A case study of occupational exposure to hepatitis B shows how to transform occupational health nursing care through reflective practice. Sarah Challinor and Anne Harriss look at how OH supported the return to work of a hepatitis B positive surgeon.
This article describes the case of Serena, a 58-year-old surgeon infected with the hepatitis B virus (HBV). Hepatitis B is a major public health concern. Worldwide, an estimated 240 million people have a chronic HBV infection, with about 780,000 people dying annually from complications (World Health Organisation (WHO), 2015).
Surgery involves exposure prone procedures (EPP) posing risks of transmitting blood from worker to patient during surgery (Department of Health (DH), 2007). EPP workers must be free from infectious blood borne viruses (BBVs), including hepatitis B and hepatitis C, and must not pose an infection risk for HIV in order to protect patients during accidental surgical exposure (DH, 2007).
Diagnosis resulted in Serena immediately ceasing surgical procedures in compliance with EPP guidance. Her career was in doubt until it could be established she was non-infectious and no longer a risk to patients (DH, 2007).
This case study highlights the underpinning pathophysiology and the role of the occupational health nurse (OHN) in facilitating a successful return to work (RTW).
Serena presented to OH requesting an immunity check for hepatitis B. Results showed no detectable antibodies, suggesting that a test for infection markers was appropriate. A hepatitis B surface antigen (HBsAg) test was positive. This is the earliest indicator of an active hepatitis B infection and may be present before symptoms of infection are present. Her hepatitis Be antigen (HBeAg) was negative. This antigen is usually only present during active HBV infection.
Serena’s status indicated that she had a hepatitis B infection and was a transmission risk to patients while operating. She was required to stop performing EPPs immediately and was referred to a hepatologist.
As infection with HBV is notifiable (Public Health England (PHE), 2010), the local public health team was notified. Further identified validated samples were taken a week apart to confirm results and that the preliminary diagnosis was correct.
Serena qualified as a doctor then surgeon in an HBV-endemic country before moving to the UK in 1997. Blood tests taken on arrival in the UK by a previous OH provider indicated she was a non-responder to hepatitis B immunisation, but no further action had been taken at that point. Serena denied acquisition risk factors, including overseas hospital/dental treatment, tattoos, piercings, intravenous drug use or high-risk sexual activities (WHO, 2015; PHE, 2014). Serena suspected that she may have sustained either a splash or sharps injury several times, both risk factors for hepatitis B (PHE, 2014).
Hepatitis B pathology
HBV can survive extracorporeally for seven days and is infectious in microscopic amounts (WHO, 2015). HBV is a DNA virus of the hepadnaviridae family and highly infectious (Dudley, 2009). Blood transports HBV to the liver, where it infects hepatocytes within the parenchyma of the liver and continues replication.
Chronic infection causes liver inflammation, and fibrosis ensues as the immune system attempts to destroy infected hepatocytes (Dudley, 2009; Liaw and Chu, 2009).
Hepatitis B can be self-limiting or may progress to chronic infection. Many people remain asymptomatic for several years. The first indication of infection is often evidence of serious liver disease, including cirrhosis or cancer. By this stage it is too late to treat infection and prevent complications (Lai et al, 2003; Liaw and Chu, 2009).
UK prevalence is comparatively low (PHE, 2015), but the risk of acquiring infection from a healthcare worker is not insignificant. Since 1970, 47 healthcare staff – the majority being EPP workers – were the infection source in 437 patients, possibly resulting from them bleeding into the patient (Buster et al, 2003; Gunson et al, 2003).
An assessment of serology underpinned a decision as to whether or not Serena was fit for work. An understanding of serological assessment requires some knowledge of the structure of the HBV and how it impacts on the antibody response.
Hepatitis B virus structure
The hepatitis B virus is a member of the hepadnaviridea family of viruses. In essence, the significant elements of its structure relating to the serology testing used to assess immunity or infectivity include a double outer shell within which is an inner core containing the viral DNA and DNA polymerase. Antigens associated with the viral components result in a patient infected with hepatitis B producing antibodies as a part of their immune response. Knowledge of the virus structure is essential to understanding the immune response and thus the serology measured in assessing the infectivity or immunity of the infected person.
At the centre of the virus – the inner core – is a double-stranded DNA. A core antigen, HBcAg, is associated with the viral inner core. An outer envelope, in turn, surrounds this inner structure. Two further antigens, HBeAg and HBsAg, are associated with the outer envelope of the virus.
