How to Reduce Hepatitis B in the Workplace

The success of GE China’s HBV vaccination program offers an example for companies considering similar programs

by Stephen A. Maloy

General Electric China Co., Ltd. (GE China) offered a voluntary, free hepatitis B virus (HBV) vaccination program to all employees between February 2007 and March 2009, in what may have been the first time a major foreign employer in China attempted a company-wide HBV inoculation program. GE China believes the program reduced the risk of new HBV cases among staff and reduced associated work time lost, boosted staff morale, and improved employees’ opinion of the company. Other companies in China may wish to consider similar vaccination programs.

About the virus

HBV is a viral liver disease estimated to have affected 2 billion people worldwide, of whom more than 350 million continue to live with chronic HBV, according to the World Health Organization (WHO). The disease is particularly prevalent in China, where more than 7 percent of the total population is affected by chronic HBV, according to the PRC Ministry of Health (MOH). (WHO puts the number at 8 to 10 percent.) The disease is transmitted through body fluids, such as blood, semen, and saliva. WHO estimates that the HBV virus is 50 to 100 times as infectious as HIV/AIDS and can survive outside the body for at least seven days. Over a lifetime, unprotected residents of China have more than a 60 percent chance of contracting HBV, according to the Hepatitis B Foundation.

The disease does not have a particularly high mortality rate, but it often requires a long recovery period and is difficult to cure completely. In addition, chronic HBV victims have other serious health issues related to the disease. Globally, 25 percent of chronic HBV sufferers who contracted HBV during childhood will later die from cirrhosis or liver cancer caused by the chronic condition, according to WHO.

Recent studies in Shanghai suggest that the average direct and indirect medical cost of a case of chronic HBV is about $3,000. Using more advanced and effective interferon-based treatment can raise the medical cost from $5,000 to $15,000 per person, based on US data. The economic impact of the disease on employees and employers in terms of absenteeism, reduced productivity, and emotional distress is probably considerably greater.

A vaccine against HBV became commercially available in 1982 and has been continuously improved to the point where it can offer about 95 percent protection against the disease. Though the vaccine is widely available, the vaccination process requires an initial test to determine whether the antigen is already present, followed by three separate injections at fairly precise intervals over a six-month period. In the United States, the full HBV vaccination program typically costs $75 to $165 per person. The cost of missed time from work to visit the doctor’s office often exceeds the cost of the vaccinations.

HBV discrimination and the law

Given the seriousness of the HBV problem in China, many Chinese and multinational corporations (MNCs) have adopted measures to reduce the spread of the virus within their workforce. In the past, some employers attempted to screen out all HBV carriers through pre-employment physicals, while others aimed to screen out employees with active HBV that would affect their fitness for work.

HBV sufferers in China frequently face discrimination in many areas of lifemdash;at school, at work, eating out, and dating. During the last few years, numerous periodicals have highlighted the plight of HBV sufferers, and several HBV action groups have formed. Though Chinese press reports often focus on foreign companies’ discrimination against HBV carriers, anecdotal evidence suggests the problem is at least as acute among Chinese employers. A May 2007 survey conducted by the Chinese University of Political Science and Law found that 49 percent of 3,500 respondents in 10 Chinese cities would be unwilling to work with HBV carriers and that 55 percent would not hire them.

MOH and the PRC Ministry of Human Resources and Social Security in May 2007 co-issued the Notice on Protection of Hepatitis B Surface Antigen (HBsAg) Carriers’ Right to Employment. According to the notice, which took effect May 18, 2007, labor and social security and health bureaus at various levels are responsible for protecting HBsAg carriers’ right to employment and their privacy. (HbsAg is a protein antigen test which is used to determine whether an individual is a carrier of HBV.) The notice states:

• HBV carriers’ right to employment shall be protected. An employer shall not refuse to employ or dismiss an HBV carrier because the person is a carrier, unless the carrier is banned from the job by laws, regulations, or MOH rules.
• An employer’s physical examination standards shall be strictly regulated to protect the privacy of carriers. An employer may categorize liver function as one of the physical examination standards but shall not use Hepatitis B Virus Serology Index as one of the physical examination standards unless the carrier is banned from the job by laws, regulations, or MOH rules. Medical institutes at various levels shall protect carriers’ privacy during the physical examination.

