Hepatitis C presents new risks, concerns
Sunday, August 02, 1998
By Steve Twedt and Anita Srikameswaran, Post-Gazette Staff
Writers
http://www.post-gazette.com/healthscience/19980802bhepc1.asp
With growing awareness of hepatitis C and its threat to public
health, new concerns are being raised by health professionals who
have become infected while caring for people with the
sometimes-fatal liver disease.
Two local nurses say they've had to battle present or former
employers while dealing with the physical and emotional toll of
hepatitis C, which they contracted at work. Worry about revealing
his infection cost Jeff Endlich a job. Diane Dagnal has nearly lost
her career and now fears she won't be able to pay her medical bills
as her health deteriorates.
"I'll get a call like this once a month," said Susan Wilburn,
senior specialist for occupational safety and health for the
American Nurses Association in Washington, D.C.
"Part of the problem is that we have 800,000 needle sticks a
year, and the employer may not report it" to federal occupational
safety officials. "I think it's happening more now because there's
more risk. It is the next big blood-borne disease."
Another problem is the nature of hepatitis C, a disease caused
by a virus that until recently had no name and can lurk unnoticed
in the body for years before destroying the liver. There is no
vaccine, and the available treatments rarely cure. The disease
kills up to 10,000 people each year.
Because of its greater hardiness, health officials say hepatitis
C virus has infected four times as many people as the AIDS-causing
virus, HIV, a disparity with serious implications for health
workers.
While an estimated 35 health care workers are infected with HIV
each year on the job, one recent medical journal said up to 2,200
health workers will get hepatitis C.
A viral infection of the liver, hepatitis C is contracted
through blood. That's why the majority of those infected have been
intravenous drug users, blood transfusion recipients, hemodialysis
patients, hemophiliacs and health care workers who are exposed to
patients' blood.
For 75 percent of those who get hepatitis C, the infection will
never go away. And up to half of those people will develop
cirrhosis and eventually may need a transplant. In fact, it has
become the most common cause of liver transplants.
Blood donations have been routinely screened for hepatitis C
since 1992, which has resulted in a sharp decline in the overall
number of new infections since the mid-1980s. But federal officials
reportedly will soon recommend that everyone who received a
transfusion before 1992 get tested. Clotting factor for
hemophiliacs has been considered safe since 1987.
Where did she get it?
During her three decades as an emergency room nurse, 23 years at
South Side Hospital, Diane Dagnal, 54, was exposed to illness and
death on a daily basis. She followed all the proper precautions --
she wore gloves, she carefully disposed of needles, she assumed all
blood was infectious. It wasn't enough.
Nine months ago, during a pre-employment physical for her new
job at Medical Center, Beaver, Dagnal was diagnosed with hepatitis
C.
Today, Dagnal is physically fatigued and fighting depression.
She works two days each week at Beaver, where, she said,
supervisors and co-workers have been supportive. Still, she expects
she'll quit in the next few weeks because of the unending
fatigue.
While dealing with that, Dagnal also is fighting on another
front -- her employer at South Side and Beaver, the University of
Pittsburgh Medical Center, is contesting her claim for workers'
compensation. She filed the claim to cover her medical bills
because, now that she can't work full time, her health insurance
will run out next spring.
"I feel I gave my life to this profession," Dagnal said. "I went
into it knowing I was exposing myself to diseases. I also expected
to be taken care of if I did get something, but that's not
happening to me."
A UPMC attorney declined to comment on the pending case, but the
medical center has contested Dagnal's claim in written documents,
saying she cannot prove she was infected at work.
It's true. Because hepatitis C symptoms may not surface for more
than 10 years, Dagnal can't pinpoint when she was infected. Just
last year, the federal Centers for Disease Control began
recommending hepatitis C tests for health workers -- but only when
they are exposed to blood.
So veteran nurses such as Dagnal, who could have been infected
any number of times in the past 10 to 20 years, must plead their
case without clear documentation.
"If she's a nurse, chances are she was infected on the job,"
Wilburn said. "And if we're going to tell that nurse -- whose job
is to take care of people and expose herself to these blood-borne
pathogens -- to prove they were infected on the job, then we're
going to lose nurses. No one is going to be willing to put
themselves in that kind of a position."
Dagnal, a mother of six and grandmother of 11, has never had a
transfusion and has never used drugs. If she wasn't infected on the
job, where could it have happened?
Dagnal was diagnosed in 1990 -- before a hepatitis C test was
widely available -- with what was then called non-A, non-B
hepatitis. She had asked for the blood work because she was losing
weight and wasn't feeling well. To this day, she does not know when
she was infected. How much blood, how many needles, does an
emergency room nurse handle in a month, let alone 30 years?
"I have no recollection of a needle stick. But where else would
I get it? Nobody in my family had it."
Since 1990, she's had two more possible exposures, both
documented. In 1991, she was helping restrain a heroin addict
brought into South Side Hospital's emergency room and her bloody
vomit covered Dagnal. The doctor's incident report described
Dagnal's exposure as "massive."
Then, in 1994, she was starting an IV and "either I moved or the
patient moved, and I stuck my hand."
Dagnal said she didn't get tested for hepatitis C until she
started feeling ill last fall. Now she faces a toxic and
experimental treatment mixing interferon injections and Ribavirin
tablets, a six-month, $300,000 protocol with unpleasant side
effects similar to chemotherapy. Standard treatment with interferon
has been effective for only about 20 percent of the patients, but
the combination treatment is believed more promising.
More cases surfacing
Nationally the rate of hepatitis C infection has decreased since
the 1980s, largely due to the development of a test to screen blood
donations for hepatitis C. Yet Allegheny County health officials
have already learned of 920 suspected cases of hepatitis C this
year. Because of the long latency period before symptoms appear,
most cases are detected by chance, through blood donation,
pre-employment physicals or hospital blood work-ups.
