Infection

Brief Report

Occupational Risk for Hepatitis A and Hepatitis E among Health Care Professionals?
M. Nbling, F. Hofmann, F.-W. Tiller

Abstract
Background: Since transmission routes of hepatitis E virus (HEV) and hepatitis A virus (HAV) are believed to be similar, comparable risk factors and a correlation between the two seroprevalence rates may be assumed. Materials and Methods: Anti-HAV and anti-HEV serology was assessed in 511 German subjects from nursing, pediatric nursing and administration groups, none of whom had been vaccinated against HAV. At the same time a standardized questionnaire on occupational and individual parameters was completed. Results: Overall seroprevalence for anti-HEV was 3.9%, for anti-HAV 28%. Multivariate analysis revealed that anti-HEV seroprevalence was significantly higher in persons working in emergency admission or in surgery, while persons working in childrens psychiatry were more likely to be anti-HAV positive. Comparing the two serological results, no contingency difference was found (2 = 0.42 (df = 1), p > 0.05). Conclusion: Specific departments of health care show higher prevalence of anti-HAV or anti-HEV. In the case of HEV further studies in the exposed working field are needed. Since no connection between the two serological results was found, transmission mechanisms might be (partly) different.

Key Words
Hepatitis E Hepatitis A Occupational risk Health care workers
Infection 2002; 30: 9497 DOI 10.1007/s15010-002-2023-3

can reach rates of up to 40% in endemic areas. In Central Europe it is estimated to be around 14% among the normal population; a study in Munich detected 4% in a relatively small sample [4].Transmission of HEV occurs mostly by the fecal-oral pathway via contaminated drinking water [5]. Parenteral infections or contact transmissions in health care professionals have also been observed [6].The latter are of special interest for occupational medicine in the field of health care workers. In general, epidemiological knowledge about seroprevalence, occupational and individual risk factors for hepatitis E is very limited and a lot of questions remain open [7]. Hepatitis A virus (HAV) was first isolated in 1973. Transmission of HAV is mostly fecal-oral. Seroprevalence is closely related to general socio-hygienic living standards and to age [8-10]. In Europe the seroprevalence has decreased rapidly during the last decades.Values of < 10% are currently observed in the younger generation. Tourists and other travelers to endemic regions [1114], food handlers [1517], sewage and (probably) sewage workers [1820], and some other smaller groups are considered as risk groups. Health care workers and personnel of day care centers are also at higher risk for infections with HAV [21, 22]. Since transmission routes and geographic spread of the two viruses are believed to be similar, it may be supposed that anti-HAV positive persons are more likely to be antiHEV reactive and vice versa. The main objective of this study was to identify (and quantify) factors associated with significantly higher antiHAV and anti-HEV seroprevalence (risk factors). The other objective was to check whether the risk groups for HAV infection were the same as the risk groups for HEV

Introduction
Hepatitis E is an acute, self-limiting disease caused by hepatitis E virus (HEV) and is endemic in a number of developing countries in Asia, Africa, the Middle East and Central America. HEV was first identified by immune electron microscopy in feces of patients with enterically transmitted non-A, non-B hepatitis [1, 2]. Case fatality is usually low (0.53%) [3], but is especially high among pregnant women (1530%, reason unknown). Seroprevalence of anti-HEV
M. Nbling (corresponding author), F. Hofmann Dept. of Applied Physiology, Occupational Medicine and Infectiology, University of Wuppertal, FB14 Safety Engineering, Gaustr. 20, D - 42097 Wuppertal, Germany; Phone: (+49/761) 82526, Fax: -83432, e-mail: ffas.freiburg@t-online.de F.-W. Tiller Medical Immunological Laboratories Munich, Bayerstr. 53, D-80336 Munich, Germany Received: February 15, 2001 Revision accepted: December 4, 2001

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Table 1 Contents of questionnaire.

Variable Age (years) Age dummy (years)

Categories for analysis

lence risk ratios) by far and were therefore not used as an approximation of the RR [23]. Instead, the b-coefficients and their standard errors are given. Following the suggestions of Hosmer and Lemeshow [24], the likelihood ratio test (LR) was used instead of the Wald statistic when performing logistic regression analysis.

Sociodemographic factors 1950 (in groups of 2 years) 1940, 4150 (born close to World War II) Sex Female, male No. of children 0 to 5 No. of brothers and sisters 0 to 14 Profession Years of occupation Occupational history Work related factors Administration, nurse, pediatric nurse < 5, 59, 1014, > 14 Area(s) and duration of occupation(s) in months

Results and Discussion

As can be seen from table 2, thanks to the age-standardized enrolment, mean and SD for age were very similar in the three professional groups. The overall seroprevalence of anti-HEV was 3.9% (20/511) and 28% (143/511) for anti-HAV (which included 102 positive and 41 borderline results). In the following results borderliners for anti-HAV are presented in a single group with the positives, since analysis revealed a close similarity between the positive and the borderline group.

