THE WAYS TO DO BATTLE

By Carisa A. Paraz, MD, Contributing Writer

During the workshops, participants zeroed in on three major population groups that need to be protected from hepatitis-B virus to stem the tide of infection-overseas Filipino workers, health-care workers and professionals, and pregnant women and newborns. The workshops were presided over by Drs. Oscar Tinio, president of the Philippine College of Occupational Medicine; Erlinda Valdellon, president of the Hepatology Society of the Philippines; Lulu Bravo, executive director of the University of the Philippines-National Institutes of Health; and Rogelio Mendiola, president of the Philippine Obstetrical and Gynecological Society.

Protect OFWs

    Although local statistics show that biological hazards, including infection from viruses, only make up six percent of occupational hazards, hepatitis B remains a major threat to our workforce. Preemployment medical examinations do not routinely include hepatitis-B screening, which is of special import to overseas Filipino workers (OFWs).

    One major concern is whether HBV-positive applicants should be allowed to work abroad. Although their positions varied, participants noted that the ultimate decision rests with the prospective employer, not the examining physician. Currently, most foreign employers do not hire HBV-positive workers.

    As for holding employers accountable if the virus is contracted by an OFW while employed, the consensus was to determine first if the infection is work-related or not. If the workers can prove that the infection was a direct result of their job, then the employers may be held accountable and the workers may be able entitled to additional benefits.

    But under no circumstances should discrimination against HBV-positive workers be tolerated. OFWS whose HBV status was previously unknown and then test positive in a succeeding checkup should not be expelled from their job because of the test result. On the other hand, OFWs seeking employment cannot refuse preemployment medical examination.

    Participants recommended the formulation of workforce guidelines on hepatitis B, which should include screening and mandatory vaccination for those who are qualified. Because most workers who test positive for HBV are not aware of the disease, it was recommended that an awareness and education program be conducted for workers. Helping them understand the disease can help them avoid it or get treated effectively. Lastly, preventive programs should be developed to curb the spread of hepatitis B. Particular focus should be given to health-care workers since they are more prone to acquiring the disease at work. M

Screen all health-care workers

    The risk of acquiring or transmitting hepatitis B is a serious concern among health-care workers, especially for those exposed to blood, either through caring for patients directly or working in laboratories. Health-care workers should be especially wary of procedures that can expose them to the virus, which include those that require the use of sharp instruments, laboratory examination of blood specimens, surgery, and caring for patients with open wounds.

    It was the consensus of the participants to make HBV testing a preemployment requirement for all health-care workers. However, they also agreed that testing positive for HBV should not be a ground for denying employment or dismissing a health-care worker from work.

    Other issues discussed during the workshop were less unequivocal.

    Is it reasonable to choose the HBV-negative applicant over the equally qualified HBV-positive one? It depends on the viral load and the procedures that the applicant will be performing. Applicants with high viral load and who will be doing procedures that can expose them to the virus should naturally be given less risky jobs.

    Should patients be informed about the HBV status of the health-care workers taking care of them? Again, most of the participants considered this a gray area, noting that disclosure would depend on certain situations and conditions. At any rate, there is always the option of vaccination for the patient who is about to be treated by an HBV-positive health-care worker. In all cases, however, HBV-positive health-care workers should always take the necessary precautions to avoid transmitting the virus.

    Should potential health-care workers be made to disclose their HBV status? Participants agreed that it should be disclosed only to the employer. Confidentiality is still a must.

    Among the recommendations in the workshop were:

    o All health-care workers should apply standard precautions to every patient.

    o All those in contact with body fluids should be vaccinated against HBV and checked for quantitative anti-HBs response within one to three months after the final dose.

    o All health-care workers performing risky procedures should know their HBV status, preferably at an early stage of their career and provide proof of anti-HBs response prior to starting job (and preferably before starting training).

    o Nonresponders should be given additional three doses with a conventional HBV vaccine; those doing risky medical procedures must undergo individual risk assessment with annual testing of anti-HBc and HbsAg.

    o Health-care workers who refuse to be vaccinated should confirm that they understand the implications of their refusal.

    o All HbeAg-positive health-care workers should not perform risky medical procedures; those who want to must be referred to an expert panel and present results of quantitative HBV-DNA testing.

    o All HBV infected health-care workers should be referred to a hepatologist/gastroenterologist for treatment and counseling.

    o All efforts must be made to respect the privacy of infected health-care workers. M

Stop mother-to-child transmission

    Perinatal transmission, one sure way to catch the virus, can easily be prevented through routine screening of pregnant women and immunization of the newborn. Studies show that among unvaccinated infants born to HBsAg-positive and HBeAg-positive mothers, nine out of 10 become chronically infected. Routine screening of pregnant women is expected to have a large impact on curbing the rise of hepatitis-B infections in the country, yet only very few doctors and hospitals do this.

    Also, while hepatitis-B vaccination is already included in the government's Expanded Program on Immunization, it is not made mandatory at birth. Thus, participants pushed for a law that will make hepatitis-B vaccination mandatory for newborns within 24 hours of birth.

    In the meantime, what can be done is to screen all pregnant women to identify newborns that would require at-birth vaccination and treatment. Once a pregnant woman tests positive, other members of the family should be screened as well.

    Moreover, since midwives attend to a high number of births in the country, the gap in vaccination can be closed by training midwives to administer the vaccine to newborns, mothers, and other at-risk members of the community. "[We should] utilize every available hand that could help us in the delivery of health care," said Mendiola.

    Vaccination should also be routinely given to other at-risk groups such as adolescents, men who have sex with men, heterosexuals with multiple partners, persons diagnosed with a sexually transmitted infection, commercial sex workers, intravenous-drug users, inmates of long-term correctional facilities, and persons receiving hemodialysis. M