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Waste Manage Res 2005: 23: 79–86 Printed in UK – all right reserved
Waste Management & Research
ISSN 0734–242X
Vaccinations for waste-handling workers. A review of the literature A review of the literature relating to the need for vaccination against infectious disease in the solid waste industry was conducted, focusing on hepatitis A, hepatitis B and tetanus. Databases (Medline, PreMedline, EMBASE, CINAHL, Current Contents, Cochrane Database, HTA Database, DARE, OSHROM) were searched up to and including August 2003. Articles were included in the review if they reported the prevalence of immunity to hepatitis A, hepatitis B or tetanus in solid waste workers or the incidence of clinical infection with any of these diseases. Papers about hazardous or medical waste, incineration or other infectious diseases were excluded. Fortyfour papers constituted the evidence database. Only one paper studied the prevalence of antibodies to hepatitis A and hepatitis B in solid waste workers compared with sewage plant workers and office workers, and no difference was found between these groups of workers. There was some evidence to support a theoretical risk of infection with hepatitis A, B and tetanus; however, no studies could be found of the risk of these diseases in solid waste workers. No single cases of these diseases being acquired occupationally in solid waste management were identified in the literature. Workers in the solid waste industry may theoretically be at increased risk of acquiring infectious diseases occupationally. However, at present no studies could be found which have documented this risk.
Rebecca Tooher Tabatha Griffin Elen Shute ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia
Guy Maddern University of Adelaide, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia. Keywords: Waste management, infection, vaccination, solid waste: wmr 746–1
Corresponding author: Professor Guy Maddern, ASERNIP-S, PO Box 553, Stepney, South Australia 5069. Tel: +61 8 8363 7513; fax: +61 8 8362 2077; e-mail:
[email protected] DOI: 10.1177/0734242X05048037 Received 8 March 2004; accepted in revised form 29 July 2004
Introduction Workers in the solid waste management (SWM) industry may be exposed to infectious agents that cause disease. Some of these diseases are preventable using readily available vaccines. At present it is unclear whether solid waste workers are at increased risk of contracting vaccine-preventable diseases compared with others who do not work in SWM, or whether the level of risk of developing these diseases outweighs the possible side effects of vaccination and the potential for increased resource use. Solid waste is defined as the solid component of any left over, surplus or unwanted by-product from any business or
domestic activity (Environmental Protection Agency, South Australia, 2000). It does not include hazardous and medical waste that is managed separately from other solid waste. Solid waste management encompasses a very wide range of activities including: collecting kerbside municipal garbage and recyclable materials; collection, sorting and processing of recyclable materials; composting of green waste; collection and processing of building and demolition, and of commercial and industrial waste. There is a diverse range of occupations in SWM including garbage collectors, truck drivers, machine/plant operators, waste pickers/sorters, supervisory
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and administrative staff. The SWM industry is considered to be occupationally hazardous (Campbell 1994, Kitsantas et al. 2000) with commonly reported injuries including sprains and strains, back injuries, lacerations, abrasions and contusions (Cimino 1975, Gellin 1985, An et al. 1999). A vaccine-preventable disease is an infectious disease that can be prevented in an individual by administering a vaccine. There are three vaccine-preventable diseases which are thought to be potentially hazardous for solid waste workers: hepatitis A, hepatitis B and tetanus. Exposure to these diseases can theoretically occur at a number of different stages or processes in the management of solid waste. Work at different locations (for example in a compactor truck or at a landfill site) exposes workers to a range of hazards. For the purposes of this review, potential pathways of infection for vaccine-preventable diseases in SWM are hypothesized to be the following: • hepatitis A – contact with contaminated water and/or faecal matter (in disposable nappies and other waste); • hepatitis B – cuts, abrasions, and lacerations from waste contaminated with blood or blood products, needlestick injuries from contaminated waste; and • tetanus – puncture wounds and others abrasions and lacerations from contaminated waste, particularly metal, wood splinters, and waste contaminated with soil and animal manure. These pathways of infection suggest that some solid waste workers may be at higher risk of infection with vaccine-preventable diseases than others. Those workers involved in the manual handling and sorting of waste could be expected to come into contact with more contaminated waste than a truck or plant operator. Workers responsible for cleaning bins, trucks and other plant may be at a higher risk than other workers not in direct contact with waste or waste-handling machinery. This review seeks to identify any evidence of occupational infection with vaccine-preventable disease in SWM workers and to determine whether SWM workers are at increased occupational risk compared with general population, other waste workers (e.g. sewage workers) or other workers (e.g. health care workers).
