STATEMENT ON HEPATITIS AND THE UNIVERSITY

Many viruses affect the liver, but the term hepatitis is commonly used for infection with one of three particular viruses - Hepatitis A, B and C - which have the liver as their main target in the body. The clinical disease and mode of spread is different for each of these viruses, and this affects their impact on the University community.

• Hepatitis A
  1. Transmission
  2. Implications for Staff and Students
• Hepatitis B
  1. Transmission
  2. Control
  2.1 General
  2.2 Implications for non-infected Staff and Students
  (a) Social Contact
  (b) Contact with Blood
  (c) General Staff - Cleaning, Gardening, Plumbing, First Aid
  (d) Risk to Medical, Dental and Other Health Care Staff and Students
  (e) Use of Human Blood & Tissues in Practical Classes & Research Laboratories
  (f) Travellers
  2.3 Students and Staff infected with Hepatitis B virus
  3. Specialist Services offering advice on Hapatitis B
  4. References
• Hepatitis C
  1. Transmission
  2. Control
• Precautions for contact with Human Blood
  1. Choice of Technique
  2. Waste Disposal
  3. Accidents
  4. Disinfectents
• Common Disinfectents for Hospital Use
  1. Phenolics
  2. Halogens
  3. Alcohols
  4. Aldehydes
• Notice - Precautions for Contact with Human Blood
  1. Precautions to Prevent Contact
  2. What to do after Accidental Contact with Human Blood

HEPATITIS A

Patients with Hepatitis A complain of tiredness and nausea. They usually have fever and jaundice, which may last for one to two weeks after which recovery is rapid. Virus excretion seldom persists for more than a few days after the onset of jaundice. There are no long term effects of Hepatitis A, and infection confers lifelong immunity. Children often experience mild or asymptomatic infection.


1. TRANSMISSION

The virus is spread by oral ingestion of food or water contaminated with faeces from a patient or asymptomatically infected person. The disease has become less common in Australia so that fewer school-age children become infected. As a result, a higher proportion of young adults are susceptible and outbreaks may arise in institutions due to breakdown in food handling procedures. The greatest risk occurs on field trips when sanitation may be inadequate. The incubation period is about 3 weeks.
Transmission is prevented by hand washing, particularly by food handlers, and by provision of uncontaminated drinking water. The virus is readily inactivated by heat and detergents as for instance in domestic washing-up or clothes washing.

Travellers to countries with a high prevalence of hepatitis A (ie most areas except Australia, Northern Europe and North America) may also be at risk, especially if they are exposed to local conditions outside large city hotels which usually maintain high standards of food hygiene. A single dose of normal pooled human immunoglobulin confers protection for 2 to 5 months, depending on dose.

A vaccine is now available in Australia. It is expensive, but worthwhile for frequent or prolonged travel to endemic areas.


2. IMPLICATIONS FOR STAFF AND STUDENTS

2.1 Occurrence of a case in a residential group (eg college or field station) should be notified without delay to the local Public Health Unit by the general practitioner caring for the patient. This is a legal obligation and expert advice regarding management of contacts will be provided. OHS & Injury Management should be informed at the same time . Hepatitis A patients should not be involved in any kind of food handling until one week after the jaundice has cleared. Ordinary personal hygiene practices will prevent spread to other people.

2.2 Travellers to endemic countries are advised to have an innoculated with the vaccine for Hepatitis A prior to departure. This can be arranged through a general practitioner or the University Health Service. A few days notice is required. Frequent travellers, especially those undertaking field work in remote areas, may well be immune because of past exposure, even if they have never experienced an attack of jaundice. Laboratory tests of immunity can be arranged either through a general practitioner or the University Health Service.

2.3 Staff and students working in health care settings should be aware of Health Department Policy Directives in relation to Hepatitis A vaccination, which may need to be considered for those having direct contact with blood or body substances - see NSW Health Policy Directive 2007_006 (1 February 2007): Occupational Screening and Vaccination Against Infectious Diseases .

