PREVALENCE OF HEPATITIS B & C AMONG DENTAL PROFESSIONALS WITH EMPHASIS ON SAFETY MEASURES. Research Article. University Journal of Dental Sciences

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1 PREVALENCE OF HEPATITIS B & C AMONG DENTAL PROFESSIONALS WITH EMPHASIS ON SAFETY MEASURES Dr. Dinesh Pilania, Dr. Shoaib R. Tippu, Dr Jinendra Jain, Dr. Vineet Gupta, Dr. Brijesh Gupta, Dr. Pranjan Mitra, Dr. Baljeet Singh, Dr. Deepak Kurup 1 1,4 Reader Rashthan Dental College, Consultant OMFS, 3 HOD Dept of OMFS Ideas Dental College, 5 Reader Dept. of OMFS Ideas Dental College, 6 Senior Lecturer Ideas Dental College, 7 Principal Ideas Dental College, 8 Reader Ideas Dental College University Journal of Dental Sciences Research Article ABSTRACT : AimTo bridge the gap & paucity of data about the incidence & prevalence of blood borne viruses' viz. hepatitis B & C transmission among the dentists & dental assistants in Jaipur, Rajasthan.And to spread awareness about these blood borne viruses amongst the dental students, dental professionals & dental auxiliaries. Materials & methods70 dentists, 70 students & 40 dental auxiliaries filled a detailed questionnaire designed to measure occupational risk of hepatitis B & C and supplied a sample of blood. Antibodies to hepatitis C virus (anti HCV) were assessed by second-generation enzyme immunoassay and recombinant immunoassay. Hepatitis B virus (HBV) surface antigen, antibodies to HBV and core antigen were measured by enzyme immunoassay. ResultsAnti HCV was found in 8.33% of oral surgeons, 1.72% of general dentists, and 5.71% of dental auxiliaries. Anti HCV was more prevalent in dental personnel who were older, had more years of practice, and had serological markers of HBV infections. Serological markers of HBV infection were found in 8.62% of general dentists and 16.67% of oral surgeons.conclusion These data confirm high rates of HBV infection among oral surgeons, but suggest that the risk of HCV infection is considerably lower. Keywords: Hepatitis A, Hepatitis B, Seropositivity Conflict of interest: Nil No conflicts of interest : Nil INTRODUCTION Hepatitis B virus (HBV) infection is a well-known occupational hazard among health care personnel[1-2]. Like HBV, hepatitis C virus (HCV) is blood-borne, and transmission of HCV to health care workers by needle stick exposure has been demonstrated[3-4]. However, the magnitude of the risk of HCV infection for health care personnel remains controversial[5-7].the highest prevalence of HBV in health care personnel has been found among dentists and oral surgeons[1-2]. For example, one study of HCV infection in New York City found antibodies to HCV (anti-hcv) in 1.7% of dentists, 9.3% of oral surgeons, and 0.1% of controls[8].they hypothesized that the high prevalence of anti- HCV among New York City oral surgeons was due to their frequent exposure to high-risk patients. Therefore this study is designed to assess the prevalence of HBV and HCV viral infection amongst dental surgeons and dental assistants of Jaipur, Rajasthan and to further explore the risk of occupational acquisition of HBV and HCV by comparing the prevalence among oral surgeons and general dentists. MATERIALS AND METHODS In order to study the prevalence and risk factors for HBV and HCV, blood samples and updated questionnaires were collected from 180 subjects, amongst the dental professionals, oral surgeons, postgraduate students, interns & dental auxiliaries. The study was approved by the ethical committee of the institute& written informed consent was taken. All the participants were given a detailed questionnaire about information on demographics (age, gender, and location), professional characteristics (type, duration, number University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 51

2 of patient treated, quantity of practice), occupational exposure (nature and estimated number of accidental parental inoculations and status of vaccination against hepatitis B). Nursing staff and technicians collected Blood sample. The collected blood was stored & tested. Antibodies to HCV (anti HCV) were assessed by second-generation enzyme immunoassay and recombinant immunoblot assay. HBV surface antigen, antibodies to HBV surface and core antigens were measured by enzyme immunoassay. RESULTS Anti HCV was found in 8.33% of oral surgeons, 1.72% of general dentists, and 5.71% of dental auxiliaries. Anti HCV was more prevalent in dental personnel who were older, had more years of practice, and had serologic markers of HBV infection. Serologic markers of HBV infection were found in 8.62% of general dentists and 16.67% of oral surgeons. These data confirm high rates of HBV infection among oral surgeons, but