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APIC position paper: Hepatitis C exposure in the health care setting
APIC position paper: Hepatitis C exposure in the health care setting 1998 APIC Guidelines Committee Association for Professionals in Infection Control and Epidemiology, Inc 1998 APIC Guidelines Committee Martha G. DeCastro, RN, MS, CIC (Chair) Gerald A. Denys, PhD, ABMM Loretta L. Fauerbach, MS, CIC Joanne K. Ferranti, RN, BSN, CIC Kathryn Hawkins, MT, BS, CIC Linda C. Masters, MPH, CIC David Rimland, MD Robert J. Sharbaugh, PhD, CIC Jolynn Zeller, RN, BS, CIC The Association for Professionals in Infection Control and Epidemiology, Inc (APIC), is a multidisciplinary, voluntary, international organization of professionals who practice infection control and the application of epidemiology in all health settings. APIC is an international leader in prevention and control of infection transmission. (AJIC Am J Infect Control 1999;27:54-5)
Hepatitis C virus (HCV) is the etiologic agent in most cases of parenterally transmitted non-A, non-B hepatitis in the United States, but it is also a significant cause of spontaneous cases of viral hepatitis. The annual incidence of newly acquired HCV infections has decreased from an estimated 180,000 in 1984 to 28,000 in 1995, mostly because of the ability to screen transfused blood. More than 80% of persons infected with HCV become chronically infected, and chronic liver disease develops in most of these persons. An estimated 3,500,000 persons are chronically infected in the United States alone. Current therapy for chronic hepatitis C includes interferon with or without Ribavirin, but response rates are poor and seldom long-lasting.
nant immunoblot assay or polymerase chain reaction) is indicated in most situations.
SEROLOGIC TESTING
OCCUPATIONAL HAZARDS
Enzyme immunoassays for the detection of antibody to HCV (anti-HCV) have now been improved and detect >95% of persons with HCV infection. Unfortunately, these assays do not detect anti-HCV in all infected persons and cannot differentiate acute, chronic, or resolved infections. Confirmation of the enzyme immunoassays with other serologic tests (eg, recombi-
Health care workers account for 2% to 4% of acute cases of hepatitis C, and most cases are thought to be a result of accidental needle sticks. The prevalence of antiHCV among hospital-based health care workers is about 1% but is as high as 2% in oral surgeons. In follow-up studies of health care workers with percutaneous exposures to HCV-infected patients, anti-HCV developed in 0% to 7% of the workers. A single study looking at development of HCV infection by polymerase chain reaction found that 10% of health care workers exposed by a percutaneous route were infected. Mucous membrane exposures to blood rarely transmit HCV. Because 1% to 2% of the US population is infected with HCV, the potential for infection from percutaneous exposures should be con-
Reprint requests: APIC, 1275 K St NW, Suite 1000, Washington, DC 20036. Copyright © 1999 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/99/$8.00 + 0
54
17/52/94655
TRANSMISSION Transfusion of infected blood and blood products accounted for the majority of HCV infection before the introduction of anti-HCV screening. Other parenteral risk factors for HCV include injection drug use, tattoos, body piercing, and needle-stick accidents. A substantial proportion of cases of acute HCV infection now has no identifiable risk factor except for “low-economic status.” Sexual transmission is thought to be uncommon, but perinatal transmission occurs from 5% to 6% of infected mothers.
AJIC
APIC Guidelines Committee 55
Volume 27, Number 1
sidered. Unfortunately, no prophylactic measures are available at this time. No vaccine has been developed, and current formulations of immune serum globulin are not effective for prevention of HCV. Interferon, with or without Ribovirin combination therapy, is approved only for the treatment of chronic infection. HOSPITAL POLICIES No measures are currently available to prevent infection with HCV after an exposure. Health care facilities should develop policies to determine the HCV status of all persons involved in potential exposures (ie, source and exposed persons). In turn, postexposure procedures for follow-up of the exposed persons also should be developed and implemented. Furthermore, education of health care workers about the risk and prevention of occupational transmission of all bloodborne pathogens should be emphasized.
We acknowledge Robert J. Sharbaugh, PhD, CIC, for his efforts in the development of this manuscript.
Suggested Reading 1. Alter MJ. Occupational exposure to hepatitis C virus: A dilemma. Infect Control Hosp Epidemiol 1994;15:742-4. 2. Beekman SE, Henderson DK. Healthcare workers and hepatitis: risk for infection and management of exposures. Infect Dis Clin Pract 1992;1:424-8. 3. CDC. Recommendations for follow-up of healthcare workers after occupational exposure to hepatitis C virus. MMWR Morb Mortal Wkly Rep 1997;46:603-6. 4. Cuthbert JA. Hepatitis C: progress and problems. Clin Microbiol Rev 1994;7:505-32. 5. Lanphear BP, Linnemann CC, Cannon CG, et al. Hepatitis C virus infection in healthcare workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994;15:745-50. 6. NIH. Management of hepatitis C. NIH consensus statement. 1997;15:1-41. 7. Suzuki K, Mizokami M, Lau JYN, et al. Confirmation of hepatitis C virus transmission through needlestick accidents by molecular evolutionary analysis. J Infect Dis 1994;170:1575-8.
