Viral Hepatitis: Some Considerations for Midwives
by Kathleen McDonald, CPM
Midwives will probably work with women who are unaware that they are infected with a hepatitis virus. As such, we are in a good position to increase hepatitis awareness in the families we work with and in the general population. I know of one midwife who died due to hepatitis C, which she believed she had contracted from a long-ago Rhogam shot. Midwives are at risk of exposure to blood-borne diseases due to our frequent contact with blood. We also need to learn how to best protect our clients from exposure.
One in 12 people worldwide (500 million) is infected with chronic viral hepatitis. Hepatitis B (HBV) affects 350 million, while 150 million have hepatitis C (HCV). An estimated 1.5 million of these people die each year due to the infection. Both of these viruses are bloodborne.
In the US alone, at least five million people are infected with hepatitis B or C, and the majority don’t even know it. These hepatitis infections cause over 15,000 deaths per year, primarily from liver cirrhosis or liver cancer. More people are now dying from hepatitis than from HIV/AIDS in the US.
Fully one-third of the world’s population—over two billion people—have been exposed to HBV, with sexual transmission common. Ninety percent of healthy adults can fight off HBV infection, but 90% of exposed newborns will develop chronic infection. Twenty-five percent of children who become chronically infected will later die of liver cirrhosis or liver cancer. HBV is endemic in China and other parts of Asia where an estimated 8–10% of the general population live with HBV.
Seventy-five to eighty percent of those who are exposed to HCV become chronically infected. Sexual transmission is rare in heterosexuals, but is common in the homosexual community, especially among those infected with HIV. One third of individuals with HIV are co-infected with HCV. The disease progression and response to treatment varies depending on which of the six HCV genotypes is involved.
This article addresses HBV and HCV, but researchers have also identified four other hepatitis viruses: A (HAV), D (HDV), E (HEV) and G (GBV-C).
Signs of hepatitis can include flu-like symptoms, fatigue, nausea, anorexia, fever, muscle aches, elevated liver enzymes (ALT and AST), jaundice, right upper quadrant (RUQ) pain, digestive problems and dark urine. HCV can also lead to diabetes, depression, neuropathy, fibromyalgia, cryoglobulinemia, lung, cardiac and skin problems, anemia and cirrhosis.
Some known risk factors for hepatitis B and C are:
· A history of injection or inhalation drug use, even once
· Medical or dental interventions without adequate sterilization of equipment
· Receiving blood or blood products before screening was introduced
· Military service (from mass inoculations using a jet-gun)
· Body-piercing, tattooing and acupuncture
· Birth to an infected mother
· Healthcare and emergency worker exposure on the job
· Having unprotected sex with an infected person or with multiple partners
· Sharing personal care items such as razors or toothbrushes with an infected person
Viral hepatitis infection is a reportable disease in the US and the UK, although laws concerning anonymity and confidentiality vary between countries and among states in the US. Infected persons can be excluded from certain jobs and barred from immigrating to some countries.
Persons living with chronic hepatitis will benefit from working closely with their care providers to decide upon a plan of care. They should avoid alcohol, tobacco and other drugs, drink lots of water, exercise regularly and minimize stress. Diet can make quite a difference and various herbs such as milk thistle are used to support the liver.
Many people who are infected with HBV or HCV go through a course of drug therapy, which can last from 24-72 weeks and is aimed at eliminating the virus and obtaining a sustained viral response (SVR). A combination of weekly interferon injections and daily ribavirin pills is most commonly used to treat HCV at present. The side effects can be grueling and treatment is expensive. Some viral genotypes are easier to treat than others. HCV can cause insulin resistance and diabetes, which can lower treatment efficacy and should be diagnosed and treated before beginning therapy.
The goal of HBV treatment is seroversion (testing negative for the HBV antibody). Six different drugs, including interferon, may be used to combat HBV; the specific drug(s) used may need to be changed if the virus becomes resistant to one regimen.
Health care workers should be tested, know their status, and if not already infected, get immunized for Hepatitis A and B. While individuals with a risk factor are more likely to test positive, others may be unaware that they are at risk from a past medical procedure, blood transfusion or a Rhogam shot.
Midwives who work with a woman who is infected with HBV should ensure that the first dose of HBV immune globulin and hepatitis B vaccine is available to be given to the newborn within 12 hours of birth. If you are not able to prescribe these they can probably be obtained by the mother from her pediatrician, or with the assistance of your local health department’s infectious disease specialist or epidemiologist. The newborn of a woman who is HBV-positive should receive a series of three vaccinations, which will greatly reduce (by up to 95%) the risk of acquiring HBV at birth (90% without treatment). The first dose of HBV immune globulin along with the hepatitis B vaccine should be given within 12 hours after birth, and subsequent vaccinations are given at about one month and between three to five months after birth.
