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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

Protocol for the follow-up of healthcare workers exposed to hepatitis C virus is desperately needed, but limited data on occupational risk, transmission risk, and the benefits of therapy are hampering efforts to fashion one, according to a report from the U.S. Centers for Disease Control and Prevention (CDC).
"However, to address individual workers' concerns about risk and outcome, CDC, in collaboration with the Hospital Infection Control Practices Advisory Committee, recommends that individual health-care institutions consider implementing policies and procedures for follow-up for Hepatitis C Virus infection after percutaneous or permucosal exposures to blood."
Baseline and follow-up (e.g., six-month) testing for anti-Hepatitis C Virus and alanine aminotransferase activity for the person exposed to anti-Hepatitis C Virus positive source.
PCR is not a licensed assay, however, and the accuracy of the results are highly variable.
 

These six issues are:
LIMITED DATA ABOUT THE OCCUPATIONAL RISK FOR TRANSMISSION
While needlestick exposure to infectious blood is a risk factor for hepatitis C and this risk is intermediate between that of hepatitis B virus and HIV, data are limited or nonexistent about the risk for transmission associated with other types of occupational exposures. "Thus, meaningful estimates of the risk for Hepatitis C Virus infection cannot be provided to healthcare workers who sustain such exposures," the report states.
LIMITATIONS OF AVAILABLE SEROLOGIC TESTING FOR DETECTING INFECTION AND DETERMINING INFECTIVITY
Testing methods readily available in the clinical setting are subject to limitations. For the commercially available EIAs that detect anti-Hepatitis C Virus, the average interval between exposure and seroconversion is eight to 10 weeks. In many populations, including healthcare workers, the rate of false positivity for anti-Hepatitis C Virus is at least 50 percent, and supplemental assays always should be used to assess the validity of repeatedly reactive EIA results. Approximately 5 percent of infections will not be detected unless PCR is used to detect Hepatitis C Virus RNA.


    



"Although such assays are available from several commercial laboratories for research use, they are not standardized, and each test costs approximately $200," the report states. "Both false-positive and false-negative results can occur as a consequence of improper handling and storage or contamination of test samples. In addition, the detection of Hepatitis C Virus RNA may be intermittent, and a single negative PCR test result is not conclusive."
POORLY DEFINED RISK FOR TRANSMISSION BY SEXUAL AND OTHER EXPOSURES
"All anti-Hepatitis C Virus positive persons should be considered potentially infectious; however, neither the presence of antibody nor the presence of Hepatitis C Virus RNA is a direct measure of infectivity in settings where unapparent parenteral or mucosal exposures occur," the report states. "Although epidemiologic studies have implicated exposure to infected sexual and household contacts as well as to multiple sex partners in the transmission of Hepatitis C Virus, the efficiency of transmission from these exposures is low."

Studies of infants born to anti-Hepatitis C Virus positive mothers have documented an average rate of perinatal transmission of 5 percent, increasing to 9 percent among infants born to mothers who were Hepatitis C Virus RNA positive at the infant's birth (Mast et al., Semin Ped Infect Dis 1997;8:17-22). Acquisition of Hepatitis C Virus infection from breast milk has not been documented, and in studies of breastfeeding among infants born to Hepatitis C Virus infected women, the average rate of infection was 4 percent in both breastfed and bottlefed infants."
LIMITED BENEFIT OF THERAPY FOR CHRONIC DISEASE
"One benefit from a follow-up protocol is the opportunity for eligible healthcare workers to seek evaluation for chronic liver disease and treatment," the report states. "Although alpha interferon therapy is safe and effective for the treatment of chronic hepatitis C, sustained response rates generally are low; the occurrence of mild to moderate side effects in most patients has required discontinuation of therapy in up to 15 percent of patients. No clinical, demographic, serum biochemical, serologic, or histologic features have been identified that reliably predict which patients will respond to treatment and sustain a long-term remission."
COST OF FOLLOW-UP
The estimated annual cost of providing postexposure follow-up testing nationally is $2 million to $4 million; the estimated cost for each person for a six-month course of therapy is $200,000 (CDC, unpublished data, 1995).


    


MEDICAL AND LEGAL IMPLICATIONS
A post-exposure follow-up protocol should address individual workers' concerns about their risk for Hepatitis C Virus infection and possible disease outcomes, and identify those healthcare workers who become infected with Hepatitis C Virus, this information provides healthcare workers with the opportunity to be counseled about their risk for transmitting Hepatitis C Virus to others and to be evaluated for development of chronic disease, and, if eligible, for therapy for chronic hepatitis C.

The report concludes that infected healthcare workers should refrain from donating blood, organs, tissues, or semen, and household contacts should not share toothbrushes and razors. However, there are neither recommendations against pregnancy or breastfeeding nor recommendations for changes in sexual practices among Hepatitis C Virus infected persons with a steady partner.

"Infected persons should be informed of the potential risk for sexual transmission to assist in decision-making about precautions," the report states. "Persons with multiple sex partners should adopt safer sex practices, including reducing the number of sex partners and using barriers (e.g., latex condoms) to prevent contact with body fluids."

 

 

 

 

 

 

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