occupational infectious disease exposures in ems personnel

The Journal of Emergency Medicine. Vol 11, pp. 9-16, 1993 Printed in the USA CopyrIght 0 1993 Pergamon Press Ltd.

OCCUPATIONAL INFECTIOUS DISEASE EXPOSURES IN EMS PERSONNEL

Elizabeth Reed, RN, MPH,*t Mohamud R. Daya, MD,*t Jonathan Jui, MD,*t* Kathy Grellman, RN,* Leith Gerber, RN,* and Mark 0. Loveless, MD*

*Portland Bureau of Fire, Rescue and Emergency Services, tOregon Health Sciences University Division of Emergency Medicine. and *Oregon Health Sciences University Division of Infectious Disease, Portland, Oregon

Reprint Address: Elizabeth Reed, RN, MPH, Portland Fire Bureau, EMS Section, 55 S.W. Ash Street, Portland, OR 97204-3590

0 Abstract-Reports of occupationally transmitted hepatitis B virus (HBV) and human immunodeficiency virus (HIV) prompted the Portland Bureau of Fire Rescue and Emergency Services (PFB) to institute a comprehensive program for handling and tracking on-the-job infectious disease exposures. Data were collected for a 2-year period beginning January 1,1988, and ending December 31,1989, utilizing verbal and written exposure reports, prehospital care reports, and PFB statistical information. Two hun- dred and fifty-six (256) exposures were categorized. The overall incidence of reported exposure was 4.4/1,OOO emergency medical service (EMS) calls. Of these exposures, 14 (5.5%) were needle sticks, 15 (5.9@/0) were eye splashes, 8 (3.1%) were mucous membrane exposures, 38 (14.8%) were exposure to nonintact skin, 120 (46.9%) were exposures to intact skin, and 61 (23.8%) involved respiratory exposure only. The incidence of exposure of nonintact skin or mucous membranes to blood or body fluids and needle sticks was 1.3/1,008 EMS calls. Forty-eight individuals (64% of those incurring needle sticks, or exposure of nonintact skin or mucous membranes to blood or body fluids) were treated and followed for signs of infection. Of this group, 11 individuals (26%) previously vaccinated against hepatitis B demonstrated inadequate HBsAb titers at the time of exposure. Requests for HIV and HBV information on source patients were made for needle sticks or exposure of nonintact skin or mucous membranes to blood or high- risk body fluids. Information on the source patient’s HIV status was obtained for 57% of these requests. Glove use was documented in 78% of reported exposures to intact skin and in 72% of reported needle sticks or exposure of nonintact skin and mucous membranes. The incidence of significant exposure was l.l/l,OOO Advanced Life Support (ALS) calls and 1.4/1000, on Basic Life Support (BLS) calls. These data document the risk of infectious disease

exposure in the prehospital setting and strongly support the need for infectious disease education programs and hepatitis B vaccination for all prehospital care personnel.

0 Keywords- exposure; occupational; hepatitis B; HIV; EMS; paramedic; firefighter; prehospital; epidemiology; seroprevalence; infectious disease; emergency

INTRODUCTION

It has been previously documented that medical personnel in the hospital setting are at an increased risk for occupationally acquired hepatitis B infection (1). Previous studies have documented a high hepatitis B seroprevalence rate among prehospital care providers (2-4). However, epidemiologic data on the type, frequency, and outcome of infectious disease exposures in the prehospital setting are limited (5). Emergency medical service (EMS) personnel are at increased risk for occupational exposure to bloodborne infectious disease because of the trauma, accident, and rescue situations they encounter in their working environment .

Concerns over the occupational transmission of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) prompted the Portland Bureau of Fire, Rescue and Emergency Services (PFB) to institute a program of education, management, and treatment related to infectious disease exposures incurred in the line of duty. The purpose of this investigation is to determine the type, frequency, and outcome of

RECEIVED: 20 Se tember 1991; FINAL SUBMISSION RECEIVED: 27 April 1992; 0736-4679/93 $6.00 + .OO ACCEPTED: 19 d ay 1992

9

10 E. Reed, M. R. Daya, J. Jui, K. Grellman, L. Gerber, M. 0. Loveless

infectious disease exposures incurred by first responders employed by the PFB.

