Hepatitis B HEALTH MANAGEMENT

CPD
CONTINUING
A case study of occupational exposure to hepatitis B shows how
to transform occupational health nursing care through reflective
practice. Sarah ChaUinor and Anne Harriss look at how OH
PROFESSIONAL supported the return to work of a hepatitis B positive surgeon.
DEVELOPMENT
(HBsAg) test was positive. This is

ase study:
the earliest indicator of an active
hepatitis B infection and may be
present before symptoms of infec
tion are present. Her hepatitis Be
antigen (HBeAg) was negative. This
antigen is usually only present dur

occupational
ing active HBV infection.
Serenas status indicated that she
had a hepatitis B infection and was
Our learning for a transmission risk to patients while
operating. She was required to stop
life service helps performing EPPs immediately and

exposure to
was referred to a hepatologist.
you use the As infection with HBV is notifi
able (Public Health England (PHE),
journal for CPD- 2010), the local public health
team was notified. Further identi
related private fied validated samples were taken

hepatitis B
a week apart to confirm results
study. One article and that the preliminary diagnosis
was correct.
in each issue is Serena qualified as a doctor then
accompanied by surgeon in an HBV-endemic country
before moving to the UK in 1997.
a set of questions SH H Blood tests taken on arrival in the
UK by a previous OH provider indi
and answers. cated she was a non-responder to
hepatitis B immunisation, but no
These have been further action had been taken at that
point. Serena denied acquisition risk
devised by Anne factors, including overseas hospital/
dental treatment, tattoos, piercings,
Harriss, associate intravenous drug use or high-risk
sexual activities (WHO, 2015; PHE,
OH professor at 2014) . Serena suspected that she may
have sustained either a splash or
London South sharps injury several times, both risk
factors for hepatitis B (PHE, 2014).
Bank University,
and are designed Hepatitis B pathology
HBV can survive extracorporeally
to help you reflect for seven days and is infectious in
microscopic am ounts (WHO,
in a structured his article describes order to protect patients during acci 2015) . HBV is a DNA virus of the

manner on what
you have learnt.
/ A *Some of the articles
in our continuing pro
fessional development section
display a STUDY TIME logo.
The number displayed beside
this is the number o f hours
that we estimate reading and
reflecting on the article itself
and any recommended further
reading should contribute to
wards your prep requirement.
T
the case of Serena, a dental surgical exposure (DH, 2007). hepadnaviridae family and highly
58-year-old surgeon Diagnosis resulted in Serena infectious (Dudley, 2009). Blood
infected w ith the immediately ceasing surgical pro transports HBV to the liver, where
h e p a titis B virus cedures in compliance with EPP it infects hepatocytes within the
(HBV). Hepatitis B is guidance. Her career was in doubt parenchyma of the liver and con
a major public health until
concern.
it could be established she was tinues replication.
Worldwide, an estimated 240 mil non-infectious and no longer a risk Chronic infection causes liver
lion people have a chronic HBV to patients (DH, 2007). inflammation, and fibrosis ensues
infection, with about 780,000 peo This case study highlights the as the immune system attempts to
ple dying annually from complica underpinning pathophysiology and destroy infected hepatocytes (Dud
tions (World Health Organisation the role of the occupational health ley, 2009; Liaw and Chu, 2009).
(WHO), 2015). nurse (OHN) in facilitating a suc Hepatitis B can be self-limiting
Surgery involves exposure prone cessful return to work (RTW). or may progress to chronic infec
procedures (EPP) posing risks of tion. Many people remain asymp
transmitting blood from worker to The client tomatic for several years. The first
patient during surgeiy (Department Serena presented to OH requesting indication of infection is often evi
of Health (DH), 2007). EPP workers an immunity check for hepatitis B. dence of serious liver disease,
must be free from infectious blood Results showed no detectable anti including cirrhosis or cancer. By
borne viruses (BBVs), including bodies, suggesting that a test for this stage it is too late to treat infec
hepatitis Band hepatitis C, and must infection markers was appropriate. tion and prevent complications (Lai
not pose an infection risk for HIV in A hepatitis B surface antigen et al, 2003; Liaw and Chu, 2009).