HEPATITIS B

Hepatitis B is transmitted by blood and some body fluids. It is a significant public health problem because the virus causes both acute and chronic infection. Symptoms of acute infection may include jaundice, fever, nausea and vomiting which may persist for several weeks. Chronic infection may lead to liver cirrhosis or even liver cancer.

Carriers of Hepatitis B virus may have no symptoms but are potentially infectious to others and may themselves suffer from liver disease later in life. Australia is fortunate to have a low prevalence of both acute and chronic hepatitis B, but some groups including Aboriginals and immigrants from the Mediterranean or Asian regions have a much higher prevalence rate. 10% or more of some groups have evidence of persistent infection of the virus without any past history of jaundice.


1. TRANSMISSION

Blood, saliva and sexual secretions of hepatitis B carriers and persons with acute hepatitis B are potentially infectious. Transmission usually requires that the virus be inoculated beneath the skin, but mucosal contact, especially sexual, is also effective. The incubation period is about three months. The quantity of virus in the blood may be so high that a minute amount of blood is infectious. Even a scratch with a blood-contaminated object such as a comb, pin, razor or toothbrush may then transmit the disease. However, in highly endemic groups, most hepatitis B transmission occurs from asymptomatic carrier-mothers to their infants, who become carriers in their turn. Symptoms of disease seldom appear until the fifth or sixth decade of life when chronic liver disease or hepatic cancer may develop.

The hepatitis B virus can survive in blood and bodily fluids in clinical and non-clinical areas.

2. CONTROL

Effective vaccines are available. Their use in the community has been particularly targeted to infants born to carrier mothers and the sexual partners of known carriers. Immunisation of all health care workers is strongly advised - see below. Hepatitis B is of concern to the University in a number of different context as outlined below.

2.1 GENERAL
The student age group is at high risk of contracting sexually transmitted diseases and diseases which can be transferred via intravenous drug use. Hepatitis B is a problem in both contexts and should be included in the general health educational programs on campus.

2.2 IMPLICATIONS FOR NON-INFECTED STAFF AND STUDENTS

(a) SOCIAL CONTACT, eg in lectures and practical classes, residential colleges and sporting facilities is not associated with the transmission of Hepatitis B. N.B. incidents of bleeding during body contact sports may present a risk and immunisation of participants at risk is advised.

(b) CONTACT WITH BLOOD, FOR EXAMPLE FOLLOWING ACCIDENTS OR INJURIES ON CAMPUS: all cases of external bleeding should be handled carefully using the precautions summarised in the Precautions Section. Should an inoculation (needlestick) injury be sustained involving the blood of another person, the wound should be washed with copious amounts of running water and advice sought at once from the University Health Service. Arrangements will then be made to ascertain the Hepatitis B status of the other person and to offer the injured person an injection of the Hepatitis B vaccine or specific Hepatitis B immunoglobulin, which provides protection against infection if administered within 48 hours of exposure. Should an incident occur when the University Health Service is closed, advice should be sought from the casualty department at the nearest large public hospital (Royal Prince Alfred Hospital if on Camperdown/Darlington campus).

(c) GENERAL STAFF ENGAGED IN CLEANING, GARDENING, PLUMBING AND FIRST AID WORK are at low risk of exposure to the Hepatitis B virus due to the nature of their work. However, they can and should arrange for immunisation through their general practitioner or the University Health Service (see below for more details about immunisation). If you are unsure whether you should be immunised against Hepatitis B because of potential workplace exposure, contact OHS & Injury Management for advice.

(d) THE RISK TO MEDICAL, DENTAL AND OTHER HEALTH CARE STAFF AND STUDENTS: The occupational risk of acquiring Hepatitis B is high. The National Health and Medical Research Council strongly advises immunisation of all medical and paramedical staff who are in direct contact with patients, or with human blood, body fluids or tissues. This is consistent with the relevant NSW Health Department Policy Directive (Reference 1) which recommends vaccination of all Health Care Workers and Other Qualified Personnel in Health Care Areas. This aims to protect health care workers (including students) and patients from Hepatitis B transmission. The University supports this policy.