Once the virus gains entry to the body, it is transported through the circulatory system and in to the liver. Once the virus has infected the liver, it replicates in the hepatocytes. The immune system is then primed in response to this infection and produces antibodies to the viral antibodies in an attempt to rid the body of the infection. The resulting pathological damage leads to hepatic inflammation.
The immune response involves the production of antibodies following exposure to antigens associated with the viral structure. These include hepatitis B surface antigen (HBsAg), hepatitis B core antigen (HBcAg) and the hepatitis Be antigen (HBeAg).
As the names suggest, HBsAg is associated with the surface of the virus and is also referred to as the envelope antigen. The HBcAg related to the core of the virus. The HBeAg is closely associated with the nucleocapsid of the virus. This circulates within the serum as a soluble protein.
Exposure to hepatitis B virus antigen (HBsAg) stimulates an antigen-antibody response. Antibody production is stimulated in response to specific antigen exposure: HBsAg stimulates hepatitis B surface antibodies (anti-HBs); HBcAg stimulates the production hepatitis B core antibodies (anti-HBc), and hepatitis e antibodies (anti-HB-e) are produced in response to exposure to the HBeAg.
The natural history and progress of the disease for each patient is variable and is dependent on the individual’s age at the time of infection, their immune status and the stage at which the disease is diagnosed. Although patients with acute hepatitis B are normally HBeAg positive, this was not the case with Serena, and it was for this reason that she was unaware of her infectivity. Her infectivity was only confirmed by the presence of viral DNA. Patients who are HBeAg positive have viruses that are actively replicating. Patients are highly infectious and contact with their body fluids can lead to HBV infection.
An understanding of the antigen-antibody response is essential in order to understand the serology that reflects the degree of infectivity or immune status.
Viral load is crucial in assessing infectivity and relates to how much virus to which a patient is exposed. Although some individuals may clear infection quickly, others become chronic carriers, with persistent viral replication present in the blood.
For many years, absence of HBeAg equated with non-infectivity, However, several EPP workers were identified as infection sources despite negative HBeAg (Buster et al, 2003).
Newer tests demonstrated that some HBeAg-negative individuals have high levels of hepatitis B virus genetic material – HBV DNA – indicating high infectivity (Schalm et al, 2003; Buster et al, 2003).
Serena was HBeAg negative but HBV DNA positive with implications should she bleed into a patient during surgery and furthermore for her own health as HBV DNA presents an increased risk for liver damage. HBV DNA is more sensitive for detecting infectivity than HBeAg.
Prior to DNA testing, Serena would probably have continued EPP work without restrictions.
These new testing methods led to fresh DH guidance relating to fitness to perform EPP work: HBV DNA levels must be below 103 copies per millilitre (ml).
Transmission is unlikely below this level, although possible at a risk ratio of 1:2,500,000 (Schalm et al, 2003; Corden et al, 2002). Serena’s HBV DNA levels were above 103 copies/ml but fewer than 104 copies/ml. She posed an immediate infection risk due to this viral load and deemed unfit to continue her role as a surgeon.
Assessment of fitness to work
A key OH role is evaluating whether or not employees have functional capacity to perform specific job roles, essential for effective RTW planning (Everton et al, 2014). Central to the assessment process were key themes: personal aspects; work characteristics; work environment; and legal aspects congruent with the fitness-for-work model of Murugiah et al (2002).
- Personal aspects: Serena is an experienced surgeon, married with a child. Although well, HBV impacts upon her fitness to perform surgical procedures and she immediately ceased work.
- Work characteristics: her surgical work tasks involved EPPs so Serena posed a risk to patients. She took sick leave, in part from her distress regarding the implications for her career, family and the patients on whom she had operated.
- Work environment: Serena’s infectivity posed a risk to patient safety. DH guidance on EPP workers with BBVs prohibits any variation in assessment of fitness.
Individuals with health conditions that are substantial, long term and affect day-to-day activities may be considered disabled under the terms of the Equality Act 2010 (Office for Disability Issues, 2011). The decision of whether or not an individual is considered disabled under this Act is a legal matter (Howard and Williams, 2013). People with protected characteristic(s), including disability, have the right not to be discriminated against.
