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Hepatitis C presents new risks, concerns

Sunday, August 02, 1998

By Steve Twedt and Anita Srikameswaran, Post-Gazette Staff Writers

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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