Occupationalhealth&wellbeing M arch 2 0 1 7 27
 HEALTH MANAGEMENT Hepatitis B
UK prevalence is comparatively
low (PHE, 2015), but the risk of
acquiring infection from a health
care 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 bleed
ing into the patient (Buster et al,
2003; Gunson et al, 2003).
An assessment of serology under
pinned a decision as to whether or
not Serena was fit for work. An
understanding of serological assess
ment 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 th e hepadnaviridea family of
viruses. In essence, the significant
elements of its structure relating to
the serology testing used to assess
imm unity or infectivity include a
double outer shell within which is
an inner core containing the viral
DNA and DNA polymerase. Anti
gens associated with the viral com
ponents result in a patient infected
with hepatitis B producing antibod
ies as a p a rt of th e ir im m une
response. Knowledge of the virus
stru ctu re is essential to u nder
standing the immune response and
th u s the serology m easured in
assessing the infectivity or immu
nity 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, sur
rounds this inner structure. Two
fu rth e r an tig en s, 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 hepat-
ocytes. The immune system is then
primed in response to this infection
and produces antibodies to the viral
antibodies in an attem pt to rid the
body of the infection. The resulting
p ath o lo g ical dam age leads to
hepatic inflammation.
The immune response involves
the production of antibodies follow
ing exposure to antigens associated
w ith th e viral structure. These
include hepatitis B surface antigen
(HBsAg), hepatitis B core antigen
(HBcAg) and the hepatitis Be anti
gen (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
28 M arch 2017
INDICATORS OF HEPATITIS B INFECTION
Serology results
HBsAg (hepatitis Anti-H Bs
B surface (hepatitis B
antigen) surface antibody)
+ -
+ +/-
+ +
- Immune to hepatitis B as a result of prior
- +
- +
circulates w ithin the serum as a
soluble protein.
Exposure to hepatitis B virus
antigen (HBsAg) stim ulates an
antigen-antibody response. Anti
body production is stim ulated in
response to specific antigen expo
sure: HBsAg stimulates hepatitis B
surface antibodies (anti-H B s):
HBcAg stimulates the production
hepatitis B core antibodies (anti-
HBc), and hepatitis e antibodies
(an ti-H B -e) are p ro d u ce d 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
individuals age at the time of infec
tion, their immune status and the
stage at which the disease is diag
nosed. 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 infectiv
ity. Her infectivity was only con
firmed by the presence of viral DNA
Patients who are HBeAg positive
have viruses that are actively repli
cating. Patients are highly infectious
and contact with their body fluids
can lead to HBV infection.
A i understanding of the antigen-
antibody response is essential in
order to understand the serology
that reflects the degree of infectiv
ity 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 per
sistent viral replication present in
the blood.
For m any years, absence of
HBeAg equated with non-infectiv-
ity, However, several EPP workers
were identified as infection sources
despite negative HBeAg (Buster et
al, 2003).
Newer tests dem onstrated that
some HBeAg-negative individuals
have high levels of hepatitis B vims
genetic m aterial - HBV DNA -
Indicating
Anti-H Be (total
hepatitis B core
anti-body)
- Early acute HBV infection
+ Acute or chronic HBV infection
infection with the virus
Range of possibilities: Past HBV infection
Low level HBV carrier status
- Immune as a result of previous
immunisation to hepatitis B
World Health Organization (2002) p.30, citing Hollingerand Liang (2001)
indicating high infectivity (Schalm Work environm ent: Serenas
et al, 2003; Buster et al, 2003). infectivity posed a risk to patient
Serena was HBeAg negative but safety. DH guidance on EPP work
HBV DNA positive with implica ers with BBVs prohibits any varia
tions should she bleed into a patient tion in assessment of fitness.
during surgery and furthermore for
her own health as HBV DNA pre Legal aspects
sents an increased riskfor liver dam Individuals with health conditions
age. HBV DNA is more sensitive for that are substantial, long term and
detecting infectivity than HBeAg. affect day-to-day activities may be
Prior to DNA testing, Serena considered disabled u n d er the
would probably have continued term s of the Equality Act 2010
EPP work without restrictions. (Office for Disability Issues, 2011).
These new testing methods led The decision of whether or not an
to fresh DH guidance relating to individual is considered disabled
fitness to perform EPP work: HBV u nder this Act is a legal m atter
DNA levels must be below 103 cop (Howard and Williams, 2013). Peo
ies per millilitre (ml). ple with protected characteristic(s),
Transmission is unlikely below including disability, have the right
this level, although possible at a risk not to be discriminated against.
ratio of 1:2,500,000 (Schalm et al, Serenas condition was substan
2003; Corden et al, 2002). Serenas tial, lifelong and more than minor
HBV DNA levels were above 103 or trivial, with significant implica
copies/ml but fewer than 104 cop- tions to her professionally. Although
ies/m l. She posed an imm ediate protected under the Equality Act,
infection risk due to this viral load health and safety legislation always
and deemed unfit to continue her overrides the Act duties (Howard
role as a surgeon. and Williams, 2013).
Employers are required under
Assessment of fitness health and safety legislation, includ
to work ing the Health and Safety at Work
A key OH role is evaluating whether Act 1974 and the Management of
or not employees have functional Health and Safety at Work Regula
capacity to perform specific job tions 1999, to assess and, as far as
roles, essential for effective RTW reasonably practicable, eliminate
planning (Everton et al, 2014). Cen risks to staff and those who may be
tral to the assessment process were affected by their activities, therefore
key themes: personal aspects; work Serena had to stop working.
characteristics; work environment;
and legal aspects congruent with Clinical flags and
th e fitn ess-fo r-w o rk m odel of return-to-work plans
Murugiah et al (2002). Clinical flags are useful in assessing
Personal aspects: Serena is an factors facilitating RTW plans
experienced surgeon, married with (Watson, 2010). The system uses
a child. A lthough well, HBV coloured flags representing biopsy-
impacts upon her fitness to perform chosocial factors impacting upon
surgical procedures and she imme fitness to work. They are:
diately ceased work. Red flags: these relate to bio-
Work characteristics: her surgi logical/pathological factors. For
cal work tasks involved EPPs so Serena, the likelihood of infectivity
Serena posed a risk to patients. She was the main determ inant of her
took sick leave, in part from her dis RTW. Successful treatment was cru
tress regarding the implications for cial in assessing w hether or not
her career, family and the patients returning to EPP work was ever pos
on whom she had operated. sible. After diagnosis, Serena started
Occupationalhealth&wellbeing