GE China’s vaccination programs

In China, GE operates through more than 50 Sino-foreign joint ventures and wholly foreign-owned enterprises. GE China serves as a holding company for many GE investments and as a platform company for the corporate support functions of GE in China. GE China has about 11,900 employees, with about 6,800 employees in Shanghai, 1,800 in Beijing, and 850 in Hangzhou, Zhejiang. Annual sales exceed $5 billion.

GE’s first experience with employee vaccination programs in China took place during the 2003 severe acute respiratory syndrome (SARS) crisis. Though GE had no SARS cases among its workforce, several employees contracted the common flu. The early symptoms of the flu and SARS are quite similar. Though flu vaccines provide no protection against SARS, after considerable discussion, the corporate medical operation decided to offer all employees a voluntary flu vaccination program. The rationale was as follows:

• If the incidence of flu could be reduced in the workforce, the number of false alarms about the possibility of a SARS case, with attendant efforts to isolate potentially affected staff, could be reduced;
• Reduction in flu cases would have some payback in terms of reduced absenteeism during the flu season; and
• During a time when employees were under great emotional stress, the vaccination program sent them an important message about company concern for their health and well-being.

The program enjoyed broad employee participation. There seemed to be fewer absences than usual during the flu season, though no serious effort was made to measure the reduction. As a result of the program’s popularity with staff, GE China offers flu vaccinations to employees annually.

GE responds to China’s notice on testing for HBV antigen

GE requires a pre-employment physical for all new employees. Prior to the May 2007 notice that prohibits testing for the HBV antigen, GE tested for the HBV antigen. Having the HBV antigen did not affect a candidate’s employment prospects, unless the candidate was suffering from active HBV and could not safely perform the job. Once GE’s legal team advised its medical department of the notice, however, GE immediately discontinued pre-employment testing for the HBV antigen. Dr. Wu Jin, GE’s medical director for China, began to consider the steps the company could take to protect employees from HBV. An educational program that emphasized the importance of good hygiene was an obvious first step. Wu, however, asked: “Why not further protect employees by offering vaccination against HBV to all employees on a voluntary basis?”

In February 2008, Wu raised her proposal with the GE China Human Resources Council, which was sympathetic but concerned about the cost. Wu took her campaign to the corporate leadership, and in early 2008, the company agreed to provide the first $25,000 in funding for the program. Shortly thereafter, all of the GE businesses in China agreed to participate.

Steps to a successful HBV vaccination program

Because an HBV vaccination program requires a blood test, followed by three separate vaccinations on a fairly rigid schedule, the program demands a greater level of management and communication than a flu vaccination program. It also requires a higher level of employee commitment. GE China’s Managing Nurse Zuo Wenxiu developed a system to implement the vaccination program and ensure that it ran smoothly and efficiently. The system included a checklist to confirm that employees received timely communications for each step of the program. Thanks to efficient procedures, most employees were able to be vaccinated and return to work in less than five minutes.

The medical department and human resources and communications groups developed a program to educate employees about HBV and the vaccine. The team created posters and displayed them around the facilities. It also used the employee magazine to urge employees to participate by including a personal letter from a senior manager about HBV and the importance of vaccination.

Critical to any vaccination program is a process to ensure that employees make an informed and voluntary decision to participate. The medical and legal teams developed information fact sheets and consent forms that were signed by all participating employees.

Program results

The first round of vaccinations began on July 1, 2008 and ran for 15 days at eight GE locations in Shanghai and two locations in Beijing. Plant nurses or local clinic staff administered vaccinations at other sites. The second round of vaccinations occurred at GE locations between August 4 and 26 in the same sequence as the first round. The final round took place between January 4 and February 3, 2009.

Program records indicate that of the 3,212 employees who began the program, 2,569 employees completed it, or about 21.6 percent of GE’s workforce in China and 80 percent of employees who began the program. (No employees reported adverse reactions to the vaccinations.)

Because much of its workforce is urban and relatively well-educated, GE expected a substantial number of employees to have been previously vaccinated against HBV through other programs. But managers were surprised to find that in a high-tech business in Shanghai, almost one-quarter of the employee population was able to benefit from the program.

GE tracked costs closely throughout the program. To minimize costs, company medical staff from on-site company clinics administered most inoculations, and volunteers from the human resources department handled much of the paperwork. In the final account, the program cost $40,000—the largest part of which was for the cost of the vaccines. Though the cost of the regime varied from city to city, all locations paid between ¥100 and ¥120 ($15 and $18) per employee for the three-dose regime. The net cost of the program per employee protected was a little under $16.