• Staff: Most clinical staff will be immunised through the teaching hospitals. Some research staff as well as academic and technical staff concerned with practical class work will also require immunisation, which is available through the University Health Service.
• Students: Hepatitis B immunisation is included in the immunisation schedule offered to all medical and paramedical (including Medicine, Dentistry, Pharmacy, Microbiology, Nursing, Physiotherapy and Occupational Therapy) students through the University Health Service. The University strongly recommends that students be vaccinated before they enter clinical training (see References).

The standard course of Hepatitis B immunisation involves three injections at 0, 1 and 6 months, but the range may vary dependant on the age of the individual concerned. Boosters may be required 3-5 years after completion of the initial course. Both staff and students should have antibody tests to demonstrate adequate response to the primary course of the vaccine and to give guidance about the timing of future booster doses.
A small percentage of healthy individuals fail to develop immunity after immunisation. The administration of Hepatitis B specific immunoglobulin is advised should they be accidentally exposed to Hepatitis B. This can be arranged through the University Health Service or the Casualty Departments of large hospitals (if exposure occurs out of hours) and should be done at once if a needlestick incident or injury occurs.

Information on hospital policies and precautions to be observed when taking blood samples and handling infected material is available from hospital Infection Control Units and from OHS & Injury Management , University of Sydney. HEALTH CARE WORKERS, INCLUDING STUDENTS, SHOULD BE AWARE OF THEIR OBLIGATIONS UNDER NSW HEALTH DEPARTMENT POLICIES (Reference 1).

(e) USE OF HUMAN BLOOD AND TISSUES IN PRACTICAL CLASSES AND RESEARCH LABORATORIES: Exercises using human tissue, and particularly blood, have been devised as an alternative to the use of animal experimentation in undergraduate courses. Other body fluids, eg urine or saliva, are also used. In addition, blood and tissues from volunteer staff, students and patients are frequently employed in research laboratories.

• Use of blood in practical classes: When patient blood samples are used they should be screened as Blood Bank samples are. To meet the standards required for blood transfusion, the blood should be tested for syphilis, Hepatitis B and C, HIV and HTLV1 prior to use in undergraduate classes.
• If student blood samples are used it is preferable for individual students to use their own blood. This should be obtained under aseptic conditions. If blood is spilled it should be dealt with as described in Precautions for Contact with Human Blood. Suitable freshly prepared disinfectant solutions and absorbent material should be readily available in the classroom. Instruments, glassware and blood samples should be decontaminated before entering the wash-up system for re-usable items or being discarded in the University waste. Clinical and related wastes should not be discarded in ordinary waste streams, but according to special guidelines which can be obtained from OHS & Injury Management.
• Use of human blood in research laboratories: All human blood and tissues should be handled as if they are infectious. Advice about specific problems, eg decontamination of complex apparatus, may be obtained from OHS & Injury Management. Disposal of wastes associated with human blood and tissues should be in accordance with the University's must be in accordance with the University's Hazardous Waste Policy (Reference 2). Copies are obtainable from OHS & Injury Management.

(f) TRAVELLERS: are reminded that the infective risks of non-medical injections (including tattooing, ear piercing and acupuncture) as well as those of casual sexual encounters are much higher in tropical areas and developing countries than in Australia because of the higher prevalence rate in these areas.


2.3 STUDENTS AND STAFF INFECTED WITH HEPATITIS B VIRUS

(a) HEPATITIS B CASES: Should return to normal activities at the discretion of their medical adviser. The usual arrangements about sick leave will apply.

(b) HEPATITIS B CARRIERS: Most Hepatitis B carriers are in excellent health and pose no risk to their University contacts. Studies of households show transmission to household contacts other than sexual partners is very rare.

Nevertheless, publicity about chronic liver disease and long-term infectivity in carriers often generates concern from staff and students from ethnic groups with high carrier rates and may expose them to some element of discrimination. This is best dealt with as part of the education program mentioned above, but expert assessment and advice about specific measures are from the liver clinics at the major teaching hospitals as an aid to prevent spread within the family group.

