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Hepatitis B vaccine and hepatitis B markers: Cost effectiveness of screening prehospital personnel
Brief Reports
HepatitisB Vaccineand HepatitisB Markers: Cost Effectivenessof Screening Prehospital Personnel DANIEL G. HANKINS, MD, KARESS D. EBERT, RN, CONSTANCE M. SIEBOLD, RN, TIMOTHY K. FULLER, NREMT-P, RALPH J. FRASCONE, MD, BRIAN C. CAMPION, MD The purpoee of this study was to evaluate the coet effectivenese of screening emergency medical technicians (EMTs) and paremedical pereonnel prior to administering hepatitis B vaccine. Hepatitis B screening and Heptavax@ vaccine were offered to 259 basic EMTs and paramedics. Di the 259 individuals, 62 refused screening, and six who had already received hepatitis B vaccine were excluded from the study. The screening was not continued after the reeutte ol the first 174 teets returned negative. All 191 pelticipante were vac&ted. No hepatitis B Mace antigen car&e and only three individuals poeltlve for hepatitls B surface antibody were found among those screened. This etudy corroborabs the Centers for Dieease Control guidelinee of coet ebctbeneee in screening prehoepital health care workers. (AmJ EmsrgMed 1987;5:~206)
It has been estimated that health care workers with frequent blood contact have a 1 to 2% prevalence of hepatitis B surface antigen (HB,Ag). ’ We screened our urban group of emergency medical technicians (EMTs) and paramedics prior to administering hepatitis B vaccine (Heptavax@). Our findings of prevalence and incidence of hepatitis markers in our screened population and compliance with the administration of the vaccine are reported. MATERIALS AND METHODS
Hepatitis B screening and Heptavax@ vaccine were offered to 259 basic EMTs and paramedics in the eastern metropolitan area of the Twin Cities of Minneapolis and St. From the Departments of Emergency Medical Services and Emergency Medicine, St. Paul-Ramsey Medical Center, St. Paul, Minnesota. Manuscript received April 15, 1986; revision accepted July 1, 1986. Supported in part by St. Paul-Ramsey Foundation. Address reprint requests to Dr. Hankins: Department of Emergency Medicine, St. Paul-Ramsey Medical Center, 840 Jackson Street, St. Paul, MN 55101. Key
Words:
Hepatitis antibody, hepatitis B vaccine, hepatitis surface
antigen. 0735-6757187 $0.00 + .25
Paul, Minnesota. These cities are considered to have significant exposure to hepatitis B from blood exposures at trauma scenes, contaminated needlesticks, and delivery of infants of high-risk mothers. The Eastern Twin Cities Emergency Medical Services system includes the city of St. Paul and its suburbs. The system includes four paramedical advanced life-support (ALS) services (one professional fire, two professional police, and one volunteer fire services) and 11 basic life-support (BLS) volunteer fire services. There are approximately 2 1,000 ambulance runs per year. The runs include every conceivable medical and trauma situation. The number of runs per EMT varies a great deal depending on the ambulance service. The population of metropolitan St. Paul was estimated at 786,000 persons in 1983, of which 2.1% were black. It was estimated that there were 100,000 gay males in the entire Twin Cities area. Minnesota also has a sizeable portion of refugees from Southeast Asia (25,700) of which 42.7% live in the eastern metropolitan area (East Metro). The American Red Cross Blood Bank in St. Paul estimates that one in 7,000 to 10,000 screened bloods are positive for HB,Ag. There were 32 cases of hepatitis B reported in the counties of the East Metro in 1985. The characteristics of East Metro paramedics and EMTs are summarized in Table I. In 1985 there were 15 contaminated needle cases reported by paramedics. In the last five years, there has been one case of active hepatitis among the paramedics, which was non-A, non-B type. For screening, we elected to use HB,Ag and hepatitis B surface antibody (HB,Ab). We chose anti-HB, because the Centers for Disease Control suggests that for groups with “carrier rates of less than 2%, such as medical workers, neither test (anti-HB, or anti-HB,) has a particular advantage.“’ Tests for HB, and HB,Ab were done by enzyme immunoassay (AUSAB and AUZYME, Abbott, North Chicago, Illinois). Screening costs were $4 for HB,Ag and $4 for HB,Ab. Heptavax cost $100.50 for the series of three vaccines. It was administered to individuals at cost to the ambulance service.
