CDC will recommend HCV follow-up for health care workers
No recommendations yet to restrict HCV-infected workers
The Centers for Disease Control and Prevention in Atlanta will issue new recommendations for hepatitis C virus encouraging hospitals to perform follow-up testing for health care workers occupationally exposed to HCV, Hospital Infection Control has learned.
The CDC recommendations -- slated for publication in an upcoming hepatitis surveillance document -- state that hospitals "should consider implementing policies and procedures for follow-up after percutaneous or per-mucosal exposure to anti-HCV-positive blood to address individual workers' concerns about their risk and outcome."1 Hospital policies might include baseline HCV testing of both the source patient and the exposed health care worker, the CDC advises. In addition to baseline testing, the health care worker should be tested again at six months for HCV antibody. Above all, institutions should ensure education of health care providers regarding the risk and prevention of HCV in the occupational setting, and such information should be routinely updated to ensure accuracy, the CDC recommended. (See summary of recommendations, p. 58.)
Move marks change from earlier stance
The move is significant in that the CDC is abandoning a controversial "no recommendation" position it held in a draft version of the same document. Citing the lack of a post-exposure prophylaxis, limited treatment options, and imperfect tests, the CDC concluded in the draft version that "no recommendation can be made at this time for follow-up of health care workers after occupational exposure to hepatitis C." That position was criticized by the agency's Hospital Infection Control Practices Advisory Committee, and the committee and the CDC amended the recommendations to encourage follow-up of exposed health care workers. (See Hospital Infection Control, January 1996, pp. 1-4.)
"One could say that this is a CDC recommendation, but we didn't feel that it could be any stronger than this, given the limitations of all of the [HCV] information," says Miriam J. Alter, PhD, chief epidemiologist in the CDC hepatitis branch.
Indeed, with neither a vaccine nor a post-exposure prophylaxis available, health care workers who seroconvert for HCV face an uncertain future with limited medical options. (See personal account from nurse, p. 61.) What is known is that approximately 85% of those infected with HCV later develop long-term, chronic infection. Of those, 67% will develop liver disease with persistently elevated liver enzymes, according to the CDC.2 Needlesticks pose the greatest risk of occupational transmission, with studies following health care workers after such exposures finding seroconversion rates that averaged 3.5%.3-6 In a study that used polymerase chain reaction (PCR) to measure HCV infection by detecting HCV RNA, the incidence was 10% following needlesticks.7
Warning of the potential for imperfect test results, the CDC advised that overall about 5% to 10% of infections may not be detected unless PCR is used to detect HCV RNA. Even with those tests -- which cost about $200 -- improper handling or contamination can cause false readings, the agency cautioned. In addition, the agency advised supplemental testing for workers who are repeatedly reactive by enzyme immunoassays due to possible false-positive HCV results.
Many hospitals already testing
Despite the limitations in testing, many infection control professionals have already adopted HCV follow-up policies similar to those recommended by the CDC.
"I feel real strongly about it because we are seeing a lot more HCV in our hospital," says Sharon Self, RN, MS, CIC, infection control practitioner at City Hospital in Martinsburg, WV. "As ill as those employees can become, I think it is very unfair to not at least try to identify whether it was a work-related incident."
Under a policy first implemented in 1994 at the hospital -- and now being considered for revision -- source patients are tested if possible. They are not, however, routinely tested due to the potential for false negatives. Instead, emphasis is placed on counseling and testing the exposed employee at baseline, one month, three months, and one year.
"I know we don't have a step 'A, B, and C' that has proven absolutely that we can pick this up every time, but certainly if someone is exposed to hepatitis C on the job, they have the right to know that," Self emphasizes.
Under the policy at Presbyterian Hospital in Oklahoma City, the source patient is tested for HCV and, if positive, the exposed worker is tested at baseline, three months, six months, and one year after the exposure, says Tracy Privett, RN, epidemiology nurse specialist at the hospital. For exposures in which the source is unknown -- i.e., needlesticks due to improperly discarded sharps -- the health care worker also is tested according to the same protocol.
"If they do convert, we want to make sure that they get treatment," she says.
Infected HCWs, nosocomial cases
While encouraging follow-up for health care workers exposed to HCV, the CDC report and recommendations also address nosocomial transmission of HCV and the controversial issue of the HCV-infected health care worker. Nosocomial transmission of HCV is possible if breaks in technique occur or if disinfection procedures are inadequate and contaminated equipment is shared between patients, the CDC warns. Hospitalized patients may serve as a reservoir for transmission, with prevalence reported in a range from 2% to 18%.8-10 The CDC cited one report from Greece, where nosocomial transmission apparently occurred to six patients who developed acute non-A, non-B hepatitis over a nine-day period after prolonged hospitalization. Five were found to be HCV positive, though none had received transfusions or undergone surgery.11 In Australia, a case of cross-transmission among patients was reported when four patients who underwent outpatient surgery on the same day became infected with HCV. The HCV genotype was identical to that of a chronically infected patient who underwent surgery just prior to the four cases, the CDC reported.12
The emerging threat of HCV as a nosocomial and occupational infection -- as well as the recent detection of what is being called hepatitis G virus -- underscores the need for stringent infection control measures and barrier precautions in clinical settings with frequent blood exposures. (See related story, p. 62.) Still, the threat of hepatitis transmission has never carried the weight of HIV among health care workers, who may be becoming complacent regarding blood exposures, says Donald Fry, MD, chairman of the department of surgery at the University of New Mexico Hospital in Albuquerque.
A return to 'old sloppy habits'
"I am sensing, as I lecture from place to place and as I am involved in my own practice, that we are sliding back into indifference in operating room practice," he says. "There have not been large numbers of health care workers who have gotten infected with HIV, and other than the Florida dentist, we have no evidence of HIV transmission from health care providers to patients. I sense that people are sliding back into their old sloppy habits."