Materials and methods Literature search strategies Searches of Medline, PreMedline, EMBASE, CINAHL, Current Contents, Cochrane Database, HTA Database, DARE, and OSHROM were conducted from inception up to, and including, August 2003. Broad search terms were
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used as it was expected that there would not be a large amount of literature available on this topic. MESH terms were Waste Management, Infection, Vaccination, Accidents, Occupational, Occupational Exposure, Occupational Diseases, Risk Factors, Hepatitis B and Freetext terms were (waste and infect*) or (waste and vaccinat*) or [waste and (hepatitis A or HAV or hepatitis B or HBV or tetanus)]. Inclusion criteria Articles were included in the review if they reported the prevalence of immunity to hepatitis A, hepatitis B or tetanus in solid waste workers, or incidence of clinical infection with any of these diseases. Papers that either addressed the issue for subsets of workers or addressed the theoretical risk to workers in the SWM industry based on the experience in other industries, were also included. Papers about hazardous or medical waste, incineration and other infectious diseases were excluded. The selection of articles was carried out by two reviewers independently and any differences were resolved by discussion. No language restriction was used in the literature search. However, foreign language papers were only retrieved when they were judged, on the basis of their English abstract, to add substantially to the English language evidence base. Evidence database An evidence database of 120 articles was created from the results of the literature searches. When the full text of these articles was obtained, 76 articles did not meet the inclusion criteria of the review and were excluded. There were 44 included studies: 20 for hepatitis A, 11 for hepatitis B, and 13 for tetanus (one paper, Corrao et al. 1985, studied both hepatitis A and B in solid waste workers).
Results Hepatitis A Twenty articles were identified relevant to the questions of the review and hepatitis A (Table 1). There was only one study of hepatitis A in solid waste workers (Corrao et al. 1985). This study compared 93 solid waste workers with sewage workers and office workers. The presence of antibodies to the hepatitis A virus (HAV) was not significantly different in solid waste workers compared with other workers. This study only reported limited methodological detail and it was difficult to determine the quality of the study. There were no papers reporting an increased risk of hepatitis A infection for solid waste workers, and no case reports of individual workers contracting hepatitis A from a work-related cause. Fifteen studies considered the occupational risk of hepatitis A infection by measuring the presence of antibodies to
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Table 1: Included studies for hepatitis A. Study
Population
Outcomes
Arvanitidou et al. 1998 GREECE
167 sewage workers.
Hepatitis A antibodies are very common among sewage workers supporting an increased occupational risk for these workers.
Benbrik et al. 2000 FRANCE
591 sewage workers compared with water plant workers and administrative workers (n = 643).
Seroprevalence for HAV not significantly different in any groups of workers. Risk factors for HAV seroprevalence were exposure to soil polluted with sludge water, floating corpses, and non-occupational factors such as fishing and gardening.
Bonnani et al. 2001 ITALY
65 sewage plant workers compared with other workers (n = 160).
No significant difference between sewage workers and other workers in HAV seroprevalence was found. Older workers, those with less education and those born in Southern Italy had higher rates of antibodies to HAV.
Brugha et al. 1998 UK
241 sewage workers.
Frequent occupational exposure to raw sewage was found to be a significant risk factor for infection with HAV.