MATERIALS AND METHODS

EMS System

The city of Portland, Oregon, has a population of approximately 534,000, a total area of approximately 195 square miles, and a population density of 2,746 per square mile (6). Portland utilizes a 911 system with a dual basic life support (BLS) and advanced life support (ALS) first response provided by the PFB, and transport provided by EMS providers in the private sector.

Study Population

The individuals in this study were all firefighter- emergency medical technicians employed by the Portland Fire Bureau. The bureau has 650 firefight- ers with emergency medical technician (EMT) levels ranging from EMT-l to EMT-4 (paramedic). All are paid personnel, with no volunteer utilization within the organization.

Occupational Exposure Program

Integral to the success of this program was the implementation of an occupational health program and the selection of a full-time occupational health nurse (OHN). Other essential personnel included an infectious disease consultant from Oregon Health Sci- ences University (OHSU) and specially trained PFB lieutenants assigned to the EMS section. PFB personnel who sustained occupational infectious disease exposures were instructed to notify the EMS lieutenant on duty immediately. The lieutenant determined the type and level of exposure utilizing a standardized classification system (Table 1). All level II and III exposures were reported immediately to the OHN

Table 1. Definition of Exposure Levels

Level I

Level ii

Level Iii

Respiratory exposure-close contact with patients suspected of having an illness spread by drop- let inhalation or respiratory contact; no direct contact with blood or body fluids.

Contamination of intact skin with blood or body fluids.

Needle sticks, contamination of nonintact skin (in- cluding chapped, cracked, or abraded skin) or mucous membranes with blood or body fluids.

who discussed the exposure with the employee, of- fered counseling, and determined appropriate treatment based on established protocols. Personnel were referred to the emergency department (ED) and the Infectious Disease Clinic at the Oregon Health Sci- ences University for treatment and follow-up.

Treatment Protocols

Previous experience demonstrated that information regarding HBV and HIV status of source patients is not available on a consistent basis. Specific protocols were developed that do not require source patient information for the assessment and management of exposed individuals.

In consenting exposed employees, the management of level III blood exposures related to HIV and HBV included the following:

(1) HIV transmission: A baseline HIV serology was completed on the exposed employee at the time of exposure and at 3- and 6-month follow-up visits. (AZT prophylaxis is now available to our personnel. It was not available at the time of this study.)

(2) Hepatitis B transmission: Previously unvaccinated individuals received 0.06 mL/kg of H-BIG@’ (Hepatitis B Immune Globulin) and HBV vaccine (Recombivaxo) within 48 hours of exposure. All individuals with completed HBV vaccination had received Recombivaxe or Heptavax@ by the intramus- cular deltoid method. A quantitative Hepatitis B Surface Antibody (HBsAb) titer was obtained if one had not been previously documented. Partially vaccinated and fully vaccinated individuals without a documented HBsAb titer of 10 Standard Ratio Units (SRU) received H-BIG@. Known vaccine nonresponders received H-BIG@ at the time of exposure and 1 month postexposure.

Data Collection

Descriptive data were collected and analyzed for 1988 and 1989. Exposures were characterized using the classification system described in Table 1. All fire- fighters were instructed to document exposures to blood and body fluids using a standardized system of verbal and written reports. Training programs were held prior to implementation of this project to familiarize personnel with the reporting system and to review the use of universal precautions and protective equipment. Data were obtained by retrospective analysis of exposure reports, prehospital care reports, and follow-up documentation by the OHN

Occupational Exposure 11

Table 2. Source Patient Testing Requests RESULTS

1988 1989

Requests for information* 35 14 Information obtained 17 (49%) 9 (64%) Source patients HBV + 1 0 Source patients HIV+ 1 1

*Requests were made to the healthcare facilities caring for the source patients, not to the source patient directly.

and OHSU clinic data. Level II and level III exposures were characterized in detail on the exposure report form and in data collection.

Laboratory tests on exposed personnel were performed by the clinical laboratory at OHSU. HBsAb titers were measured by the radioimmunoassay (RIA) method. A minimum of 10 SRU was used to desig- nate immunity in previously vaccinated individuals.

In addition, all level II and level III exposure were evaluated for the following factors: (Tables 3, 5):

Data collected from January 1, 1988, through De- cember 31, 1989, were analyzed (Table 4). During this period, the PFB responded to a total of 110,247 calls of which 58,688 (53%) were medical involving patient care. A total of 256 exposures were evaluated of which 61 (23.8%) were level I, 120 (46.9%) were level II, and 75 (29.3%) were level III (Figures 1, 2). The overall incidence of reported exposure was 4.41 1,000 EMS calls. The incidence of level III exposures was 1.3/1,000 EMS calls. The exposure parameters of all level III exposures are shown in Table 5.

