- Email: [email protected]
Tolerability of HIV postexposure prophylaxis among healthcare workers
112
Letters to the Editor A.J. Francee, D. Nathwanie a Department of Infectious Diseases, Castle Hill Hospital, Hull & East Yorkshire Hospitals NHS Trust, Hull, UK b Department of Public Health, Tayside Health Board, Kings Cross Hospital, Dundee, UK c Infection Control, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK d Microbiology, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK e Infection Unit, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK E-mail address: [email protected]
unit staff. To overcome conflicts of interest about bed use, NHS trusts should consider empowering infection control teams as the final arbiters of side/isolation room use.
Acknowledgements The authors wish to thank Prof P. Davey, Professor of Pharmacoeconomics, Medicines Monitoring Unit, University of Dundee, Dundee, UK; Drs A. MacConnachie and J. Ferguson, Senior House Officers, Infection Unit, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK; Ms K. Craig, Infection Control Nurse, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK; and all nursing staff on Wards 5, 8, 9, 11, 15 and 31 at Ninewells Hospital and Wards 9 east and 8 at Kings Cross Hospital.
References
Available online 15 August 2005
1. Barlow GD, Sachdev N, Nathwani D. The use of isolation facilities in a United Kingdom infectious diseases unit. J Hosp Infect 2002;50:127—132. 2. Damji S, Barlow GD, Patterson L, et al. An audit of the use of isolation facilities in a UK National Health Service trust. J Hosp Infect 2005;60:213—217. 3. Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobialresistant Staphylococcus aureus, Enterococcus, Gram-negative bacilli, Clostridium difficile, and Candida. Ann Intern Med 2002;136:834—844. 4. Solomkin JS, Bjornson HS, Cainzos M, et al. A consensus statement on empiric therapy for suspected Gram-positive infections in surgical patients. Am J Surg 2004;187:134—145. 5. Infection control policy. Tayside Health Board, Department of Public Health; 1994. 6. Cooper BS, Stone SP, Kibbler CC, et al. Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature. BMJ 2004;329:533. 7. Lewis AM, Gammon J, Hosein I. The pros and cons of isolation and containment. J Hosp Infect 1999;43:19—23. 8. Cepeda JA, Whitehouse T, Cooper B, et al. Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study. Lancet 2005;365:295—304.
G.D. Barlowa,*, J. Knightb, I. McKayc, G. Oranged, G. Phillipsd, S. Kitec, J. Morrisone,
*Corresponding author. Tel.: C44 1482 875875. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.05.006
Tolerability of HIV postexposure prophylaxis among healthcare workers
Sir, Antiretroviral postexposure prophylaxis (PEP) is widely used after potential exposures to human immunodeficiency virus (HIV) to reduce the risk of infection in the healthcare setting. Few data are available on the safety and tolerability of antiretroviral drugs among healthcare workers (HCWs) who are prescribed prophylaxis. We reviewed registry data on occupational HIV exposures, the PEP regimens used, and the side effects associated with PEP. The study was approved by the institutional review board committee. From 1998 to 2003, 820 episodes of 816 HCWs were registered after a recent exposure event that carried a risk for HIV transmission. Nurses (27%) were the largest group of HCWs at risk, followed by
Letters to the Editor medical students (21%) and nurse aids (17%). Other HCWs at risk were physicians (10%), housekeepers (8%), laboratory technicians (7%), nurse and nurse aid students (6%), and others (4%). The source patient was known in 642 (78%) of the episodes. Of these, 125 (15%) were known to be HIV-positive at the time of exposure. The majority [676 (82%)] of exposures were percutaneous; 103 (13%) were mucous membrane and 41 (5%) were skin exposures. Sixty-four HCWs were prescribed HIV PEP and 70% of HIV PEP regimens consisted of two drugs. The others consisted of three drugs (22%), one drug (6%) and four drugs (2%). The initial prescribed antiretroviral drugs were zidovudine (38%), lamivudine (33%), indinavir (11%), didanosine (10%), nevirapine (1%), ritonavir (1%) and nelfinavir (1%). The most common drug combinations were zidovudine and lamivudine together, with or without indinavir. Thirty-two (50%) HCWs completed all of the drugs in the regimen as prescribed. The regimen was changed in four (6%) HCWs because of adverse drug events. Of the 32 HCWs who discontinued all PEP drugs earlier than the intended duration of prophylaxis, 13 (36%) did so because the source patient turned out to be HIV-negative and 12 (33%) had adverse effects attributed to PEP drugs. Overall, 18 (28%) HCWs reported some symptoms while on PEP. The adverse effects were nausea (33%), vomiting (20%), dizziness (14%), fatigue (12%), diarrhoea (6%), rash (2%), hepatitis (2%), haematuria (2%), abdominal pain (2%), headache (2%), anorexia (2%) and flu-like symptoms (2%). Two (3%) HCWs were reported to have serious adverse effects. The first HCW developed a generalized erythematous rash, fever and abnormal liver function tests after two days of PEP (zidovudine, lamivudine, nevirapine) initiation. Nevirapine hypersensitivity was diagnosed. A new regimen was started after the first regimen had been discontinued for a week and was completed without any adverse effects. The second HCW developed gross painless haematuria and flank pain after two weeks of indinavir as part of a PEP regimen (zidovudine, lamivudine, indinavir). Ultrasonography showed no evidence of nephrolithiasis or obstruction of the urinary tract. Gross haematuria and flank pain may be caused by small ureteric stones. He improved after indinavir was changed to nelfinavir and with hydration. None of the HCWs were reported to have HIV seroconversion during the study period. This retrospective study showed a high frequency of clinical adverse effects, although they were rarely severe or serious. We may have underestimated the occurrence of adverse events as there appeared to be a greater tendency to
113 report adverse effects when HCWs had symptoms. The toxicity profile of antiretroviral agents is a relevant consideration. All antiretroviral agents were associated with adverse effects, especially gastrointestinal symptoms.1 Adverse effects of antiretroviral drugs have been reported for patients with HIV infection but this may not reflect the experience of uninfected people. Our report showed that one-third of HCWs had to stop taking the drugs. As the treatment duration of PEP influenced the success of chemoprophylaxis in an animal model,2 an important goal of PEP is to encourage and facilitate compliance with a four-week PEP regimen. Adverse effects of antiretroviral drugs were frequent reasons for the discontinuation or modification of therapy, as well as PEP.3 The tolerability of PEP regimens among HCWs was therefore poor, mainly due to gastrointestinal effects, leading to an incomplete course. This, in turn, compromised treatment efficacy. Severe toxicities associated with nevirapine administration for PEP have been reported.4 The US Public Health Service do not recommend using nevirapine for basic or expanded PEP regimens.4,5 Some have suggested use of a short course, half dose of a nevirapine-containing regimen,6 but adverse effects could occur. Protease inhibitors have been commonly associated with gastrointestinal side effects,3 and a few cases of nephrolithiasis have been reported.7 In conclusion, adverse effects from HIV PEP were common. Appropriate counselling for the exposed HCW is crucial, and the risk of infection should be weighed against the potential toxicity of antiretroviral agents. Finally, education efforts aimed at occupational exposure prevention are still important.
References 1. Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med 2003;348:826—833. 2. Tsai CC, Emau P, Follis KE, et al. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. J Virol 1998;72: 4265—4273. 3. Lee LM, Henderson DK. Tolerability of postexposure antiretroviral prophylaxis for occupational exposures to HIV. Drug Saf 2001;24:587—597. 4. Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures—worldwide, 1997–2000. MMWR Morb Mortal Wkly Rep 2001;49:1153— 1156.
114
Letters to the Editor
5. U.S. Public Health Service. Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001;50:1—52. 6. Rey D, Partisani M, Hess-Kempf G, et al. Tolerance of a short course of nevirapine, associated with 2 nucleoside analogues, in postexposure prophylaxis of HIV. J Acquir Immune Defic Syndr 2004;37:1454—1456. 7. Swotinsky RB, Steger KA, Sulis C, et al. Occupational exposure to HIV: experience at a tertiary care center. J Occup Environ Med 1998;40:1102—1109.
S. Kiertiburanakula,*, B. Wannayingb, S. Tonsuttakulb, P. Kehachindawatb, S. Apivanichb, S. Somsakulb, K. Malathuma a Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand b Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand E-mail address: [email protected] Available online 15 August 2005
*Corresponding
author. Tel.: C662 201 1922; fax: C662 201
2107. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.04.013
No carriers of hepatitis C among operating room personnel in a university hospital setting in The Netherlands
Sir, Transmission of hepatitis C virus (HCV) from patients to healthcare workers and vice versa can occur through parenteral or percutaneous exposure, such as needlestick injuries. The average incidence of seroconversion to HCV after a needlestick injury from an HCV-positive source is 1.8% (range 0–7%).1 The risk of infection is relatively low and the infection rate in healthcare workers ranges from 0.0 to 0.9%.2–5 Operating room personnel are amongst the most intensively exposed to blood and body fluids.
