Routine HCV testing considered for high-risk health care workers
December 1, 1999 7 minutes read
Routine HCV testing considered for high-risk health care workers
EH consultant cites both medical and liability issues for screening
In what is emerging as a controversial debate for hospital occupational health programs, some employee health professionals are implementing routine testing programs for hepatitis C virus (HCV) to record baseline serostatus of at-risk health care workers. Citing both medical and hospital liability issues, an employee health consultant for a California health care chain of 48 hospitals is recommending that the facilities consider voluntary HCV screening programs, Hospital Employee Health has learned.
"What I am going to recommend is that they focus on the health care workers that actually take care of the high [HCV] -prevalence patients — for example, the trauma, dialysis, or liver transplant patients," says Cynthia Fine, RN, MSN, CIC, employee health and infection control program consultant for Catholic Healthcare West in Oakland, CA. "[The policy] wouldn’t include health care workers who don’t have blood exposures. So it would be the nurses and the phlebotomists — the people that really do have blood exposure — and certainly it would not be a mandatory test."
As currently planned for those hospitals that decide to enact the policy, HCV testing will be offered on initial hire and to existing employees who want to know their serostatus, she says. As part of the program, the workers will be educated about risk factors so they can make an informed decision about whether they want to be tested, she says. Currently, the Centers for Disease Control and Prevention in Atlanta does not recommend routine testing of health care workers for HCV "unless they have risk factors for infection."1 (See guidelines, p. 136.)
Fine argues that the policy is within the spirit of that recommendation, because only workers whose jobs may involve blood exposures will be offered voluntary testing. Also, all existing protocols for testing source patients and following workers after exposures will remain in place, she notes. The CDC has not recommended routine testing for all health care workers, in part because data show that only 1.4% of those reporting a history of health care employment are HCV-positive.2
"Because the [HCV] prevalence among health care workers is very low, we do not recommend routine screening of health care workers to identify individuals with infection," says Miriam Alter, PhD, chief of epidemiology in the CDC hepatitis branch. "Health care workers who are exposed to blood in the workplace are at occupational risk of acquiring HCV, primarily as a result of needlestick exposures to blood contaminated with HCV. That is different from the fact that health care workers in general have a low prevalence of HCV infections. We recommend that health care workers with an exposure be followed for infection, rather than recommending that health care workers as a group be screened." (See related story on HCWs’ bloodborne exposures, p. 137.)
The HCV testing policy will be optional for Catholic West hospitals, but those that treat a lot of trauma patients or do liver transplants may consider it more seriously due to heightened risk of exposures or greater prevalence of the virus in the patient population, Fine says. A highly mutable virus for which there is no vaccine, HCV is the leading cause of chronic liver disease in the United States. Overall, some 4 million Americans have HCV antibodies and 2.7 million of those people are chronically infected with the virus.
The risk factors most strongly associated with HCV among people ages 17 to 59 are illegal drug use and high-risk sexual behavior, according to the CDC study by Alter and co-authors. The study also indicates that blood transfusions may have been the source of infection in about 7% of cases.
To avoid false positives and other testing problems, employee health professionals who implement screening programs should follow the CDC testing algorithm for HCV, Alter adds. (See chart, p. 134.) "Obviously, if they are going to do any kind of screening of health care workers, they have to confirm the result," she says. Though the CDC recommends against routine testing, such public health guidelines are not designed to address peripheral issues like worker’s compensation disputes, Alter concedes.
Disputed infections a reality
But the reality that employee health directors face is that workers who have acquired HCV in the community may claim the infection is occupational, and the courts may rule in their favor because blood exposures to HCV patients do carry known risks. "Even if they don’t have a needlestick in the past — or some [exposure] that’s documented — it usually is going to come out that the health care worker gets the benefit of the doubt and is covered for the infection," Fine says.
HCV testing at time of employment could redirect liability claims back to the previous health care employer, she notes, adding that the long-term medical expenses associated with chronic infection can be exorbitant. "You can end up with hepatocellular carcinoma or liver transplants," she says. "While we certainly want to be responsible for the infections that are a result of our employment, we don’t want to have to pay for the ones that aren’t."
