2013 Volume 55 Issue 5 Pages 392-397
Background: Laboratory confirmation of viral hepatitis infection represents an important issue for working age populations, as early detection and treatment can help ameliorate clinical progression of the disease. On the other hand, prejudice may occur in the workplace against those identified by a positive hepatitis test. This study investigated attitudes towards viral hepatitis testing in Japanese people of working age, including their desire to undergo such testing, and prejudice against persons infected with hepatitis virus. Methods: A total of 3,129 working age individuals were recruited from a company that conducts Internet surveys in Japan. Results: Of the respondents, 21.3% had previously undergone viral hepatitis testing, most frequently when it was an additional option during a health checkup or health screening for local residents (36.2%) and when it was included in regular health checkups in their workplace (19.2%). Among the respondents with no history of testing, 68.7% expressed a desire to undergo testing, of whom 74.8% wanted to have the test as part of their regular health checkups in the workplace. According to the respondents, if a coworker tested positive for hepatitis, 36.0% reported that they would be anxious about it, 32.0% would try to avoid contact with the infected person as long as circumstances permitted, and 23.7% said they might harbor some kind of bias. Conclusions: Although further promotion of viral hepatitis testing is needed and this might be achieved during regular health checkups in Japanese workplaces, educational strategies will also be essential to help reduce bias against those who test positive.
(J Occup Health 2013; 55: 392-397)
Progression of viral hepatitis to liver cirrhosis and liver cancer can be prevented by treatment, especially if the infection is identified at an early stage1, 2). In Japan, the Basic Act on Hepatitis Measures was enacted in 2009 and has been facilitating a project to provide opportunities for viral hepatitis screening3). However, because most hepatitis virus carriers are asymptomatic, they are not likely to be self- motivated to undergo viral hepatitis testing4, 5), and it remains unclear what proportion of the working generation population has already undergone such testing in Japan. The prevalence of hepatitis B surface (HBs) antigen-positive and hepatitis C virus (HCV) antibody-positive Japanese individuals has been shown to increase with age until 69 years6, 7). According to a survey of 3,740,000 people who donated blood between 2001 and 2006, the prevalence of hepatitis C antibody was lowest (0.06%) in blood donors aged 20-24 years and highest (1.08%) among those aged 65-69 years. The prevalence of HBs antigen in the same study was lowest (0.15%) in those aged 20-24 years, and highest (1.36%) in those aged 55-59 years.
The Japanese Ministry of Health, Labour and Welfare has requested that companies add viral hepatitis testing to blood examinations conducted as part of routine health checkups held in the workplace8). Business owners are obligated by the Occupational Health and Safety Law to provide health checkups including blood screening to their employees who are 35 years of age and to those in their 40s or older once per year. If viral hepatitis testing was included in such health checkups, employees could be examined for this disease without the need for additional, invasive tests9). However, there are issues regarding who would bear the cost, privacy concerns when handling test results in the workplace and how to deal with employees who simply do not want the test10).
It is extremely rare for viral hepatitis to be transmitted between individuals who are working together in an ordinary (nonmedical) workplace11, 12). However, there is often a general anxiety among workers about the risk of cross-infection from coworkers. Given the well-known routes of transmission of viral hepatitis including homosexual intercourse and the use of injected drugs13, 14), infected persons may be confronted with anxiety and biases from surrounding people. This may unduly inhibit infected persons from continuing with their work, as well as interfere with the promotion of viral hepatitis testing15, 16). The implementation of measures to eliminate anxiety and prejudice toward infected persons while promoting screening opportunities for hepatitis viruses in the working generation must, therefore, be given high priority. The purpose of this study was to clarify the viral hepatitis screening status of people in the working generation, their desire to undergo such screening and prejudice toward coworkers who might test positive for hepatitis.
Around 3,000 individuals of working age (between 20 and 69 years of age), without gender or age bias, were randomly extracted from the registry of an Internet research company (among a randomly selected group of 7,937 persons in the total 1.60 million registrants), and a survey of this study population was then carried out via the Internet in September 2011. People who were interested in a survey with financial incentives for responding voluntarily registered. The web survey company contacted selected registrants to respond to the survey and ceased recruitment when the total number of participants reached the target number. Participants were recruited in clusters, targeting 300 individuals for each gender in each age group. Persons working as or living with family members who were medical professionals (doctors, nurses, pharmacists) or working in occupations in industries pertaining to medicines and health foods, health care and welfare services were excluded from the study. This study was approved by the Kitasato University School of Medicine Ethics Committee prior to implementation.