Since healthcare workers are generally tested only after possible exposure to HCV, prevalence studies among operating room personnel in developed countries are few.6 We therefore wanted to establish the prevalence of hepatitis C among operating room personnel in our university hospital. Therefore, we conducted a crosssectional seroprevalence survey among operating room personnel using anti-HCV enzyme-linked immunosorbent assay testing (AxSYM System, HCV version 3.0, Abbott Laboratories, Chicago, IL, USA). We also assessed demographics and other variables, such as potentially unsafe practices, by means of a questionnaire. Participants were divided into a high-risk group consisting of surgeons (including surgical residents) and operative nurses providing direct surgical care, and a low-risk group consisting of anaesthetists and others providing anaesthetic care. The study was approved by the Medical Ethics Committee of the Leiden University Medical Centre. Informed consent was obtained from all participants. Investigators were blinded to the identity of the participants. Surveys were distributed to 226 surgical ward workers, and 81 surveys (response rate 35.8%) were returned (35.9% from the high-risk group and 35.6% from the low-risk group). There were 15 male and 66 female participants of mean age 40.1 years (SD 11.5, range 21–63 years). Only one out of 52 surgeons participated, possibly due to concerns about blinding, and anxiety about occupational and financial consequences if found to be positive for HCV. Consequently, the high-risk group consisted of one surgeon and 49 operative nurses, whereas the low-risk group consisted of 17 anaesthetists and 14 others providing anaesthetic care. None of the participants were positive for HCV. The median number of exposures to blood and other body fluids ranged from 0 to 1/year. The frequency of self-reported exposure was significantly higher in the high-risk group (P! 0.001), and a considerable number of subjects (16%, NZ8/49) reported a yearly frequency of parenteral exposure of 2 or more. In addition, these participants from the high-risk group were less inclined to undertake any action after exposure (no action in 31% vs 14%, PZ0.06). Furthermore, we found that 26% (NZ21/80) rarely used protective equipment and strategies. Several cohort studies among healthcare workers showed prevalences of HCV around 0.5%.2–5 These results are comparable with those found in our study in which we found that none of the participants were positive for HCV, suggesting that the rate of HCV is low, although the response
Letters to the Editor A.J. Francee, D. Nathwanie a Department of Infectious Diseases, Castle Hill Hospital, Hull & East Yorkshire Hospitals NHS Trust, Hull, UK b Department of Public Health, Tayside Health Board, Kings Cross Hospital, Dundee, UK c Infection Control, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK d Microbiology, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK e Infection Unit, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK E-mail address: [email protected]
unit staff. To overcome conflicts of interest about bed use, NHS trusts should consider empowering infection control teams as the final arbiters of side/isolation room use.
Acknowledgements The authors wish to thank Prof P. Davey, Professor of Pharmacoeconomics, Medicines Monitoring Unit, University of Dundee, Dundee, UK; Drs A. MacConnachie and J. Ferguson, Senior House Officers, Infection Unit, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK; Ms K. Craig, Infection Control Nurse, Ninewells Hospital & Medical School, Tayside University Hospitals NHS Trust, Dundee, UK; and all nursing staff on Wards 5, 8, 9, 11, 15 and 31 at Ninewells Hospital and Wards 9 east and 8 at Kings Cross Hospital.
References
Available online 15 August 2005
1. Barlow GD, Sachdev N, Nathwani D. The use of isolation facilities in a United Kingdom infectious diseases unit. J Hosp Infect 2002;50:127—132. 2. Damji S, Barlow GD, Patterson L, et al. An audit of the use of isolation facilities in a UK National Health Service trust. J Hosp Infect 2005;60:213—217. 3. Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobialresistant Staphylococcus aureus, Enterococcus, Gram-negative bacilli, Clostridium difficile, and Candida. Ann Intern Med 2002;136:834—844. 4. Solomkin JS, Bjornson HS, Cainzos M, et al. A consensus statement on empiric therapy for suspected Gram-positive infections in surgical patients. Am J Surg 2004;187:134—145. 5. Infection control policy. Tayside Health Board, Department of Public Health; 1994. 6. Cooper BS, Stone SP, Kibbler CC, et al. Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature. BMJ 2004;329:533. 7. Lewis AM, Gammon J, Hosein I. The pros and cons of isolation and containment. J Hosp Infect 1999;43:19—23. 8. Cepeda JA, Whitehouse T, Cooper B, et al. Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study. Lancet 2005;365:295—304.
