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Guidance on the investigation and management of occupational
exposure to hepatitis C
COMMUNICABLE DISEASE AND PUBLIC
HEALTH 258 VOL 2 NO 4 DECEMBER 1999
* This guidance was written by Dr Mary Ramsay
and endorsed by the PHLS Advisory Committee on Blood Borne Viruses on 2
February 1999 (membership
This document updates previous PHLS guidance on the risks and
management of occupational exposure to hepatitis C. In line with recent
from the UK Health Departments, the PHLS now recommends that all source
patients, subject to appropriate consent, should be tested for evidence
of hepatitis C
infection. A baseline serum should be obtained from the exposed health
and stored for at least two years. Health care workers exposed to known
sources should be followed up at six, 12, and 24 weeks after exposure.
at six and 12 weeks should be tested for hepatitis C virus (Hepatitis C Virus) RNA and
taken at 12 and 24 weeks for anti-Hepatitis C Virus. Health care workers exposed to a
believed not to be infected do not require active follow up for
hepatitis C unless
requested or if they develop symptoms or signs of liver disease.
personnel exposed to a source whose hepatitis C status is unknown or a
unavailable for testing will depend upon a risk assessment by a
Health care workers who are found to be positive for Hepatitis C Virus RNA or antibody
hepatitis C should be referred to an appropriate consultant for
consideration of early
Guidance on the risks and management of occupational exposure to
hepatitis C was last issued in
1993 by the PHLS Hepatitis Subcommittee 1
Since then, knowledge has increased about the prevalence of hepatitis C
virus (Hepatitis C Virus) infection in the United Kingdom (UK), the risks of
occupational transmission, and the benefits of treatment. Guidance on
the management of potential exposures to Hepatitis C Virus was issued recently in the
United States (US) 2
and Canada 3
and recommendations in these documents differ from those in the previous
PHLS guidance 1
In addition, the UK Health Departments have issued recommendations on
the management of significant exposures with regard to the potential
risks of HIV, hepatitis B virus, and Hepatitis C Virus infection 4
These developments provided an opportunity for the PHLS Advisory
Committee on Blood Borne Virus Infections to reconsider and revise the
recommendations of the PHLS group. This guidance is intended to
supplement the detailed guidance on the management of blood
exposure incidents produced by the UK Health Departments 4
The evidence base
Risks of exposure to hepatitis C
Population based studies suggest that the prevalence of Hepatitis C Virus infection in
western Europe and North America is below 2.5%, lower than in many other
parts of the world 5
Studies of low risk groups in the UK suggest that the prevalence of
anti-Hepatitis C Virus in the general population is below 1%
The prevalence among new blood donors is currently 0.06% 6
but a seroprevalence of 0.72% was found in UK organ donors 7
The prevalence in the West Midlands of anti-Hepatitis C Virus among pregnant women was
but in a more recent PHLS study of pregnant women the prevalence was
0.33% in Greater London and 0.22% in Yorkshire (J Parry, personal
Patients receiving health care in the UK are likely to have a higher
prevalence of Hepatitis C Virus infection than the general population. Known high risk
exposures for Hepatitis C Virus infection in the UK include injecting drug use,
receipt of blood transfusion or blood products, tattooing, and having
been born abroad 9,10 . The
prevalence of Hepatitis C Virus among injecting drug users (IDUs) in studies in
England and Wales was 46% in South Wales
11 , 59% in one area of rural England
12 , 59% among IDUs undergoing
voluntary HIV testing in north west England (J Craske, personal
communication), and 67% in IDUs attending a regional drug clinic in the
north east 13 . In Scotland,
studies of IDUs have found prevalences of anti-Hepatitis C Virus between 77% and 90%
14,15 . People with haemophilia
who received untreated clotting factors
16-18 and patients on renal dialysis in some units
19 are also known to have a high
prevalence, although the prevalence has been low in some renal units
16,20 . In some specialties and
locations, therefore, the risk of exposure to an Hepatitis C Virus infected source may
be high. Exposure to Hepatitis C Virus positive sources in the UK is likely to be
commoner than exposure to sources positive either for HIV or for
hepatitis B surface antigen 21
Risk of transmission to health care workers
Health care workers may be at greater risk of hepatitis C than the
general UK population
but the prevalence of anti-Hepatitis C Virus in such staff is lower than among health
care workers in the US 22
and western Europe
