Infectious Diseases

Hepatitis B

General Description: Hepatitis B is a viral infection that causes an inflammation of the liver. Signs and symptoms of infection range from mild flu-like illness to severe weakness, loss of appetite, jaundice, joint pain, and pathology of other organ systems. Vaccine for high-risk occupations and prevention of maternal transmission to the newborn has been available since the 1980s, and a childhood immunization has been available since 1992.

Mode of Transmission: In the U.S., most commonly by high-risk sexual contact or intravenous drug use involving shared needles. Transmission through blood transfusion or health care associated needlestick injury has decreased substantially in the U.S. since the blood supply was first screened in the 1970s and the widespread use of hepatitis B vaccine. LEOs are at risk of percutaneous exposure (e.g., during blind searches for contraband). The virus can survive in the environment for up to 7 days on inanimate objects or surfaces.

Efficiency of Transmission/Attack Rate: The risk of contracting the infection from a person depends upon the concentration of virus in the source patient. The risk of a percutaneous stick with a needle containing a high concentration of virus particles has been estimated widely (between 1% and 40%) in an individual who has not been immunized.b

Period of Communicability: All persons who are HBsAg-positive are potentially infectious. Less than 5% of persons with normal immune systems become chronic carriers of the hepatitis B virus. (See Appendix B for Post-Exposure Protocol.)

Effect on LEO Fitness for Duty: Symptoms of acute hepatitis B can be debilitating and therefore can compromise physical capability and situational awareness. The spectrum of chronic hepatitis B infection ranges from an asymptomatic carrier state to liver failure requiring transplant and multi-system impairment and disability.

Chronic hepatitis B can be treated by two classes of medications: 1) interferon; and 2) nucleos(tide) analogues. In general, the nucleos(tide) analogues are tolerated better than interferon. Therapeutic regimens may be individualized by the treating physician.

Interferon, used to treat hepatitis B infections, can cause behavioral changes, particularly depression, with onset of symptoms as early as 2 weeks after initiation of treatment. Therefore, LEOs undergoing treatment with interferon should be closely monitored on a weekly basis for behavioral changes for the first 12 weeks of therapy. After the first 12 weeks of therapy, at least a monthly check should be performed until therapy is completed. Until the treating physician can document that the officer is clinically stable and not manifesting depressive symptoms, cognitive impairment, or fatigue, the LEO should be excluded from patrol. Nucleos(tide) analogue side effects that may affect the LEO’s ability to perform essential job functions include general malaise, fatigue, and gastrointestinal symptoms (see Medications chapter).

HBV-positive LEO and Defensive Tactics Training

The potential for the LEO or recruit to sustain bleeding injuries exists in both the training facility and the routine work environment. The portals of entry of bloodborne pathogens are abrasions, other wounds, mucous membranes, or conjunctiva. However, the absolute risk of transmission is unknown in the absence of ongoing serosurveillance. Decontamination of training facility equipment should be performed on a routine basis (see Appendix A).

Based on the likelihood of the LEO bleeding and the person being exposed having non-intact skin or a mucous membrane exposure, the Task Group has stratified risk of transmission into the three categories below. This list is meant to be exemplary only and is not intended to be a complete inventory of possible activities that can be considered.

Category I: Activities with no risk of bloodborne virus transmission:

• Motor vehicle operation
• Interviewing a non-violent, compliant subject
• Searching a non-violent, compliant subject

Category II: Activities where bloodborne virus transmission is theoretically possible, but unlikely:

• Physical training
• Administering first aid
• Use of duty weapons
• Exposure to chemical agents – e.g., oleo-capsicum (OC) and/or orthocholorobenzal-malonotrite (CS)

Category III: Activities where there is definite risk of bloodborne virus transmission:

• Defensive tactics training
• Handcuffing
• Restraining subjects
• Administering first aid to violent subjects
• Administering first aid to subjects having a seizure

In addition to these categories, the Task Group recommends that persons known to be infected with hepatitis B, be excluded from intentional skin breaching or puncturing (e.g., receiving a TASER discharge with darts).

Each risk assessment should be individualized. The evaluating physician may consider reviewing the viral load thresholds for work restrictions cited in the 2021 updated Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions.5

Although there are no studies to support which activities can be performed at specific viral load, it is the consensus of the Task Group that the LEO with chronic hepatitis B could safely perform all essential job tasks with a viral load of <1000 IU/mL.

For individuals with chronic hepatitis B infection, in over 95% of cases, nucleotide/nucleoside reverse transcriptase inhibitors suppress but do not result in a sustained virologic response after stopping the medication (in contrast to treatment for hepatitis C). In other words, if the objective is to keep the viral load as low as possible, the individual cannot discontinue the medication.

Reduction of viral load is generally considered to be at steady state after taking nucleotide/nucleoside reverse transcriptase inhibitors for 12 weeks. At that time, if the viral load were <1000 IU/mL, the LEO could safely perform all essential job tasks without restrictions.

For those LEOs who are taking nucleotide/nucleoside reverse transcriptase inhibitors, the viral load should be checked every 6 months and submitted to the police physician for review. For those LEOs who are not taking nucleotide/nucleoside reverse transcriptase inhibitors, or have discontinued therapy, the viral load should be checked every 3 months.

In addition to these categories, the Task Group recommends that persons known to have chronic hepatitis B, be excluded from intentional skin breaching or puncturing (e.g., receiving a TASER discharge with darts).

LEO-specific Clinical Studies and Reports:
Averhoff FM, Moyer LA, Woodruff BA, et al. Occupational exposures and risk of hepatitis B virus infection among public safety workers. J Occup Environ Med. 2002;44(6):591-6. PMID 12085488

Bandaranayake DR, Salmond CE, Tobias MI. Occupational risk of hepatitis B for police and customs personnel. Am J Epidemiol. 1991;134(12):1447-53. PMID 1776619

Bonoli F, Poissonnet CM. Biological hazards among police workers: a hospital-based prevention programme. J Hosp Infec. 2009;72(2):189-90. PMID 19380183

Chen GX, Jenkins EL. Potential work-related bloodborne pathogen exposures by industry and occupation in the United States part I: an emergency department-based surveillance study. Am J Ind Med. 2007;50(3):183-90. PMID 17290363

Chen GX, Jenkins EL. Potential work-related exposures to bloodborne pathogens by industry and occupation in the United States part II: a telephone interview study. Am J Ind Med. 2007;50(4):285-92. PMID 17340611.

Goldberg RL, Spilberg SW, Weyers SG. Medical Screening Manual for California Law Enforcement. Sacramento: California Commission on Peace Officer Standards and Training (POST), 2015; Chapter VII–Infectious Diseases.

CDC. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers: a response to P.L. 100-607 The Health Omnibus Programs Extension Act of 1988. MMWR Morb Mortal Wkly Rep. 1989;38 Suppl 6:1-37.

Jessop AB, Del Buono F, Solomon G, Mullen-fortino M, Rogers JM. Police exposures to infectious agents: an audit of protective policies. Occup Med (Lond). 2014;64(7):546-8.

Navy and Marine Corps Public Health Center. Medical Surveillance Procedures Manual and Medical Matrix Edition 11. Portsmouth, Virg: U.S. Navy; 2011.

bThere is no evidence to suggest that LEOs have a higher risk for immunizable diseases than the general public, other than bloodborne pathogens. Vaccination for hepatitis B can be performed either at the time of hire or at the time of exposure. If done at the time of exposure, there is a “window of opportunity” of 7 days after exposure during which immunization, when combined with administration of hepatitis B immune globulin will be protective.