205
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 5, Number 3 n May 1987
TABLE1. Characteristics of Paramedics and EMTs
DISCUSSION
Average age
In our screening of urban and suburban paramedical personnel, no hepatitis B surface antigen carriers and only three hepatitis B surface antibody-positive individuals were found. Our data are consistent with and supportive of CDC guidelines for cost effectiveness. Our expected prevalence was less than 2%, and although the cost of screening was only $8, it was not cost effective to perform screening. The total cost of vaccine and screening would have been $20,723 if all individuals had been screened and vaccinated. If no screening had been done, $1,528 (7.3%) of the total cost would have been saved, a significant savings to an emergency medical service system. Our number of hepatitis B virus markers is much lower than that recorded in Boston or Seattle2.3 and comparable to that recorded in Salt Lake City.4 This may reflect a higher incidence of hepatitis B on the east and west coasts. HB,Ab positivity among emergency medical personnel was seven times greater in Seattle and 10 times greater in Boston than in our study. Our data provide support for the position that medium-sized and smaller urban areas need not screen for hepatitis B before vaccinating EMTs and paramedics with hepatitis B vaccine. Our data also show that compliance of the administration of the vaccine can be high (75% of the population received all three inoculations) in a prehospital paramedical population. We do not know if our compliance rate is higher or lower than that of other urban areas. We feel that better compliance can be obtained in any urban area by repetitive educational activities about the safety and efficacy of the hepatitis B vaccine.
Sex
Average length of service (mean t SD) Average number of intubations per paramedic per year (mean 2 SD) Average number of intravenous administrations per paramedic per year (mean ? SD)
38.01 yr 98.2% male; 3.8% female 79.4 5 43.4 mo 2.7 ? 1.2
81.9 + 16.78
RESULTS The results are summarized in Table 2. Of the 259 people offered screening and vaccines for hepatitis B, 174 were screened, and 191 were vaccinated. None of the individuals screened was positive for HB,Ag. After the first 174 individuals, it was deemed not cost effective to do further screening. Subsequent Heptavax was given without screening to 17 individuals. Three individuals were positive for HB,Ab, none of which was a result of receiving hepatitis B immune globulin. Six individuals of the 259 had already received Heptavax for significant exposures and were not included in the study. Sixty-two individuals either refused screening or did not respond to the initial offer of screening. Many of these individuals were members of the St. Paul Fire Department who, although EMTs, were not in jobs in which they acted as first responders or EMTs (e.g., dispatch, administration).
TABLE2. Results of Screening
REFERENCES
Emergency Medical Technicians
No.
(%)
Offered screening and vaccine Previously vaccinated Total in screening pool Actually screened Vaccinated Positive for HB&g Positive for HBab
259 6 253 174 191 0 3
(100) (69) (75) (0) (1.7)
ABSREVIA~ONS: HB&b, hepatitis B surface antibody; HBAg, hepatitis B surface antigen.