In the UK, the overall prevalence of infection was estimated to be 0.23%
among all health care workers and 0.28% in those at risk of occupational
contact with blood and body fluids
the US, a review of published studies in health care workers who
received a needlestick injury from an anti-Hepatitis C Virus positive source estimated
the risk of transmission to be 1.8% (range 0%-7%)
In a recent meta-analysis, the risk of transmission was shown to be
greater if the source patient was known to be positive for Hepatitis C Virus RNA; no
transmission occurred from Hepatitis C Virus RNA negative sources 27
of transmission from health care workers
Only two episodes of transmission from an Hepatitis C Virus infected surgeon to
patients have been described to date
In the UK, transmission from an Hepatitis C Virus infected surgeon was implicated in a
single case of acute hepatitis C detected after cardiothoracic surgery
In the lookback investigation that followed, 277 patients were tested
but no other infected individuals were identified 30
This suggests that the risk of transmission from health care worker to
patient is much lower than the risk of transmission from surgeons
positive for hepatitis B e antigen 30
Based on this evidence, health care workers with Hepatitis C Virus infection in the UK
are not restricted from performing exposure prone procedures unless they
have been shown to transmit hepatitis C to a patient 28
Nevertheless, health care workers with Hepatitis C Virus infection should be seen in
occupational health departments to be advised on scrupulous adherence to
the optimal precautions for control of bloodborne virus infections in
order to reduce the potential risk of transmission during exposure prone
In addition, infected health care workers should be advised about the
local arrangements for the reporting, assessment, and management of any
incidents in which patients appear to have been exposed to a health care
worker™s blood. Patients who sustain a significant exposure to blood
(box 1) should be managed in the same way as exposed health care staff.
Management of hepatitis C infection
The UK Health Departments have concluded that there is no effective post
exposure prophylaxis for
hepatitis C 4
The use of immunoglobulin has been suggested, but a US review in 1998
concluded that it did not prevent Hepatitis C Virus infection 31
Prophylaxis with alpha-interferon did not prevent transmission of
hepatitis C after a needlestick injury in Japan 32
No formal assessments of antiviral agents for post
exposure prophylaxis have been performed, but their use has not been
recommended in the US 2
Alpha-interferon is now commonly used to treat chronic hepatitis C
Better response rates are likely to be seen with combination therapies
that include ribavirin
A recent European consensus statement recommended that combination
therapy should be offered to all previously untreated infected
individuals without contraindications 38
Evidence based guidance on the management of patients with hepatitis C
currently being developed by professional groups in the UK may involve
the selection of patients on the basis of abnormal liver function, Hepatitis C Virus
RNA positivity, and grade of abnormality on a liver biopsy 33
A decision about whether to continue treatment may depend upon
demonstration of a virological response as assessed by genome detection.
Evidence on the optimal timing of treatment for acute and chronic
hepatitis C infection is unclear. The use of interferon for acute
hepatitis in a small number of patients suggested that early treatment
might prevent chronic carriage 32
A subsequent meta- analysis of the use of alpha- and beta-interferon in
acute hepatitis C infection concluded that short term early treatment
produced better response rates than treatment of chronic infections
Control data on untreated infections were limited, however, so the
difference in response could reflect the natural clearing of acute
infection. More recently, workers in Italy reported the results of a
randomised controlled trial of beta-interferon in acute hepatitis C, in
which the rates of chronic infection in treated (15/20) and untreated
groups (16/20) were similar 40
The US Centers for Disease Control and Prevention has concluded that
there is insufficient evidence to suggest that treatment of acute
hepatitis is more successful than early treatment of chronic hepatitis
In Canada, however, early treatment of health care workers who
seroconvert following percutaneous exposures is now recommended 3
A recent consensus conference in Europe also stated that most experts
now favour treating patients with acute hepatitis C infection 38
The recommendations of the committee for the management of a significant
exposure (box 1) 1
Investigation of source patients
most settings, most source patients are likely to be anti-Hepatitis C Virus negative.
