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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 follow-up after Hepatitis C Virus exposure needed.
Author(s): Boyles, Salynn

Clark, Cathy
Source: Blood Weekly; 08/18/97, p11, 3p
Document Type: Article
Subject(s): HEPATITIS C virus

MEDICAL personnel -- Health risk assessment
Geographic Term(s): UNITED States
Abstract: Discloses that the US Centers for Disease Control and
Prevention (CDC) has identified the need for a protocol for the
follow-up of healthcare workers exposed to hepatitis C virus. Limited
data on occupational risk, transmission risk, and the benefits of
therapy; Details of a CDC report on the issue; Medical and legal
implications.
Full Text Word Count: 1282
ISSN: 1065-6073
Accession Number: 9708283406
 
Persistent Link to this Article:
http://search.epnet.com/direct.asp?an=9708283406&db=hch
 
Cut and Paste: <A
href="http://search.epnet.com/direct.asp?an=9708283406&db=hch">Protocol
for follow-up after Hepatitis C Virus exposure needed.</A>
 
Database: Health Source: Nursing/Academic Edition
Section News Reports

Occupational Risk

PROTOCOL FOR FOLLOW-UP AFTER Hepatitis C Virus EXPOSURE NEEDED

A 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).

"In the absence of 1) pre-exposure or post-exposure prophylaxis, 2)
recommendations that are unique for hepatitis C virus (Hepatitis C Virus) to prevent
Hepatitis C Virus transmission to others, and 3) effective therapy for most persons
with chronic hepatitis C, the overall public health benefit associated
with the identification of Hepatitis C Virus infections in healthcare workers will be
limited," the report stated (MMWR, July 4, 1997;46(26):603-606).

"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."

The report states that at a minimum, such policies should include:

* Baseline testing for antibody to Hepatitis C Virus (anti-Hepatitis C Virus) for the source.
* 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.
* Confirmation by supplemental anti-Hepatitis C Virus testing of all anti-Hepatitis C Virus results reported as repeatedly reactive by enzyme immunoassay (EIA).
* Recommendation against postexposure prophylaxis with immune
globulin or antiviral agents (e.g., interferon).
* Education of healthcare workers about the risk for and
prevention of bloodborne infections, including hepatitis C, in
occupational settings, with the information routinely updated to ensure
accuracy.

Previously reported follow-up studies of healthcare workers who sustain
a percutaneous exposure to blood from an anti-Hepatitis C Virus positive patient have reported an average incidence of anti-Hepatitis C Virus seroconversion after
unintentional needlesticks or sharps exposures of 1.8 percent (range:
0-7 percent) (Alter et al., Hepatitis Surveillance Report No. 56,
1995;3-6; Mitsui et al., Hepatology 1992;16:1109-1114). A seroconversion
rate of 6 percent was documented in the United States (Lanphear et al.,
Infec Control Hosp Epidemiol 1994;15:745-750).

Although these follow-up studies have not documented transmission
associated with mucous membrane or nonintact skin exposures, the
transmission of Hepatitis C Virus from a blood splash to the conjunctiva was described in one case report (Sartori et al., Scand J Infect Dis 1993;25:270-271).


Several studies suggest that interferon treatment begun early in the
course of Hepatitis C Virus infection is associated with a higher rate of resolved
infection. Among healthcare workers in the post-exposure period, onset
of Hepatitis C Virus infection could be detected earlier by measuring Hepatitis C Virus RNA using polymerase chain reaction (PCR) rather than by measuring anti-Hepatitis C Virus using EIA. PCR is not a licensed assay, however, and the accuracy of the results are highly variable. Also, there are currently no data
indicating that treatment begun early during the course of chronic Hepatitis C Virus
infection is less effective than treatment begun during the acute phase
of infection. Furthermore, alpha interferon is approved for the
treatment only of chronic hepatitis C.

 




"Determination of whether treatment of Hepatitis C Virus infection is more beneficial
in the acute phase than in the early chronic phase will require
evaluation with well-designed research protocols," the report states.

"In the absence of post-exposure prophylaxis, at least six issues need
to be considered in defining a protocol for the follow-up of healthcare
workers occupationally exposed to Hepatitis C Virus."

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."

The report was presented by the Hepatitis Branch, Division of Viral and
Rickettsial Diseases, National Center for Infectious Diseases, CDC.