Travel factors Travel during last 10 years 12 geographic world zones: travelling (yes/no)and length of stay in months

Risk factors
None of the sociodemographic factors such as age, sex, number of children or number of brothers and sisters, was significantly related to anti-HEV seroprevalence in a multivariate model. The same was shown for the general occupational parameters, profession and overall years of occupation. From the more detailed parameters concerning travelling and occupational history, two travel zones (Latin/South America and Far East/South East Asia) and two specific occupational areas, emergency admission and surgery, were significantly associated with higher seroprevalence (Table 3). In the multivariate model for anti-HAV positivity, the most important factor was a dummy buildup of age. This separated the persons born and growing up under the poor hygienic conditions prevailing in the first years after World War II (with a very high prevalence) from the subjects born later, during the German economic boom (showing a low anti-HAV prevalence). Further factors related to a higher probability of positive serological results were the parameters a) family size: number of brothers and sisters and number of children, underlining the possibility of secondary transmission and b) travel to the La-Plata states (Argentina and Uruguay). Of the occupational factors, the working time in childrens psychiatry was positively related to the anti-HAV seroprevalence (Table 4).

Table 2 Sample and mean of age by profession.

No. Administration Nurses Pediatric nurses Total 173 178 160 511

Mean (years) 33.5 32.8 33.5 33.3

SD 9.23 9.17 9.21 9.20

ANOVA: F = 0.28 (df = 2), eta = 0.03, p > 0.05 (0.76)

infection, determined from a contingency table of the two sets of serological results.

Materials and Methods

The study was performed as a cross-sectional study in three hospitals in southwestern Germany. Enrolment was standardized by age (range: 1950 years) and profession (control group working in administration, nurses and pediatric nurses). Serological results for anti-HAV and anti-HEV (IgG-ELISA) titers were combined with data collected by means of a standardized questionnaire on basic sociodemography, individual work history and travel behavior (Table 1). Both serological results and a questionnaire were available for 511 Germans (all born in Germany and not vaccinated against HAV).

Correlation of Anti-HEV and Anti-HAV

Since HAV and HEV are mostly transmitted in a similar way (fecal-oral), a correlation between anti-HEV- and antiHAV test results may be presumed. According to this hypothesis, persons with positive anti-HAV results would be more likely to test positive for anti-HEV and vice versa. However, as the results in the contingency table show (Table 5), our data do not substantiate this hypothesis. Serological results of anti-HAV and anti-HEV testing are not related to one another, they are statistically independent. The rate of anti-HEV positivity was 3.8% among the positives for HAV and, almost equally, 4.2% for the HAV negatives.

Statistics
Statistical analysis was carried out by means of crosstabs with Pearsons 2 statistic, analysis of variance and logistic regression analysis. Since the study type is cross-sectional and the outcome is not rare (at least in the case of anti-HAV), odds ratios (calculable as: OR = eb) would overestimate the relative risks (RR, as preva-

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Table 3 Predictors and estimation model for anti-HEV.

Predictor Occupation in surgery unit (yes no) Occupation in emergency unit (months) Travel to Latin/South America (excluding Argentina/Uruguay) (months) Travel to Far East/South East Asia (excluding Japan) (months) Constant

b 1.6141 0.0202 0.0335 0.0492 3.6802

SE (b) 0.6231 0.0078 0.0207 0.0238 0.2914

Sig (LR) < 0.05 (0.022) < 0.05 (0.011) < 0.01(0.0098) < 0.10 (0.072)

df 1 1 1 1

Model build and fit by logistic regression analysis. Sig(LR): likelihood ratio test; borders: p(in) < 0.05, p(out) > 0.10; model parameters: n = 511; -2LL = 147; GOF = 526; Hosmer/Lemeshow C = 3.2, df = 2, p > 0.20; model 2 = 21.7, df = 4, p < 0.001; cases correctly classified (cutoff = 0.5): 96.3%

Table 4 Predictors and estimation model for anti-HAV.

A general risk for the whole working sector of health care professionals for HAV and/or HEV infections was not found (in Germany). However, employment in certain departments or units of nursing and pediatric nursing was associated with higher anti-HEV or higher anti-HAV prevalence rates.This was also true of travel to endemic regions and some sociodemographic factors. In the case of anti-HEV, further studies, especially in the exposed working fields (e. g. endoscopy), are necessary to control these findings and to provide more detailed results. Concerning a correlation presumed between anti-HEV and anti-HAV on the basis of the similar transmission route, no such connection could be demonstrated. Whether or not transmission mechanisms other than the fecal-oral route are responsible for these findings is unclear.

Predictor Occupation in childrens psychiatry (months)

b 0.0280

SE (b) 0.0155

Sig (LR) < 0.05 (0.0473)

df 1
1.

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