The exclusion of Hepatitis C Virus infection in the patient should reassure the
exposed health care worker. Identification of a source patient who is
positive for anti-Hepatitis C Virus should prompt appropriate assessment of the
patient and follow up of the health care worker. The advisory committee
therefore recommends that, where possible, a baseline serum from the
source patient should be obtained and tested for anti-Hepatitis C Virus. Patients who
are anti-Hepatitis C Virus positive should be further investigated for Hepatitis C Virus RNA (an
EDTA plasma may be required by the
local laboratory). In immunocompromised patients (including those on
renal dialysis) 41
in patients with features suggestive of acute hepatitis C infection, the
use of genome detection should be considered even if the source patient
is found to be anti-Hepatitis C Virus negative. These investigations will normally
entail pre-test discussion and obtaining fully informed consent from the
source patient 4
Specimens from the source patient must be stored in a secure archive at
a temperature at or below 20 o
for at least two years after the incident.
Source patients found to be anti-Hepatitis C Virus and/or Hepatitis C Virus RNA positive should be
referred to an appropriate consultant with an interest in hepatitis C
the event that the source patient cannot be identified or if the patient
refuses to be tested or is unavailable for testing, management should be
based upon a risk assessment. This risk assessment should be conducted
by one of the doctors designated to offer advice on the managment of
exposures to bloodborne viruses within the health authority or NHS Trust
Epidemiological and clinical information about the incident and/or the
source patient should be obtained and reviewed. If the source patient is
considered to be ‚high risk™ then the health care worker may be managed
as if exposed to a source known to be positive. Such high risk exposures
would normally be limited to sharps injuries contaminated with fresh
blood from a member of a known high risk group (for example, an IDU).
Because the risk of transmission of bloodborne viruses from dried blood
is likely to be lower than from fresh blood, the advisory committee does
not consider community needlestick injuries from discarded needles to be
‚high risk™ exposures.
Investigation of the exposed health care worker
Baseline serum should be obtained from the exposed person and stored in
a secure archive at -20 o
or below for at least two years (box 2). If the source patient is not
infected with Hepatitis C Virus, no further follow up with respect to Hepatitis C Virus is required
unless the health care worker develops liver disease. Information,
counselling, and psychological support should be available for any
employee who reports an exposure
and a potential risk of any bloodborne viral infection 4
If, after the provision of information, the exposed person requests
follow up, additional testing may be offered. At a minimum, this follow
up should include testing for anti-Hepatitis C Virus at six months.
For health care workers exposed to a source known to be positive for
anti-Hepatitis C Virus or Hepatitis C Virus RNA (or a source whose hepatitis C status is unknown but
who is assessed to be at ‚high risk™), serum should be obtained from the
health care worker at baseline, six weeks, 12 weeks, and 24 weeks after
exposure (box 2). Serum should be tested for Hepatitis C Virus RNA at six and 12 weeks
and for anti-Hepatitis C Virus at 12 weeks and 24 weeks.
Early testing of the serum of the health care worker for Hepatitis C Virus RNA will,
if negative, give some reassurance at this stage. In a follow up study
of individuals who sustained needlestick exposures to patients with non-
A, non-B hepatitis, both of the health care workers who developed anti-Hepatitis C Virus
were Hepatitis C Virus RNA positive one
month after exposure 45
early genome detection was not performed on health care workers who did
not seroconvert. The negative predictive value of genome detection at
six weeks is therefore not documented, but it seems likely that this
would correlate with a lower risk of transmission.