In addition, there is a public health aspect, because people can be unaware of their HCV infection for years, unknowingly aggravating the course of the disease by consuming alcohol instead of making lifestyle adjustments, she adds. Indeed, the old mindset that virtually nothing can be done for HCV infection is changing, as more promising therapies with drugs like interferon come into play, says David Van Thiel, MD, director of the liver transplant program at Loyola University Medical Center in Chicago.
"[HCV] is just one of the most important problems we have in the nation, let alone for health care workers, but there’s a lot of misinformation," he says. "The disease is treatable, it is manageable, but most of the people who have it don’t know they have it. The symptoms are pitifully few other than fatigue and malaise. People don’t go to the hospital or go to the doctor because they are tired or have malaise. So people have to become more aware of those kinds of complaints and at least be assessed for hepatitis C."
However, Van Thiel sees both pros and cons to routine HCV testing of health care workers. "Some hospitals are clearly doing it," he says. "It’s an intelligent decision on their part in terms of liability, because if someone comes down with hepatitis C, it’s impossible for the hospital to prove that the individual didn’t acquire it as a consequence of their employment. So from a liability point of view, it’s clearly the way to go. The real concern is that they will use it to blackball’ people or not to hire people. Those are concerns that I think are real. It’s actually against the law not to hire them because of a hepatitis C positive result [i.e., under the Americans with Disabilities Act]."
In that regard, Fine says her policy includes assurances that the test result will not have any effect on employment. "[HCV-positive people] could still work as usual using the normal, standard precautions when caring for patients, so it wouldn’t limit their employment," she says. "Again, [testing] would have to be something that was their option whether to do or not."
Testing source patients a better alternative?
Still, even those workers screened initially negative still could acquire HCV in the community, complicating such testing approaches and raising questions about resource allocation for employee health departments, says Robert Ball, MD, MPH, infectious disease consultant epidemiologist at the South Carolina Department of Health in Columbia.
"Considering that most hepatitis C is not occupationally acquired but extracurricularly’ acquired through needle-sharing and sex, hospitals would have to screen their employees not only at entry but frequently each year," he says. "Even then, what do you do with a positive unless you’ve had a bona fide exposure?"
Indeed, workers who are baseline negative but later test positive may claim they had a needlestick or other exposure they did not report, he notes. "That has actually happened, so the most efficient way to manage those situations is not to test employees regularly and waste precious limited resources, but to require them to report any and all exposures immediately," he says. "Once an exposure incident is reported, immediately test the source patient. In a small percent [of cases] they may not know who the source patient is, but most source patients will be negative. So even if that worker has a negative baseline and positive hep C testing three to six months later, they still didn’t get it from that source patient."
Worker’s comp providers are taking a more aggressive stand in contesting infection claims based on undocumented occupational exposures, so workers need to be told in no uncertain terms, "If you don’t report it at the time, it basically didn’t occur," Ball emphasizes.
"Worker’s comp [providers], with an economic bottom line as their target and the goal of protecting their investment, are going to be looking at these and requiring documentation more and more critically," he says. "They’re basically going to be saying, We’re not going to pay that worker $100,000 to $200,000 or whatever it takes to cover that incident, unless your employee health people can really document that the employee got it occupationally.’"
Still, it’s important to remember that workers exposed to blood in the hospital are clearly at risk, because HCV prevalence in hospitalized patients is generally much higher than in the population at large. Though prevalence will obviously vary by locale, CDC surveillance data indicate that a 1.8% prevalence of HCV in the general population jumps to more than 8% when you look solely at hospital patients, Ball reminds.
But even then, few health care workers will need baseline and follow-up HCV testing, because roughly only one in 10 source patients will be positive for HCV, he adds. So instead of routine screening, Ball advocates that employee health professionals re-emphasize reporting exposures, meticulously document the incidents, and rapidly test source patients in order to determine whether to follow the exposed worker.
"There is still an unfortunate, tragic mindset that since there is no postexposure prophylaxis [for HCV], then nothing should be done, and that is the furthermost thing from the truth," he says. "The health care worker’s future medical prognosis and care, as well as worker’s compensation benefits, [call for] a well thought-out, organized management plan."
Reference
1. Centers for Disease Control and Prevention. Recom mendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47 (No. RR-19):1-39.
2. Alter MJ, Kruszon-Moran D, Nainan OV, et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med 1999; 341:556-562.
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