Hepatitis B
Up to 500 acute cases of hepatitis B are notified every year in the UK. Most
infections are asymptomatic - it is estimated that the true incidence may be
at least three times higher (Ramsay et al, 1999). Hepatitis B is a serious
condition associated with acute morbidity. Typically infection occurs by
transfer of body fluids, and occupationally acquired infection is a real risk to
healthcare workers involved in exposure prone procedures1. However, it is
not just healthcare workers who are at risk from patients; higher incidences
of transmission have been documented from workers to patients, usually
associated with major surgery (Mukerjee et al, 1996). For midwives,
occupational risk is most strongly associated with needle stick injuries and
splashes from contaminated body fluids at delivery. These risks have been
kept relatively low by the adoption of universal precautions and by high
vaccination coverage among healthcare workers (Collins and Heptonstall,
1994)
Hepatitis B may be transmitted perinatally from mother to child, often
without the woman being aware that she is infected. Babies acquiring
infection at this time run a high risk of becoming chronic carriers of the
virus. Appropriate immunisation, starting at birth, can prevent the
development of carrier status in around 90-95% of cases.
The UK Departments of Health recommended that all healthcare workers
who perform exposure prone procedures should be immunised against
hepatitis B (DoH, 2000). In 1998 it also recommended that all pregnant
women should be offered antenatal screening for hepatitis B, and that
babies born to infected mothers should receive a complete course of
immunisation at birth (NHS Executive, 1998).
RCM Position
The RCM supports antenatal testing for hepatitis B, but affirms that this
should only be undertaken with the woman’s explicit informed consent.
Similarly, the RCM commends testing and vaccination against hepatitis B as
an important health and safety measure for all midwives whose work may
involve undertaking exposure prone procedures. It further believes that
midwives who have failed to seroconvert, or who have not been vaccinated
1
Exposure prone procedures are those where there is a risk that injury to the health care worker could
result in their blood contaminating a patient's open tissues.
1
for whatever reason, should be facilitated to remain in midwifery practice.
The RCM commends hepatitis B vaccination to midwives as the most
effective way to protect themselves, their colleagues, and the women and
infants in their care from hepatitis B. However, it also recognises that
vaccination is not safe or effective for some midwives, and that others may
reach their own informed decision to refuse immunisation.
Midwives should be aware of the Nursing and Midwifery Council’s advice that
Registrants who are Hepatitis B e-antigen (HBeAG) positive would not be
able to undertake exposure prone and if they decline testing or vaccination,
they would be treated as positive and have their practice restricted (NMC,
1996). However, the RCM believes it is possible and desirable to
accommodate these midwives without compromising client safety, and urges
NHS employers to negotiate appropriate procedures for doing so with their
employees’ representatives. Many NHS organisations have chosen to opt for
regular screening of staff, so allowing non-infected midwives who have not
been vaccinated to continue working across all areas of midwifery practice.
Some have also asked staff who choose not to be vaccinated to sign a record
accepting personal responsibility for their decision.
While it is not possible to lay down detailed guidance for every situation,
the RCM recommends that NHS employers should work with employees’
representatives to ensure that, as far as possible, good employment
practice is reinforced by the need to protect clients and staff against
hepatitis B. However, if mmidwives refuse to be tested, they would not be
allowed to carry out exposure prone procedures in future.
The RCM Recommends that:
Midwives ensure that all pregnant women are provided with information
about hepatitis B, including routes of transmission and implications for
maternal and infant health.
Midwives offer antenatal testing early in pregnancy, supported by written
information and referral routes to appropriate specialist advice and
counselling services.
Each woman be given the time and support necessary to reach her own
informed decision; while testing may be positively recommended, a decision
to refuse testing should be respected.
Women diagnosed as infected with Hepatitis B should be appropriately
referred for discussion on the implications for themselves, their
pregnancies, and their sexual partners. Where possible, this discussion and
any written information should be available in the mother’s first language.
Midwives discuss and provide written information to parents on the risks and
benefits of Hepatitis B vaccination for babies of Hepatitis B positive women
to ensure that the baby receives the appropriately prescribed dose prior to
transfer home.
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Midwives ensure effective communication between midwives, parents,
health visitors and GPs at the time of postnatal transfer, to ensure that the
baby receives follow-up hepatitis B vaccination.
Midwives ensure appropriate confidentiality for women who are infected
with hepatitis B and disclose information on a need to know basis only.
Midwives familiarize themselves with UK departments of health policies and
guidance relating to exposure prone procedures and Hepatitis B infected
health care workers.
Midwives who perform exposure prone procedures, are HBeAG) negative and
whose viral loads do not exceed 103 geq/ml should have their viral loads retested regularly every 12 monthly because research suggests that viral loads
in some Hepatitis B infected individuals may change over time.
Midwives contact their RCM representative in situations where they perceive
an employment relations issue arising as a result of testing or vaccination
for hepatitis B.
Employers provide midwives with full and clear information on the risks of
occupationally acquired hepatitis B infection, and on vaccination and its
possible failure rates and adverse reactions.
Employers ensure appropriate confidentiality for midwives who are infected
with hepatitis B.
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References and related documents
Collins M, Heptonstall J. (1994) Occupational acquisition of acute hepatitis B
infection by health care workers in England and Wales, 1985-93.
Communicable Disease Report 4: R153-5
Department of Health (2002) Hepatitis B infected health care workers: Guidance on
implementation of Health Service Circular 2000/020
Department of Health (2007) Hepatitis B infected healthcare workers and
antiviral therapy. Department of Health, London.
Department of Health (1998) HSC 1998/063: Guidance for clinical health
care workers: protection against infection with blood-borne viruses.
Department of Health, London.
Department of Health (1996) Protecting health care workers and patients
from Hepatitis B. EL (96)77 Addendum to HSG (93)40. Department of
Health, London.
Department of Health (1993) Protecting health care workers and patients
from Hepatitis B. HSG (93)40. Department of Health, London.
Department of Health (2000) Information for midwives: hepatitis B testing in
pregnancy. Department of Health, London.
Department of Health (1998) Screening of pregnant women for hepatitis B
and immunisation of babies at risk HSC1998/127. Department of Health,
London
Dimond B (2006) Legal Aspects of Midwifery 3rd ed. Books for Midwives
Press, Edinburgh.
Dimond B (1995) Protecting health care workers and patients from Hepatitis
B. Midwifery Matters 64: 3-5
Edwards M. (1995) Hepatitis B: immunising health workers and patients.
Nursing Times 91(36): 29-31
Feely M (1997) Hepatitis and hepatitis immunisation.
117(1): 41-6
J Roy Soc Health
Howard G. (1996) Hepatitis B and the employer’s duty to vaccinate.
Occupational Health 48(8): 284-6
Mukerjee AK, Westmoreland D, Rees HG. (1996) Response to the discovery
of two practising surgeons infected with hepatitis B. Communicable Disease
Report. CRD review 6(9): R126-8
NICE (2008) Antenatal care: Routine care for the healthy pregnant woman,
NICE, London
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Norris L, Edgar J. (1996) Hepatitis B - Are you protected? Occupational
Health 46(6): 210-1
Nursing and Midwifery Council (2006) A-Z advice sheet B, Blood-borne
viruses. www.nmc-org.uk (accessed February 2008).
Ramsay M, Gay N, Blogun K, Collins M. (1999) Control of hepatitis B in the
UK. Vaccine 16(4) supplement 52-5
First Published: 1999
Updated: June 2008
Review Date: June 2011
Approved by the RCM Professional Policy Committee
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