Health Referrals - Hepatitis "B" Procedure

1.1 In May 1985, The Ministry of Education issued a Memorandum to Directors of Education regarding the 
management of Hepatitis B carriers. General recommendations developed by the Disease Control and 
Epidemiology Services of the Ministry of Health accompanied this memorandum. Based on these 
recommendations the following procedures were developed.

2.1 Hepatitis B is an acute infection of the liver caused by the Hepatitis B virus. Its symptoms can include 
jaundice, fever, nausea, dark urine and loss of appetite. Not everyone who is exposed to the virus 
becomes infected. Of those who are infected, less than half develop the disease. This is dependent 
upon the route of exposure, the dose and defense mechanisms of the person exposed.

2.2 The vast majority of people who become ill recover completely. These people develop an antibody 
which indicate immunity against HBV. This antibody can be measured by serological tests. Five to ten 
percent of those who develop hepatitis will become chronic carriers. Carriers are people who, although 
they may not be ill, continue to carry all or part of the hepatitis B virus in their blood. The presence of 
a specific antigen determined by serological tests indicates that the carrier is more likely to spread the 
disease than those carriers where this antigen is not present. Among the general population in Ontario, 
less than 0.2% of blood donors are found to be carriers. However, the rate of carriage of Hepatitis B 
antigens is much higher in certain groups, such as institutionalized mentally handicapped persons.

2.3 Hepatitis B is spread by the introduction of blood containing Hepatitis B virus into the bloodstream of 
another person through a break in the skin or by introduction onto a mucousal surface such as the eye, 
or gums or mouth. Hepatitis B virus may also be found in semen or saliva, but the risk of transmission 
by these fluids is very much lower. The virus is not transmitted by stools and urine.

2.4 The risk of the spread of the disease from a Hepatitis B carrier with normal behavior is very low 
provided good hygiene is followed. The purpose of maintaining good hygiene is to reduce the 
opportunity for infected blood serum, or other secretions from a carrier to enter a susceptible person's 
bloodstream.

2.5 For individuals who are at increased risk of disease, immunization with Hepatitis B vaccine should be 
considered. However, because environmental contamination with the virus could infect non-immunized individuals, the use of vaccine does not negate the value of the environmental guidelines

3.1 The Ministry has recommended that all residents of institutions for the mentally handicapped be screened during their stay at the institution and prior to being discharged to a group home or other community setting.

4.1 The Consultant for the Associated Developmental will request that the parent/guardian of a mentally 
handicapped pupil who is seeking admission/readmission to a Durham District School Board school 
provide results of a Hepatitis B test. This test is required only for students who met any of the following 
criteria:

1. residence in a group home or institution for the mentally handicapped, or
2. attendance in a facility licensed under the Day Nurseries Act.

4.2 Should the parent/guardian wish further information, the A/D Consultant will direct the parent/guardian, through the Superintendent of Education/Special Education to the Medical Officer of Health.

4.3 The Medical Officer of Health will review the Hepatitis B results from the local physician.

4.4 The Medical Officer of Health and the Superintendent of Education/Special Education will review all of 
the circumstances related to the situation.

4.5 Following the advice of the Medical Officer of Health, the Superintendent of Education/Special 
Education and/or I.P.R.C. will provide placement for the pupil.

4.6 If the pupil is not able to attend school immediately, the Superintendent of Education/Special Education will make other arrangements for the pupil's education.

4.7 All of the above will occur in a confidential manner and will be managed by the Superintendent of Education/Special Education

5.1 The Superintendent of Education/Special Education will notify the Superintendent of Education/Area 
and the Principal of an identified Hepatitis B carrier student in a school.

5.2 The Principal will inform the Superintendent of Education/Area and the Superintendent of Education/Special Education of the names of the Durham District School Board employees who have had frequent contact with the identified student.

5.3 All Durham District School Board employees who have had contact with the identified student will be 
required to participate in a screening program for the presence of Hepatitis B.

5.4 It is strongly recommended that a Durham District School Board employee working with high risk carriers be vaccinated.

