Introduction

Viral hepatitis is still an important health problem in our country. Healthcare workers (HCWs) are at a higher risk for acquiring viral hepatitis. They can get infected through percutaneous injury from a contaminated sharp instrument or exposure to infected blood and body fluids (1,2). Among HCWs, sero-positivity rates in different age groups from different cities and different occupational groups have been reported to vary between 77.5% and 100% for anti-hepatitis A virus (HAV) IgG, 1% and 4% for hepatitis B surface antigen (HBsAg) and 0% and 2% for anti-hepatitis C virus (HCV) (3,4,5,6). At hospitals, housekeeping staff generally work as subcontracted laborers and often change between the business and health-care sectors. They are a very difficult group to follow up because of frequent job switches but they have similar risks of acquiring viral hepatitis with other HCWs. In this study, we aimed to investigate viral hepatitis transmission risk, serologic status and vaccination rates in our hospital housekeeping staff who do not get any specific education and have different working conditions but have similar environmental risks with other HCWs.

Materials and Methods

The study was conducted between January 2013 and May 2013 in Yenimahalle Training and Research Hospital, a 250-bed secondary-care hospital. All 81 members of the cleaning staff (46 male, 35 female)  were included in our research. The mean age of the subjects was 35.8 years (range: 20-53 years). A questionnaire was completed through a one-on-one interview with each housekeeping staff member, and data regarding education level, previous experience in working in a healthcare setting, previous participation in training programs covering occupational exposure to blood-borne pathogens and protection methods, and hepatitis B vaccination status were collected. Serological tests for hepatitis A, B and C were done using the direct chemiluminescence sandwich immune test method (ADVIA Centaur® CP Immunoassay System, Germany) in our microbiology laboratory. The test results were added to the form.

Results

Four subjects (4.9%) were found to be HBsAg-positive, 24 (29.6%) were anti-HBs-positive and 51 (63%) subjects were anti-HAV IgG-positive. None of them tested positive for anti-HCV (Table 1). One of them was unaware of being HBsAg-positive. Only 7 (8.6%) of them have previously received hepatitis B vaccine and 17 (21%) of them had natural immunity against hepatitis B. Anti-HAV IgG testing was not performed in 25 (30.9%) of them. Anti-HAV IgG sero-positivity rate was 91.1% for the remaining. Nearly half of them (39/81, 48.1%) were primary school graduates, 18 (22.2%) had completed secondary school and 24 subjects (29.6%) were high-school graduates. Only 14 of them (16%) had 0-5 years’ experience and only one subject (2.5%) had 5-10 years’ experience of working in a healthcare setting (Table 2). We had 15 (%18.5) housekeeping staff members who had worked at another hospital previously and 4 of them reported previous participation in training covering occupational exposure to blood-borne pathogens and protection methods. Thirty-nine of the 66 cleaning staff with no previous experience reported that they had received no training. As a result, only 38.3% (31/81) in total had a previous training on exposure risks and protection methods. Two (2.5%) reported that they had had contact with contaminated material while not wearing gloves. Thirteen (16%) reported that they had been injured at least once with a sharp instrument (Table 2).

Discussion

HCWs, including housekeeping staff, are at risk of acquiring hepatitis following accidental exposure to blood and body fluids (1). This risk is higher in countries like Turkey where hepatitis is more common, since the HBsAg positivity rate in HCWs will be proportionate to the HBsAg positivity rate in the general population (7,8). In the literature, reported HBsAg sero-positivity rates among HCWs vary between 1% and 4.4%. Data from studies investigating the serologic status of hospital housekeeping staff revealed similar HBsAg sero-positivity rates between hospital housekeeping staff and HCWs, being between 1.5% and 4.4%. In our study, 4.9% of the hospital housekeeping staff were positive for HBsAg. To our knowledge, this is the highest encountered sero-positivity rate for this group when compared with the results of similar studies from Turkey (5,9). In the literature, reported anti-HBs sero-positivity rates and hepatitis B vaccination rates among HCWs ranges from 20.6% to 79.3% and from 44.4% to 90%, respectively (5,10,11,12). Vaccination rates were lower among HCWs working in private hospitals compared to those in state hospitals (5). Both in our study and in other studies, it has been shown that hepatitis B sero-positivity rate among HCWs is higher than in the normal population (13). One housekeeping staff member who was unaware of being HBsAg-positive was followed up by our infectious diseases clinic. It is important to test HCWs for HBsAg and follow up of sero-positives (11).