Cadilhac & Roudot-Thoraval, 1996 FRANCE
155 sewage workers compared with water department workers not exposed to sewage (n = 70).
No significant difference in seroprevalence of HAV in sewage workers compared to other workers. Exposure to sewage was found to be a significant risk factor for HAV infection.
Chriske et al. 1990 GERMANY
93 sewage workers.
HAV infection in sewage workers found to be high in younger workers. No significant difference in HAV infection in sewage workers compared with the general population was found.
Corrao et al. 1985 ITALY
No significant difference in HAV seroprevalence between solid waste workers 93 solid waste workers compared with five sewage workers and other workers. and three office workers.
De Serres et al. 1995 CANADA
76 sewer workers compared to non-sewer workers (n = 76).
Franco et al. 2003 ITALY
Review of literature on risk Reviewed nine studies of sewage workers. groups for hepatitis A infection. Seven of nine found an increased risk of antibodies to HAV in sewage workers. In countries where seroprevalence of HAV in the community is high, occupational risk is low as most workers have already been exposed to HAV prior to starting work.
Frolich & Zeller 1993 GERMANY
408 occupational exposed and HAV seroprevalence higher in sewage workers over 40 years old than in other workers. unexposed sewage workers (n = 202).
Glas et al. 2001 SWITZERLAND
Systematic review of hepatitis A 17 studies were included in the review. in workers exposed to sewage. No evidence of increased risk of aquiring HAV occupationally was found. A slightly increased risk of having antibodies to HAV was found in some studies. The quality of most studies limited the conclusions which could be made.
Heng et al. 1994 SINGAPORE
600 sewage workers compared with non-occupationally exposed population (n = 453).
Seroprevalence of HAV signficantly higher for sewage workers than for other workers. Seroprevalence was significantly correlated with age and educational level.
Levin et al. 2000 ISRAEL
100 sewage workers compared with blue-collar workers (n = 100).
Seroprevalence of HAV high in both sewage workers and other workers but difference not significant. The main risk factor in sewage workers was age.
HAV seroprevalence not significantly different for sewage workers compared with other workers. HAV seroprevalence increased significantly with age.
Nuebling & Hofmann 2001 343 sewage workers. GERMANY
Presence of HAV antibodies in workers significantly related to age, country of origin and task-related exposure. A dose-response relationship was found with duration of exposure and HAV seroprevalence.
Ohlendorf 1993 GERMANY
Sewage workers compared with sewer maintenance workers (16 workers in total).
Found a relationship between duration of employment and antibodies to HAV in sewage workers – those working for less than 5 years showed no antibodies to HAV whereas those working more than 11 years showed HAV antibodies.
Poole & Shakespeare 1993 UK
40 sewage workers compared with road workers and office workers (n = 38).
Seroprevalence of HAV significantly higher in sewage workers than in other workers.
Skinhoj et al. 1981 DENMARK
77 sewage workers compared with gardeners and clerical workers (n = 180)
Seroprevalence of HAV significantly higher in sewage workers than gardeners or office workers. Seroprevalence correlated with age rather than duration of employment.
Thorn et al. 2002 SWEDEN
1453 sewage workers compared with workers not exposed to sewage (n = 839).
Sewage workers were at significantly increased risk of experiencing respiratory problems, gastrointestinal problems and headaches, tiredness and concentration difficulties compared with other workers.
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Table 1: Included studies for hepatitis A. (Continued) Study
Population
Outcomes
Trout et al. 2000 USA
157 wastewater workers compared with city workers not occupationally exposed to wastewater (n = 148).
Wastewater work was not significantly associated with HAV seroprevalence. No statistically significant occupation risk factors for HAV antibodies were found.
Venczel et al. 2003 USA
365 sewage workers compared with road and drainage workers (n = 166).