5.5 If a Durham District School Board employee working with high risk carrier(s) decides not to be vaccinated, he/she will be asked to sign a waiver absolving the Durham Board of responsibility.

6.1 The supervisor of the staff will inform his/her immediate supervisor who will inform the Superintendent of Inclusive Student Services.

6.2 A supervisor will assign the staff member to his/her home pending a review of the situation.

6.3 The Medical Officer of Health assisted by the Superintendent of Inclusive Student Services, will review 
all the circumstances related to the situation including the conditions of the workplace. The Durham District School Board will be provided with a statement indicating the following:

1. circumstances relative to the workplace which may be modified;
2. if the circumstances in (a) are possible to modify, the statement will indicate that the staff member cannot be returned to school in the adjusted circumstances with no harm to others;
3. if circumstances in (a) are not possible to modify, the statement will indicate that the staff member cannot be returned to work as he/she poses a potential threat to others;
4. if no modification is required the statement will indicate that the staff member can be returned to his/her workplace and is not a potential threat to others;
5. if no modification is required the statement will indicate that the staff member cannot be returned to work as he/she is a potential threat to others.

6.4 All of the above will occur in a confidential manner and will be managed by the Superintendent of Inclusive Student Services.

7.1 Hepatitis B is an infection of the liver caused by the Hepatitis B virus. Its symptoms can include jaundice, fever, nausea, dark urine, and loss of appetite. About three quarters of those who are infected have no symptoms. There is no treatment available which will kill the Hepatitis B virus.

7.2 The majority of people who get Hepatitis B recover eventually. These people are immune to the Hepatitis B virus and cannot be infected a second time. However, in about 5-10% of the people who get Hepatitis B the symptoms of the illness disappear but the virus remains. These individuals, called carriers, feel well but carry the virus in their bodies and can give it to others. The virus may remain for many years, possibly for life, and can lead to cirrhosis and liver cancers. Persons with Down's Syndrome are more likely than others to become carriers after a Hepatitis B infection. At present, the death rate of Hepatitis B is 2-3% with most deaths occurring much later from cirrhosis of the liver or liver cancer.

7.3 A blood test can determine whether a person has ever had Hepatitis B (often without being aware of it) and whether the virus remains in the body.

7.4 The Hepatitis B virus is transmitted by close personal contact with body fluids of a carrier or a person with a recent Hepatitis B infection.

7.5 Contact with infected blood is the most common way in which the virus is transmitted, but it can also be spread through sexual contact or biting. Some groups of persons, including residents and staff of a long-term care facility, and family members of Hepatitis B carriers, have an increased chance of getting Hepatitis B.

7.6 In order to determine whether the students and staff of the school your child attends have an increased 
chance of getting Hepatitis B, a survey of immunity must be done. This involves blood testing to identify 
the proportion of persons in the group who have had Hepatitis B, and the proportion who are carriers. 
This information may then be used to develop a plan to prevent the spread of Hepatitis B in the school. 
Hepatitis B can be prevented by careful personal hygiene to avoid unnecessary contact with blood and 
body fluids. A safe and effective vaccine is also available to protect those who have not already had 
Hepatitis B.

This fact sheet is designed to give employees facts about Hepatitis B.

8.1 Hepatitis B is an infection of the liver caused by a virus. Some individuals never feel sick. Others get a 
sort of flu that may turn their skin and eyes yellow. A very few develop a severe illness that leads to 
death.

9.1 Most people who get Hepatitis B recover completely and are protected from future infection. But as many as one out of 10 persons with the infection continues to carry the virus. Hepatitis B carriers may have small amounts of Hepatitis B virus in their blood and other body fluids for the rest of their lives. Usually, carriers are otherwise completely healthy, although some may develop liver cirrhosis (scarring) or liver cancer years later. A simple blood test can tell if a person is a carrier. About one out of every 200 Canadians is a Hepatitis B carrier.

10.1 Hepatitis B is spread when the blood or semen of an infected person (usually a carrier) enters another 
person's body. Persons most likely to get Hepatitis B are:

• babies born to mothers who are Hepatitis B carriers
• household members of carriers
• sexual partners of carriers
• medical and dental workers who treat carriers
• intravenous drug users who share needles

10.2 Hepatitis B is not spread by water or food, or by casual contact, such as occurs at most schools or workplaces. Urine and stool are not infectious. Infection through saliva is theoretically possible but not likely.

