Hepatitis A: What You Need to Know

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I am currently investigating a claim for a maintenance worker client who contracted the Hepatis A virus at work, where he was clearing and unblocking toilets that were left in a poor state.

Background on Hepatitis A

The Hepatitis A infection may result in no symptoms in some, especially children, but in adults typically causes a gastrointestinal illness with typical symptoms of nausea, loss of appetite, fatigue, muscle ache, gastrointestinal upset, abdominal pain and jaundice.

Hepatitis A causes jaundice in more than 70% of adults infected and usually results in illness for 4-6 weeks. Around 11-22% are admitted to hospital and fatality rate is 1.8% in those greater than 50 years.

It is a self-limited illness that does not cause permanent (i.e. chronic) damage to the liver or other organs.

Hepatitis A virus (HAV) is a virus that remains stable and persists in the environment for extended periods. Occupational exposure to HAV can occur by contact with faecal remains and/or infected faecal remains.

Hepatitis A

Risk factors

The number of confirmed Hepatitis A cases in England and Wales is progressively decreasing. Only 396 cases were reported in 2019.

The risk factors identified in England and Wales cases are:

Travel to countries with high prevalence (usually related to poor sanitation) – identified in 48% of cases in 2019.
Sexual transmission – typically in men who have sex with men, and typically seen in young adults (transmission is via faecal-oral transmission rather than semen/vaginal secretions).
Food contamination – this appears to be a declining cause – food can be contaminated during any stage from growth, harvest, manufacture, distribution, usually due to contamination by food handlers.
Close contact, usually household /carer to an infected person.

Hepatitis A as an occupational hazard

People occupationally exposed to raw or untreated sewage have been identified as a high risk group for whom Hepatitis A vaccination may be indicated.

A significant risk of the infection is among sewage workers who enter sewers to unblock pipes and carry out maintenance work; flushers and fitters, who clean inlet screens and sewage pumps; and electricians, supervisors, and engineers whose work involves infrequent contact with raw sewage.

The Brugha study in 1998 checked Hepatitis A antibodies in 214 employees at drainage depots and sewage treatment plans in London. Those who reported exposure to raw sewage, most commonly were 3.7 times more likely, to have antibodies to HAV (Hepatitis A).

The table below indicates 60% of those with frequent exposure had been infected with HAV whereas only 28% never exposed had been infected.

Exposure to raw sewage:	Hep A Antibody positive	Hep A Antibody negative	Odds ratio
Never	22	57	1.0
Sometimes	27	72	1.14
Most of the time	30	20	3.73

In this study frequent occupational exposure to raw sewage was a significant risk factor for HAV infection, independently of other known risk factors. Of 50 employees who reported occupational exposure to raw sewage most of the time, 30 employees (60%) had already had the Hepatitis A infection.

On the other hand, there was no association between Hepatitis A and exposure to treated sewage(wastewater or sewage which has passed through a treatment plant to ensure all harmful bacteria, pollutants and contaminants are removed).

The authors of the study recommended that employees likely to be exposed to raw sewage be tested for Hepatitis A antibody before commencement and if they test negative, they should be provided with the Hepatitis A vaccination.

Controlling and eliminating the risk of Hepatitis A

What should employees do to keep them safe at work?

Workers in the sewage industry should:

Implement a strict personal hygiene

Adopt and maintain a good hygiene including regular hand-washing, avoiding hand to mouth/eye and cleaning / protecting cuts.
Employers ought to provide nailbrushes and disposable paper towels. Where there is a higher risk of contaminations, showers should be provided.
Take rest breaks away from the direct working area.
Wash all cuts, abrasions and other breaks in the skin and cover these areas with waterproof dressings and/or gloves.

Wear appropriate clothing

Wear protective clothing such waterproof footwear and clothing as well as waterproof / abrasion resistant gloves. Face visors are beneficial and provide good protection against splashes.

Wear PPE

This includes face masks, goggles and gloves to allow them to reduce their exposure.

Have the Hepatitis A vaccine

Immunisations are available for Hepatitis A.

Who should have the hepatitis A vaccine?

People who may be exposed to Hepatitis A through their job – this includes sewage workers, people who work for organisations where levels of personal hygiene may be poor, such as a homeless shelter, and people working with monkeys, apes and gorillas.

The Hepatitis A vaccination is recommend by the British National Formulary for those likely to be exposed untreated sewage in their occupations.

The workers can receive the vaccination through their workplace or by consulting their GP.

What should your Employer do to minimise the risk of Hepatitis A?

Employers have a duty to enforce, implement and encourage the use Respiratory Protective Equipment (RPE).

Employers should provide all employers with adequate face masks, goggles and gloves when working with untreated sewage in order to reduce the risk of the Hepatitis A infection.

Vaccination

Employers should make it a part of their standard health and safety policy to ensure that all workers who are exposed to sewage during their work ought to receive the Hepatitis A vaccination annually/every so often following the advice of a health professional.

Employers should also ensure the workers are aware of the advantages and disadvantages of the Hepatitis A vaccination as well as its limitations.

The company should keep adequate records of any immunisation provided.