206
1. Center for Disease Control: Recommendations for protection against viral hepatitis. Ann Intern Med 1985;103:391402 2. Kunches LM, Craven DE, Werner BG, et al: Hepatitis B exposure in emergency medical personnel, prevalence of serologic markers and need for immunization. Am J Med 1983;75:269-272 3. Valenzuela TD, Hook EW, Copass MK, et al: Occupational exposure to hepatitis B in paramedics. Arch Intern Med 1985;145:1976-1977 4. Clawson JJ, Jacobson JA: Prevalence of antibody to hepatitis B virus surface antigen in emergency medical personnel in Salt Lake City, Utah. Ann Emerg Med 1986;15:183-184
HepatitisB Vaccineand HepatitisB Markers: Cost Effectivenessof Screening Prehospital Personnel DANIEL G. HANKINS, MD, KARESS D. EBERT, RN, CONSTANCE M. SIEBOLD, RN, TIMOTHY K. FULLER, NREMT-P, RALPH J. FRASCONE, MD, BRIAN C. CAMPION, MD The purpoee of this study was to evaluate the coet effectivenese of screening emergency medical technicians (EMTs) and paremedical pereonnel prior to administering hepatitis B vaccine. Hepatitis B screening and Heptavax@ vaccine were offered to 259 basic EMTs and paramedics. Di the 259 individuals, 62 refused screening, and six who had already received hepatitis B vaccine were excluded from the study. The screening was not continued after the reeutte ol the first 174 teets returned negative. All 191 pelticipante were vac&ted. No hepatitis B Mace antigen car&e and only three individuals poeltlve for hepatitls B surface antibody were found among those screened. This etudy corroborabs the Centers for Dieease Control guidelinee of coet ebctbeneee in screening prehoepital health care workers. (AmJ EmsrgMed 1987;5:~206)
It has been estimated that health care workers with frequent blood contact have a 1 to 2% prevalence of hepatitis B surface antigen (HB,Ag). ’ We screened our urban group of emergency medical technicians (EMTs) and paramedics prior to administering hepatitis B vaccine (Heptavax@). Our findings of prevalence and incidence of hepatitis markers in our screened population and compliance with the administration of the vaccine are reported. MATERIALS AND METHODS
Hepatitis B screening and Heptavax@ vaccine were offered to 259 basic EMTs and paramedics in the eastern metropolitan area of the Twin Cities of Minneapolis and St. From the Departments of Emergency Medical Services and Emergency Medicine, St. Paul-Ramsey Medical Center, St. Paul, Minnesota. Manuscript received April 15, 1986; revision accepted July 1, 1986. Supported in part by St. Paul-Ramsey Foundation. Address reprint requests to Dr. Hankins: Department of Emergency Medicine, St. Paul-Ramsey Medical Center, 840 Jackson Street, St. Paul, MN 55101. Key
Words:
Hepatitis antibody, hepatitis B vaccine, hepatitis surface
antigen. 0735-6757187 $0.00 + .25
Paul, Minnesota. These cities are considered to have significant exposure to hepatitis B from blood exposures at trauma scenes, contaminated needlesticks, and delivery of infants of high-risk mothers. The Eastern Twin Cities Emergency Medical Services system includes the city of St. Paul and its suburbs. The system includes four paramedical advanced life-support (ALS) services (one professional fire, two professional police, and one volunteer fire services) and 11 basic life-support (BLS) volunteer fire services. There are approximately 2 1,000 ambulance runs per year. The runs include every conceivable medical and trauma situation. The number of runs per EMT varies a great deal depending on the ambulance service. The population of metropolitan St. Paul was estimated at 786,000 persons in 1983, of which 2.1% were black. It was estimated that there were 100,000 gay males in the entire Twin Cities area. Minnesota also has a sizeable portion of refugees from Southeast Asia (25,700) of which 42.7% live in the eastern metropolitan area (East Metro). The American Red Cross Blood Bank in St. Paul estimates that one in 7,000 to 10,000 screened bloods are positive for HB,Ag. There were 32 cases of hepatitis B reported in the counties of the East Metro in 1985. The characteristics of East Metro paramedics and EMTs are summarized in Table I. In 1985 there were 15 contaminated needle cases reported by paramedics. In the last five years, there has been one case of active hepatitis among the paramedics, which was non-A, non-B type. For screening, we elected to use HB,Ag and hepatitis B surface antibody (HB,Ab). We chose anti-HB, because the Centers for Disease Control suggests that for groups with “carrier rates of less than 2%, such as medical workers, neither test (anti-HB, or anti-HB,) has a particular advantage.“’ Tests for HB, and HB,Ab were done by enzyme immunoassay (AUSAB and AUZYME, Abbott, North Chicago, Illinois). Screening costs were $4 for HB,Ag and $4 for HB,Ab. Heptavax cost $100.50 for the series of three vaccines. It was administered to individuals at cost to the ambulance service.