11.1 It is very unlikely that a child or teacher would get Hepatitis B at school. In situations such as an injury 
where blood may be spilled, school staff giving first aid should use recommended sanitary procedures 
and wear disposable plastic or rubber gloves.

12.1 Children and adults are not routinely tested for Hepatitis B. When a child is found to be a Hepatitis B 
carrier, it is likely that only the child's family physician and the Department of Public Health will know. The Health Protection and Promotion Act requires complete confidentiality - as with any health condition.

12.2 If special circumstances exist that increase the risk of a Hepatitis B carrier spreading the infection, the 
Department of Public Health may ask for extra precautions, or have the student or teacher stay home 
from school. The Medical Officer of Health will judge each case on an individual basis.

13.1 There are three ways to prevent Hepatitis B:

1. Hepatitis B Vaccine
   Three injections of Hepatitis B vaccine can protect against Hepatitis B. The vaccine is recommended for people most likely to get Hepatitis, such as household members of carriers, sexual partners of carriers and medical/dental workers who treat carriers.
2. Hepatitis B Immune Globulin
   Hepatitis B Immune Globulin injections may be given to a person who has already been exposed to the Hepatitis B virus but it is not always effective.
3. Avoid Contact with Blood
   Since people don't always know if they are Hepatitis B carriers, all blood should be handled with care. If you give first aid, wear plastic or rubber disposable gloves and wash your hands carefully afterwards. Clean up spilled blood carefully with detergent and water. Then wipe the surface with a bleach solution.

13.2 If you are concerned that you might be at risk, contact your family doctor and share your concerns with 
him or her.

14.1 General Preventative Measures

1. Special care should be taken with regard to person-to-person contact with known carriers when blood and/or saliva contact may be involved.
2. Good personal hygiene especially hand washing of both the carrier and attendant.
3. Good housekeeping maintenance - Regular cleansing with an approved commercial disinfectant or diluted Javex of desk, floors, door knobs used by a carrier.

14.2 Personal Guidelines

1. Do not share items with a known carrier that may be placed in the mouth such as toys, pencils, rulers, food, utensils, glasses, cups, bottled beverages. Dishes and cutlery may be handled in the normal way.
2. Do not share or use toothbrushes, razors, scissors, nail files or other personal toiletry items of a known carrier.
3. Carriers should be cautioned against or prevented from placing their fingers in other's mouths and from having another individual's fingers in their mouths.
4. Avoid kissing a Hepatitis B carrier on the mouth.
5. The blood of Hepatitis B carriers is hazardous. Avoid it.

14.3 Procedures Relating to Bleeding Hepatitis B Carriers

14.4 If a carrier has bleeding or oozing wounds, a wet skin condition, a nose bleed or is menstruating the 
attending person is at risk. In this situation:

1. Disposal surgical gloves should be used by the attendant.
2. Gloves, sanitary napkins, bandages and surgical or gauze pads must be discarded in sealed bags or containers. Incineration of these is preferable. If not, double bag and dispose in garbage.
3. Wash hands carefully and thoroughly using dispenser soap rather than bar soap. Always wash hands before moving to another person.
4. Toilet seats, desks, floors and other environmental surfaces soiled by blood or by saliva from a drooling carrier, should be immediately cleaned with detergent or soap and water. Destroy the wash cloth as in (b) above.
5. Follow the soap and water wash with; further cleaning using a disinfectant solution which should then be removed with water. Destroy the wash cloth as above. The most readily available disinfectant is Javex in a concentration of one cup per gallon of water. The solution must be prepared fresh each time it is used.
6. Adherent blood and other materials should be scraped from objects and surfaces before disinfecting.
7. Smaller articles that can tolerate it may be boiled for 15 minutes to destroy the virus.