suggest that the risk of HCV infection is considerably lower and are in accordance with the study conducted by Robert S. Klein et al[8]&david L. Thomas[9].MalathiNarasimhan et al [10]contradicts the results with their study showing that Periodontists were predominantly affected. DISCUSSION Viral hepatitis is an important consideration in dental practice, given the risk of patient to patient and patient to HCW transmission. Although the transmission of HBV and HCV occurs mainly through blood & blood products, saliva may be an additional source of infection with HBV & HCV. The incidence of HBV and HCV is increasing all over the world. The issue of viral hepatitis examines the important topic of blood borne infections in HCWs. Global epidemiology of blood borne infections in healthcare workers estimated numbers of HCWs vary, with a world health organization figure of 35 million rising to as many as 100 million if all healthcare staff is included, in addition to the doctors, nurses, and midwives in active practice. If we assume that the prevalence rates are at least similar to those in the general population, it is clear that the number of infected healthcare workers is a cause for concern, particularly in underresourced health systems. The risk of transmission of HBV and HCV is most serious between patients, either directly or indirectly. The risk of transmission to HCWs from patients is higher than that of HCWs to patients. It has been shown that some areas of healthcare can represent a higher risk with surgery, gynecology, and orthopaedic services heading this unfortunate list. The most common route of transmission is via needle stick injuries, especially those involving hollow needles. Operating in cavities where the tips of the fingers holding sharp surgical instruments are not always visible also poses an important risk for those performing exposure-prone procedures. It is therefore essential that HCWs acknowledge the risk, and exercise caution. When injuries do occur, it is also important that they are reported and the circumstances examined; standardization of such reporting procedures would help the process of data collection and analysis considerably[11]. The transmission of blood borne infections within the healthcare setting can occur in three directions: from patient to patient, from HCWs to patient, and from patient to HCWs. Although epidemiological evidence suggests that healthcare related exposures are not the primary source of HBV or HCV transmission, the fact that any transmission occurring within this setting gives rise to concern. The most common transmission route is from patient to patient, followed by patient to vulnerable HCWs, and more rarely from HCWs to vulnerable patient[11]. Patient to patient transmission is usually indirect, resulting from contact with HCWs hands, medical equipment and devices, or environmental surfaces and is often a result of failure to adhere to basic principles of aseptic technique for the preparation and administration of parenteral medications in multi dose vials. Therapeutic injections are reported as accounting for 21 million new HBV infections and 2 million new HCV infections each year. Many of these injections are performed in less than ideal conditions, often with reuse of needles or multi dose vials and mainly, but not exclusively, in developing countries[12]. Surgery is still a major risk factor for acute hepatitis C. Data from the Sistema Epidemiologico Integratodell' Epatite Virale Acuta (SEIEVA) show that the risk ranges from 2.1 for biopsy/ endoscopy to 12.1 for gynecology surgery, probably due to breaches in infection control procedures between patients. Outbreak or single cases of HCV infections in other hospital settings were linked to contaminated instruments, multi dose vials, or anesthetic circuitry. This is similar to observations made for HBV infection. University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 52

3 Patient-to-healthcare worker transmissionthe risk of HBV infection in a HCW after a needle stick injury and in the absence of vaccination or post exposure prophylaxis is 37%- 62% if the source patient is HBeAg positive and, 23%-37% if the patient is HBeAg negative[13]. HCV transmission occurs through occupational exposure to blood, but less efficiently than HBV transmission. The average rate of HCV infection in exposed HCWs is 0.5% (range: 0%-10%). The introduction of universal precaution measures has had an impact on HCV transmission rates. Prevalence rates among healthcare workers remain similar to or lower than those of general population, even among those in specialties with a high likelihood of Percutaneous exposures (e.g. Surgeons), suggesting that transmission