Liability issues fuel HCV screening debate
Workers’ comp, public health benefits cited
Citing both hospital liability and health benefits, infection control professionals have joined in a growing debate about whether health care workers should be routinely tested for hepatitis C virus. While some weighing the pros and cons have concluded that limited health care resources would be best spent elsewhere, others argue that it is time to consider voluntary HCV testing policies. Regardless, there is growing consensus that HCV is eclipsing HIV as the prime occupational infection issue of the future.
"We’re seeing fewer and fewer long-term HIV patients in the hospital because of the protease inhibitors and all [the other drug therapies]," says Sue Felt, RN, infection control professional at San Francisco General Hospital. "And we can all get vaccinated against hep B, but hep C is still rather prevalent in our patient population and certainly a risk. It is much easier to transmit than HIV."
In addition, HCV increasingly raises troubling liability issues because workers infected through other risk factors may claim a job exposure caused the disease, she notes. "In cases in the past — not specifically about hepatitis C — health care workers have often prevailed in the courts, even if there was no initial report of injury," she says. "It’s presumed, for instance, if you get TB and you are a health care worker, that you probably got it at work."
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.1 The risk factors most strongly associated with HCV traditionally have been a history of transfusions and injecting drug use. Many of those infected are undiagnosed, as HCV is often asymptomatic in those carrying the virus. Routine testing of health care workers is one way to flush out some of those "silent infections," which may be helped by treatment intervention, Felt says. "At least the [health care worker] can get a diagnostic work-up," she says. "In a city like San Francisco, where there are quite a number of clinical trials going on with hepatitis C treatment, I think that it is a good public health move to test people and recommend that those [who are HCV-] positive avail themselves of treatment."
Voluntary HCV test offered
Felt has not recommended such a routine testing policy yet at her hospital, but a colleague in Oakland is moving ahead with a voluntary worker-testing program based on a similar rationale. Citing both medical and hospital liability issues, an infection control consultant for the Catholic Healthcare West chain of 48 hospitals is recommending that HCV screening programs be considered by the facilities. "I am recommending 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. "[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 in order to make an informed decision about whether they want to be voluntarily tested, she says. (See form, p. 12.) 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.
Was infection acquired in community?
Echoing Felt’s sentiments, Fine says another motivating factor is that workers who have acquired HCV in the community may claim the infection is occupational. "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 concern, 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. In addition, Fine says her policy includes assurances that the test result will not have any effect on employment. "[Those who are HCV-positive] 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." Centers for Disease Control and Prevention guidelines state that the agency does not recommend routine testing of health care workers for HCV "unless they have risk factors for infection."2 Fine says her policy for routine HCV testing of workers whose jobs may involve blood exposures is in keeping with that guidance, particularly because all existing protocols for testing source patients and following workers after exposures will remain in place.
Still, health care employment was not associated with heightened risk for hepatitis C virus infection in recent CDC data, as only 1.4% of 769 people reporting a history of medical-related occupation had HCV antibodies, reports the CDC.1 However, infection control professionals should note that workers exposed to blood in health care settings are still at risk of HCV infection and should be followed accordingly.
"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."
In addition, even workers who initially screen negative still could acquire HCV in the community, complicating such testing approaches and raising questions about resource allocation, says Robert Ball, MD, MPH, infectious disease consultant epidemiologist at the South Carolina Department of Health in Columbia. "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."
References
1. 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.
2. 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.
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