205
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 5, Number 3 n May 1987
TABLE1. Characteristics of Paramedics and EMTs
DISCUSSION
Average age
In our screening of urban and suburban paramedical personnel, no hepatitis B surface antigen carriers and only three hepatitis B surface antibody-positive individuals were found. Our data are consistent with and supportive of CDC guidelines for cost effectiveness. Our expected prevalence was less than 2%, and although the cost of screening was only $8, it was not cost effective to perform screening. The total cost of vaccine and screening would have been $20,723 if all individuals had been screened and vaccinated. If no screening had been done, $1,528 (7.3%) of the total cost would have been saved, a significant savings to an emergency medical service system. Our number of hepatitis B virus markers is much lower than that recorded in Boston or Seattle2.3 and comparable to that recorded in Salt Lake City.4 This may reflect a higher incidence of hepatitis B on the east and west coasts. HB,Ab positivity among emergency medical personnel was seven times greater in Seattle and 10 times greater in Boston than in our study. Our data provide support for the position that medium-sized and smaller urban areas need not screen for hepatitis B before vaccinating EMTs and paramedics with hepatitis B vaccine. Our data also show that compliance of the administration of the vaccine can be high (75% of the population received all three inoculations) in a prehospital paramedical population. We do not know if our compliance rate is higher or lower than that of other urban areas. We feel that better compliance can be obtained in any urban area by repetitive educational activities about the safety and efficacy of the hepatitis B vaccine.
Sex
Average length of service (mean t SD) Average number of intubations per paramedic per year (mean 2 SD) Average number of intravenous administrations per paramedic per year (mean ? SD)
38.01 yr 98.2% male; 3.8% female 79.4 5 43.4 mo 2.7 ? 1.2
81.9 + 16.78
RESULTS The results are summarized in Table 2. Of the 259 people offered screening and vaccines for hepatitis B, 174 were screened, and 191 were vaccinated. None of the individuals screened was positive for HB,Ag. After the first 174 individuals, it was deemed not cost effective to do further screening. Subsequent Heptavax was given without screening to 17 individuals. Three individuals were positive for HB,Ab, none of which was a result of receiving hepatitis B immune globulin. Six individuals of the 259 had already received Heptavax for significant exposures and were not included in the study. Sixty-two individuals either refused screening or did not respond to the initial offer of screening. Many of these individuals were members of the St. Paul Fire Department who, although EMTs, were not in jobs in which they acted as first responders or EMTs (e.g., dispatch, administration).
TABLE2. Results of Screening
REFERENCES
Emergency Medical Technicians
No.
(%)
Offered screening and vaccine Previously vaccinated Total in screening pool Actually screened Vaccinated Positive for HB&g Positive for HBab
259 6 253 174 191 0 3
(100) (69) (75) (0) (1.7)
ABSREVIA~ONS: HB&b, hepatitis B surface antibody; HBAg, hepatitis B surface antigen.
206
1. Center for Disease Control: Recommendations for protection against viral hepatitis. Ann Intern Med 1985;103:391402 2. Kunches LM, Craven DE, Werner BG, et al: Hepatitis B exposure in emergency medical personnel, prevalence of serologic markers and need for immunization. Am J Med 1983;75:269-272 3. Valenzuela TD, Hook EW, Copass MK, et al: Occupational exposure to hepatitis B in paramedics. Arch Intern Med 1985;145:1976-1977 4. Clawson JJ, Jacobson JA: Prevalence of antibody to hepatitis B virus surface antigen in emergency medical personnel in Salt Lake City, Utah. Ann Emerg Med 1986;15:183-184