Serena’s condition was substantial, lifelong and more than “minor or trivial”, with significant implications to her professionally. Although protected under the Equality Act, health and safety legislation always overrides the Act duties (Howard and Williams, 2013).
Employers are required under health and safety legislation, including the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999, to assess and, as far as reasonably practicable, eliminate risks to staff and those who may be affected by their activities, therefore Serena had to stop working.
Clinical flags and return-to-work plans
Clinical flags are useful in assessing factors facilitating RTW plans (Watson, 2010). The system uses coloured flags representing biopsychosocial factors impacting upon fitness to work. They are:
Red flags: these relate to biological/pathological factors. For Serena, the likelihood of infectivity was the main determinant of her RTW. Successful treatment was crucial in assessing whether or not returning to EPP work was ever possible. After diagnosis, Serena started taking Tenofovir, a nucleotide analogue drug that inhibits HBV DNA replication. Nucleotide analogues are the recommended first line of treatment. They have a high barrier to resistance, are well tolerated, affordable and effective in inducing a non-infectious state (WHO, 2015).
Yellow flags: these assess how individuals interpret their situation (Watson, 2010). Serena did not cite problems with maladaptation to illness and did not readily express feelings. She was focused on moving the process along and commencing treatment.
Blue flags: these relate to the employee’s perception of the workplace (Watson, 2010). Serena was keen to RTW as soon as possible. There was no indication she disliked her workplace or wished to end her career. Work avoidance was not a significant issue.
Black flags: these relate to factors outside the individual’s control (Watson, 2010), particularly interpersonal relationships. Serena stated that she had implemented procedures to limit contact with her body fluids by using a separate bathroom, linen, cutlery and crockery. The family was HBV negative and supportive of her. Her concerns for their welfare dominated discussions despite continued reassurances. There was little Serena could do to expedite her RTW as it was only possible if treatment was effective and subject to the agreement of the public health team. This may have left her feeling powerless, but this concept was not explored in detail.
Pink flags: these are enabling factors enhanced by positive reinforcement (Watson, 2010; Parker, 2014). Being a surgeon was firmly entrenched in Serena’s sense of personal identity, a strong incentive financially and personally to return to her post.
Pink flags are supported by reassurance and education, but the reassurance that Serena sought appeared focused on biological markers of recovery. She responded quickly to treatment and returned to work six months later. Her DNA levels have remained below 103 copies/ml for more than two years and she remains well on medication, with no signs of liver damage.
This is positive in relation to her physical health and being able to return to professional practice as this impacted on her self-esteem and thus indirectly her mental health.
Sarah Challinor PGCert, BSc (Hons), DipHE, RN is clinical manager at OHWorks. Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, NTFHEA, PFHEA, FRCN, Queens Nurse is associate professor and course director at London South Bank University.
Arnold EC and Underman Boggs K (2016). “Interpersonal Relationships. Professional communication skills for nurses” (7th ed). St Louis: Elsevier.
Atesci FC, Cetin BC, Oguzhanogulu NK, Karadag F and Turgut H (2005). “Psychiatric disorders and functioning in hepatitis B virus carriers”. Psychosomatics, vol.46, pp.142-147.
Benner, P (1989). “From novice to expert”. The American Journal of Nursing, vol.82(3), pp.402-407.
Black, C and Frost D (2011). “Health at work – an independent review of sickness absence”. Accessed 17 May 2016.
Buster EHCT, van der Eijk AA and Schalm SW (2003). “Doctor to patient transmission of hepatitis B virus: implications of HBV DNA levels and potential new solutions”. Antiviral Research, vol.60, pp.79-85.
Corden S, Ballard AL, Ijaz S, Barbara JAJ, Gilbert N, Gilson RJC, Boxall EH and Tedder RS (2003). “HBV DNA levels and transmission of hepatitis B by healthcare workers”. Journal of Clinical Virology, vol.27(1), pp.52-58.
Department of Health (2007). “Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: new healthcare workers”. London: DH.
Department of Health (2007) “Hepatitis B infected healthcare workers and antiviral therapy”. London: DH.
Dudley T (2009). “Viral hepatitis”, in: Sargent S (ed), “Liver diseases. An essential guide for nurses and healthcare professionals”. Chichester: John Wiley and Sons Ltd, pp.135-157.
Edwards R (2014). “Occupational nursing in the UK: preventing illness, promoting health and reducing absence”. pp.36-39. Accessed 15 May 2016.