taking Tenofovir, a nucleotide ana
logue 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
problem s with m aladaptation to
illness and did not readily express
feelings. She was focused on mov
ing the process along and com
mencing treatment.
Blue flags: these relate to the
employees perception of the work
place (Watson, 2010). Serena was
keen to RTW as soon as possible.
There was no indication she dis
liked her workplace or wished to
end her career. Work avoidance was
not a significant issue.
Black flags: these relate to factors
outside the individuals control
(Watson, 2010), particularly inter
personal relationships. Serena
stated th at she had implemented
procedures to limit contact with her
body fluids by using a separate bath
room, 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 treatm ent 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 rein
forcement (Watson, 2010; Parker,
2014). Being a surgeon was firmly
entrenched in Serenas sense of
personal identity, a strong incentive
financially and personally to return
to her post.
Pink flags are supported by reas
surance and education, but the reas-
su ran c e th a t S eren a so u g h t
STRUCTURE OF THE HEPATITIS B VIRUS
tfOOOOQ
DNA po ymerase
Hepatitis B core
antigen
Partially double-sided DNA
Occupational health& wellbeing
appeared focused on biological
markers of recovery. She responded
quickly to treatm ent and returned
to work six months later. Her DNA
levels have remained below 103 cop-
ies/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.
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March 2017 29
HEALTH MANAGEMENT Hepatitis B
CPD activity: Occupational exposure to hepatitis B
Lifelong learning and continuing professional development (CPD) are the processes by which professionals, such as nurses, develop
and improve their practice.
There are two ways to address your CPD: formally, by attending courses, study days and workshops; or informally, through private
study and reflection.
Reading articles in professional journals is a good way of keeping up to date with what is going on in the field of practice, but reflecting
on what you have learnt from the articles is not always easy. These questions are designed to help you identify what you have learnt from
studying the article on the previous three pages. They will also help you to clarify what you can apply in practice and what you need to
explore further.
1>ln itial sero lo g y resu lts w h en
S e re n a firs t p resen ted to OH
in d icated w ere:
a) Hepatitis B surface antigen positive
(HBsAg+)
b) Hepatitis Be antigen positive (HBeAG)
c) The presence of viral DNA
d) No detectable antibodies
2>The e a rlie s t sero lo g ic a l in d ic a to r
o f a c tiv e h e p a titis is th e p re s e n c e of:
a) Hepatitis B surface antigen
b) Hepatitis surface antibodies
c) Viral DNA
d) Jaundice and hepatomegaly
3>The h e p a titis B virus can survive
o u tsid e th e body for:
a) 24 hours
b) 48 hours
c) 7 days
d) One month
4 > H e p a titis B virus belongs to w h ic h
fa m ily of viruses?
a) Hepadnaviridae
b) Adenoviridae
c) Hepataviridae
d) Heparnaviridae
5>Fibrosis fo llo w s chronic in fectio n