QuestionnaireThe question about the opportunity to undergo viral hepatitis testing, i.e., “Have you had at least one blood test for hepatitis B or C virus screening?” was to be answered with “Yes”, “No” or “Unclear.” Questions regarding the desire to undergo viral hepatitis screening, “Do you want to have viral hepatitis screening if it is free of charge?” and “Do you want to have a blood test for viral hepatitis screening as part of a health checkup in the workplace if it is free of charge?” were answered as “Yes, definitely”, “Probably”, “Probably not” and “Definitely not”. These questions were not asked of participants who had already undergone viral hepatitis screening (as indicated on their questionnaire). Questions about the recognition of hepatitis patients included “Would you be anxious about possibly becoming infected from a coworker who carries the hepatitis virus?” “Would you avoid contact with a coworker who is infected with a hepatitis virus as far as possible?” and “Would you be biased against a coworker who is infected with a hepatitis virus, suspecting that the coworker may be a homosexual or a drug user or that they have multiple sexual partners?” The options for answers to these questions were also “Yes, definitely”, “Probably”, “Probably not” or “Definitely not”.
Individuals who had previously undergone viral hepatitis testing were asked about the reasons for being tested and were required to choose at least one of the following 13 answers: 1) Viral hepatitis testing was an additional option as part of a complete health checkup or health screening for local residents; 2) Viral hepatitis testing was included in regular health checkups implemented in the workplace; 3) Viral hepatitis testing was included in pregnancy health checkups or medical examinations at the time of surgery in a hospital; 4) My doctor recommended it; 5) I donated blood; 6) A health screening examination found an abnormality in my liver function; 7) One of the persons around me was infected with a hepatitis virus or had hepatitis, hepatic cirrhosis or liver cancer; 8) A medical examination other than a regular health checkup found an abnormality in my liver function; 9) There was a possibility that I was given a blood transfusion or blood product in the past; 10) Publicity of the Ministry of Health, Labour and Welfare or a news report motivated me to be tested; 11) My family or an associate recommended it; 12) I am/was engaged in handling of blood products (for example, for experiments, research and development, nursing care); 13) I had suggestive symptoms.
Completed responses to the questionnaire were obtained from 3,129 individuals. Table 1 shows the characteristic of the participants. A history of hepatitis B or C viral screening was present in 21.3% of respondents (28.7% of those aged 40 to 69 years), absent in 65.9% and unclear in 12.8%.
| Total | ||
|---|---|---|
| N=3,129 | (%) | |
| Gender | ||
| Male | 1,572 | (50.2) |
| Female | 1,557 | (49.8) |
| Age (yr) | ||
| 20-29 | 618 | (19.8) |
| 30-39 | 628 | (20.1) |
| 40-49 | 627 | (20.0) |
| 50-59 | 632 | (20.2) |
| 60-69 | 624 | (19.9) |
| History of viral hepatitis testing | ||
| Yes | 668 | (21.3) |
| No | 2,062 | (65.9) |
| Unclear | 399 | (12.8) |
| Do you want to have viral hepatitis screening if it is free of charge? | ||
| Yes, definitely | 674 | (21.5) |
| Probably | 1,043 | (33.3) |
| Probably not | 565 | (18.1) |
| Definitely not | 179 | (5.7) |
| Already tested | 668 | (21.3) |
| Do you want hepatitis screening as part of a workplace health checkup if it is free of charge? | ||
| Yes, definitely | 866 | (27.7) |
| Probably | 982 | (31.3) |
| Probably not | 426 | (13.6) |
| Definitely not | 187 | (6.0) |
| Already tested | 668 | (21.3) |
| Would you be anxious about possibly becoming infected from a coworker who carries the hepatitis virus? | ||
| Yes, definitely | 284 | (9.1) |
| Probably | 841 | (26.9) |
| Probably not | 1,323 | (42.3) |
| Definitely not | 681 | (21.8) |
| Would you avoid contact with a coworker who is infected with a hepatitis virus as far as possible? | ||
| Yes, definitely | 211 | (6.7) |
| Probably | 792 | (25.3) |
| Probably not | 1,356 | (43.3) |
| Definitely not | 770 | (24.6) |
| Would you be biased against a coworker who is infected with a hepatitis virus, suspecting that the coworker may be a homosexual or a drug user or that they have multiple sexual partners? | ||
| Yes, definitely | 114 | (3.6) |
| Probably | 628 | (20.1) |
| Probably not | 1,386 | (44.3) |
| Definitely not | 1,001 | (32.0) |
The most frequent reason for having undergone viral hepatitis testing was that “viral hepatitis testing was an additional option as part of a complete health checkup or health screening for local residents” (36.2%), followed by “viral hepatitis testing was included in regular health checkups implemented in the workplace” (19.2%) and “viral hepatitis testing was included in pregnancy health checkups or medical examinations at the time of surgery in a hospital” (15.4%) (Table 2). Individuals wanting hepatitis screening, if it was free of charge, accounted for 54.8% of respondents (“Yes, definitely” and “Probably”). Those who wanted to have viral screening, if it was free of charge and included in regular health checkups in the workplace, accounted for 59.0% of respondents (“Yes, definitely” and “Probably”). Among respondents with no history of testing, 68.7% expressed a desire to undergo testing, of whom 74.8% wanted to have the test as part of their regular health checkups in the workplace.