1. Exposed employee’s age and EMT level. 2. Type of call resulting in exposure (trauma or med-

ical). 3. Whether cardiopulmonary resuscitation (CPR)

was performed on the call. 4. Glove usage.

Table 3. Exposure Parameters Level II Exposures (Exposure of Intact Skin to Blood or Body Fluids)

Of the 75 level III exposures reported, 64 (85%) involved exposure to blood or high-risk body fluids. The remaining 11 individuals were exposed to other body fluids. The 75 level III exposures included 14 (18.7%) needle stick injuries, 15 (20.0%) exposures of mucous membranes of the eye, 8 (10.7%) exposures to mucous membranes other than the eye, and 38 (50.7%) exposures to nonintact skin (Table 6, Fig- ure 3). The incidence of needle stick injury was 0.24/ 1,000 EMS calls, or approximately one needle stick injury per 4,000 EMS calls. We found that 29% of reported needle stick exposures involved BLS providers. These incidents occurred while cleaning up the scene after ALS procedures were performed or while assisting ALS providers with patient care and stabilization. ALS personnel incurred needle sticks when improper disposal techniques were used. In this study, no needle sticks occurred from recapping or IV insertion.

1988 1989 Total (%)

EMT age at time of exposure

20+ 8 5 13(11) 30+ 48 28 76 (63) 40+ 12 15 27 (23) 50+ 4 0 4 (3)

EMT level * 1 59 35 94 (78) 2 6 6 12 (10) 4 7 7 14 (12)

Type of call Trauma 56 37 93 (78) Medical 16 11 27 (22)

CPR performed on call Yes 1 7 8 (7) No 71 41 112(93)

CPRltrauma 0 2 2 (2) CPRlmedical 1 5 6 (5)

n = 120 Abbreviations: EMT, emergency medical technician; CPR, cardi- opulminary resuscitation; PFB, Portland Bureau of Fire, Rescue and Emergency Services. ??55 (9%) of the PFBs on-line personnel are EMT 4’s.

All employees who incurred level III exposure were counseled regarding exposure risks. The 64 individuals who sustained level III exposures to blood and high-risk body fluids were urged to seek medical follow-up. Forty-eight individuals elected to receive treatment and follow-up with the PFB-sponsored program. The remaining individuals chose not to seek medical care or to seek care with their private physicians. The employees who obtained treatment outside of our study were contacted 6 months after exposure for follow-up and reported good health with no signs or symptoms of HBV or HIV infection. Forty-three of the individuals evaluated had been previously vaccinated for HBV with either Recombi- vax@ (Merck, Sharp & Dohme) or Heptavax@ (Merck, Sharp & Dohme). Serologic testing subsequently showed that 11 (26%) of the 43 previously vaccinated individuals had inadequate HBsAb titers (< 10 SRU). Unvaccinated individuals received a single dose of H-BIG@ (0.06 mL/kg of body weight) and their first HBV vaccination (Recombivax@, 1 mL IM deltoid). Individuals with inadequate titers received


Table 4. Exposure Statistics 1988-1989

1988 1989 Total

Total PFB calls 53,226 57,021 110,247 ALS calls 11,612 11,689 23,301 (21%) BLS calls 16,984 18,403 35,387 (32%) Total EMS Calls 28,596 30,092 56,688 (53%) Reported exposures

Level I 28 33 61 (23.8%) Level II 72 48 120 (46.9%) Level Iii 50 25 75 (29.3%)

Totals 151 106 256 incidence of exposure

incidence of reported exposure = 4.4/1,000 EMS calls incidence of reported level ill exposure = 1.3/l ,000 EMS calls incidence of level iii exposure-ALS personnel = 1.111 ,000 ALS Calls Incidence of level ill exposure-BLS personnel = 1.4/l ,000 BLS Calls

Total Portland Fire Bureau EMS personnel, 650 Abbreviations: EMS, emergency medical service; PFB, Portland Bureau of Fire, Res- cue and Emergency Services; ALS, advanced life support; BLS, basic life support.

a booster dose of Recombivax@ and had their HBsAb titer rechecked in 6 weeks using the HBsAb by RIA method. Individuals were followed for 6 months. No individuals in this cohort developed Hepatitis B. This included 2 individuals who were exposed to HBV positive blood. Treatment results are summarized in Table 7.