But while reinforcing infection control, the renewed emphasis on tracking and reporting HCV infections as they occur in health care workers will bring with it an "ethical crisis," Fry notes. The debate will center on whether HCV-infected workers, particularly those who perform invasive procedures, should have restrictions placed on their medical practice.
"I have a real personal interest in this because of the risk it represents to me as a practitioner, " Fry tells Hospital Infection Control. "Because New Mexico has a reasonably enlightened attitude about health care workers who carry viruses, I encourage my people who have had exposures to be followed up for a year for HCV antibodies. [But] several states have potential imprisonment and fines for those who knowingly engage in invasive procedures with HIV disease. I think it is important for people to know if they're [HCV] infected, but I would recommend that remain confidential information."
No restrictions on infected workers
Noting the risk of transmission is very low, the new CDC recommendations call for no restrictions of HCV-infected workers -- but remind that they should practice strict aseptic technique. On the contrary, CDC recommendations for HIV and hepatitis B virus call for health care workers who perform invasive procedures to know their HIV status and HBV e antigen status.13 If infected, they should consult expert review panels regarding their continuing practice. It appears it may be particularly difficult to devise such a policy on HCV due to current limitations in testing and difficulty determining infectiousness on an individual basis. Still, the new CDC recommendations estimate that the risk of HCV transmission per needlestick with infected blood is roughly between that for the other two bloodborne viruses -- greater than HIV but less than HBV.
Provider-to-patient transmission?
The issue also arose after a report from Spain of transmission from an HCV-infected surgeon to five open heart surgery patients.14 (See Hospital Infection Control, June 1995, pp. 74-76.) In addition, there is a report of provider-to-patient HCV transmission in the United Kingdom, where it was rather cryptically reported in a public health document that a patient who underwent cardiothoracic surgery at the London Chest Hospital developed acute symptomatic HCV infection.15 The infection was linked to an HCV-positive health care worker -- the specific medical profession was not identified -- and some 300 patients were contacted for follow-up, according to the report. In light of the case, an advisory group on hepatitis recommended that health care workers in the UK who have been associated with HCV transmission should no longer perform exposure-prone procedures.
Hospital Infection Control was able to confirm through inquiries to public health officials in London that no other patient treated by the health care worker was found to be HCV infected, but no other information was available. An investigator at the Communicable Disease Surveillance Centre would not discuss the case on the record, and the communications office did not return a call seeking additional information. The CDC did not include the UK case in its HCV report and recommendations. Regardless, even if the case is more thoroughly documented and reported in the future, it would not necessarily warrant the CDC opening up the issue for debate in the United States, Alter says.
"I don't know whether there is sufficient reason to do it at this time," she says. "We have no reports in the United States. Right now, we have no plans to have any more formal discussions regarding specific recommendations for HCV-infected health care workers. At this time, we feel the recommendations that are currently published for preventing transmission of bloodborne pathogens from health care workers should be sufficient."
References
1. Centers for Disease Control and Prevention. Issues and Answers: What is the risk of acquiring hepatitis C for health care workers and what are the recommendations for prophylaxis and follow-up after occupational exposure to hepatitis C virus? Hepatitis Surveillance Report no. 56. Atlanta; 1996 [in press].
2. Alter MJ. Epidemiology of hepatitis C in the West. Semin Liver Dis 1995; 15:5-14.
3. Hernandez ME, Bruguera M, Puyuelo T, et al. Risk of needlestick injuries in the transmission of hepatitis C virus in hospital personnel. Hepatology 1992; 16:56-58.
4. Zuckerman J, Clewley G, Griffiths P, et al. Prevalence of hepatitis C antibodies in health care workers. Lancet 1994; 343:1,618-1,620.
5. Petrosilla N, Puro V, Ippollito G, et al. Prevalence of hepatitis C antibodies in health care workers. Lancet 1994; 344:339-340.
6. Lanphear BP, Linneman CC, Cannon CG, et al. Hepatitis C virus infection in health care workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994; 15:745-750.
7. Mitsui T, Iwano K, Masuko K, et al. Hepatitis C virus infection in medical personnel after needlestick accident. Hepatology 1992; 16:1,109-1,114.
8. Louie M, Low DE, Feinman SV, et al. Prevalence of bloodborne infective agents among people admitted to a Canadian hospital. Can Med Assoc J 1992; 146:1,331-1,334.
9. Kelen GD, Green GB, Purcell RH, et al. Hepatitis B and hepatitis C in emergency department patients. N Engl J Med 1992; 326:1,399-1,404.
10. Bile K, Aden C, Norder H, et al. Important role of hepatitis C virus infection as a cause of chronic liver disease in Somalia. Scand J Infect Dis 1993; 25:559-564.
11. Tassopoulos NC, Hatzakis A, Vassilopoulou-Kada H, et al. Hepatitis C virus is associated with hospital epidemic of acute non-A, non-B hepatitis [abstract]. Program and abstracts of the 1990 International Symposium on Viral Hepatitis and Liver Disease, Houston, 1990; p. 155.
12. New South Wales Health Department. Investigation of possible patient-to-patient transmission of hepatitis C in a hospital. NSW Public Health Bulletin 1994; 5:47-51.
13. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40:1-9.
14. Esteban JI, Gomez J, Martell M, et al. Repeated transmission of HCV from surgeon to patients during cardiac surgery [abstract]. Hepatology 1995; 22:347A.
15. Communicable Disease Surveillance Centre. Hepatitis C virus transmission from health care worker to patient. CDR Weekly 1995; 26:121. *
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