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From the PEPline: HCV and needlesticks: Fear often outweighs risk
Reassure, educate, and offer testing to HCWs
By Jason Tokumoto,
National Clinicians’ Consultation Center
Ronald H. Goldschmidt, MD
Director of the Family Practice Inpatient Service
Director of PEPline
San Francisco General Hospital
[Editor’s note: The National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) provides advice to both health care workers and their treating clinicians on managing occupational exposures to bloodborne pathogens. After nearly 30,000 calls, it has developed some approaches that may be helpful to readers of Hospital Employee Health. This is the first of occasional columns on post-exposure issues.
If you have a question about post-exposure response that you would like to see addressed in HEH, please e-mail Michele Marill at firstname.lastname@example.org. Or you can contact PEPline directly through the National Clinicians’ Consultation Center web site: www.ucsf.edu/hivcntr, or by calling the PEPline at (888) 448-4911.]
Exposures to bloodborne pathogens can be frightening. Our experience at the PEPline, however, is that the health care workers’ fears can be substantially greater than the real risk of transmission. Educating the health care worker about the actual risk usually provides genuine reassurance and prevents unrealistic concern. This is often the case with HIV and HCV, in which the risks of transmission and infection are quite low.
The PEPline staff’s most important step in providing post-exposure consultation is to convey to callers that they will get the help and support they need while being treated in a respectful, nonjudgmental way. The next steps include obtaining a comprehensive assessment of the exposure, deciding whether testing and treatment are needed, and providing counseling and crisis management.
The PEPline receives many questions that deal with hepatitis B and C. Here is an example of a fairly common hepatitis C question:
Question. A registered nurse sustained a superficial needlestick to her thumb after giving an intramuscular injection two days ago. The source patient is known to have hepatitis C and has a negative HIV antibody (ELISA) and hepatitis B surface antigen. The occupational health nurse called the PEPline wanting to know what follow-up HCV testing should be done for the nurse and whether there is any prophylaxis for HCV.
Answer. Our first task is to make sure that the occupational health nurse knows the actual risk and conveys the information to the health care worker (HCW) accurately. Our experience is that HCWs, and their treating clinicians, often have an exaggerated idea about the degree of risk that actually exists. Just knowing the actual risk often results in a dramatic sense of relief. In this case, the average per-episode risk generally is regarded as 1.8% for a percutaneous exposure from HCV-positive blood.
In a review of literature on occupational exposure to HCV, Janine Jagger, PhD, MPH, director for the International Health Care Worker Safety Center at the University of Virginia in Charlottesville, estimates the true risk is even lower — about 0.5%.1
Although various tests and testing protocols have been suggested, the PEPline recommendations are consistent with the Public Health Service Guidelines. We recommend a basic and relatively simple testing schedule, which has the convenience of following the same schedule as HIV testing (when needed):
Baseline HCV antibody test (ELISA); retest at three months and six months. The HCV antibody generally turns positive in nine to 12 weeks, and nearly all seroconvert by six months.
For those HCWs who want to know earlier, we recommend HCV RNA (viral load) testing at six weeks, consistent with the HIV testing schedule. This approach applies especially if early treatment is desired.
Although measuring hepatic enzyme (ALT) levels has been part of some protocols, the PEPline does not recommend it as a screening test. People who have elevated ALT levels from causes other than acute hepatitis C can experience unnecessary anxiety and concern about hepatitis C in these instances. In addition, a normal ALT does not exclude hepatitis C.
HCWs with clinical syndromes consistent with acute hepatitis C should be tested for HCV RVA (viral load) at the time of clinical illness.
For the individual who has an exposure to a source whose HCV status is unknown, the PEPline recommends HCV antibody test at baseline, three months, and six months. HCV RNA (viral load) testing is not recommended unless the exposure was from a high-risk source.
Because no post-exposure prophylaxis is effective in decreasing the risk of transmission of HCV, we would emphasize that there is no current treatment necessary.
Finally, the PEPline clinician would make sure the occupational health nurse and the exposed health care worker are aware that in one important study, early treatment of HCV infection has been shown to be effective in acute hepatitis C.2 This information can be most reassuring to the exposed HCW at the time of the exposure.
It is also important to convey that some HCWs clear the virus on their own, there are no studies that compare early treatment with later treatment, and treatment itself can be associated with substantial toxicity. Later, if the HCW actually develops hepatitis C infection, further discussions with someone knowledgeable about the risks and benefits of early treatment will be essential.
1. Jagger J, Puro V, De Carli G. Occupational transmission of hepatitis C virus (letter). JAMA 2002; 288:1,469. Author reply: 1,469-1,471.
2. Jaeckel E, Cornberg M, Wedemeyer H, et al. Treatment of acute hepatitis C with interferon alfa-2b. N Engl J Med 2001; 345:1,452-1,457.