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NIH panel favors early HCV testing after stick
Give HCWs option for early treatment
Health care workers should be tested for hepatitis C infection within two to eight weeks after exposure, an expert panel has recommended. Although the panel doesn’t take a position on early treatment of hepatitis C, early testing offers that option.
"If you are infected with the virus, then the earlier you know, the earlier you can initiate treatment before chronic infection is established," says James Boyer, MD, director of the Liver Center at the Yale University School of Medicine in New Haven, CT, and chair of the National Institutes of Health Consensus Development Conference on Management of Hepatitis C.
The HCV RNA first reaches detectable levels in the blood two weeks after transmission, Boyer notes. Revised recommendations issued by the panel advise that if the early test results are negative, additional HCV antibody testing should occur at six months.
Early treatment of HCV gained favor after a report in 2001 by German researchers, who found that 42 of 43 patients who completed a 24-week series of interferon therapy had undetectable levels of HCV RNA and normal liver enzyme levels.1 However, the study did not include a control group of untreated patients, and all patients had symptoms of acute HCV.
Other studies have found that one-third to one-half of HCV-infected patients clear the infection on their own.2 It also is unclear whether early treatment is more effective than treatment initiated at six months.
Because of the significant side effects of the interferon, some HCV experts prefer a more conservative approach to treatment.
Boyer acknowledges that "there’s no hard proof" that early treatment is better. The decision should be made on a case-by-case basis by a liver specialist, he says. "I think a lot of people will choose to be treated. They should at least be offered that. Patients should be referred to an expert in that area to make a decision about whether to treat or to wait.
"There are a lot of unanswered questions in this field still," Boyer says. "The panel felt this was the safest way to go at the present time. Certainly, if I got a needlestick from a hepatitis C-positive source, that’s what I would want to do."
EHPs reconsider HCV testing
Employee health professionals are reviewing their HCV post-exposure testing in light of the recommendations. PEPline, a national post-exposure hotline based at San Francisco General Hospital, is considering whether to recommend earlier RNA testing.
PEPline has recommended HCV antibody baseline testing at exposure, viral load and PCR or branch DNA testing at six weeks, and antibody testing at three months and six months. Early testing brings the inevitable question: What do you do with positive results?
"Our position on the PEPline is that there is no clear answer as to whether early treatment is right or wrong, based on this [New England Journal of Medicine] study and based on what we know about hepatitis C," says Ronald H. Goldschmidt, MD, director of the family practice inpatient service at San Francisco General Hospital and director of PEPline.
"At the same time, it’s our obligation as the PEPline to make sure health care workers and the clinicians taking care of them . . . are informed about this study and the data so they can make an informed decision about whether to take medications against hepatitis C," he says. "There’s no right and no wrong here, at least at this point. It’s a personal choice," Goldschmidt points out. "Health care workers have to know there is a potential treatment. There are risks and benefits, and they need to discuss it with someone knowledgeable.
At the Marshfield (WI) Clinic, 16 employees have been exposed to blood from HCV-positive patients, says Bruce Cunha, RN, MS, manager of employee health and safety. None became infected with hepatitis C. The clinic has been testing at exposure, three months, six months, and one year.
"I’m still really confused on this. We’re going to take a wait and see attitude," Cunha says of the recommendation for early testing. "How much good are the tests going to do unless the physicians decide they’re going to start treating?" he says. "We’re talking about a disease that you can have for 20 years without any signs or symptoms. I do think you need to give the body a chance to take care of it."
[Editor’s note: PEPline is available 24 hours a day at (888) 448-4911. Information on PEPline is also available on the Internet at PEPline piece to: www.ucsf.edu/hivcntr. For more information on the consensus panel statement, see http://consensus.nih.gov/cons/116/revisions.htm.]
1. 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.
2. Seeff LB. Natural history of chronic hepatitis C. NIH Consensus Statement: Speaker abstracts. June 12, 2002.