Of the 48 individuals who participated in this program, 43 were evaluated for HIV seroconversion with HIV testing at the time of exposure, and at 3 and 6 months postexposure. There were no documented seroconversions in this group, which included one individual with a nonintact skin exposure to blood and amniotic fluid of a patient who tested HIV positive. Another individual with a nonintact skin exposure to HIV-positive blood chose to be followed by his private physician. This individual also tested HIV negative 6 months postexposure.

The infectious disease status of source patients was requested through the healthcare providers caring for the patients. HIV and HBV testing were requested for all level III exposures involving blood or high-risk body fluids. HIV testing was performed on the source patient and the results communicated to

Non Intact Skin 14.8%

Figure 1. Levels of Exposure 1988 to 1989. Figure 2. Epidemiology of Exposures 1988 to 1989.

the exposed individual for 49% of the requests made in 1988 and for 64% of the requests made in 1989. All tests were performed with the consent of the source patient or the source patient’s next of kin. Oregon law states that in the event of occupational exposure, HIV tests cannot be performed without the consent of the source patient. Two HIV-positive and one HBV-positive source patients were identified (Table 2).

Parameters related to needle stick exposures are detailed in Table 8. Level II and level III exposures were evaluated to determine if any factors affected the overall risk of significant exposure. Comparison data were obtained from PFB records. The numbers of level III exposures that occurred on trauma and medical calls was similar, 53% occurred on trauma calls and 47% on medical calls. The total numbers of trauma and medical calls responded to by the PFB during the study period were not available. The incidence of level III exposure for ALS personnel was l.l/l,OOO calls compared with 1.4/1,000 calls for BLS personnel.

Of the calls involving level III exposures, 20% in-

Intact Skin 46.9%

Mucosal 3.1%

Respiratory 23.8 eedlesticks 5.5%

Eye Exposure 5.9%


Table 5. Exposure Parameters: Level Ill Eqosure8 (Exposure of Nonintact Skin or Mucous Membranes to Blood or Body Fluids and Needle Sticks)

1988 1989

EMT age at time of exposure 20+ 7 2 30+ 34 18 40+ 9 7 50+ 0 0

EMT level’ 1 30 13 2 3 3 4 17 9

Type of call Trauma 28 12 Medical 22 13

CPR performed during call Yes 11 4 No 39 21

CPRltrauma calls 2 0 CPRlmedical calls 9 4

n = 75. Abbreviations: See Table 3 footnotes. ??Fiffy-five (9%) of on-line personnel are EMT 4’s.

Total (%)

9 (12) 50 (67) 16 (21)

0

43 (57) 6 (8)

26 (35)

40 (53) 35 (47)

15 (20) 60 (80) 2 (3)

13 (17)

volved patient CPR. Gloves were worn by 78% of the individuals reporting level II exposures and 73% of the individuals reporting level III exposure (Table 9). Of the needle sticks reported, 29% were incurred by EMT l’s and 71% by EMT 4’s. All of the reported needle stick injuries in this study occurred on medical calls.

DISCUSSION

The epidemiology, management, and prevention of infectious disease exposures in prehospital care personnel has not been well characterized. Previous studies have documented that prehospital care personnel are at increased risk for exposure to hepatitis B and demonstrate a seroprevalence rate greater than the general population (4). The prehospital setting is a unique environment for infectious disease exposures (7). The delivery of medical care under subopti- ma1 and uncontrolled working conditions increases the risk of exposure to blood and other body fluids.

Table 6. Epidemiology of Level Ill Exposures: 1988 and 1989

1988 1989 Total (%)

Needle sticks 9 5 14 (18.7) Eye exposure 10 5 15 (20.0) Nonintact 26 12 38 (50.7) Mucous membrane 5 3 8 (10.7) Total 50 25 75

The HIV and hepatitis B status of emergency department patients in the Portland area was studied in 1988. It was found that 0.45% of emergency department patients were HIV positive, and 12% were hepatitis B core antibody positive (8). High-risk situations include the care and extrication of trauma victims and the delivery of advanced life support in- cluding intubation, establishing IV access, and ad- ministering medications (2,5,7).