Collation of information on such exposures will contribute towards the
prospective estimation of transmission risks and the likely predictive
value of laboratory investigations. All exposures to known
anti-Hepatitis C Virus or Hepatitis C Virus RNA positive sources should therefore be reported to the
PHLS national surveillance
scheme for health care workers occupationally exposed to bloodborne
viruses (box 3). An equivalent
scheme for Scotland is coordinated by the Scottish Centre for Infection
and Environmental Health. If the health care worker is found to be
positive for anti-Hepatitis C Virus or Hepatitis C Virus RNA at any stage, retrospective
investigation of baseline specimens from the health care worker and
source patient for Hepatitis C Virus RNA, if not already available, can then be
performed. Additional studies that may be useful at this stage include
genotyping and viral load. Genotyping of source and health care worker
will help to confirm whether transmission from patient to health care
worker has occurred 43
and specimens for genotyping can then be referred to the PHLS Hepatitis
and Retrovirus Laboratory in Colindale. Estimates of viral load in the
source patient may also help to inform the management of such incidents
in the future.
Advice to exposed health care workers
during follow up
is difficult to offer advice on the appropriate management of health
care workers exposed to a
known Hepatitis C Virus infected source during follow up. The risk of transmission is
and there is insufficient evidence to advise mandatory restriction of
work practices. Occupational health departments may wish, however, to
suggest additional precautions during certain procedures 4
In line with the Blood Transfusion Service recommendations 44
before donating blood, health care workers who have been exposed to an
individual infected with hepatitis should be referred to the medical
officer for assessment. We advise similar caution with respect to
donations of other tissues. In studies of chronic Hepatitis C Virus infection, the
transmission of infection from mother to child is believed to occur in
less than 10% of cases 45
Sexual transmission from chronically infected individuals occurs, but
the risk appears to be low
The risk of transmission to infants and sexual partners may be higher in
acute than chronic infections, but the magnitude of this increased risk
is unknown. Discussion of the possible benefits of adopting safer sexual
practices and the avoidance of pregnancy during follow up is therefore
Health care workers found to be anti-Hepatitis C Virus and/or Hepatitis C Virus RNA positive at any
stage during follow-up should be referred to an appropriate consultant
with an interest in hepatitis C infection. The evidence for the
effectiveness of early treatment is limited, but referral will allow
early assessment and a consideration of the potential role of treatment.
As treatment options are likely to change over the next few years, early
detection will enable recruitment into clinical trials and the early
implementation of any treatment shown to improve outcome. Health care
workers found to be anti-Hepatitis C Virus and/or Hepatitis C Virus RNA positive should also be
referred to occupational health for advice.
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Definitions of occupational exposure 1
the skin of the health care worker is cut or penetrated by a needle or
other sharp object (for example, scalpel blade, trochar, bone fragment,
or tooth), which is contaminated with blood or other body fluid
the eye(s), the inside of the nose or mouth, or an area of non-intact
skin of the health care worker is contaminated by blood or other body
includes all percutaneous exposures and any mucocutaneous exposure to
blood or bloody body fluids (but not mucocutaneous exposure to other
Summary of investigation and follow up of healthcare workers
Known Hepatitis C Virus infected source
Obtain baseline serum for storage from health care worker
Obtain serum/EDTA for genome detection at six and 12 weeks
Obtain serum for anti-Hepatitis C Virus at 12 and 24 weeks
Source known not to be infected with Hepatitis C Virus
Obtain baseline serum for storage from health care worker
Obtain follow up serum if symptoms or signs of liver disease develop
Hepatitis C Virus status of source unknown
obtain baseline serum for storage from health care worker
designated doctor to perform risk assessment
Manage as known infected source
Obtain serum for anti-Hepatitis C Virus at 24 weeks