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Management of healthcare
workers after occupational exposure to hepatitis C virus
Patrick G P Charles, Peter W Angus, Joseph J Sasadeusz and M
Lindsay Grayson
MJA 2003; 179 (3): 153-157
http://www.mja.com.au/public/issues/179_03_040803/cha10198_fm.html
Abstract
The increasing rate of hepatitis C virus (HCV) infection in
the community means that there is increased risk of occupational
exposure for healthcare workers.
In metropolitan hospitals in Victoria, we found that 80–150
healthcare workers have occupational exposures from HCV-infected
patients annually.
As there is a 1.8%–3% risk of transmission of HCV from a
needlestick injury, two to five healthcare workers are likely to
acquire HCV each year in Victoria.
These needlestick injuries pose a personal, legal and
professional risk to healthcare workers and their patients.
Recent information shows that early antiviral treatment of
acute HCV infection has high cure rates.
Current local and international protocols for management of
healthcare workers exposed to HCV do not address these issues.
We propose a management protocol after needlestick injury that
is stratified according to the likelihood of HCV acquisition and
potential risk of staff-to-patient transmission, and that is
consistent with the current legal and clinical context of HCV
infection in Australia.
NEEDLESTICK INJURIES pose a potential occupational risk to
healthcare workers, particularly through transmission of
bloodborne viruses, such as hepatitis B and C viruses and HIV.1
An effective vaccine is available to prevent hepatitis B virus (HBV)
infection,2 and post-exposure antiviral prophylaxis is effective
in reducing HIV transmission.1,3 However, currently there are no
measures that reduce hepatitis C virus (HCV) transmission.4 This
is a potential problem given the growing epidemic of HCV
infection in the Australian community and among hospital
patients.5,6 Early recognition of acute HCV infection in
healthcare workers may also reduce the risk of staff-to-patient
transmission, as recent data suggest that early antiviral
treatment of acute HCV infection vastly increases viral
clearance.7
After a recent incident at our hospital in which a healthcare
worker acquired HCV from a needlestick injury, we investigated
the frequency of HCV exposure among healthcare workers at major
metropolitan hospitals in Victoria and reviewed available
guidelines for managing occupational exposures to HCV. We
propose a risk-stratified standard protocol for follow-up of
healthcare workers who suffer occupational needlestick injuries
from source patients known to be HCV-infected.
Issues to consider
HCV infection and detection after needlestick injury
The reported risk of HCV transmission after needlestick injury
from an HCV-infected patient is considered to be 1.8%–3%.8-13
The transmission risk is predominantly from patients with
hepatitis C viraemia detectable by polymerase chain reaction (PCR).8
The lower limit of HCV detection by PCR under optimal processing
and storage conditions is generally 100 virus copies/mL, but
variability in hepatitis C viraemia among some chronic HCV
carriers means that PCR detection can fluctuate, even among
those considered to be continuously viraemic.14,15 Perinatal
maternal–fetal transmission, although not necessarily analogous
to needlestick-injury transmission, appears more likely when
maternal viral titres are above 106 copies/mL and is rare when
mothers are PCR-negative.16,17
Current third-generation enzyme immunoassays for HCV antibody
have nearly 100% sensitivity and detect seroconversion 4–10
weeks after infection. Delayed antibody detection and even
false-negative results can occur among recently infected
patients with renal failure, HIV infection and HCV-associated
mixed essential cryoglobulinaemia.14 Elevation of serum alanine
aminotransferase (ALT) concentration occurs after 4–12 weeks.
Although used by some as a marker of recent HCV infection,
raised ALT levels are not specific to this infection, and may
fluctuate.14,18 In contrast, HCV viraemia can be detected by PCR
between 10 days and 6 weeks after infection.19 Thus, PCR
detection of hepatitis C viraemia appears more useful than HCV
antibody or ALT testing in the early detection of acute HCV
hepatitis.4,20 The Medicare schedule fee for HCV PCR is
currently $90, compared with $15.30 for HCV antibody
determination and $16.35 for liver function tests.21
Risk of occupational exposure to HCV
We collaborated with six major metropolitan hospitals in
Melbourne, Victoria, to determine the number of occupational
exposures to blood and body fluids (including needlestick
injuries) reported at each institution, and the number of these
that involved a source patient with HCV infection as defined by
the presence of HCV antibody. Consent was obtained from the
source patient before testing for HCV (as well as HIV and HBV).