Benefits outweigh costs

A simple analysis of the program would suggest the following:

2,569 employees vaccinated × 95% effectivity rate × 7 to 10% risk of contracting chronic hepatitis = 170 to 244 cases of chronic hepatitis prevented.

170 to 244 chronic HBV costs avoided × $3,000 average treatment cost = $510,000 to $732,000 saved.

170 to 244 chronic cases avoided × up to 25% fatality rate from complications (for example, liver cancer or cirrhosis) = up to 40 to 60 lives saved.

The numbers above are admittedly crude, and a few factors may result in the value being somewhat overstated. For example, the incidence of HBV in Shanghai and other major GE locations is lower than the national average, and the GE workforce is better educated than the national average and presumably better trained in hygienic practices. Also, the 25 percent fatality rate applies to those who caught HBV as children. Reliable data on fatality rates for those who caught HBV as adults is unavailable, but the rate is likely to be lower.

For a few reasons the results may also be understated. For example, no benefit was ascribed to work time gained due to HBV infections avoided, the number of HBV cases avoided that would have developed into chronic HBV, the incremental protection to employees who had only one or two vaccinations but did not complete the program, or the benefit of having a high percentage of the workforce protected from HBV to workers who had declined vaccination.

Another significant benefit was the impact on employee morale. Many employees who participated in the program expressed the view that GE management looked at big problems and was unafraid to try novel and “big” solutions. Employees felt that the company was concerned about their health and welfare. A post-vaccination survey of participating employees showed a 96 percent satisfaction rate with the program.

Further validation of the positive employee reaction was noted in a recent edition of China Business News Weekly, which conducted a survey of employees of roughly 30 Chinese and MNC companies, including GE, early in 2009. One of the questions in the survey was: “During the past year, what was the most considerate benefit your company provided to you?” The answer from an unidentified GE China employee was “The company arranged for vaccinations several times…. We could see the company cares for the employees.”

GE’s positive experience developing and implementing an HBV vaccination program for its staff has resulted in a range of benefits to the employees and the company itself in terms of health, goodwill, and avoided costs. Other companies, and even governments, could benefit from offering similar programs.

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Reasons to Support Workplace Vaccination Programs

General Electric China Co. Ltd. (GE China) believes the hepatitus B virus (HBV) vaccination program was an unqualified success and is considering offering free vaccinations to all new employees. The company may also offer employees who declined the initial program or who were unable to complete the course of vaccinations because of scheduling issues a second chance to complete the program.

The company believes that many factors contributed to the success of the program and can improve the effectiveness of workplace-based vaccination programs:

• Multi-shot programs often founder when busy patients cannot fit the shots into their work schedules. Since most people spend more waking hours at work than anywhere else, appointments for employer-run inoculation programs are easier for employees to keep.
• Individuals usually acquire vaccinations at “retail rates,” but the scale of a corporate program reduces costs dramatically. Bulk purchases and the use of workplace healthcare resources that are already mandated by PRC law kept GE’s per-patient cost low.
• Management engagement and leadership helps company vaccination programs succeed. When employees see their leaders taking the time to walk down to the clinic, they often follow.

Though the analysis of the data from the GE China experiment is rather crude, the results are striking. Other employers may wish to consider similar programs for their employees.

To cover the large population over 15 years of age that is not currently covered by vaccination programs, the PRC government could subsidize the cost of vaccines for employer-run HBV inoculation programs. This is a good idea for three reasons:

• Avoided healthcare treatment costs and productivity losses make the program an investment with immediate returns for China’s future.
• Because most large employers already run government-mandated health clinics in their factories, and employees can more easily attend vaccination programs at their workplaces, such programs can be completed at lower cost and with higher participation rates.
• The program sends a clear message of joint government and industry concern for the health and well-being of workers.

Finally, affiliates of the All-China Federation of Trade Unions, China’s official labor union organization, could also assist in educating workers about HBV and the benefits of participating in vaccination programs.

—Stephen A. Maloy[/box]

[author]Stephen A. Maloy is general counsel-Asia Pacific at General Electric Co. He is based in Hong Kong and Shanghai. GE has posted detailed material on its vaccination program to further assist organizations considering similar programs.[/author]