14.5 Additional Notes

1. Transmission of Hepatitis B by food has not been documented. Food handling is therefore permitted providing the handicap does permit understanding, adoption and regular use of personal hygiene guidelines. If not, the carrier should not handle food for consumption by others.
2. Caution - it is recommended that susceptible staff members or attendants who are pregnant should not work with Hepatitis B carriers. Because of the risk of transmission to the fetus appears greatest in mothers who develop infection late in pregnancy.
3. Swimming Pools - only carriers with open wounds or who are menstruating need be excluded from public swimming pools.
4. Casual Contact - the risk from occasional or casual contact (e.g. school bus, cafeteria, or library contacts) is minimal.

15.1 Introduction

These recommendations have been developed to address the concerns as School Boards begin to integrate children discharged from a long-term care facility into the regular school system. Because there is a higher rate of carriage of Hepatitis B in long-term care developmental disabled individuals these guidelines will outline the procedures for identification and risk assessment of Hepatitis B carriers. They will include recommendations for use of Hepatitis B vaccine and environmental precautions for reducing the risk of transmission. These recommendations will also be of use for group homes and foster homes who are considering admission of Hepatitis B carriers or may already have such carriers enrolled.

16.1 Hepatitis B is an acute infection caused by the Hepatitis B virus (HBV). Not everyone who is exposed becomes infected. Of those who are infected, less than half develop disease. This is dependent upon the route of exposure, the dose and defense mechanisms of the person exposed.

16.2 The vast majority of people who become ill recover completely. These people develop antibodies which indicates immunity against HBV. This antibody can be measured by serological tests. Five to ten percent of 
those who develop Hepatitis will become chronic carriers. Carriers are people who, although they may not be ill, continue to carry all or part of the Hepatitis B virus in their blood. Certain of the different components of a virus particle are known as antigens. The outer coat of the HBV is known as surface antigen or HBsAG. This is the antigen which is measured by serological tests to identify people who may be carriers. Some carriers have a further antigen known as e antigen or HbeAg. The presence of this antigen usually indicates that the carrier is more likely to spread the disease than those carriers in whom only HBsAg is found. Amongst the general population in Ontario less than 0.2% of the blood donors are found to be carriers. However, the rate of carriage of Hepatitis B antigens is much higher in certain groups such as long-term care facility developmental disabled persons.

16.3 Hepatitis B is spread by the introduction of blood containing Hepatitis B virus into the bloodstream of another person through a break in the skin or by introduction onto a mucousal surface such as the eye, or gums or mouth. Hepatitis B virus may also be found in semen or saliva, but the risk of transmission by these fluids is very much lower. The virus is not transmitted by stools and urine.

16.4 The risk of spread of disease from a Hepatitis B carrier with normal behavior is very low provided good hygiene is followed. The purpose of maintaining good hygiene is to reduce the opportunity for infected blood, serum, or other secretions from a carrier to enter a susceptible person's bloodstream.

16.5 For individuals who are at increased risk of disease, immunization with Hepatitis B vaccine should be 
considered. The vaccine is safe and highly effective. However, because environmental contamination with the virus could infect non-immunized individuals, the use of vaccine does not negate the value of the environmental guidelines.

17.1 All residents of a long-term care facility must be screened for Hepatitis B antigen and antibody during 
their stay in the institution. Initial screening should determine surface antigen and antibody during their stay in the institution. Initial screening should determine surface antigen and antibody status (HBsAg and anti-HBs). Retesting should be done at the time of discharge from the institution on all residents except those shown to be immune by the presence of anti-HBs. Prior to discharge all residents identified as carriers of HBsAg should have been tested for 'e'-antigen (HBeAg).

1. When a resident of a Long-Term Care Facility is being considered for admission to a group home or other community setting, the administrator of the institution will submit the following information to the group home: pertinent information about health and behavior patterns and HBV carrier status.
2. Using this information, where the individual is identified as a carrier, the group home shall consult with the medical officer of health (MOH) before placement is approved.
3. When an individual who has resided in a Long-Term Care Facility is being considered by the school board for special education a request for a medical risk assessment shall be made to the MOH by the Identification, Placement and Review Committee (IPRC).
4. The MOH will then forward to the committee (IPRC) an assessment of the individual which includes judgment of the risk category and identifies appropriate preventive measures.
5. School officials should determine a course of action after considering the information available to them, including the assessment and recommended preventive measures from the MOH

18.1 All individuals shall be tested to determine their antigen/antibody status with regard to hepatitis B before they are discharged from the institution. Where carrier status is identified the person responsible for the group home or community setting will make this information, together with an evaluation of behavior or special medical problems which might increase risk, available to the MOH.