Reported occupational exposures of healthcare workers to HCV at
these hospitals is shown in Box 1. Of 1450 reported occupational
exposures over 111 months, 138 were from HCV-infected patients.
At all institutions, needlestick injuries made up more than 60%
of the total number of exposures. There is currently no national
Australian standard for the reporting of blood and body fluid
exposures. Information was not available from all institutions
on the rate of HCV among all inpatients, but at Hospital 1 the
overall rate was 1.5% in 2002 (unpublished data), suggesting a
possible reporting bias (approximately tenfold) towards
exposures from HCV-positive source patients.
As information on the number and working hours of healthcare
workers potentially exposed to needlestick injuries at each
institution was not available, a healthcare worker- and
time-dependent rate of needlestick injury could not be
calculated. Given that our survey included only larger Melbourne
hospitals, and that the predicted risk of HCV acquisition
associated with each needlestick injury is 1.8%–3%,8-13 two to
five healthcare workers are likely to be infected with HCV
through occupational exposure in Victoria each year.
Implications of infection in healthcare workers
Liver disease
Acute HCV infection is symptomatic in 15%–20% of patients, but
is rarely severe enough to require hospitalisation.20 However,
about 75%–85% of HCV-infected patients develop chronic
hepatitis, and about 15%–25% develop cirrhosis. Half of these
individuals develop hepatic decompensation or hepatocellular
carcinoma.14,22 Until recently, in the absence of evidence that
any treatment was effective in preventing chronic hepatitis,
early detection of acute HCV infection was considered to be of
limited therapeutic importance. However, recent data show that
early treatment with interferon-alfa monotherapy results in
viral clearance in over 90% of recipients.7 Results for combined
interferon and ribavirin in acute treatment of hepatitis C
infection are currently inconclusive. The optimal timing of
acute therapy after exposure remains uncertain, but some studies
report similar results for immediate therapy and therapy that is
delayed by 3–6 months.7,14,23-25
Psychological and sexual issues
Many healthcare workers are extremely anxious after needlestick
injuries, with widespread effects on work performance, personal
relationships and psychological health, leading to depression
and, at times, a sense of abandonment and isolation.26 This may
occur regardless of counselling. Given the relatively low rate
of HCV seroconversion after needlestick injury, it is often
these psychological issues that have the greatest impact on
injured healthcare workers. Anxiety can last for over a year,
and the psychological counselling costs appear similar to the
direct medical costs of these injuries.27,28 Many healthcare
workers express concern about possible sexual transmission of
HCV to partners, as well as maternal–fetal transmission for
those who are currently pregnant or attempting to become
pregnant. There is even a report of therapeutic abortion being
sought.27 Although data on couples where one partner has chronic
hepatitis C suggest that the rate of sexual transmission of HCV
is low,29-32 the risk during seroconversion is less certain.
Hence some HCV-exposed healthcare workers opt either to use
condoms or to abstain from sexual contact until they are certain
they have not acquired HCV,27 which may exacerbate interpersonal
stress, depression and sense of social isolation. Early
confirmation that HCV acquisition is unlikely could have
positive effects on sexual and psychological health.
Risk of HCV transmission to patients
Ross and colleagues suggest that the risk of surgeons with known
HCV infection (ie, HCV-positive on PCR) transmitting HCV to
their patients is 1 in 1750 to 16 000 operations.33 However, the
actual risk is likely to be influenced by factors such as viral
load, the number and complexity of surgical procedures
performed, and the surgeon’s technique and experience. It is
often the less experienced junior medical staff who perform
at-risk procedures after hours, when experienced supervision is
least available, and fatigue is likely to be greatest.
Fortunately, relatively few cases of HCV transmission from
healthcare workers to patients have been reported, but such
episodes have been associated with time-consuming and expensive
“look-back” programs and considerable patient morbidity.34-37
Although there are few data, the risk of HCV transmission to
patients is negligible among healthcare workers with no
detectable HCV viraemia (ie, negative HCV PCR).8
Defining risk of transmission from healthcare workers may be
helpful for legal as well as infection control reasons. There
has been an instance where a surgeon had a work-related
needlestick injury from an HCV-positive source patient at a
major Australian hospital, and legal opinion obtained by the
hospital’s administration was that the surgeon should cease all
surgical procedures until confirmed as not having acquired HCV
(Melbourne Infectious Diseases Group, personal communication,
Jun 2001). This is contrary to recommendations from the US
Centers for Disease Control and Prevention (CDC).1 A risk
assessment structure regarding HCV transmission may have
assisted decision-making in this case. Without it, management of
needlestick injuries will become unworkable, as healthcare
workers will become reluctant to report injuries involving HCV-infected
patients if they believe they will be forced to cease clinical
practice without any risk assessment or compensation.
