Hepatitis C: Approach to the HCW with a Potential Exposure
January 1, 1998 3 minutes read
Hepatitis C: Approach to the HCW with a Potential Exposure
ABSTRACT & COMMENTARY
Synopsis: Conservative recommendations are best initially regarding precautions against transmission from a potentially-infected HCW to others. A long-term approach, especially with regard to safe-sex practices, can be decided upon in consultation with the HCW's follow-up physician.
Source: CDC. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. JAMA 1997;278:1056-1057.
The cdc, in collaboration with the hospital Infection Control Practices Advisory Committee, has outlined some minimum guidelines with regard to the hepatitis C virus (HCV) should a health care worker (HCW) receive a percutaneous or mucosal exposure to blood. They are: 1) baseline anti-HCV testing for the source patient; 2) baseline and six-month testing for the exposed individual for anti-HCV and alanine aminotransferase; 3) confirmatory testing if either the source or exposed individuals are found to be repeatedly positive for anti-HCV; 4) recommendation against postexposure prophylaxis with immune globulin or interferon; and 5) continued educational efforts regarding bloodborne infection and the HCW.
Several of these points are augmented in the paper. The seroconversion rate after percutaneous exposure to the blood of an HCV-positive patient is, on average, 1.8% (range, 0-7%); seroconversion rates after mucous membrane exposure are not known, but the virus can be transmitted in this manner. Whereas the mean interval from exposure to seroconversion is 8-10 weeks, there is a high rate of false-positivity and false-negativity inherent in the anti-HCV enzyme immunoassay, thus making confirmation and exclusion of transmission a complex issue. The failure of immune globulin to prevent infection after exposure has been shown, so it is not recommended; the case against interferon has not been tested per se in the literature, but inferential data coupled with the side-effect profile of interferon has led to the recommendation against its use in the prevention scenario.
Some final points were made with regard to transmission of HCV to others. Admittedly, anyone who is anti-HCV positive is potentially infectious-unfortunately, the modes of transmission are not well-understood, making post-exposure precautions seem nebulous. For example, it is advised that household contacts should not share razors or toothbrushes with the potentially infected individual, yet there are no recommendations against pregnancy and breast-feeding. It is also not recommended that the individual change sexual practices with a steady partner. There is a risk of transmission through sex, but it is felt to be sufficiently low so as not to merit a change in sexual practices with a steady, long-term partner. Obviously, the HCW should be counseled not to donate blood or body tissues until transmission of the virus has been ruled-out.
COMMENT BY RICHARD A. HARRIGAN, MD, FACEP
This is a scary disease. Chronic liver disease occurs in approximately 70% of HCV-infected individuals.1 Within this group, approximately 20% will develop cirrhosis within 20 years, and about 1-5% develop hepatoma.2 It is essential for us to obtain the appropriate demographic data and blood studies from the source patient and the exposed HCW, with chart documentation being paramount. Importantly, but unfortunately, there is no medicinal therapy we can offer the HCW who has suffered an exposure to HCV-contaminated blood. I feel conservative recommendations are best initially regarding precautions against transmission from a potentially-infected HCW to others. A long-term approach, especially with regard to safe-sex practices, can be devised in light of blood test results and after the patient has had time to digest and reflect upon the event. (Dr. Harrigan is Associate Professor of Medicine, Temple University School of Medicine, and Associate Research Director, Division of Emergency Medicine, Temple University Hospital, Philadelphia, PA.) v
References
1. Alter MJ. Semin Liver Dis 1995;15:5-14.
2. Tice A. Emerg Med Alert 1997;4:30-31.
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