Literature Review: Early HCV treatment safe and effective
July 1, 2002 3 minutes read
Literature Review
Early HCV treatment safe and effective
Sulkowski MS, Ray SC, and Thomas DL. Needlestick transmission of hepatitis C. JAMA 2002; 287:2,406-2,413.
Hepatitis C presents the greatest risk of bloodborne-pathogen transmission from needlesticks. The authors, physicians at Johns Hopkins School of Medicine in Baltimore, note that "HCV transmission following a single needlestick accident occurs approximately 10 times more often than HIV transmission, the chances of being exposed to an HCV-infected person are roughly five times greater than of being exposed to an HIV-infected person, and there are no approved methods of preventing HCV infection after an exposure.
Thus, HCV infection remains an important occupational threat to health care workers."
Unfortunately, there is no accepted post-exposure prophylaxis for HCV. Even the benefits of early treatment of acute HCV infection have been debated.
"Since 15% to 20% of patients with acute HCV infection spontaneously clear viremia, a case can be made to restrict therapy to persons who still have HCV RNA in their blood after six months, thus sparing some health care workers the potentially adverse effects of [interferon]."
The authors related the case of a 29-year-old medical intern who sustained a needlestick while treating a source patient who was known to be infected with both HIV and HCV. The needlestick occurred when the intern was trying to reinsert an IV catheter.
"I would not have called it a deep wound, maybe 2 mm to 3 mm, but it bled spontaneously," the intern said. "I knew that the patient was hepatitis C- and HIV-positive, so I washed the finger and immediately called the Needle Stick Hotline. Within 45 minutes I had started taking zidovudine, lamivudine, and nelfinavir."
Further testing showed that the source patient had a low-HIV viral load, making transmission unlikely. Thirteen days after the exposure, the intern developed a rash and a fever. HCV RNA testing at two weeks post-exposure revealed an acute infection.
"It remains unclear whether his transient rash and asthenia were due to the HCV infection, another virus, or the PEP medications," the authors note.
Virological testing continued every two to four weeks, and after eight months of sustained viremia, the intern decided to begin treatment with PEG-interferon and ribavirin, the article said.
"Within a few hours after that first injection, it felt like instant influenza," the intern related. "I had fever, myalgia, headache, and fatigue, despite taking [nonsteroidal anti-inflammatory drugs] and drinking more fluids than usual. I felt horrible. I ended up sleeping for the better part of a day after the treatment, and over the next several days the symptoms subsided. I felt almost back to normal after five to six days."
Over time, the symptoms began to subside more quickly after treatment, the intern said. But other concerns arose. The intern began losing weight, losing hair, and suffering from depression. With medication, the depression eased.
"After 10 weeks of treatment, and again six months following completion of a six-month course, qualitative testing revealed no detectable HCV RNA. Therefore, the patient has had a sustained virological response," the authors said.
The authors stopped short of recommending anti-viral treatment for acute HCV infection following a needlestick exposure.
"The optimal treatment strategy and regimen to prevent chronic HCV infection after occupational exposure is not clear; however, treatment during acute infection appears to be safe and effective," they stated.
"The high prevalence of HCV in hospitalized patients and the questions about management of occupational exposure underscore the importance of being vigilant for acute infection and of promptly referring patients with acute HCV infection to experienced clinicians who can provide updated counseling and treatment to health care workers who acquire HCV infection," the authors said.
The authors also noted that the risk of transmission of HCV relates to the HCV RNA levels in the source patient. The risk is also greater with exposure to hollow-bore needles, they said.
"Most occupational HCV transmission follows breaks in the skin, especially those made by hollow-bore needles that are removed from a patient with a high HCV RNA level and then inadvertently injected into subcutaneous tissues," they reported.
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