Recently, the Centers for Disease Control (CDC) and the American Academy of pCdiatrics (AAP) recommended that all newborn babies be vaccinated against what is regarded "the most important chronic viral infection affecting humans" - the hepatitis B virus (HBV) (New England Journal of Medicine, August 2, 1990). The new policy is being implemented because America's public health system has failed to prevent the spread of HBV causal agents blood borne pathogens that infect the liver. According to Dr. Raymond K off, Chief of Medicine, Metro West Medical Center (Framingham, MA), "HBV is significantly more contagious than the AIDS virus (HIV) in an occupational setting."
There is no accepted medical therapy or treatment for acute HBV. As a consequence, HBV disease often becomes chronic and progressive. According to CDC, about one-third of the chronic population is effectively treated with interferon; however, in the remaining infected population the disease is untreatable. Further, 5-10% of the untreatable chronic cases have the potential for developing complications such as cinbosis and cancer of the liver. Dr. Gregory Storch, Director of Infectious Diseases at St Louis Children's Hospital, noted that "many of the estimated one million chronically infected HBV persons in the'United States are potentially capable of spreading the disease to others. "
There are roughly 240,000 new infections of HBV occurring annually in the United States (Hepatitis B Prevention, CDC, September, 1991). This dramatic rise has occurred despite availability of generally safeand effectiveHBV vaccines (e.g., Recombivax HB and Energix B).
During the 1980s, the AAP determined that there was an increased risk of HBV transmission among health care workers, including staff ofinstitutions and nonresidential day care programs for those with developmental disabilities, especially children with Down syndrome. Further, the Occupational Safety and Health Administration (OSHA) reported that public school teachers and instructional aids who work in facilities where education is provided for individuals with developmental disabilities are at increased risk.
Controlling the spread of contagious disease within educational environments has always been a formidable task. The Policy Manual (July, 1991)of the Council of Exceptional Children states that an affected child should not be excluded from receipt of an appropriate education, even when circumstances require temporary removal of the child from contact with other children.
However, recent public awareness of HBV has raised concerns among educators. Exposure to an HBV student's blood or blood-contaminated body fluids, as well as contact with an open wound or weeping skin lesions, are major modes of HBV transmission. Concern about HBV transmission is also warranted for such behaviors as bittig, scratching, and selfmutilation. In response, OSHA now requires a review of local school policies and procedures.
OSHA's regulations, entitled, "Occupational Exposure to Bloodbome Pathogens" (Federal Register, December 6, 1991), are an attempt to control the transmission of HBV in health care workers. Where known HBV carriers are in atten_ce, OSHA recommends that staff of non-residential day care and school programs comply with the following guidelines:
Clinical trials of hepatitis B vaccines licensed in the United States showed that 80-95% of all people vaccinated developed immunity to HBV (Morbidity and Mortality WeeklyReport,November22,1991). If a protected antibody response develops, vaccine recipients are virtually 100% protected against illness, even if directly exposed to the virus. There are some side effects to the hepatitis B vacCine injections (e.g., soreness, redness and swelling on the arm), but they are usually mild.
HB v is a threat to the public health of children and school staff and deserves our serious attention. Has your day care center or school developed a need to know philosophy and policies to maintain medical confidentiality of a child who is diagnosed as hepatitis B positive? What health care precautions, including vaccination, should your school administration adopt for noninfected children when a hepatitis B infected child is identified? Further, what steps has your school taken to comply with the recent OSHA recommendations?