Hepatitis C virus (HCV) is the etiologic agent in most cases of parenterally transmitted non-A, non-B hepatitis in the United States, but it is also a significant cause of spontaneous cases of viral hepatitis. The annual incidence of newly acquired HCV infections has decreased from an estimated 180,000 in 1984 to 28,000 in 1995, mostly because of the ability to screen transfused blood. More than 80% of persons infected with HCV become chronically infected, and chronic liver disease develops in most of these persons. An estimated 3,500,000 persons are chronically infected in the United States alone. Current therapy for chronic hepatitis C includes interferon with or without Ribavirin, but response rates are poor and seldom long-lasting.
nant immunoblot assay or polymerase chain reaction) is indicated in most situations.
SEROLOGIC TESTING
OCCUPATIONAL HAZARDS
Enzyme immunoassays for the detection of antibody to HCV (anti-HCV) have now been improved and detect >95% of persons with HCV infection. Unfortunately, these assays do not detect anti-HCV in all infected persons and cannot differentiate acute, chronic, or resolved infections. Confirmation of the enzyme immunoassays with other serologic tests (eg, recombi-
Health care workers account for 2% to 4% of acute cases of hepatitis C, and most cases are thought to be a result of accidental needle sticks. The prevalence of antiHCV among hospital-based health care workers is about 1% but is as high as 2% in oral surgeons. In follow-up studies of health care workers with percutaneous exposures to HCV-infected patients, anti-HCV developed in 0% to 7% of the workers. A single study looking at development of HCV infection by polymerase chain reaction found that 10% of health care workers exposed by a percutaneous route were infected. Mucous membrane exposures to blood rarely transmit HCV. Because 1% to 2% of the US population is infected with HCV, the potential for infection from percutaneous exposures should be con-
Reprint requests: APIC, 1275 K St NW, Suite 1000, Washington, DC 20036. Copyright © 1999 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/99/$8.00 + 0
54
17/52/94655
TRANSMISSION Transfusion of infected blood and blood products accounted for the majority of HCV infection before the introduction of anti-HCV screening. Other parenteral risk factors for HCV include injection drug use, tattoos, body piercing, and needle-stick accidents. A substantial proportion of cases of acute HCV infection now has no identifiable risk factor except for “low-economic status.” Sexual transmission is thought to be uncommon, but perinatal transmission occurs from 5% to 6% of infected mothers.
AJIC
APIC Guidelines Committee 55
Volume 27, Number 1
sidered. Unfortunately, no prophylactic measures are available at this time. No vaccine has been developed, and current formulations of immune serum globulin are not effective for prevention of HCV. Interferon, with or without Ribovirin combination therapy, is approved only for the treatment of chronic infection. HOSPITAL POLICIES No measures are currently available to prevent infection with HCV after an exposure. Health care facilities should develop policies to determine the HCV status of all persons involved in potential exposures (ie, source and exposed persons). In turn, postexposure procedures for follow-up of the exposed persons also should be developed and implemented. Furthermore, education of health care workers about the risk and prevention of occupational transmission of all bloodborne pathogens should be emphasized.
We acknowledge Robert J. Sharbaugh, PhD, CIC, for his efforts in the development of this manuscript.
Suggested Reading 1. Alter MJ. Occupational exposure to hepatitis C virus: A dilemma. Infect Control Hosp Epidemiol 1994;15:742-4. 2. Beekman SE, Henderson DK. Healthcare workers and hepatitis: risk for infection and management of exposures. Infect Dis Clin Pract 1992;1:424-8. 3. CDC. Recommendations for follow-up of healthcare workers after occupational exposure to hepatitis C virus. MMWR Morb Mortal Wkly Rep 1997;46:603-6. 4. Cuthbert JA. Hepatitis C: progress and problems. Clin Microbiol Rev 1994;7:505-32. 5. Lanphear BP, Linnemann CC, Cannon CG, et al. Hepatitis C virus infection in healthcare workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994;15:745-50. 6. NIH. Management of hepatitis C. NIH consensus statement. 1997;15:1-41. 7. Suzuki K, Mizokami M, Lau JYN, et al. Confirmation of hepatitis C virus transmission through needlestick accidents by molecular evolutionary analysis. J Infect Dis 1994;170:1575-8.