| Total | 20-39 years | 40-69 years | ||||
|---|---|---|---|---|---|---|
| N=668 | (%) | n=128 | (%) | n=540 | (%) | |
| Viral hepatitis testing was an additional option as part of a complete health checkup or health screening for local residents. | 242 | (36.2) | 20 | (15.6) | 222 | (41.1) |
| Viral hepatitis testing was included in regular health checkups implemented in the workplace. | 128 | (19.2) | 30 | (23.4) | 98 | (18.1) |
| Viral hepatitis testing was included in pregnancy health checkups or medical examinations at the time of surgery in a hospital. | 103 | (15.4) | 35 | (27.3) | 68 | (12.6) |
| My doctor recommended it. | 44 | (6.6) | 9 | (7.0) | 35 | (6.5) |
| I donated blood. | 41 | (6.1) | 11 | (8.6) | 30 | (5.6) |
| A health screening examination found an abnormality in my liver function. | 36 | (5.4) | 10 | (7.8) | 26 | (4.8) |
| One of the persons around me was infected with a hepatitis virus or had hepatitis, hepatic cirrhosis, or liver cancer. | 26 | (3.9) | 5 | (3.9) | 21 | (3.9) |
| A medical examination other than a regular health checkup found an abnormality in my liver function. | 22 | (3.3) | 5 | (3.9) | 17 | (3.1) |
| There was a possibility that I was given a blood transfusion or blood product in the past. | 21 | (3.1) | 1 | (0.8) | 20 | (3.7) |
| Publicity of the Ministry of Health, Labour and Welfare or a news report motivated me to be tested. | 21 | (3.1) | 0 | 0.0 | 21 | (3.9) |
| My family or an associate recommended it. | 19 | (2.8) | 6 | (4.7) | 13 | (2.4) |
| I am/was engaged in handling of blood products. | 19 | (2.8) | 11 | (8.6) | 8 | (1.5) |
| I had suggestive symptoms. | 12 | (1.8) | 2 | (1.6) | 10 | (1.9) |
Concerning the recognition of infected persons, 9.1 and 26.9% of respondents answered “Yes, definitely” and “Probably”, respectively, to the question as to whether they would be anxious about becoming infected if they found out that a coworker was infected with a hepatitis virus (Table 1). The percentage of respondents who would avoid contact with an infected person as far as possible was 6.7%, and the percentage of those who would probably do so was 25.3%. In addition, 3.6% of respondents reported that they would suspect infected persons of being homosexuals or drug users or having multiple sexual partners, and 20.1% reported that they would probably do so.
We investigated the current status of viral hepatitis screening and attitudes among Japanese of working age, including their desire to have viral hepatitis screening and their anxiety and prejudice toward coworkers infected with hepatitis viruses. In this study, around one-fifth of respondents had previously undergone viral hepatitis testing. If the test was free of charge, 54.8% of respondents wished to have the test. In addition, a higher proportion (59.0%) of respondents wished to have viral testing during their regular health checkups in the workplace if it was free of charge. On the other hand, 32 to 36% of respondents said they would have anxiety or biases regarding the risk of infection from a coworker if a coworker had tested positive for viral hepatitis. About 24% of respondents harbored biases toward infected coworkers, suspecting that they might be homosexuals or drug users or have multiple sexual partners. Although provision of viral hepatitis testing as part of regular health checkups in the workplace should be considered for the promotion of viral hepatitis screening, this would clearly need to be implemented with a significant privacy protection when handling test results. Furthermore, the dissemination of accurate knowledge concerning the disease such as the limited risk of infection with viral hepatitis at workplaces and standard precautions in order to prevent infection would also be needed.