Seroprevalence of HAV in wastewater workers was similar to other workers. Factors associated with presence of antibodies to HAV were age greater than 40 years, birth outside USA, education level, work in field crew rather than roads and drainage.
the hepatitis A virus (HAV seroprevalence) in the blood of workers exposed to sewage. They have been considered here because both sewage workers and solid waste workers may be exposed to faecal matter and therefore may be exposed to a risk of infection with hepatitis A. However, it could reasonably be expected that solid waste workers would be exposed to raw sewage less often than sewage workers and would therefore experience a lower risk of infection. The studies of sewage workers provide indirect evidence of the risk of hepatitis A in solid waste workers, with the applicability of the results of these studies dependent on the extent to which solid waste workers are involved in tasks similar to those of sewage workers (and thus to similar levels of risk). Some of these studies also measured the incidence of clinical hepatitis A infection in the population of workers being studied. The results of these studies do not provide a clear picture of the occupational risk of hepatitis A in sewage workers. Seven studies found an increased risk (Skinhoj et al. 1981, Frohlich & Zeller 1993, Ohlendorf 1993, Poole & Shakespeare 1993, Heng et al. 1994, Arvanitidou et al. 1998, Brugha et al. 1998) but eight studies found no increased risk (Chriske et al. 1990, De Serres et al. 1995, Cadilhac & Roudot-Thoraval 1996, Benbrik et al. 2000, Bonanni et al. 2000, Levin et al. 2000, Trout et al. 2000, Venczel et al. 2003). However, there are methodological problems with these studies which limit the validity of their conclusions (Glas et al. 2001). These problems include comparing sewage workers with a control group that may not have been representative of the general population, not matching the control groups on factors such as age and sex which are known to be related to HAV seroprevalence, and not adjusting the risk estimate for important confounding variables such as socio-economic background or non-occupational exposure to HAV.
Hepatitis B Eleven articles were identified as relevant to the questions of the review and hepatitis B (Table 2). There was only one study of hepatitis B seroprevalence in solid waste workers (Corrao et al. 1985), comparing 93 solid waste workers with sewage workers and office workers. Presence of antibodies to
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HBV was not significantly different in solid waste workers compared with other workers. There were no papers reporting an increased risk of hepatitis B infection for solid waste workers, and no case reports of individual workers contracting hepatitis B from a work-related cause. Evidence of an infectious pathway for Hepatitis B in solid waste workers was provided by nine studies which reported either rates of injuries caused by sharps or needlesticks or exposure to potentially contaminated blood products in solid waste workers. Only injuries that could result in infection with hepatitis B (i.e. injuries which punctured the skin) have been considered. Cuts and abrasions ranged from 4.6 to 23.7% of all injuries reported and lacerations between 7.3 and 18.4%. Needlestick injuries and sightings are much rarer and have been reduced in those cities that have introduced systems for the disposal of needles/syringes in normal household waste (Drda et al. 2002, Lawitts 2002). Sharps, including glass, metals and yard waste have been reported to account for up to 30% of household waste (An et al. 1999). Drda et al. (2002) reported that over 10 000 lbs of sharps were collected in San Francisco over a 2-year period after a sharps collection system was introduced. Olowokure et al. (2003) reported that half of a random sample of diabetic patients surveyed in one health district in the UK did not use a safe method of disposal for their needles and syringes. They estimated that 2.5 million sharps are generated annually by diabetic patients in the health district suggesting that over a million sharps could potentially be found in normal household garbage in 1 year.
Tetanus Thirteen articles were identified relevant to the questions of the review and tetanus (Table 3). There were no studies of tetanus immunity or infection in solid waste workers, no articles which reported an increased risk of tetanus infection for solid waste workers, and no case reports of individual workers contracting tetanus from a work-related cause. The included articles report the increased risk of tetanus, prevalence of immune status, or cases of injuries leading to tetanus infection in occupational groups other than solid waste manage-
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Table 2: Included studies for hepatitis B. Study
Population
Outcomes
An et al. 1999 USA
1711 municipal solid waste workers in Florida.
Rates of contusions and lacerations 12.3 and 8.3%, respectively, in solid waste workers.