A balance needs to be found between the rights of the injured
healthcare worker and those of the healthcare worker’s future
patients. Hospital administrations need to feel confident that
needlestick injury reporting is accurate and that healthcare
workers who are exposed to HCV are not placing their patients at
significant risk of HCV transmission. Investigations that
promptly identify acute HCV infection (eg, HCV PCR) could assist
in identifying healthcare workers who should be re-deployed from
exposure-prone procedures, while allowing other injured
healthcare workers to continue routine practice. HCV antibody
and ALT levels detect acute infection later than PCR, and
neither gives an accurate assessment of healthcare worker
infectivity. Clearly, the appropriate management of needlestick
injuries poses a new challenge to the healthcare sector, both in
terms of reducing the overall risk of needlestick injury, the
fair and reasonable management of injured staff and the
protection of patients.
Protocol for management of healthcare workers exposed to HCV
Although some Australian guidelines have been proposed, they
lack practical applicability and have not been widely
adopted.38-39 Thus, many hospitals have developed their own
protocols, resulting in substantial variability and subsequent
confusion (and anxiety) among injured healthcare workers as to
which protocol is most appropriate. Overseas recommendations for
testing healthcare workers exposed to HCV vary widely and have
recently been revisited.1,4,9,20,40-42 While all are based on an
assessment of the likelihood of HCV acquisition, few consider
the benefits of early disease recognition in terms of the health
of healthcare workers, transmission to patients or legal risk
assessment.
An effective management plan for prevention and management of
needlestick injuries in healthcare workers needs to be
multifaceted. Our proposed plan to reduce needlestick injuries
and their risk is shown in Box 2. For post-needlestick injury
management, we believe there needs to be a consistent approach
by all healthcare institutions that recognises the current
therapeutic, personal and legal context of HCV management in
Australia. We propose an investigation protocol that considers
the likely risk of HCV transmission not only from the source
patient but also from the healthcare worker to other patients
should the healthcare worker be infected (Box 3).
We have classified healthcare workers according to whether their
occupation involves exposure-prone procedures, defined as those
with “potential for direct contact between the skin (usually
finger or thumb) of the healthcare worker and sharp surgical
instruments, needles, or sharp tissues (spicules of bone or
teeth) in body cavities or in poorly visualised or confined body
sites”.38 Based on this, healthcare workers with potentially
high risk of HCV transmission — “high transmitter risk” —
include surgeons, operating room nurses, intensive care staff,
interventional radiologists and their assistants, and emergency
department staff. We consider all other healthcare occupations
to be “low transmitter risk”.4,43
After an occupational exposure, the healthcare worker should be
counselled about the degree of risk associated with the type of
exposure: needlestick injuries pose a greater risk than
splashes, and those from a hollow-bore needle a greater risk
than those from a solid needle.1,3,39 We also propose that the
protocol considers the presence of HCV viraemia in the source
patient, and includes early detailed assessment of HCV
acquisition among healthcare workers in whom early disease
recognition could have widespread consequences. These
consequences may include significant psychological effects
which, although possibly disproportionate to the transmission
risk of the injury, will be more easily resolved by early
evidence that HCV transmission is unlikely. Other aspects of the
counselling process that can help alleviate healthcare worker
anxiety include rapid initiation of testing, reminders about
when to have follow-up testing or vaccination and, when
possible, continuity of care at subsequent visits.27
Injured healthcare workers should remain on routine duties after
needlestick injury unless there is evidence of HCV acquisition.
The latter should be assessed, counselled and offered
appropriate therapy by experts in HCV management and treatment.