In Japan, the government recommends that all people aged 20 years or older undergo viral hepatitis testing at least once in their lifetimes3). However, the actual percentage of those who have actually received viral hepatitis testing has been shown to be only 21.3%. Although the government has suggested comprehensive urgent countermeasures against hepatitis C, such as the recommendation in 2002 of viral hepatitis testing for all people age 40 years or older, the percentage of participants in this study who were 40 to 69 years of age and who had undergone viral testing was only 28.7%. In comparison, a free hepatitis B testing campaign was previously carried out for Asian people living in San Francisco and found high anti-hepatitis B awareness in this population, with a testing rate of 60%17). In Japan, opportunities for viral hepatitis testing are provided through various channels, including viral hepatitis tests that have been added to blood examinations at regular health checkups in the workplace, free testing in public health centers, free testing in designated medical institutions, and health screening for local residents. In this regard, advancing knowledge and conveying an effective message regarding the benefits of screening are clearly required12).
In the current study, 12.8% of participants said they were not sure whether or not they had previously undergone viral hepatitis testing (Table 1). This suggests that not only is the implementation of viral hepatitis testing important, but also that appropriate reporting of test results be made to the person who was tested. It is possible that those who were tested were not informed of their results or that they did not have adequate knowledge to understand the test results even if they had been informed18). Therefore, dissemination of knowledge about viral hepatitis to the general public remains an important issue, together with the more widespread implementation of testing. Aside from being tested and vaccinated themselves19), health-care professionals should also make greater efforts to explain test results to patients and standard precautions at workplaces. This would allow individuals who tested either positive or negative to more clearly understand their results, even if their test had been implemented as one of many clinical examinations conducted during pregnancy health checkups or medical examinations at the time of surgery12).
In working-age populations, the proportion of individuals who wanted viral hepatitis testing (without personal expense) as part of their regular health checkups in the workplace was higher than the proportion of those who wanted to have the testing if it was simply free of charge. This suggests that the testing rate increases among people of working age if easy access to free-of-charge viral hepatitis tests is provided during opportunities such as regular health checkups in the workplace. On the other hand, a certain proportion of people in the current study reported that they did not want to be tested (“Probably not” and “Definitely not”), accounting for 24% of untested participants (Table 1). Along with the dissemination of knowledge about hepatitis itself, this result suggests that it is also important to provide a full explanation of the privacy protection policy in the handling of test results when implementing viral hepatitis testing in the workplace20).
Excluding those who handle blood products as part of their occupation, the risk of hepatitis virus infection is extremely low in ordinary workplaces. It is entirely inappropriate for persons infected with hepatitis to be treated in a discriminatory manner or subjected to any kind of prejudice21). In this study, 20-30% of participants reported anxiety about becoming infected from coworkers who had tested positive for hepatitis, agreeing that they might have discriminatory views toward infected coworkers (Table 1). If viral hepatitis testing is implemented in Japanese workplaces, significant efforts aimed at privacy protection and due consideration regarding the method of disseminating accurate and detailed knowledge are clearly necessary, and should be based on the fact that anxiety and prejudice do still exist among some individuals.
This study has a limitation that is worth considering. Because the subjects we recruited had access to the Internet and volunteered to participate in the survey, there may have been a certain degree of selection bias. Considering social stratification, the percentage of people who had a history of viral hepatitis testing in this study might have been higher than that in the general working generation population22).
In conclusion, this study suggests that further promotion of viral hepatitis testing is needed in Japan and that greater opportunities for such testing need to be provided in the workplace. On the other hand, a certain proportion of workers said they might harbor anxiety and prejudice toward coworkers who tested positive for viral hepatitis even though the risk of workplace transmission is very low. Any such test results would therefore need to be subject to the utmost confidentiality, while the dissemination of accurate knowledge is also necessary to ensure that infected persons and those around them are able to work in a setting free of misguided anxiety.
Conflict of interests: None to declare.
Acknowledgments: This study was funded by a Health Labour Sciences Research Grant from The Ministry of Health, Labour and Welfare (H23-Hepatitis-general-001). The funders had no role in study design, data collection and analysis, the decision to publish or preparation of the manuscript.