Cimino, 1975 USA
11 500 solid waste workers.
Rates of contusions and lacerations 23.7 and 16.3%, respectively, in solid waste workers. Needlestick injuries 50–100/year.
Corrao et al. 1985 ITALY
93 solid waste workers compared to five sewage workers and three office workers.
No significant difference in HBV seroprevalence between solid waste workers and other workers.
Drda et al. 2002 USA
Solid waste workers (garbage collectors) (n not reported).
More than 10 000 lbs of sharps collected in San Francisco over 2-year period. Reported needle-stick injuries: 1989, 21; 2001, 6.
Gellin 1985 USA
160 solid waste workers.
Rates of contusions and lacerations 21.5% in solid waste workers.
Ivens et al. 1998 DENMARK
667 domestic waste collectors.
Rates of contusions and lacerations 5.3 and 22.8%, respectively, in solid waste workers.
Lawitts 2002 USA
6400 solid waste workers.
Needlestick injuries: 1997, 33; 2001, 6. Sharps sightings: 1997, 234; 2001, 90. No workers have become infected with HBV from a needlestick injury.
Liss et al. 1990 CANADA
Waste disposal worker.
Case report of worker with needlestick injury.
Olowokure et al. 2003 UK
Diabetic patients in general community. Half of a random sample of diabetic patients disposed of needles and sharps in household waste.
Turnberg & Frost 1990 USA
940 solid waste workers.
50% of workers reported lacerations and contusions occurring at work. 6% of workers reported needlestick injuries.
Yang et al. 2001 TAIWAN
1032 household waste collectors compared with clerical workers (n = 320).
37% of injuries caused by sharp objects (nearly three times as many as in the control groups).
Table 3: Included studies for tetanus. Study
Population
Outcomes
Bizzini et al. 1978 FRANCE
283 car factory workers.
Younger workers were more protected against tetanus than older workers (age related decline in immunity). Degree of immunity was influenced by contact with machine fluids (that contained Clostridium tetani bacteria and spores).
Carducci et al. 1987 ITALY
805 people living in communes in Tuscany.
Found an age-related decrease in immunity. A higher percentage of people were immune in industrialized areas. The lowest immunity levels were found in pensioners and housewives.
Cellisi et al. 1988 ITALY
General community (n = 1045).
Found an age related decrease in immunity. Immunity higher in males than females. Immunity highest in workmen and lowest in housewives.
Fara et al. 1980 ITALY
Steel mill workers (n not reported).
Rates of immunity were related to previous military service, industrial accidents or other accidents. Use of prophylaxis was preventive measure for over half of workers rather than use of vaccination (prior to risk exposure).
Gleeson 2001 IRELAND
315 catering industry students.
Incidence and nature of occupational injury suggests that workers in the catering industry were at significant risk and should be vaccinated.
Hayney et al. 2003 USA
102 farmers compared to 102 non-farmers.
Antibodies to tetanus were significantly higher in farmers compared to non-farmers. Farming and age were correlated with increased tetanus seroprevalence.
Holland and Carruth 2001 USA
4808 women on farms.
There was an age-related decrease in keeping up to date with tetanus immunization. Approximately half of the women received vaccination after an accident as for a preventive measure. There was significant risk of tetanus for women living/working on farms.
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Table 3: Included studies for tetanus. (Continued) Study
Population
Outcomes
Litvoc et al. 1991 BRAZIL
General community (n not reported).
Groups at higher risk of tetanus were old aged, those living in certain areas, and those classified occupationally as domestic activities, rural workers and pensioners
Luisto 1989 FINLAND
106 tetanus cases in hospital.
Over one-third of the cases of tetanus reported in Finland were in agricultural and forest workers (highest risk group).
Luisto & Seppalainen 1992
28 occupationally acquired cases of tetanus (out of 106).
Listed cases of tetanus caused by occupational accidents (farming, forestry, driving, construction, other). Highest proportion of accidents were in agriculture and forestry.