G.D. Barlowa,*, J. Knightb, I. McKayc, G. Oranged, G. Phillipsd, S. Kitec, J. Morrisone,
*Corresponding author. Tel.: C44 1482 875875. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.05.006
Tolerability of HIV postexposure prophylaxis among healthcare workers
Sir, Antiretroviral postexposure prophylaxis (PEP) is widely used after potential exposures to human immunodeficiency virus (HIV) to reduce the risk of infection in the healthcare setting. Few data are available on the safety and tolerability of antiretroviral drugs among healthcare workers (HCWs) who are prescribed prophylaxis. We reviewed registry data on occupational HIV exposures, the PEP regimens used, and the side effects associated with PEP. The study was approved by the institutional review board committee. From 1998 to 2003, 820 episodes of 816 HCWs were registered after a recent exposure event that carried a risk for HIV transmission. Nurses (27%) were the largest group of HCWs at risk, followed by
Letters to the Editor medical students (21%) and nurse aids (17%). Other HCWs at risk were physicians (10%), housekeepers (8%), laboratory technicians (7%), nurse and nurse aid students (6%), and others (4%). The source patient was known in 642 (78%) of the episodes. Of these, 125 (15%) were known to be HIV-positive at the time of exposure. The majority [676 (82%)] of exposures were percutaneous; 103 (13%) were mucous membrane and 41 (5%) were skin exposures. Sixty-four HCWs were prescribed HIV PEP and 70% of HIV PEP regimens consisted of two drugs. The others consisted of three drugs (22%), one drug (6%) and four drugs (2%). The initial prescribed antiretroviral drugs were zidovudine (38%), lamivudine (33%), indinavir (11%), didanosine (10%), nevirapine (1%), ritonavir (1%) and nelfinavir (1%). The most common drug combinations were zidovudine and lamivudine together, with or without indinavir. Thirty-two (50%) HCWs completed all of the drugs in the regimen as prescribed. The regimen was changed in four (6%) HCWs because of adverse drug events. Of the 32 HCWs who discontinued all PEP drugs earlier than the intended duration of prophylaxis, 13 (36%) did so because the source patient turned out to be HIV-negative and 12 (33%) had adverse effects attributed to PEP drugs. Overall, 18 (28%) HCWs reported some symptoms while on PEP. The adverse effects were nausea (33%), vomiting (20%), dizziness (14%), fatigue (12%), diarrhoea (6%), rash (2%), hepatitis (2%), haematuria (2%), abdominal pain (2%), headache (2%), anorexia (2%) and flu-like symptoms (2%). Two (3%) HCWs were reported to have serious adverse effects. The first HCW developed a generalized erythematous rash, fever and abnormal liver function tests after two days of PEP (zidovudine, lamivudine, nevirapine) initiation. Nevirapine hypersensitivity was diagnosed. A new regimen was started after the first regimen had been discontinued for a week and was completed without any adverse effects. The second HCW developed gross painless haematuria and flank pain after two weeks of indinavir as part of a PEP regimen (zidovudine, lamivudine, indinavir). Ultrasonography showed no evidence of nephrolithiasis or obstruction of the urinary tract. Gross haematuria and flank pain may be caused by small ureteric stones. He improved after indinavir was changed to nelfinavir and with hydration. None of the HCWs were reported to have HIV seroconversion during the study period. This retrospective study showed a high frequency of clinical adverse effects, although they were rarely severe or serious. We may have underestimated the occurrence of adverse events as there appeared to be a greater tendency to
113 report adverse effects when HCWs had symptoms. The toxicity profile of antiretroviral agents is a relevant consideration. All antiretroviral agents were associated with adverse effects, especially gastrointestinal symptoms.1 Adverse effects of antiretroviral drugs have been reported for patients with HIV infection but this may not reflect the experience of uninfected people. Our report showed that one-third of HCWs had to stop taking the drugs. As the treatment duration of PEP influenced the success of chemoprophylaxis in an animal model,2 an important goal of PEP is to encourage and facilitate compliance with a four-week PEP regimen. Adverse effects of antiretroviral drugs were frequent reasons for the discontinuation or modification of therapy, as well as PEP.3 The tolerability of PEP regimens among HCWs was therefore poor, mainly due to gastrointestinal effects, leading to an incomplete course. This, in turn, compromised treatment efficacy. Severe toxicities associated with nevirapine administration for PEP have been reported.4 The US Public Health Service do not recommend using nevirapine for basic or expanded PEP regimens.4,5 Some have suggested use of a short course, half dose of a nevirapine-containing regimen,6 but adverse effects could occur. Protease inhibitors have been commonly associated with gastrointestinal side effects,3 and a few cases of nephrolithiasis have been reported.7 In conclusion, adverse effects from HIV PEP were common. Appropriate counselling for the exposed HCW is crucial, and the risk of infection should be weighed against the potential toxicity of antiretroviral agents. Finally, education efforts aimed at occupational exposure prevention are still important.