Staff and students who are both health care workers and carriers should consult the infection control staff at the institutions where they practice regarding suitable precautions to prevent infection of others. Tests are available to estimate the infectivity of individual carriers and several antiviral treatment schedules are sufficiently promising to warrant clinical trials. Individual carriers may choose to consult one of the liver clinics or their own medical advisers regarding these new developments. FOR INDEPENDENT AND CONFIDENTIAL ADVICE, CARRIERS MAY CONSULT ONE OF THE SPECIALIST SERVICES LISTED BELOW.

Screening of staff or students to detect carriers is not recommended by the NSW Department of Health. The 2007 Policy Directive from the NSW Department of Health place the onus on individual health care workers (including students) to know their own status and, should they be infective, to refrain from performing "exposure prone procedures". These are defined by the Department as follows:exposure prone procedures "are those procedures where there is potential for contact between the skin (usually finger or thumb) of the HCW and sharp surgical instruments, needles or sharp tissues (splinters/pieces of bone/tooth) in body cavities or in poorly visualised or confined body sites including the mouth" (Reference 3).

3. SPECIALIST SERVICES OFFERING ADVICE ON HEPATITIS B

Hospital Departments of:

• Infectious Diseases
• Microbiology
• Gastroenterology.

Hospital Liver Clinics or your GP can refer you to one of these services.


4. REFERENCES

1. NSW Health Department Policy Directive 2007_006 (1 February 2007): Occupational Screening and Vaccination Against Infectious Diseases; NSW Health Department Policy Directive 2005_162 (25 January 2005): HIV, Hepatitis B or Hepatitis C - Health Care Workers Infected; NSW Health Department Policy Directive 2005_247 (27 January 2005): Infection Control Policy; NSW Health Department Guidelines 2005_037 (27 January 2005): Infection Control Guidelines for Oral Health Care Settings.
2. Clinical and Related Wastes - Guidelines for Management, issued by the Risk Management Office, July 1993
3. NSW Health Department Policy Directive 2005_162 (25 January 2005): Health Care Workers Infected with HIV, Hepatitis B or Hepatitis C - Glosssary.

HEPATITIS C

Hepatitis C is the term now used to describe the infection previously referred to as "blood borne Non-A Non-B hepatitis". A specific diagnostic test has recently been developed and it is already known that previous estimates of the prevalence of acute infection and the carrier rates were much too low. The virus appears to be even more common than hepatitis B in Australia and some other countries such as Japan report still higher carrier rates.

Acute hepatitis C is seldom severe, but a high proportion of patients develop persistent infection and are at risk of developing chronic liver disease in later life.


1. TRANSMISSION

The virus is readily transmitted by inoculation of blood from acute cases and carriers, but little else is known about its spread in the community.


2. CONTROL

For the present, control measures are directed at prevention of contact with human blood and tissues as described for hepatitis B. Refer to NSW Health Department guidelines (NSW Health Department Policy Directive 2005_338 (27 January 2005): Occupational Screening and Vaccination Against Infectious Diseases; NSW Health Department Policy Directive 2005_162 (25 January 2005): Health Care Workers Infected with HIV, Hepatitis B or Hepatitis C; NSW Health Department Policy Directive 2005_247 (27 January 2005): Infection Control Policy; NSW Health Department Guidelines 2005_037 (27 January 2005): Infection Control Guidelines for Oral Health Care Settings)for more guidance on control measures for Hepatitis C.

PRECAUTIONS FOR CONTACT WITH HUMAN BLOOD

1. CHOICE OF TECHNIQUE

(a) Procedures should be adopted that minimise the chance of accidental injury by needles and other sharp instruments; the most important are the avoidance of re-capping needles, and the safe disposal of sharps.

(b) Avoid contact with blood if your own hands or lower arms have open cuts, unhealed wounds or dermatitis. If contact with blood is even remotely possible, wear disposable gloves and protective gowns. If your eyes are likely to be splashed with blood, wear protective spectacles or goggles. Additional precautions may be needed in particular circumstances - seek advice from the Infection Control Unit in the institution concerned.

(c) At the conclusion of the procedure, wash down blood contaminated bench tops and other surfaces with disinfectant (household bleach freshly diluted 1:5 in water is effective), discard gloves into contaminated waste bag, place protective clothing in contaminated laundry bag and wash your hands thoroughly with soap and water.