w ith h e p a titis B as a resu lt o f th e
Resources for your research needs
Access these resources to refresh your
knowledge of hepatitis B
An introductory overview of HBV
w w w .yo u tu b e.co m /w atc h 7 v s A R 7 _
O m O xTw A
(Accessed 24 June 2016)
Hepatitis B acquisition, treatment
and consequence
w w w .yo u tu b e.co m /w atc h 7 v s zR 9 J H y g
B5M
(Accessed 24 June 2016)
Replication of the HBV virus
w w w .y o u tu b e .c o m /
w a tch ? v= sV p iX aE M s7l
(Accessed 24 June 2016)
Further online resources
Interpreting Hepatitis serology results
w w w .cd c.g ov/h epatitis/h b v/p d fs/
s e ro lo g ic c h a rtv 8 .p d f
(Accessed 24 June 2016)
30 March 2017
im m u ne system a tte m p tin g to d estro y
w h ic h of th e follow ing?
a) Hepatitis B DNA
b) Infected hepatocytes
c) Hepatitis B RNA
d) The cell wall of the hepatitis B virus
6>H e p a titis Be an tig e n is
a s s o c ia te d w ith :
a) The nucleocapsid of the virus
b) Viral DNA
c) Viral RNA
d) Surface antibodies
7>S erena w a s tre a te d w ith :
a) Interferon Alpha used to regulate the
immune system
b) Lamivudine - an antiretroviral agent
c) Tenofovir - a nucleotide analogue that
inhibits HBV DNA replication
d) Prednisolone - a synthetic glucocorticoid
8>Enabling fa c to rs en han ced by
p ositive re in fo rc e m e n t a re re fe rre d
to as:
a) Red flags
b) Pink flags
c) Blue flags
d) Brown flags
9>Blood te s ts ta k e n on h e r a rriv a l in
th e U K su gg ested th a t S eren a w as:
Fitness for work:
w w w .a g iu s .c o m /h e w /re s o u rc e /
honw .htm
(Accessed 24 June 2016)
Journal articles
Public Health England (2014). Hepatitis B:
clinical and public health management.
w w w .g ov.uk/g uid ance/hep atitis-b -
c lin ical-an d-pu b lic-h ealth -
m anagem ent
(Accessed 4 May 2016)
Public Health England (2015). Acute
hepatitis B (England): annual report for 2014
w w w .gov.uk/governm ent/uploads/
syste m /u p lo a d s /a tta c h m e n t d a ta /
file /4 5 7 4 0 8 /h p r3 0 1 5_hbv-ann.pdf
[Accessed 4 May 2016].
Public Health England (2016). General
orthopaedic surgery exposure prone procedure
(EPP) categorisation. Advice from the UK
a) Immune to hepatitis B
b) A poor responder to hepatitis B
immunisation
c) A non-responder to hepatitis B immunisation
d) Probably highly infectious for hepatitis B
10>ln som e people, th e firs t in d icatio n
of in fectio n w ith h e p a titis B could be:
a) Postural hypotension with pitting oedema
b) Hypertension without pitting oedema
c) Biliary atresia
d) Serious liver disease including cirrhosis or
liver cancer
o<0f
o<6
Q<8
o<l
e<9
q<5
e<p
o<
e<3
pa
sjsmsuv
Advisory Panel for Healthcare Workers
Infected with Bloodborne Viruses (UKAP)
w w w .gov.uk/governm ent/uploads/
s y s te m /u p lo a d s /a tta c h m e n t d ata/
file/511570/U K A P _G en eral_
O rth o p a e d ic surgeonry_EPP_
C a te g o ris a tio n FIt'IAL to be _
u plo aded .pd f
[Accessed 14 May 2016].
Sarafino, E.P. and Smith, T.W. (2012) Health
Psychology. Biopsychosocial Interactions, (7th
Ed), Hoboken: John Wiley and Sons Inc.
Occupationalhealth&wellbeing
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