Q I want to train as a midwife, but don't want to take the required hepatitis B vaccination. Is there any way out of this? In addition, what are the risks of contracting this disease as a midwife? - Name and address withheld
A Although hepatitis B is highly infectious (with few warning symptoms), its prevalence is low - less than 0.5 per cent in North America and Western Europe, and 2-7 per cent in South America, the Middle East and Eastern Europe. Rates are higher - 8-20 per cent - in tropical Africa and South East Asia (J Med Virol, 1994; 44: 144-51).
Women are universally screened for hepatitis B in pregnancy, whether or not they are at risk, but infection rates among pregnant women are also low, with a national prevalence of around 0.1-0.2 per cent (Vaccine, 1990; 9 [suppl]: S6-9).
Rates are highest in inner-city areas and infection is related to ethnic origin. In a sample of 3522 pregnant women in the West Midlands, only 20 (0.56 per cent) were carriers (Epidemiol Infect, 1994; 113: 523-8). In largely middle-class areas such as East Anglia and Oxford, the prevalence is 0.083 and 0.15 per cent, respectively (Epidemiol Infect, 1996; 117: 121-31).
There is no evidence to show what midwives' specific risk might be. Nevertheless, since 1993, the Department of Health has recommended that all healthcare workers who do 'exposure-prone' procedures be immunised against hepatitis B. Staff who decline the jab are treated as though they have tested positive for the disease, and not allowed to carry out procedures where there is a risk that injury to themselves will result in their blood contaminating a patient's open tissues or vice versa.
According to the Royal College of Midwives (RCM), the risk of a midwife being infected by a mother is strongly associated with needlestick injuries and splashing of contaminated blood or amniotic fluid into the mucous membranes of the mouth, eyes or any open wound.
The risk to midwives is greatly increased by routine procedures such as breaking the waters, attaching fetal scalp electrodes, and cutting and suturing of the perineum - procedures that have no benefits and lots of risks for the mothers as well. Midwives are also in danger of getting amniotic fluid or blood in their mouths or eyes is when the woman is lying on her back at eye-level on a high platform - the 'normal' delivery position in the average labour ward.
Regular testing of medical staff for hepatitis B rather than universal vaccination would seem to be a more logical way to go. Our own enquiries suggest that even though they insist on the jab, universities can't make vaccination a condition of taking a midwifery course. But this changes once you are trained and looking for employment with a Trust, which can refuse you a placement.
Remember, however, that the hepatitis B vaccine fails in around 10 per cent (Nurs Times, 1995; 91: 29-31) and includes, among other things, yeast, aluminium and thimerosal (mercury). It has been linked with autoimmune diseases such as arthritis (Scand J Rheumatol, 1995; 24: 50-2), neurological diseases such as Guillain-Barr'e syndrome (J Med Assoc Thai, 2000; 83: 1124-6), multiple sclerosis and gut disorders (Hepatogastroenterology, 2002; 49: 1571-5) among susceptible adults.
The RCM recommends that midwives who decide against, or don't respond to, vaccination be regularly screened (see Hepatitis B: A Serious Hazard, RCM Position Paper 9a, March 1999). Likewise, some employers may agree to your signing a disclaimer and having your blood tested regularly to prove you are not a carrier, although this may require some assertive negotiation on your part.