Midwifery
Council
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Idaho Midwifery Council |
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).
Diagnosis
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.
Treatment
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.
Prevention
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 kgf116@hotmail.com.