In contrast to the 1,684 hepatitis C cases last year, the county
had 15 new cases of hepatitis A and eight cases of hepatitis B last
year.
Lynda Arnold of Norristown, Montgomery County, has organized an
association for the protection of health workers. Arnold, an
intensive care nurse in Lancaster, was infected with HIV after she
was accidentally stuck with a needle used on an AIDS patient in
1992. Now she works full time to help protect health workers
against needle sticks and support those who have become infected
with viruses such as hepatitis C and HIV.
"Some facilities are very supportive, and there are others that
really don't care," Arnold said. "They're trying to protect
themselves against losses."
Dagnal's contention that she was infected on the job "would be a
very reasonable possibility," Arnold said. "Unfortunately, if the
incident isn't documented and if there wasn't follow up, testing
and watching, then I guess you can attribute it to anything."
She favors voluntary testing of health workers, but knows that
might not be an attractive choice. Without a proven treatment,
"they would have to wonder, 'What am I going to do about it?' There
is no cure."
Perhaps more importantly, she said, workers will wonder what
their employer will do: "Am I going to lose my job?"
Who should be told?
Nurse Jeff Endlich, 45, doesn't know what to expect if he
reveals on job applications that he is infected with hepatitis C
virus; sometimes there is no problem, and other times jobs vanish.
Once, his failure to disclose his disease was cited as a reason for
dismissal.
Endlich, like many nurses, has been stuck accidently by a few
needles during his career. While working at UPMC Presbyterian in
the late 1980s, he drew blood from an intensive care patient who
had non-A, non-B hepatitis.
"The patient became very agitated, grabbed the needle, and
injected his blood into me," Endlich said, indicating his left
palm. "I went to defend myself, push him away. He didn't know what
he was doing."
A father to five children, Endlich had been healthy and active.
Like Dagnal, he had never had a transfusion nor used intravenous
drugs. For several years after the needle injury, he had no idea he
was infected. He felt tired and run down, but attributed it to long
hours. In early 1992, exhausted, he collapsed at work. Tests showed
he had hepatitis C.
He continued working at Presbyterian, with the knowledge and
support of staff. He took interferon, which was covered by workers'
compensation.
Two years ago, Endlich was offered a job at an area hospital; he
indicated on an application form that he had hepatitis C.
"I got a parking pass, did the interview, was told to start on a
Monday morning. I was all set to start. I got a call on a Friday
afternoon and they told me that ... the employee health nurse said,
'Sorry, we can't hire you because of the hepatitis C."'
Endlich left Presbyterian last year to pursue additional
schooling and to take a lucrative part-time job at Mercy Hospital.
This time, he did not disclose his infection on an employment form
because of his prior difficulties. A routine physical required of
all new employees picked up the infection, and physicians cleared
him for work, in accordance with Mercy's Policies and Procedures
Manual.
"I was in the float pool and I'd be sent to any of the ICUs,
critical care areas, emergency rooms at both Mercy and Providence
hospitals. I enjoyed the job tremendously, to have the ability to
walk in and take over the care of a critically ill patient."
But after he worked for seven months, the hospital found out
Endlich had known prior to his employment he had hepatitis C.
"What (Mercy) actually fired me for was withholding and
falsifying information," namely for failing to acknowledge the
infection on the employment form, Endlich said. Withholding of such
information is grounds for dismissal, according to the hospital's
guidelines.
Shortly after his departure from Mercy in October, he told his
story to the Equal Employment Opportunities Commission.
"I'd like my job back," he said. "An apology would be nice. Win
or lose, that's not the point. I would rather see this human
relations commission enlighten them. There was no reason for them
to do what they did to me."
In January, Endlich got a job as an ICU nurse at Latrobe Area
Hospital. As to his hepatitis status?
"They didn't ask. I thought, I'll tell them up front just to see
what happens. We had a 45-minute discussion about hepatitis C, I
explained the precautions I use," including putting on gloves
whenever he enters a patient's room and staying away from work if
he has a wound that might pose a risk to others. The hospital
agreed that those measures were appropriate.
Endlich doesn't know whether he can trust prospective employers
to treat him fairly, a fear that other infected people share.
In June, the U.S Supreme Court ruled that asymptomatic
HIV-infected people are protected under the Americans with
Disabilities Act in a 5-4 decision that was a triumph for HIV
activists. People having hepatitis C may also have to turn to the
ADA for protection.
"It's certainly possible," said lawyer Edward Gentry, who is a
board member of the Pittsburgh AIDS Task Force. "I would apply the
same standard to hepatitis."
According to the U.S. Department of Justice, the ADA bars
employment discrimination against "qualified people with
disabilities," who are people with a "physical or mental impairment
that substantially limits one or more major life activities ... a
record of such an impairment, or (are) regarded as having such an
impairment."
Employers can cite health concerns as a reason not to hire a
disabled person, but the standards must be objective and
scientifically proven.
Federal health officials downplay the risk of health workers
passing the virus to someone in their care, although one published
report from Spain has reported that a heart surgeon had infected
five patients. "If I have a paper cut and don't know it, I could
give it to a patient," Dagnal acknowledged.
She and Endlich wonder how many of their colleagues have
hepatitis C but may not find out about their infection for
years.
"So many nurses do not report needle sticks," Endlich said.
"Either they're too embarrassed, or they're frightened. That's a
big problem."
Even if an infection is not passed, keeping an accurate record
of needle injuries would show the risks health care workers face on
the job.
"There are bound to be many health care workers who have this,
and it won't be a cheap thing to identify them all," Dagnal
said.
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