18.2 The MOH will review the information and assign to the individual a risk category based on an assessment of behavior and medical problems.

1. Minimal Risk
   Category 1 carrier - e antigen negative, normal behavior, no significant medical problems - may be 
   integrated into a general program as these individuals present very little risk of infection except where 
   there is blood contact.
2. Intermediate Risk
   Category 2 carriers - e antigen positive, normal behavior, no significant medical problems - although 
   these individuals may not present a risk in terms of behavior, the presence of 'e' antigen identifies them as potentially more infectious because of increased amounts of virus in the blood and secretions.
   Category 3 carriers - e antigen negative but because of their behavior or medical problems these individuals are likely to present more risk than those in Category 1 and 2 - the actual risk of spread from secretions such as saliva is not likely to be significant. However, placement should be made depending on the nature of the behavior and/or any medical problems and availability and use of support staff.
3. Greatest Risk
   Category 4 carriers - e antigen positive and because of medical or behavior problems these individuals 
   present the greatest hazard - special care must be taken to identify their program needs from an educational and a medical perspective. It is possible that some individuals may not be suitable for community placement or placement in a school setting.

20.1 Annual hepatitis B screening tests should be performed on all those who are identified as susceptible and who do not (for whatever reason) receive hepatitis B vaccine and whose occupation requires frequent contact with carriers who present intermediate or greatest risk.

20.2 HBsAg positive individuals may be considered carriers once two tests separated by at least a six-month
interval have been reported as positive.

20.3 The status of HBeAg carriers may change in that this antigen may disappear from the blood. 
Consideration should be given to retesting HBeAg carriers annually to determine if the 'e' antigen is lost.

21.1 Methods of prevention of transmission of hepatitis B fall into three general categories.

1. Immunization
2. Environmental Controls
3. Education of staff, parents and pupils

22.1 Passive Immunization - Hepatitis B Immune Globulin

22.2 Hepatitis B immune globulin (HBIG) is recommended for use in prevention of hepatitis B following an 
acute exposure to HBV. The decision to use HBIG is based on the type and tiling of the exposure, the infectivity of the secretion, blood or plasma to which the exposure occurred, and the immune status of the person exposed. The decision to administer HBIG must be made by a physician. The MOH will recommend the appropriate course of action.

22.3 Active Immunization - Hepatitis B Vaccine

22.4 Hepatitis B vaccine provides safe and effective long-term protection against hepatitis B. Clinical trials 
have shown a level of protection of 90-95% after three doses of vaccine. The duration of protection is not known, but vaccine-induced antibody has persisted for at least three years.

1. Group Homes
   Household contacts of Hepatitis B carriers are at increased risk over the general population. Therefore, all residents and staff of group homes and other similar community residential settings which include at least one hepatitis B carrier (categories 1 through 4) should, if susceptible, be offered immunization.
2. Schools
   Category 1 - individuals in this category are considered at low risk of transmitting infection. Routine immunization is not recommended for school contacts.
   Category 2 & 3 - these individuals are at intermediate risk of transmitting infection. Individual circumstances should be reviewed to determine the classroom contacts at risk for whom immunization should be recommended. These may include some or all of the teachers, support staff and other pupils. In some cases, it is desirable to tailor the individual's educational program in such a way as to keep the number of contacts within reasonable limits.
   Category 4 - these individuals are considered at high risk of transmitting infection. All those with regular classroom contact, that is, teachers, support staff and pupils who may be exposed, should be immunized. The individual's educational program should be so designed in such a way so to restrict the number of contacts.