The epidemiologic survey of infectious exposures in EMS employees reported from St. Louis by Hoch- reiter and Barton documented 44 needle stick injuries over a 3-year period and reported a prevalence rate of 145 injuries/l,000 employee years (5). We documented 14 needle stick injuries in a 2-year period with a prevalence rate of 104 needle stick injuries/l ,OOOem- ployee years and an incidence of 0.24/1,000 EMS calls. The average annual incidence of needle stick injuries in our population is lower than that reported in

Non Intact Skin 50 7%

NeeFgcks

Figure 3. Level Ill Exposures 1988 to 1989.


Table 7. Hepatitis B Vaccination Sfatus of Personnel with Level iii Exposure

Previous HBV vaccine No HBV vaccine Inadequate HBsAb titers in pre-

1988 1989 Total

31 12 43 3 2 5

viously vaccinated personnel

n = 48.

9131 2l12 1 l/43

Abbreviations: HBV, hepatitis B; HBsAb, Hepatitis B Surface Antibody.

other studies. A reason for this could be that our study looked at only PFB EMS employees and did not include EMS providers in the private sector.

Our study documented several findings that have not been previously characterized. First, this study documented the incidence of three levels of potential infectious disease exposure with particular emphasis on level III exposures. We believe this information is important because it provides an overview of the infectious disease exposure problems encountered by EMS personnel. Second, this study followed a cohort of prehospital care personnel over a 6-month period for the development of infectious disease complications. Third, this study documented the treatment and the HBV status of exposed employees. Fourth, we looked at the epidemiology of level III exposures and the HIV and HBV status of source patients. And fifth, we at- tempted to characterize both employee and environ- mental factors related to significant exposure.

To the best of our knowledge, this is the first pro- spective prehospital study to follow a cohort of exposed individuals for the development of infectious disease complications. A significant portion of previously vaccinated individuals (26%) were found to have inadequate HBsAb titers (C 10 SRU) when tested; this was an unexpected finding. Reported cases of clinical hepatitis B and progression to HBV carriage have been reported in some vaccinated persons who developed peak anti-HBs levels of 10 MIU (approximately equal to 10 SRU by RIA) (9). Field trials of vaccines available in the United States have

Table 8. Epidemiology of Needle Sticks (n = 14)

1988 1989 Total (%)

EMT 1 :,

3 4 (29) EMT 4 2 10 (71)

Trauma calls 0 0 0 (0) Medical calls 9 5 14 (100)

Medical call/CPR 2 0 2 (14) Trauma call/CPR 0 0 0 (0)

Abbreviations: See Table 3 footnotes.

Table 9. Glove Usage on Calls involving Level ii and Level iii Exposures

Level II Level Ill Total

1988 (%) 1989 (%)

80/72 (83) 35148 (73) 37/51 (72) 18125 (72)

97/l 23 (78) 53/73 (72)

shown an 80%-90% efficacy in preventing infection or clinical hepatitis among susceptible persons (10). However, other investigators have reported adequate immune response rates varying from 47%-95%. Fac- tors that have been reported to be associated with minimal immune response include age, sex, obesity, and smoking (9). Some investigators believe that identification of nonresponders and inadequate responders is essential so that in the event of a significant exposure, these individuals can be treated promptly with H-BIG@. Routine testing for immunity after vaccination with hepatitis B vaccine is not cur- rently recommended by the Centers for Disease Con- trol (CDC) (10). Until further information on the correlation of HBsAb levels and protection against hepatitis B is available, we believe it is imperative that HBsAb titers be checked as a part of any hepatitis B vaccination program and that periodic testing for HBsAb be done on high-risk employees to ensure that they maintain an HBsAb level > 10 SRU.

Findings of this study suggest that BLS as well as ALS personnel are at significant risk for needle stick injuries as well as other types of exposure. We find that 29% of reported needle stick exposures involve BLS providers. These incidents occur when one is cleaning up the scene after ALS procedures are performed or when one is assisting ALS providers with patient care and stabilization. Needle sticks in ALS and BLS personnel were most often related to disposal and were not the result of recapping or IV insertion. In this study, the majority of the reported needle sticks do not involve code/CPR situations. Gloves were used on 73% of the calls that involved level III exposures in 1988 and 1989. The significant number of eye exposures demonstrates that personnel are not consistently using protective eyewear. Further investigation revealed that the protective goggles furnished were not being used because they were uncomfortable and difficult to wear. A significant number of the level III exposures to open skin involved the uncovered area of the arm above the gloves and below the shirt sleeve. We believe that the incidence of exposure could be reduced further if glove use increased, needles and contaminated IV stylets were immediately disposed of in puncture proof containers, eye protection was routinely worn,


and personnel wore long sleeve shirts or some other form of arm protection.