2. WASTE DISPOSAL

(a) Place blood-stained waste materials in a plastic bag for contaminated waste, seal and label, then arrange for disposal or incineration through the usual procedure in place in your building.

(b) Place sharps for disposal in designated containers for removal and/or decontamination through the usual procedure in your building.

(c) Consult your local Infection Control Unit or the Risk Management Office for further information on decontamination and disposal procedures for sharps and other contaminated wastes.


3. ACCIDENTS

Report any accident involving blood immediately to your supervisor or staff member in charge of the area or class where the accident occurs. For needlestick injuries involving blood, proceed to the University Health Service (in office hours), or nearest hospital casualty department (for example, Royal Prince Alfred Hospital or Westmead Hospital). This should be done without delay so the incident can be assessed and treatment offered within 24 hours if warranted.

See also NSW Health Department Policy Directive 2005_311 (27 January 2005): Mangement of Health Care Workers Potentially Exposed to HIV, Hepatitis B or Hepatitis C.

NSW Needlestick Hotline: 1800 804 823


4. DISINFECTANTS

The following table lists some commonly used disinfectants. The effectiveness of disinfectants depends on appropriate concentration/dilution and contact time for the concentration of protein encountered in the particular situation. If you require specific disinfection advice contact the Risk Management Office (or your Infection Control Unit if you are located in a hospital).

COMMON DISINFECTANTS FOR HOSPITAL USE

N.B. Always check manufacturers' labels for instructions for use.

* As a routine, instruments such as scalpels and scissors are heat sterilised or decontaminated using non-corrosive disinfectants. In an emergency, decontamination can be achieved by soaking for 30 minutes in household bleach (which contains chlorine) at the concentration recommended on the label. However, this will seriously damage most instruments.

PDF version of the Disinfectants table for printing out as a handy reference.

NOTICE - PRECAUTIONS FOR CONTACT WITH HUMAN BLOOD

1. PRECAUTIONS TO PREVENT CONTACT

(a) Wear disposable gloves whenever contact with human blood is likely or possible. Avoid contact with blood particularly if your own hands or lower arms have open cuts or unhealed wounds.

(b) Handle and dispose of needles and sharp instruments correctly, eg don't re-cap needles; dispose of used sharps in sharps containers.


2. WHAT TO DO AFTER ACCIDENTAL CONTACT WITH HUMAN BLOOD

(a) Wash hands, lower arms and any other bodily parts in contact with, or splashed by blood. Thorough washing with soap or water is adequate.

(b) Rinse eyes gently but thoroughly with water while the eyes are open.

(c) If blood gets in the mouth, spit it out and then rinse the mouth with water several times.

(d) IN THE CASE OF A NEEDLESTICK INJURY INVOLVING EXPOSURE TO HUMAN BLOOD, proceed without delay to the University Health Service or nearest large hospital casualty department for risk assessment and treatment.

(e) Place blood-stained waste materials in a plastic bag and seal for disposal or incineration.

(f) In an emergency, instruments can be effectively decontaminated by soaking them for 30 minutes in household bleach. [See manufacturer's instructions on label for appropriate concentration for disinfection.]

(g) Wipe down desks, equipment or other bloodied areas with cold tap water and then with household bleach (sodium hypochlorite) freshly diluted 1 to 5 with water.

PDF version of Notice for printing out as a handy reference.

NSW Health Department Policy Directive 2005_311 (27 January 2005): Mangement of Health Care Workers Potentially Exposed to HIV, Hepatitis B or Hepatitis C.

NSW Needlestick Hotline: 1800 804 823

ANCA Bulletin No.16: Management of Exposure to Blood/Body Fluids Contaminated with Blood, Including Needlestick/Sharps Injuries, With a Potential for HIV or other Bloodborne Infections

National Code of Practice for Health Care Workers and other People at Risk of the Transmission of Human Immunodeficiency Virus and Hepatitis B in the Workplace [NOHSC:2010(1993)]

Authorised by the Vice-Chancellor (2/5/94) and endorsed by the Infectious Diseases Committee.

Internet version revised and references updated: 27/02/03
Links updated: 06/06/05
By: Leanne Mumford.