Matzkin et al. 1985 ISRAEL
3241 males members of the Israel Defence Force.
There was an age-related decrease in immunity. There was a lower degree of immunity in office workers compared to labourers.
Simonsen et al. 1984 DENMARK
500 people randomly selected from the general community.
Age-related decrease in immunity.
Valentino & Rapisarda 2001 32 cases of tetanus in hospitals. ITALY
ment. Other occupational groups considered in these articles include agricultural workers, housewives, carpenters, drivers, car factory workers, steel-mill workers and other miscellaneous groups. The types of injuries leading to infection by tetanus in these occupational groups included wounds caused by sharp objects or through accidents with machinery, and splinters. These types of injuries have been reported in solid waste workers. Solid waste workers are also prone to puncture injuries further demonstrating the evidence for an infectious pathway for tetanus. Seven of the studies reported an age-related decrease in tetanus immunity (Bizzini et al. 1978, Simonsen et al. 1984, Matzkin et al. 1985, Carducci et al. 1987, Cellesi et al. 1988, Luisto 1989, Holland & Carruth 2001).
Discussion Vaccine-preventable disease in solid waste workers Solid waste workers may come into contact with infectious diseases which can be prevented by vaccination. This review sought to determine whether solid waste workers were at increased risk of contracting the vaccine-preventable diseases hepatitis A, hepatitis B and tetanus. These diseases were the focus of the review because pathways of infection for these diseases are known to exist in the management of solid waste. The review aimed to identify any studies which considered whether solid waste workers were at increased risk of infection with these diseases compared with the general community and any reports of workers being infected with these diseases. One study of hepatitis A and hepatitis B immunity in solid waste workers was identified, which did not find an increased risk of these diseases in SWM workers. No studies could be identified which measured the rate of immunity to tetanus in solid waste workers. Furthermore, no reports of solid waste workers contracting any of the diseases through
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Largest proportion of tetanus cases were in agricultural workers.
occupational exposure, or studies reporting vaccination programmes for solid waste workers were found. Risk of infection Indirect evidence of risk of infection with hepatitis A was provided by studies of hepatitis A seroprevalence in sewage workers. Some studies of sewage workers suggest an increased seroprevalence, whereas others showed no increased seroprevalence. As solid waste workers are probably exposed to a lower risk of infection than sewage workers, it could be inferred that seroprevalence of hepatitis A in solid waste workers would be lower than in sewage workers. Indirect evidence of risk of infection with hepatitis B and tetanus was provided by studies of occupational injuries in solid waste workers. These studies documented pathways of infection for these two diseases via puncture wounds, needlestick injuries and other contusions and lacerations. Other studies reported cases of workers in other occupations becoming infected with tetanus after similar types of accidents at work. Given the rates of puncture injuries in solid waste workers it may be warranted to vaccinate against tetanus, and where vaccination is provided universally to ensure vaccination schedules are maintained. Hepatitis B vaccinations may be appropriate for subsets of workers involved in the manual handling of waste. It should also be noted that use of personal protective equipment, such as appropriate footwear and gloves, and good personal hygiene control would also limit the chances of coming into contact with infectious agents.
Conclusion At present there have been very few studies of the seroprevalence of vaccine-preventable diseases in solid waste workers. Without such studies it is difficult to provide clear guidance to workers and employees regarding vaccinations. Given the
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rates of injuries in solid waste workers which could lead to infection, current local data would be most beneficial in formulating policy. A study measuring the seroprevalence of vaccine-preventable disease in solid waste workers and a comparison of these rates to the general community would provide evidence showing the actual risk of infection. This evidence would aid in the development of vaccination recommendations in the solid waste management industry.
Acknowledgements This report was funded by WorkCover Grants and the South Australian Government. We would like to thank Christine Glauer and Marielle Esplin for assistance with translation of foreign language papers, and Philippa Middleton for commenting on earlier drafts of the paper.
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