The rate of exposure to sharp injuries was 16% among hospital housekeeping staff in our study. This rate was lower than the rate reported in some of the previously published studies (80%). This might be due to the fact that the housekeeping staff were not questioned for repeated exposure to sharp injuries as well as underreporting and use of plastic boxes for the disposeal of used sharp instruments (13,14,15,16). Although our rate of exposure to sharp injuries among hospital housekeeping staff was lower than the rates reported in other studies, it was still high and when the high HBsAg sero-positivity rate in our population is taken into consideration, the risk of contacting to the viral hepatitis is higher than expected (12,16). Hospital housekeeping staff are considered an at-high-risk group for percutaneous injuries (15,17). Even if the rate of glove use is high in our study, the real exposure rate with blood and body fluids is not known and this poses a risk for infection (14).

In our study, the anti-HAV IgG positivity rate was similar to that in studies published previously and it was similar to that in the normal population (3,6). There are some reports on hospital outbreaks of hepatitis A. The seropositivity for hepatitis A is age-dependent and the rate of vaccination among sero-negatives is very low (3,11,18,19). Housekeeping staff and HCWs working in nursing homes, infectious diseases or pediatric clinics are at a higher risk for hepatitis A (20). Seronegative HCWs and housekeeping staff, especially those working in these high risk areas, should get vaccinated.

None of the housekeeping staff tested positive for anti-HCV. Data from studies performed between 2008 and 2012 among HCWs revealed anti-HCV positivity rates between 0% and 0.49% (4,6). In our study, none of the hospital housekeeping staff tested positive for anti-HCV. This result was similar to the normal population (4,10).

In our study, the rate of previous hepatitis B vaccination among hospital housekeeping staff was 8.6% which is very low and emphasizing the importance of hepatitis serology testing and vaccination in this group. In a study done in 2003 by Şencan et al., (21) the rate of hepatitis B vaccination among HCWs was 7.1%. In our study, the rate is similar reflecting that the attitude of HCWs towards vaccination did not improve in more than one decade. The rate of vaccination in hospital housekeeping staff was lower than in other HCWs (8,12). Not receiving any training on the risks of exposure to blood and body fluids and protection methods increases the risk of hepatitis transmission (8). Our results showed that although hepatitis serology screening tests were performed routinely and there was a training and vaccination program in place at our hospital, 61.2% of housekeeping staff did not receive any training and a high (16%) sharp injury rate was reported. We assume that this situation was due to high employee turnover.

We conclude that annual training, screening and vaccination programs are not sufficient for hospital housekeeping staff since they might miss the program as a result of employee turnover. We suggest that immediately upon starting the job, hepatitis screening tests, vaccinations and a training program about exposure risks and protection methods should be performed for this group of workers.

Ethics

Ethics Committee Approval: The study weren’t approved by any Ethics Committee, Informed Consent: Consent form wasn’t filled out by the participants.

Peer-review: External and Internal peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Semiha Solak Grassie, Concept: Semiha Solak Grassie, Sümeyra Çetin Gevrek, Design: Semiha Solak Grassie, Data Collection or Processing: Sümeyra Çetin Gevrek, Analysis or Interpretation: Semiha Solak Grassie, Literature Search: Semiha Solak Grassie,

Writing:

Semiha Solak Grassie.

Conflict of Interest: No conflict of interest was declared  the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Solak Grassie S, Çetin Gevrek S. Investigation of Hepatitis Serology and Occupational Exposure Risk to Viral Hepatitis of Hospital Housekeeping Staff. Viral Hepatitis J 2016;22:14-17.