Data demonstrate that the number of reported exposures decreased significantly in 1989. We believe this was due to continuing education and increased awareness of infectious disease issues. Our data con- firm that ALS personnel are at greater risk of exposure than BLS personnel. Thirty-five percent of the level III exposures reported in this study occurred in ALS personnel, although ALS personnel make up only 9% of the bureau’s on-line first responders.

This program was designed to operate in the ab- sence of information regarding the infectious disease status of the source patient. Major difficulties are encountered in the implementation of any prehospital infectious disease program because source patients may be lost to follow-up. In our system, first responders on EMS calls do not transport patients. For this reason, plus the fact that source patient information is often not communicated back to the first responder, it is difficult to assess risk factors in these patients. We often encountered reluctance on the part of health care providers to request HIV testing of source patients. Several reasons may account for this. First, many of these patients are not covered by insurance, and hospitals are reluctant to order tests for which they will not be paid. Second, health care providers often made the decision not to request testing of a patient if they felt the patient had no “risk factors.” Third, patients were often treated and released before testing could be requested, were un- identified, or did not enter the health care system. Fourth, we found at the beginning of this investigation that many hospitals in our area had no mecha- nism in place to handle requests for source patient testing by prehospital care providers. No patient, when asked, refused testing. However, often the requests were not made, the proper forms were not completed, or the source patient was treated and released before consent could be obtained. Patients who are the source of exposure may be indigent or have no source of funding. In circumstances where the source patient has no funding, offering to reim- burse the healthcare facility for source patient testing has a positive effect on getting tests performed: 57%

of the requests made by the PFB to healthcare facilities on behalf of exposed personnel eventually re- sulted in source patient testing and communications of the results to the exposed individual. Our data suggest that to obtain HIV and HBV results on source patients, systems or protocols must be established within the healthcare community and within local healthcare facilities to handle these requests in an organized, consistent fashion.

Weaknesses of our study include the possibility of reporting bias. Without direct observation, it is impossible to determine if all exposures are reported or if under- or overreporting occurs. This study relied on a system that utilized verbal and written reporting. Many individuals may not be concerned when an exposure occurs or may not want to bother with the reporting process and documentation. Also, individuals may exaggerate a situation when reporting an exposure because of anxiety associated with the incident. Selection bias must also be considered with those individuals who chose to have follow-up care. This study includes only infectious disease exposures incurred by prehospital care personnel employed by the Portland Fire Bureau and does not include information on other prehospital care organizations in the area. A study that includes the entire prehospital care community would provide a more accurate overall picture of this problem.

SUMMARY

Infectious disease exposures are common occupational hazards for EMS personnel. This study has been instrumental in making the issues of infectious disease education and exposure prevention a part of organization policy. A comparison of the number of 1988 and 1989 reported exposures demonstrates a 51% reduction in reported level III exposures and a 30% reduction in all reported exposures. Informa- tion derived from this study has provided a valuable basis for the evaluation of education and prevention programs directed at minimizing infectious disease risks to EMS personnel in our system.

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3. Clawson JJ, Jacobson JA. Prevalence of antibody to hepatitis B surface antigen in emergency medical personnel in Salt Lake City, Utah. Ann Emerg Med. 1986;15:183-4.

4. Pepe PE, Hollinger FB, Troisi CL, Heiberg D. Viral hepatitis risk in urban emergency medical services personnel. Ann Em- erg Med. 1986;15:115-7.


5. Hochreiter MC, Barton LL. Epidemiology of needlestick in- 8. Jui J, Modesitt S, Fleming D, et al. Multicenter HIV and jury in emergency medical service personnel. J Emerg Med. hepatitis B seroprevalence study. J Emer Med. 1990;8:243- 1988;6:9-12. 51.

6. Portland Bureau of Fire, Rescue and Emergency Services. Bu- reau Statistical Report 1988-89.

7. Kunches LM, Craven DE, Werner BG, et al. Hepatitis B exposure in emergency personnel: prevalence of serologic markers and need for immunization. Am J Med. 1983;75:269-72.

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