Hepatitis C cure rates top 40%, but CDC balks at recommending post-exposure prophylaxis policy
October 1, 2000 5 minutes read
Hepatitis C cure rates top 40%, but CDC balks at recommending post-exposure prophylaxis policy
Infected worker: Let mine be the last horror story’
Citing dramatic advances in cure rates with combination drug therapy for hepatitis C virus (HCV) infections, some clinicians at the recent Frontline Healthcare Workers Safety Conference in Washington, DC, called on public health officials to recommend post-exposure prophylaxis (PEP) for needlesticks involving HCV-positive blood.
Once considered virtually untreatable, HCV now is the subject of a new sense of urgency to "use current therapies as primary prophylaxis to [protect] the 500 to 700 health care workers a year in this country who otherwise would be doomed to occupationally acquired hep C," said Robert Ball, MD, an infectious disease physician at the University of South Carolina in Columbia and an epidemiologist at the state department of health.
The Centers for Disease Control and Prevention (CDC) is in the process of revising its post-exposure guidelines for bloodborne pathogens, but it is not expected to officially recommend a PEP protocol for HCV due to data limitations and concerns about side effects with the available drugs, Hospital Employee Health learned at the Aug. 6-8 conference.
"At this point, I don’t think we are going to add post-exposure prophylaxis for hepatitis C yet," explained Denise Cardo, MD, chief of the HIV infections branch in the CDC’s hospital infections program, "because we don’t have enough information. With the drugs available, the risk of getting a huge side effect is much higher than getting the infection. Early treatment [after seroconversion] is a good option, but we still need to learn a little bit more. If you look at the [HCV] guideline right now, it doesn’t say don’t do [early treatment]. It says consider.’ That is what many institutions are doing. We encourage them to do PCR [testing] four to six weeks after the exposure, and if they detect infection, then treat."
Nevertheless, the CDC’s hesitancy to endorse PEP with HCV drugs immediately after an exposure does not sit well with Ball. "If institutional memory serves me correctly, we had no data in the late ’80s when we as health care professionals were putting workers on AZT monotherapy early on — indeed same-day stat — post-exposure prophylaxis," he told meeting attendees. "The [CDC] hospital infections program collected that data for a number of years until we actually had proof that what we were doing intuitively worked. I suggest that the same approach now will save lives from this point on."
A silent epidemic finds its voice
In an interview at the conference, Ball cited data indicating a 41% cure rate — two of five patients — for HCV with a combination of interferon and ribavirin.1 "We no longer have the luxury of waiting until hepatitis C declares itself as chronic liver disease or cirrhosis, because by then, the return on investment — the cure rates — are much lower,"
he said. "We must intervene early, and as early as possible for the exposed health care worker means same-day response. This is exactly what we were doing with AZT for HIV in the late ’80s. Why aren’t we doing the same thing for hepatitis C? I think there ought to be a more aggressive recommendation from the CDC."
Of the roughly 400,000 U.S. health care worker needlestick exposures annually, 20,000 to 30,000 are to HCV, Ball said. (See HEH, February 2000, pp. 19-20.) Of those exposed health care workers, 500 to 700 will acquire the disease, though symptoms may not appear for years. When they do, the effect can be devastating, as evidenced by the case of Diane Mawyer, RN, who received a standing ovation after describing her grim odyssey from HCV blood exposures in the 1980s to liver and kidney transplants in the 1990s. (See story, below right.)
"If I had access to the safety devices and treatments available today, perhaps my transplants could have been avoided, and I wouldn’t be here telling this horrible story," she told conference attendees. "No matter what your role in the health care system — caregiver, administrator, researcher, government regulator, or manufacturer of medical devices — I beg you, do not underestimate the risk to health care workers. Do everything in your power to develop, provide, and utilize the best safety devices. And provide the best possible post-exposure treatment. . . . Please, let mine be the last horror story you hear."
Unfortunately, there are "most certainly" other health care workers like Mawyer who will begin experiencing symptoms related to an HCV exposure in the past, said John Wong, MD, a physician at Tufts University Medical Center in Medford, MA, who spoke on HCV at the conference. Those who have concerns (such as a history of documented needlesticks) may want to be tested and seek the benefits of early treatment, he told HEH.
"[Approximately] 85% who are acutely infected go on to develop progressive, chronic liver disease," Wong said. "But for the most part, the disease is asymptomatic — up to 20 years and even longer. There are 5% of patients who are rapid progressors, 90% average progressors, and another 5% who are slow progressors. Health care workers might have acquired infection during the ’80s who were asymptomatic when they got it acutely and have remained pretty much asymptomatic over the next 10 or 20 years. And unless they have had blood tests to look at liver enzymes, which is not necessarily routinely done, or [they] identified a needlestick injury, they won’t be aware."
Noting that HCV already is responsible for 8,000 to 10,000 deaths per year, Wong said some computer projection models suggest that HCV deaths and cases of cirrhosis will continue to increase until 2010 to 2020. "We have an opportunity now to potentially treat some of those cases earlier, when they are more likely to respond to therapy," he said. "If you progress to the point where you have very advanced liver disease, there is no treatment except liver transplant, and there is a tremendous shortage of liver donor organs."
Indeed, hepatitis C has taken an insidious toll as the leading cause of chronic liver disease and liver transplants in the United States. A highly mutable virus for which there is no vaccine, HCV infection far exceeds the estimated 1 million U.S. infections with HIV. Some 4 million Americans have HCV antibodies, and 2.7 million of those people are chronically infected with the virus.2
References
- Liang JT, Rhermann, Seeff, et al. NIH conference: Pathogenesis, natural history, treatment, and prevention of hepatitis C. Ann Intern Med 2000; 132:296-305.
- Alter MJ, Kruszon-Moran D, Nainan OV, et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Eng J Med 1999; 341:556-562.
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