A troubling shortfall in HCW hepatitis B vaccination rates
A troubling shortfall in HCW hepatitis B vaccination rates
HC employers failing to meet 90% goal
While the pressure grows to raise the rate of influenza vaccination of health care workers to 90%, an identical Healthy People 2020 goal for hepatitis B vaccination of health care workers remains quietly unmet.
Only 63% of health care personnel received the hepatitis B vaccine in 2010, according to the National Health Interview Survey, far below the Healthy People 2020 goal of 90%.1 The U.S. Occupational Safety and Health Administration requires employers to offer the hepatitis B vaccine to employees who have the potential for bloodborne pathogen exposure.
Some of the vaccination gap may be among employees who don't have exposure risks. The Centers for Disease Control and Prevention has no information about vaccination within the subset of health care workers who are at risk. But other studies show that substantial numbers of at-risk workers remain unvaccinated. A study of the medical records of workers at 425 hospitals in 2002 and 2003 found that phlebotomists had an HBV vaccination rate of just 71%, lower than physicians or nurses.2
In 2010, the Institute of Medicine found that knowledge of hepatitis B and C among health care providers was "generally poor" and that greater awareness is needed to improve vaccination rates.3 Yet there has been no highly public campaign to improve hepatitis B vaccination, as there has been for influenza vaccination.
"In general, surveillance and research on occupationally acquired infection has received less attention and resources at the CDC over the last decade compared to issues like patient safety and health care-acquired infection among the patient population," says Jane Perry, MA, associate director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville.
That followed from the dramatic decline in occupationally acquired HBV in the 1990s. And with the advent of childhood HBV immunization, the upcoming generation of health care workers will be largely protected. But it is appropriate to reassess the current occupational infection risk for both HBV and hepatitis C, Perry says.
Stunning decline in HBV cases
Hepatitis B vaccination has been an occupational health success story. The first HBV vaccine became available in 1981 and the current version was approved in 1986, but CDC reported 8,700 cases among health care workers in 1987. In its 1991 Bloodborne Pathogen Standard, OSHA required employers to provide the hepatitis B vaccine free of charge, and by 1997, the number of occupationally infected health care workers dropped to 249.
In 2009, there were just 13 known cases of acute hepatitis B caused by occupational exposure, according to CDC surveillance.
All the provisions of the Bloodborne Pathogen Standard, including the selection and use of safety devices and training, contributed to the decline in hepatitis B cases, says Dionne Williams, MPH, a senior industrial hygienist with OSHA. "The incidence rate among health care workers is lower than incidence rates among the general population," she says. "It was a complete flip [in the risk profile]."
The occupational risk of acquiring hepatitis B will drop even further with a new generation of health care workers who were vaccinated as infants or young children. Forty-seven states require hepatitis B vaccination of children who enter kindergarten.
CDC officials have just begun to draft recommendations for health care workers who received the hepatitis B vaccine as infants. About 5% of people are non-responders and do not gain immunity from the vaccine. "[Those immunized as children] had no post-vaccination serology so we can't be sure they're protected," says Mark Sawyer, MD, professor of clinical pediatrics at the University of California San Diego School of Medicine and chair of the working group on hepatitis for the Advisory Committee on Immunization Practice (ACIP).
ACIP will decide whether to recommend that health care employers test for HBV antibodies in all health care workers who were vaccinated as infants and immunize those without detectable levels. Alternately, they could provide all of them with a single dose of vaccine and perform serology testing. A third option would be to test for an immune response only after an exposure. The same policy would apply to older health care workers who had been vaccinated years ago but lack evidence of post-vaccination serology, Sawyer says.
"It's a balance between practicality, expense and protecting the most people we can," says Sawyer.
Sawyer notes that HBV is endemic in many other countries, so health care workers who care for immigrant populations remain at greater risk, despite the widespread vaccination in the United States.
OSHA cites under HBV provision
Meanwhile, 20 years after OSHA issued its requirement to offer hepatitis B vaccination, hospitals still struggle with inadequate coverage of their at-risk workers.
The requirement to offer and document hepatitis B vaccination is one of the most frequently cited provisions of the Bloodborne Pathogen Standard, Williams says. "[Health care employers] should offer it to employees and employees should be trained so they understand the benefit of getting the vaccination," she says.
At Marshfield (WI) Clinic, Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety, would like to require it. He's not sure if the OSHA standard allows that.
"We have a number of employees, including providers doctors and physician assistants who have not gotten it," he says. "We have some employees who have not gotten it and don't want to get it. That puts us at a liability. If they develop the disease, we have to cover them under workers compensation and they have the potential for passing it on to patients."
OSHA has not yet responded to Cunha's request for clarification. But in the preamble of the Bloodborne Pathogen Standard, OSHA pointed out its reasoning for not mandating the hepatitis B vaccine. The agency said it sought to "encourage rather than to coerce employee cooperation" and noted that the National Institute for Occupational Safety and Health (NIOSH) strongly opposed mandatory vaccination.
"Our thinking at the time was that you'd get greater cooperation if employees were educated properly about the efficacy of the vaccination," says Williams.
References
1. Centers for Disease Control and Prevention. Adult immunization coverage – United States, 2010. MMWR 2012; 61:66-72. Available at: http://1.usa.gov/yYe6fN
2. Simard EP, Miller JT, George PA, et al. Hepatitis B vaccination coverage levels among healthcare workers in the United States, 2002-2003. Infect Control Hosp Epidemiol 2007; 28:783-790.
3. Institute of Medicine, Committee on the Prevention and Control of Viral Hepatitis Infections. Hepatitis and liver cancer: A national strategy for prevention and control of hepatitis B and C. The National Academies Press, Washington DC, 2010. Available at http://1.usa.gov/bfjxCI.
While the pressure grows to raise the rate of influenza vaccination of health care workers to 90%, an identical Healthy People 2020 goal for hepatitis B vaccination of health care workers remains quietly unmet.Subscribe Now for Access
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