23.1 While the vaccine is highly efficacious, it does not provide complete protection to an exposed population. Environmental precautions are a crucial adjunct to these control measures. Also, if a significant contact e.g. a bite, occurs between a carrier and a non-immunized susceptible person, prompt use of hepatitis B immune globulin should be considered (see 1 above).

23.2 Hepatitis B vaccine is of no benefit to persons already immune from previous infection. The decision to screen for immunity prior to immunization is primarily a financial one. It depends on the actual costs of screening and immunizing and on the prevalence of immunity in the target population. This decision should be individualized to each situation. In most school settings it will be cost-effective.

24.1 General Preventive Measures

1. Special care should be taken with regard to person-to-person contact with known carriers when blood and/or saliva contact may be involved.
2. Good personal hygiene especially hand washing of both the carrier and attendant.
3. Good housekeeping maintenance - regular cleansing with an approved commercial disinfectant or diluted Javex of desk, floors, door knobs used by a carrier.

24.2 Personal Guidelines

1. Do not share items with a known carrier that may be placed in the mouth such as toys, pencils, rulers, food, utensils, glasses, cups, bottled beverages. Dishes and cutlery may be handled in the normal way.
2. Do not share or use toothbrushes, razors, scissors, nail files or other personal toiletry items of a known carrier.
3. Carriers should be cautioned against or prevented from placing their fingers in other's mouths and from having another individual's fingers in their mouths.
4. Avoid kissing a hepatitis B carrier on the mouth.
5. The blood of hepatitis B carriers is hazardous. Avoid it.

24.3 Procedures Relating to Bleeding Hepatitis B Carriers

If a carrier has bleeding or oozing wounds, a wet skin condition, a nose bleed or is menstruating the 
attending person is at risk. In this situation:

1. Disposable surgical gloves should be used by the attendant.
2. Gloves, sanitary napkins, bandages and surgical or gauze pads must be discarded in sealed bags or containers. Incineration of these is preferable. If not, double bag and dispose of in garbage.
3. Wash hands carefully and thoroughly using dispenser soap rather than bar soap. Always wash hands before moving to another person.
4. Toilet seats, desks, floors and other environmental surfaces soiled by blood or by saliva from a drooling carrier, should be immediately cleaned with detergent or soap and water. Destroy the wash cloth as in (b). above.
5. Follow the soap and water wash with further thorough cleaning using a disinfectant solution which should then be removed with water. Destroy the wash cloth as above. The most readily available disinfectant is Javex in a concentration of one cup per gallon of water. The solution must be prepared fresh each time it is used.
6. Adherent blood and other materials should be scraped from objects and surfaces before disinfecting.
7. Smaller articles that can tolerate it may be boiled for 15 minutes to destroy the virus.

24.4 Additional Notes

1. Transmission of Hepatitis B by food has not been documented. Food handling is therefore permitted providing the handicap does permit understanding, adoption and regular use of personal hygiene guidelines. If not, the carrier should not handle food for consumption by others.
2. Caution - it is recommended that susceptible staff members or attendants who are pregnant should not work with Hepatitis B carriers. Because of the risk of transmission during delivery, prenatal screening for Hepatitis B should be performed. The risk of transmission to the fetus appears greatest in mothers who develop infection late in pregnancy.
3. Swimming Pools - only carriers with open wounds or who are menstruating need be excluded from public swimming pools.
4. Casual Contact - the risk from occasional or casual contact (e.g. school bus, cafeteria, or library contacts) is minimal.

25.1 Education of staff, parents and pupils in understanding the implications of hepatitis B antigen carriage 
and in following guidelines for control of spread is essential for the development of educational programs. The MOH is available for consultation.

26.1 Each developmental disabled child discharged from a Long-Term Care Facility and who is placed in a 
group home or who enters the school system must have a transmission risk assessment by the MOH based on antigen/antibody status, behavior and medical problems. Susceptible children should be immunized.

26.2 Educational placement should be determined after consideration of the assessment by the MOH.

26.3 The recommendations outlined for prevention of transmission of hepatitis B must be referred to in all
cases where a carrier is present in a classroom.

26.4 The need for immunization programs for susceptible contact students and staff should be assessed for 
each situation.