References 1. Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med 2003;348:826—833. 2. Tsai CC, Emau P, Follis KE, et al. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. J Virol 1998;72: 4265—4273. 3. Lee LM, Henderson DK. Tolerability of postexposure antiretroviral prophylaxis for occupational exposures to HIV. Drug Saf 2001;24:587—597. 4. Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures—worldwide, 1997–2000. MMWR Morb Mortal Wkly Rep 2001;49:1153— 1156.
114
Letters to the Editor
5. U.S. Public Health Service. Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001;50:1—52. 6. Rey D, Partisani M, Hess-Kempf G, et al. Tolerance of a short course of nevirapine, associated with 2 nucleoside analogues, in postexposure prophylaxis of HIV. J Acquir Immune Defic Syndr 2004;37:1454—1456. 7. Swotinsky RB, Steger KA, Sulis C, et al. Occupational exposure to HIV: experience at a tertiary care center. J Occup Environ Med 1998;40:1102—1109.
S. Kiertiburanakula,*, B. Wannayingb, S. Tonsuttakulb, P. Kehachindawatb, S. Apivanichb, S. Somsakulb, K. Malathuma a Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand b Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand E-mail address: [email protected] Available online 15 August 2005
*Corresponding
author. Tel.: C662 201 1922; fax: C662 201
2107. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.04.013
No carriers of hepatitis C among operating room personnel in a university hospital setting in The Netherlands
Sir, Transmission of hepatitis C virus (HCV) from patients to healthcare workers and vice versa can occur through parenteral or percutaneous exposure, such as needlestick injuries. The average incidence of seroconversion to HCV after a needlestick injury from an HCV-positive source is 1.8% (range 0–7%).1 The risk of infection is relatively low and the infection rate in healthcare workers ranges from 0.0 to 0.9%.2–5 Operating room personnel are amongst the most intensively exposed to blood and body fluids.
Since healthcare workers are generally tested only after possible exposure to HCV, prevalence studies among operating room personnel in developed countries are few.6 We therefore wanted to establish the prevalence of hepatitis C among operating room personnel in our university hospital. Therefore, we conducted a crosssectional seroprevalence survey among operating room personnel using anti-HCV enzyme-linked immunosorbent assay testing (AxSYM System, HCV version 3.0, Abbott Laboratories, Chicago, IL, USA). We also assessed demographics and other variables, such as potentially unsafe practices, by means of a questionnaire. Participants were divided into a high-risk group consisting of surgeons (including surgical residents) and operative nurses providing direct surgical care, and a low-risk group consisting of anaesthetists and others providing anaesthetic care. The study was approved by the Medical Ethics Committee of the Leiden University Medical Centre. Informed consent was obtained from all participants. Investigators were blinded to the identity of the participants. Surveys were distributed to 226 surgical ward workers, and 81 surveys (response rate 35.8%) were returned (35.9% from the high-risk group and 35.6% from the low-risk group). There were 15 male and 66 female participants of mean age 40.1 years (SD 11.5, range 21–63 years). Only one out of 52 surgeons participated, possibly due to concerns about blinding, and anxiety about occupational and financial consequences if found to be positive for HCV. Consequently, the high-risk group consisted of one surgeon and 49 operative nurses, whereas the low-risk group consisted of 17 anaesthetists and 14 others providing anaesthetic care. None of the participants were positive for HCV. The median number of exposures to blood and other body fluids ranged from 0 to 1/year. The frequency of self-reported exposure was significantly higher in the high-risk group (P! 0.001), and a considerable number of subjects (16%, NZ8/49) reported a yearly frequency of parenteral exposure of 2 or more. In addition, these participants from the high-risk group were less inclined to undertake any action after exposure (no action in 31% vs 14%, PZ0.06). Furthermore, we found that 26% (NZ21/80) rarely used protective equipment and strategies. Several cohort studies among healthcare workers showed prevalences of HCV around 0.5%.2–5 These results are comparable with those found in our study in which we found that none of the participants were positive for HCV, suggesting that the rate of HCV is low, although the response