Weighing worker, employer issues for HCV testing
February 1, 2000 4 minutes read
Weighing worker, employer issues for HCV testing
By Patrick Joseph, MD
Chief of epidemiology, San Ramon (CA) Regional Medical Center
Summit Medical Center
Oakland, CA
Hepatitis C virus (HCV) disease remains epidemic in the United States, and health care workers are clearly at risk for occupationally acquired HCV infection. As a result, many infection control professionals have designed protocols that include postexposure serologic hepatitis C testing to diagnose infection and, perhaps, allow the institution of early therapy.
Subsequently, there have been informal discussions about the possibility of routinely screening health care workers at the time of initial employment to identify unrecognized HCV infection. ("Rou tine" in this setting means testing for HCV antibody without suspected or known exposure.)
Furthermore, some have advocated repeat testing at periodic intervals. Because there are medical, social, and financial implications of any testing policy, it is reasonable to consider the potential roles and limitations of routine testing for HCV in health care workers. Reasons to obtain routine HCV testing include the following:
1. Benefit to the health care worker (to identify the person who unknowingly is infected and provide valuable personal information to this individual), thus providing an altruistic service in this era of a silent epidemic.
2. To identify those who may pose a risk to patients for employee-patient transmission of HCV. At least at present, with very few documented cases of caregiver-to-patient transmission, this seems to be of questionable significance.
3. Risk management for the employer: To identify the health care worker who was infected prior to employment, thereby reducing the risk of workers’ compensation liability for the employer in the event that the health care worker subsequently is found to be HCV-positive.
Cost issues are among the reasons not to do routine HCV testing of health care workers. Also, work restrictions for HCV-positive health care workers presently are not indicated. Not surprisingly, the financial determinant seems to be the driving force, since there are valid medical reasons to do HCV testing. If HCV testing were free or as simple as a urine dipstick, I suspect many, if not most, employers would offer or require routine testing for all health care workers — at least at the time of employment and perhaps, as an employee benefit, at periodic intervals. But that’s not the case. Hepatitis C testing is not free. Applied nationally, the cost would be staggering. Therefore, any policy for routine (non-postexposure) HCV testing of health care workers should be based on a clear reason for identifying those who are seropositive.
Financial issue a driving force
It would be wonderfully altruistic if employers would offer HCV testing purely as a benefit for employees, to identify those who may benefit from therapy. However, considering the financial pressures on health care providers, this approach is unlikely to be widely accepted. In fact, if we could allocate funds to disease screening for our employees, we might provide a better service and a better use of funds by testing for other "silent diseases," the early treatment of which is more likely to provide benefit to the health care worker (e.g. hypertension, hyperlipidemia, hyperglycemia, hepatitis B, or even coronary artery disease). At the present time, a policy of widespread screening to identify HCV-positive employees to reduce the risk of transmission to patients is unsubstantiated by scientific data. So the most likely reason for approving the development of a routine screening policy for hepatitis C would seem to be to benefit the employer.
This is not to imply that any particular policy is unethical or inappropriate, but rather that before design, the goal of the policy should be clearly understood by all persons involved. If this latter goal is adopted, subsequent validation of the expense should be sought. Specifically, is it known that employers have borne the expense of workers’ compensation hepatitis C claims when it is likely that the employee did not acquire the infection at work? If this suspicion is probable or proven, the costs for pre-employment screening of hepatitis C in new employees should be explored.
In reality, the cost/benefit ratio for routine hepatitis C screening of health care workers remains undefined. To reach a specific definition, one must identify all components of the costs (testing, reporting, recording, record keeping, and time for explaining positive and negative results) and the benefit to the bearer of the cost.
An example of pre-employment screening might be tabulated as follows: test cost ($15 each); laboratory handling cost ($5 per person); employee health counseling and record keeping (about 15 minutes, $10). Thus, an estimated $30 would be required for each test. If 300 new employees per year were hired by this facility, the cost would be approximately $9,000 per year, or $90,000 over the next 10 years.
One must weigh these costs against the expense of workers’ compensation coverage and the likelihood that an employee would be incorrectly considered to have acquired hepatitis C on the job if no baseline data were available. Thus far, it appears that this issue is similar to most in which the driving force is allocation of limited health care resources. The answers will likely vary and will be specific to the preferences of decision makers at each institution.
Clearly, we need more data about the incidence and risk of hepatitis C in health care workers and the financial consequences to employers of unscreened workers who are found to be positive after employment. Until these data are available, I am reluctant to recommend widespread pre-employment HCV testing for all hospitals, clinics, doctors offices, labs, blood banks, and every other place in which a needlestick might occur. My hunch is that our limited funds would be more wisely applied elsewhere.
(Editor’s note: Patrick Joseph, MD, is the consulting editor of Hospital Infection Control.)
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