in healthcare settings has not been a common source of HCV infection for HCWs. Healthcare worker-to-patient Surgery is a major risk factor for transmission from an HBV infected HCW, with the level of risk varying by the type of procedure (e.g. Exposure prone invasive procedures are associated with a higher risk of transmission). The number of reports of infected HCWs transmitting HBV to patients has fallen to around 10 in the last decade14. There are a few reports of HCV transmission from infected HCWs to patients and most cases have not been associated with the performance of exposure prone procedures but rather with the use of illicit drugs by the HCWs[15]. Exposure prone procedures (EPPs) The risk of healthcare related transmission of HBV, HCV and to a lesser extent HIV is increased during the performance of EPPs. These are defined according to a UK advisory panel as: invasive procedures where there is a risk that injury to the worker may result in the exposure of patient's open tissues to the blood of the worker. These include procedures where the worker's gloved hands may be in contact with sharp instruments, needle tips, or sharp tissues (e.g. Spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible all times [16]. Risk categories It is somewhat difficult to precisely define the degree of risk procedure, but an attempt has been made to divide procedures into groups and categories as high, variable, or low risk[17]. High risk Any sub mucosal invasion with sharp, hand held instruments or procedures dealing with sharp pathology/ bone spicules, usually in poorly visualized or confined spaces (e.g. Orthopaedic surgery, trauma surgery, internal cavity surgery). Variable risk Minor dental procedures excluding examinations, routine dental extractions, internal /instrument examinations/ biopsy (e.g. Endoscopy, vaginal examination, laparoscopy), minor skin surgery. Low risk Interview consultation, dental examination, non invasive examinations or procedures (aural testing, electrocardiograph, abdominal ultrasound), intact skin palpation (gloves not required), injections/ venipuncture (gloves required). Management of occupational exposures to blood borne infections: General measures It is generally recommended that staff working in risk areas, where the chance of exposure to a blood borne infection is higher than in general care, such as genitor urinary clinics, emergency departments, or operating theatres, should seriously think about the situation of an actual exposure. In practice, this preparation for the hypothetical event has either not occurred, or the staff member's thought processes are overtaken by the emotion of the moment. It is therefore essential that a structure and an action plan be put in place by the hospital or clinic so that any incidents can be dealt with efficiently and sympathetically. The management of an exposed HCW should follow a written protocol to ensure: Prompt reporting of occupational exposures. Post exposure assessment of the exposed HCW. Sources for emergency advice and psychological support. Management options. Comprehensive follow up. Counseling of the source patient and testing if consent is given. Accessing out of hours services. Information and education of HCWs on policy, risks of blood borne viruses, reporting of incidents, and PEP availability and benefits[18]. A HCW who is exposed to HBV and subsequently experiences seroconversion should receive the following management and care: Referral to a hepatologist for specialist advice. Counseling on prevention of secondary transmission and management of household contacts. Restriction of performance of exposure prone procedures to prevent HCW-to-patient transmission. University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 53

4 Counseling on future disease management and career options[11]. HCWs exposed to HCV positive patients: In case of a known HCV infected sources, a baseline serum sample should be obtained from the HCW for storage; serum/ EDTA should be collected for genome detection at 6 and 12 weeks, and for anti HCV at 12 and 24 weeks. If the source is known not to be infected with HCV a baseline serum sample should be obtained from the HCW and follow up serum if symptoms or signs of liver disease develop. If the HCV status of the source is unknown, a baseline serum sample should be obtained from the HCW and a designated doctor should perform a risk assessment; high risk: manage as for known infected source; low risk: obtain serum for anti HCV at 24 weeks[19]. Universal precautions and the safety of healthcare workers : General precautionary measures protect both healthcare workers & patients whenever there is potential exposure to blood or