Everton S, Mogford S, Romano-Woodward D and Thornbory G (2014). “Health assessment, case management and rehabilitation”, in: Thornbory G (ed), “Contemporary Occupational Health Nursing. A guide for practitioners”. Abingdon: Routledge.
Gunson RN, Shouval D, Roggendorf M, Zaaijer H, Nicholas H, Holzmann H, de Schryver A, Reynders D, Connell J, Gerlich W.H, Marinho RT, Tsantoulas D, Rigopoulou E, Rosenheim M, Valla D, Puro V, Struwe J, Tedder R, Aitken C, Alter M, Schalm SW, Carman WF and European Consensus Group (2003). “Hepatitis B virus and hepatitis C virus infections in healthcare workers: guidelines for prevention of transmission of HBV and HCV from HCW to patients”. Journal of Clinical Virology, vol.27(3), pp.213-230.
Hollinger FB and Liang TJ in: Kipe DM et al (eds). “Fields Virology” (4th ed). Lippincott Williams & Wilkins
Howard, GS and Williams T (2013). “Disability and equality law”, in: Palmer KT, Cox RAF and Brown I (eds), “Fitness for work. The medical aspects” (5th ed). Oxford: Oxford University Press.
Institute of Directors (2006). “Wellbeing at work: how to manage workplace wellness to boost your staff and business performance”. London: IOD.
Johns C (1995). “Framing learning through reflection within Carper’s fundamental ways of knowing in nursing”. Journal of Advanced Nursing, vol.22(2), pp.226-234.
Lai CL, Ratzu V, Yuen M-F and Poynard T (2003). “Viral hepatitis B”. The Lancet, vol.362, pp.2089-2094.
Liaw Y-F and Chu C-M (2009). “Hepatitis B virus infection”. The Lancet, vol.373, pp.582-593.
Lok ASF, van Leeuwen DJ, Thomas HC and Sherlock S (1985). “Psychosocial impact of chronic infection with hepatitis B virus on British patients”. Genitourinary Medicine, vol.61, pp.279-282.
Mazzotta CP (2016). “Biomedical approaches to care and their influence on point of care nurses: a scoping review”. Journal of Nursing Education and Practice, vol.6(8), pp.93-101.
Mehta N (2011). “Mind-body dualism: A critique from a health perspective”. Mens Sana Monographs, vol.9(1), pp.202-209.
Modabbernia A, Ashrafi M, Malekzadeh R and Poustschi H (2013). “A review of psychosocial issues in patients with chronic hepatitis B”. Archives of Iranian Medicine, vol.16(2), pp.114-122.
Murugiah S, Thornbory G and Harriss A (2002). “Assessment of fitness”. Personnel Today. Accessed 14 May 2016.
Office for Disability Issues (2011). “Equality Act 2010 Guidance. Guidance on matters to be taken into account in determining questions relating to the definition of disability”. Accessed 17 May 2016..
Panella M, Marchisio S and Di Stanislao F (2003). “Reducing clinical variations with clinical pathways: do pathways work?”. International Journal of Qualitative Healthcare, vol.15(6), pp.509-521.
Parker C (2014). “Addressing obstacles to staying in or returning to work following injury or illness”. Accessed 15 May 2016.
Public Health England (2010). “Notifiable diseases and causative organisms: how to report”. Accessed 10 May 2016.
Schalm SW and Buster EHCJ (2003). “Management of hepatitis B virus infected healthcare workers based on HBV DNA levels”. Journal of Clinical Virology, vol.27, pp.231-234.
Waddell G and Burton A K (2006). “Is work good for your health and wellbeing?”. London: TSO.
Wade D (2009). “Holistic healthcare. What is it and how can we achieve it?”. Oxford Centre for Reablement. Accessed 15 May 2016.
Wade D and Halligan PW (2004). “Do biomedical models of illness make for good healthcare systems?”. British Medical Journal, vol.329(7479), pp.1398-1401.
Watson H (2010). “CPD: Psychosocial flags system”. Accessed 15 May 2016.
Wedderburn Tate C (1999). “Leadership in nursing”. London: Churchill Livingstone.
World Health Organisation (2002).“Hepatitis B”. Geneva: WHO. Accessed 12 June 2016.
World Health Organisation (2015). “Hepatitis B”. Accessed 4 May 2016.
World Health Organisation (2015). “Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection”. Accessed 16 May 2016.