Our suggested protocol is similar to the protocols of other
groups, with several notable exceptions. The CDC recommends HCV
antibody and ALT testing at baseline and 6 months after
needlestick injury. PCR testing may be done at 4–6 weeks “if
earlier diagnosis of HCV infection is desired”. These guidelines
do not take into account source viraemia or the healthcare
worker’s transmitter status.1 In fact, the CDC recommendations
state that “health care professionals exposed to HBV- or HCV-infected
blood do not need to take any special precautions to prevent
secondary transmission during the follow-up period; however,
they should refrain from donating blood, plasma, organs, tissue,
or semen”. This statement, which is referenced to a previous CDC
recommendation,4 is contradictory in terms of potential
transmission risk. Sulkowski et al, who recently described a
case similar to ours in which a healthcare worker was infected
with HCV after a work-related needlestick injury, proposed a
modified CDC investigation regimen for healthcare workers after
injury, but this still did not stratify according to
transmission risk of either source or healthcare worker.20
Previous Australian guidelines recommend HCV antibody testing
only at 0 and 3 months.39 The British and Canadian protocols are
also not specific.40-42
We believe that our proposed post-needlestick injury HCV
investigation protocol provides a practical approach for
assessing injured healthcare workers in the current therapeutic
and legal contexts of HCV management in Australia. We encourage
the development and acceptance of a common protocol for use in
all Australian hospitals.
1: Blood and body fluid exposures among healthcare workers at
major metropolitan hospitals in Victoria
Hospital Months of assessment (dates) Blood and body-fluid
exposures† HCV exposures*
________________________________________
Total (% of all exposures) Annualised no.
________________________________________
1 29 (1/99–5/01) 335 36 (11%) 15
2 16 (1/00–4/01) 205 26 (13%) 19
3 5 (1/01–5/01) 34 6 (18%) 14
4 24 (1/99–12/00) 468 25 (5%) 12
5 29 (1/99–5/01) 363 40 (11%) 17
6 8 (4/00–11/00) 45 5 (11%) 7
Total 111 1450 138 (9.9%) 84
________________________________________
* Patient was positive for antibodies to hepatitis C virus. †
60%–85% were needlestick injuries.
2: Proposed management plan to reduce needlestick injuries and
their risk among healthcare workers
1. Reduction in the risk of needlestick injuries and other
exposures through:
Adequate education of healthcare workers about phlebotomy and
intravenous cannula insertion, with credentialling of knowledge
and performance.
Systems management
• Availability of suitable sharps-disposal containers
• Introduction of safety cannulas
• Rationalisation/avoidance of unnecessary procedures
• Appropriate healthcare worker workload and adequate
staff–patient ratios (excessive tiredness and work-related
stress are clearly associated with higher rates of needlestick
injury).
2. Appropriate health management and follow-up systems for
staff, including appropriate counselling about hepatitis B and C
virus and HIV infection.
3. Appropriate vaccination program for healthcare workers,
especially hepatitis B vaccination, to prevent bloodborne
diseases.
3: Proposed protocol for follow-up of healthcare workers after
needlestick injury involving a patient with hepatitis C virus
infection
HCV Ab = antibody to hepatitis C virus. PCR = polymerase chain
reaction.
* Renal dialysis patients may have false-negative HCV Ab results
and should be screened for HCV infection with both HCV Ab and
PCR testing.
† “High transmitter risk” healthcare workers comprise surgeons,
operating room nurses, interventional radiologists and their
assistants, and emergency department and intensive care staff.
‡ “Low transmitter risk” healthcare workers comprise all others.
§ PCR done to allow early treatment if infected, to assess
potential for healthcare worker-to-patient transmission and for
legal reasons.
¶ PCR done for healthcare worker mental health and sexual
advice.
** For possible retrospective PCR if HCV Ab seroconversion
occurs.
Competing interests
None identified.
Acknowledgements
Many of the proposals in this protocol are the result of a
meeting of clinicians held in Melbourne, Victoria, in 2001 to
discuss a standardised approach to nosocomial HCV transmission.
We acknowledge the input of these clincians and also the
assistance of the infection control practitioners who helped
obtain data: Ms Rhea Martin (Austin and Repatriation Medical
Centre), Ms Fiona Wilson (Western General Hospital), Ms Joanne
Cocks (St Vincent’s Hospital), Mr Richard Bartolo (Mercy
Hospital), Associate Professor Denis Spelman (Alfred Hospital)
and Dr Alan Street (Royal Melbourne Hospital).
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(Received 31 Mar 2003, accepted 2 Jun 2003)
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