other body fluids. In the operating the atre, gowns, masks, and gloves are the general standard but no system is foolproof. Of all operating specialists, orthopaedic surgeons most frequently adhere to the recommendation, e.g. donning two pairs of gloves when operating, or application of effective barrier protection. Their main concern, however, is to protect the patient from acquiring osteomyelitis, and much less so to safeguard patients or themselves against transmission of hepatitis viruses. A number of measures may stop transmission of infection and these may involve the development of alternative technique and/ or changes in working practices. Utilizing laparoscopic surgery to reduce the inherent risks associated with open surgery is an excellent example. The use of stapling devices instead of sutures minimizes the risk of glove and skin puncture caused by suture needles. If suturing is essential, blunt needle should be used whenever feasible[20-21]. Double gloving while operating is also helpful, particularly when wearing indicator under gloves since these will change color if a puncture occurs. Although disliked for the interference with dexterity, two layers of glove will also significantly reduce the transmitted and potentially infective fluid volume; mainly in solid but to a lesser degree also in hollow-bore needles. Needle protective devices may reduce the incidence of contaminated percutaneous needle stick injury, but the safety device must also be disposed off with care. Sharp containers are not to be overfilled. Glass vials are a frequent cause of hand injury or glove damage. Multiple dose vials, or fluid bags shared amongst cases to draw up drugs, are not safe from the patient's point of view. Some anaesthetic equipment, such as disposable laryngoscopy blades, laryngeal mask airways, or gum elastic boogies, has been registered to make contamination and disease transmission unlikely. However, the equipment was often found to be of inferior quality potentially leading to difficulties in airway management, risking morbidity, or even mortality. Understandably, this can seriously hamper the wider acceptance of an otherwise quite useful development. It is clear that universal precautions only work if they are applied. It is also a fact of life that familiarity breeds, if not contempt, then at least carelessness. Regular reminders on apparently simple safety measures and discussions of the consequences of mistakes or of deliberately ignoring them should be part of routine training in each hospital department. The following list is provided by the Health Protection Agency and the National Radiological Protection Board[22]: Practice good basic hygiene with regular hand washing, also before and after donning gloves. Cover wounds or skin lesions with water proof dressings. Avoid contamination of person and clothing with blood/ body fluids. Disposable gloves and aprons should be worn when attending to dressings, performing aseptic techniques, or dealing with blood/ body fluids. Handle and dispose off sharps safely. Avoid puncture wounds, cuts, and abrasions in the presence of blood. Avoid using sharps if possible. Protect eyes, mouth, and nose from blood splashes. Know what to do if there is a sharp injury or blood splash incident. Clear up blood spillages promptly and disinfect surfaces. Dispose off contaminated waste safely. Know how to deal with soiled linen. Clean, disinfect, and sterilize equipment as appropriate. University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 54

5 Prevention of HBV and HCV infection in HCWs Vaccination is a powerful tool in the prevention of HBV infection. Since this means is not yet available for HCV or human immunodeficiency virus (HIV) infections, adherence to universal standard precautions and the use of often simple and safe techniques to avoid exposure are essential protective measure for all HCWs. Moreover, safer devices should be utilized whenever available. In the case of HBV or HIV, post exposure prophylaxis (PEP) correctly implemented and followed May literally save the life of the HCW after occupational exposure to these infectious agents. PEP recommendations are now available in most developed countries. However, policies on PEP are by no means standardized, making comparisons between countries and the collection of data problematic. Education in self protection and the protection of colleagues and patients must be an ongoing process. Regular reviews of universal standard precautions and warnings to staff about complacency must be undertaken by all healthcare facilities to ensure that transmission figures remain as low as possible[11]. Recommendations for HBV & HCV infected healthcare workers: New and relatively effective antiviral agents are now available in most western countries. There are strong arguments for offering medical and nursing students testing for blood borne viruses as soon as they enter training. It is much more difficult to answer the question of whether all medical professionals including volunteers should be tested at regular intervals. Some countries insist that doctors know their sero status, other place no restrictions on staff unless they are involved in proven transmission of a viral infection. So many factors come into play here: ethical, legal, economic, moral and cultural[11]. The incidence of hepatitis B & C is increasing all over the world. The parenteral route of infection is one of the principle causes. One main cause is neglect of sanitary anti epidemic measures: manipulations without gloves, veils, protective eyeglasses, and lack of disposable instruments, poor cleaning, disinfection, and sterilization of hardware. Awareness and alertness of dental practitioners and other dental workers is an important factor. REFERENCES : 1. Feldman RE, Schiff ER. Hepatitis in dental professionals. JAMA 1975:232: Smith JL, Maynard JE, Berquist KR. Comparative risk of hepatitis B among physicians and dentists. JInfect Dis1976:133: Kiyosawa K, Sodeyama T, Tanaka E et al. Hepatitis C in hospital employees with needlestick injuries. Ann Intern Med1991:115: Mitsui T,Iwano K, Masuko K et al. Hepatitis C virus infection in medical personnel after needlestick accident. Hepatology1992:16: Thomas DL, Factor S, Kelen G et al. Hepatitis B and C in health care workers at the Johns Hopkins Hospital. Arch Intern Med 1993:153: Kuo MY, Hahn L J, Hong CY et al. Low prevalence of hepatitis C virus infection among dentists in Taiwan. JMed Virol1993:40: Zuckerman J, Clewley G, Griffiths P, Cockcroft A. Prevalence of hepatitis C antibodies in healthcare workers. Lancet1994:343: Klein RS, Freeman K, Taylor PE, Stevens CE. Occupational risk for hepatitis C virus infection among New York City dentists. Lancet1991:338: David L. Thomas et al. Occupational risk of hepatitis C infections among general dentists and oral surgeons in North America. The American Jr of Medicine 1996:110: MalathiNarasimhan, VK Hazarey et al. Prevalence of hepatitis B surface antigen in dental personnel. J Oral MaxillofacPathol 2015: Jan-Apr: 19 (1): Viral hepatitis published by the viral hepatitis prevention board (VHPB). November 2005, Vol 14, Number PHLS AIDS & STD centre at the communicable disease surveillance centre and collaborators. Occupational transmission of HIV. Summary of published reports. December 1999 edition. Data to June Werner BG, Grady GF. Accidental hepatitis B surface antigen positive inoculations. Use of antigen to estimate infectivity. Ann Intern Med 1982:97: Gunson RN, Shouval D, Roggendorf M. et al. on behalf of the European Consensus Group. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in health care workers (HCWs): guidelines for prevention of transmission of HBV and HCV from HCW to patients. J ClinVirol2003:27: Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis2004:38: Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. Guidance for clinical health care workers: University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 55

6 protection against infection with blood-borne viruses. H S C / D e p a r t m e n t o f H e a l t h Publications and Statistics/ Publications/PublicationsPolicyAndGuidance/Publicati onspolicyandguidancearticle/fs/en?content_id= &chk=sjOK8W [Accessed November 2005] 17. Demediuk N [Accessed November 2005]. 18. Department of Health. HIV Post-exposure prophylaxis. Guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS. February isguidance feb04.pdf [Accessed November 2005]. 19. Ramsay ME, on behalf of the PHLS Advisory Committee on Blood Borne Viruses. Guidance on the investigation and management of occupational exposure to hepatitis C. Commun Dis Public Health 1999: 2: Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am CollSurg2004:199: Loudon MA, Stonebridge. Minimizing the risk of penetrating injury to surgical staff in the operating the a t r e : t o w a r d s s h a r p - f r e e s u r g e r y. J R CollSurgEdinb1998:43: Health Protection Agency and National Radiological Protection Board. Initial investigation and management of outbreaks and incidents of unusual illnesses. Version 3, March deliberate release/ Unknown/ Unusual Illness Ambulance. pdf [Accessed November 2005]. CORRESPONDING AUTHOR: Dr. Brijesh Gupta Institute of Dental Education and Advanced Studies Nr. Toll Plaza NH- 92 Gwalior Etawah Road Air Force area Pin , Phone University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 56