 75% responding that they did not have their antibody levels checked [14]. This indicates, among other things, that there is a greater emphasis on antibody checks for staff with seniority of about 20 years – that is, people who have taken the hepatitis B vaccine relatively long ago compared to staff with lower seniority of 5-10 years. Table 3 also shows that, after high school, young people have taken all doses of the vaccine and do not need further vaccination. The number of recommended vaccinations is analogous. Therefore, by comparing the numbers of vaccinated students and medical students (Table 2) to the total number of students and students in these fields in 2018, it can be concluded that there is not a large number of vaccinated individuals [20, 21].
The risk of being stabbed or otherwise injured increases in line with the increase in seniority. One in five workers with more than 15 years of service has never injured themselves. This number is higher than that of employees with up to 15 years of seniority. In this group, one in three employees reported that they had never experienced a needlestick injury [6].
Dyk-Duszyńska A. reported, on the basis of surveys conducted in 2009-2011 among 574 nurses regarding occupational exposure to HBV/HCV/HIV infection, that as part of the inclusion of post-exposure prophylaxis, hepatitis B vaccine was administered to a small number of nurses in 2009-2011, respectively: 2009 – 29, 2010 – 41, 2011 – 35. On the other hand, HBV and HCV testing was administered to the vast majority of nurses. The highest number was observed in 2010, respectively, for HBV – 509, and for HCV – 520. Among these nurses, the vast majority (553) of respondents received the mandatory 3 doses of hepatitis B vaccine as part of the mandatory vaccination of health care workers. A small number (8) did not undergo this procedure, and 13 took the vaccine but in an incomplete cycle. A booster dose was given to 349 people, 342 of whom were vaccinated as a preventive measure, and 7 as a result of post-exposure management. It is worth noting that between 2009 and 2012, 16 cases of viral hepatitis were found in nurses over 35 years of age employed in hospital wards of surgical specialties in Greater Poland [25]. It follows that these cases involved personnel already experienced with work in the profession.
According to data from a meta-analysis of 22 studies by Poorolajal et al. including 42 independent study cohorts involving 11,090 individuals, it was shown that of these cohorts, 1 involved healthcare workers aged 19-49 years vaccinated with a 3-dose hepatitis B vaccination regimen, followed for 16 years [26]. The prevalence of hepatitis B infection in this particular cohort was 0.150 (95% CI confidence interval [CI]: 0.104-2.07). It should be noted that the incidence of hepatitis B infection between 5 and 20 years after primary vaccination was 0.007 (95% CI: 0.005-0.010). In young people aged 1-19, the incidence of these infections was 0.021 (95% CI: 0.008-0.034), and in those aged 20-39, it was 0.027 (95% CI: 0.000-0.053). The above data indicate that hepatitis B infection remains extremely rare between 5 and 20 years after vaccination. A meta-analysis showed that those vaccinated in a 3- or 4-dose regimen did not require a booster [26]. On the other hand, a meta-analysis by Peto et al. examined 4613 children born between 1986 and 1990 and covered by a nationwide vaccination program in The Gambia between 1990 and 2007 against hepatitis B. In addition to the reported decline in hepatitis B infections, which can undoubtedly be linked to infant vaccination, a decline in hepatitis C infections was observed. The decline in hepatitis B incidence was observed in those born in the early 1980s [27]. Table 1 also shows a decrease in the number of hepatitis B and C cases noted after 2018, with a definite predominance of chronic cases.
Ocan et al. examined HBV antibody levels in a cross-sectional study among 300 randomly selected health care workers vaccinated with hepatitis B (regardless of when they received the vaccine) at selected medical facilities in northern Uganda. The study found that 83% (249 subjects) had protective HBV antibody levels. Only 2 cases showed active hepatitis B infection [28].
Prevalence rates of hepatitis B and hepatitis B vaccination vary around the world. In some countries, the vaccination prevalence among undergraduate nursing students was low, i.e. 25.8% [29]. Despite the introduction of national vaccination programs and the achievement of high vaccination rates in the population, many countries have higher vaccination rates among nursing and midwifery students (95% for each) than other majors in the group of students entering health sciences and health sciences [30, 31]. Epidemiological analysis illustrates the total and recorded number of hepatitis B cases according to various criteria and variables, including age, gender, virus type (A, B, C), infection type (e.g. acute or chronic), risk factors, transmission routes, as well as so-called imported infections. In addition, analysis of the implementation of diagnostic tests and mandatory immunizations for the population aged 0-18 years or recommended against hepatitis B for risk groups allows monitoring of the relationship between the number and rates of vaccinations performed and detected cases of viral hepatitis. The observed trends of omission of mandatory vaccination in the population of children and adolescents may pose a threat of increased risk of viral transmission or infection in the future, especially if they choose education and professional work in the medical professions [18, 32, 33]. In the case of unvaccinated students, screening, education and preventive measures have a significant impact on increasing health awareness and thus motivation to be vaccinated before working in a risk environment.

Summary

The most effective way of preventing infectious diseases of an occupational etiology in the workplace of a nurse/midwife is vaccination against hepatitis B. It is therefore crucial to disseminate this form of prevention among all medical staff carrying out activities involving the risk of contracting this type of virus. These prevention activities should contribute to raising awareness and ultimately reduce the risk of infection and the development of infectious disease caused by B and C viruses. The varying levels of student and staff awareness of occupational risks in the health professions, the under-reporting of work-related illnesses, the varying vaccination rates in some countries and the migration of students indicate the need to monitor hepatitis B and C antibody status, as well as indications for vaccination and/or treatment.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References