Currently no immunization is available for a baby whose mother is HCV-positive. However, the risk to the baby of acquiring the virus during birth is estimated to be only about 5%. (Consult with a specialist because protocols may change over time.)
Breastfeeding is not contraindicated with HBV and HCV, as transmission by this route has not been documented.
Midwives also need to examine their practices closely to make sure that they do not put anyone, including themselves, at risk by their actions. Consideration should be given to proper care and handling of needles; sterilization of instruments and equipment; cleaning of birth pools or tubs; disposal of contaminated waste, including the placenta; and protection during procedures.
Avoid multi-use medication vials; but if you must use them always use a new needle and syringe. Some health care workers have thought that it was sufficient to just change the needle when drawing up a second dose for the same patient; but this has resulted in outbreaks of hepatitis. People are still becoming infected during medical procedures.
An individual who is a carrier and sticks herself with the needle while suturing can infect the client. More than one case has been documented in which a patient became cross-infected from a cardiac surgeon who was a carrier.
Put all used sharps into an approved sharps container. Never overfill the container. Make sure that the containers are safely stored and disposed of in accordance with state and federal regulations. Avoid endangering waste-management workers through improper disposal.
Hepatitis viruses can stay alive on a dry surface for up to four days and potentially much longer. Isopropyl alcohol has no effect. A solution of 10% bleach in water is much more effective and should be used for cleaning birthing pools or tubs. Autoclave sterilization is best for instruments.
Midwives are at risk of exposure due to their close and frequent proximity to blood, amniotic fluid and other body fluids. For example, fresh scratches on arms or legs from gardening or another activity that are accidentally splashed with blood or fluids mixed with blood from a birth provide an opportunity for infection. A former nursing instructor of mine died of hepatitis after receiving a needle-stick injury. HBV and HCV can be 50-100 times as contagious as HIV. As little as 10 picoliters of blood can transmit infection. (One picoliter is one billionth of a milliliter.)
Blood-tainted waste such as a gauze pad with some blood on it is not considered infectious and can be discarded with solid waste. Blood-saturated waste is anything contaminated with blood that would drip, even one drop, when compressed or wrung out, and is considered infectious. Infectious waste must go into a red medical waste bag which is properly labeled and be incinerated or sterilized by a permitted waste disposal service. Contact your nearest medical waste disposal service and arrange for the disposal of your sharps containers and other medical waste, including placentas. Sharps containers can sometimes be mailed to the disposal service. If you work in a remote area and medical waste disposal is not available to you, your best option may be a burn barrel. (In the case of an anomaly or stillbirth, save the placenta so that it is available for any needed testing.)
Hepatitis awareness has been low in the US and around the world, partly because the disease can be asymptomatic and/or quite slow to progress at times. There also has been a stigma associated with hepatitis infection. Recognizing that we are facing a “silent epidemic” of hepatitis, the United States and other countries are now stepping up their public health campaigns.
It is time for birth practitioners to become more informed about viral hepatitis and to help spread the word.
Tips for Avoiding Hepatitis
· Be aware of wounds or breaks in your skin, including chapped hands from frequent washing, and protect yourself with waterproof dressings and gloves.
· Always have apron pockets full of gloves.
· If exposed, don’t wait and hope for the best. Gently increase wound bleeding, if possible, and wash with soap and warm water. Seek medical help immediately. Timely interventions can reduce your risk of developing a chronic infection. Initiate testing for infectious diseases such as HBV, HCV and HIV and file an occupational exposure report with your facility, if required.
In the US, some states regulate infectious waste exposure while other states rely solely on federal OSHA regulations. Make sure that you have on file written policies for avoiding exposure to infectious waste and for what to do if exposure takes place and that everyone you work with is familiar with these policies. If an accident takes place it is wise to fill out an occupational exposure report even if your facility does not require it, but most facilities do require this. If you are practicing solo this report may still be useful to you in the future.
A source for sample forms: The Exposure Prevention Information Network (EPINet) has their Blood and Body Fluid Exposure Report and Needlestick and Sharp Object Injury Report available for free download at http://www.healthsystem.virginia.edu/internet/epinet/forms/epinet3.cfm
A longer and slightly different version of this article first appeared in Midwifery Today #91 Fall 2009.
Kathleen McDonald, CPM, attended births in the Boise area. Now mostly retired, she is a certified HCV Educator with the Hepatitis C Support Project. For more information or to correspond contact Kathleen at firstname.lastname@example.org.
Idaho Midwifery Council
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