CDC, HICPAC mull limited options for hepatitis C

Synopsis: The Centers for Disease Control and Prevention has collaborated with the Hospital Infection Control Practices Advisory Committee (HICPAC) to provide minimum guidelines for health care workers who have been exposed to hepatitis C virus. There is currently no medicinal therapy clinicians can offer the health care worker who has been exposed to HCV-contaminated blood. Immune globulin’s failure to prevent postexposure infection has been shown, and inferential data and the side-effect profile of interferon leads to a recommendation against its use.

Source: Centers for Disease Control and Prevention. Recommendations for follow-up of health care workers after occupational exposure to hepatitis C virus. JAMA 1997; 278:1,056-1,057.

The CDC and HICPAC have outlined some minimum guidelines for handling potential HCV exposure should a health care worker receive a percutaneous or mucosal exposure to blood. The recommendations are:

• baseline anti-HCV testing for source patient;

• baseline and six-month testing for the exposed individual for anti-HCV and alanine aminotransferase;

• confirmatory testing if either the source or exposed individuals are found to be repeatedly positive for anti-HCV;

• recommendation against postexposure prophylaxis with immune globulin or interferon;

• continued educational efforts regarding bloodborne infection and the health care worker.

Several of these points are expanded upon in the paper. The seroconversion rate after percutaneous exposure to the blood of an HCV-positive patient is, on average, 1.8% (range, 0-7%). Seroconversion rates after mucous membrane exposure are not known, but the virus can be transmitted in this manner. Whereas the mean interval from exposure to seroconversion is eight to 10 weeks, there is a high rate of false positivity and false negativity inherent in the anti-HCV enzyme immunoassay, thus making confirmation and exclusion of transmission a complex issue.

The failure of immune globulin to prevent infection after exposure has been shown, so it is not recommended. The case against interferon has not been tested per se in the literature, but inferential data coupled with the side-effect profile of interferon has led to the recommendation against its use in the prevention scenario.

Some final points were made with regard to transmission of HCV to others. Admittedly, anyone who is anti-HCV positive is potentially infectious. Unfortunately, the modes of transmission are not well-understood, making postexposure precautions seem nebulous. For example, it is advised that household contacts should not share razors or toothbrushes with the potentially infected individual, yet there are no recommendations against pregnancy and breast-feeding. It is also not recommended that the individual change sexual practices with a steady partner. There is a risk of transmission through sex, but it is felt to be sufficiently low so as not to merit a change in sexual practices with a steady, long-term partner. Obviously, the health care worker should be counseled not to donate blood or body tissues until transmission of the virus has been ruled out.

Comment by Richard A. Harrigan, MD, FACEP, assistant professor of medicine, Temple University School of Medicine, Philadelphia.

This is a scary disease. Chronic liver disease occurs in approximately 70% of HCV-infected individuals.1 Within this group, approximately 20% will develop cirrhosis within 20 years, and about 1% to 5% develop hepatoma.2 It is essential for us to obtain the appropriate demographic data and blood studies from the source patient and the exposed health care worker, with chart documentation being paramount. Importantly, but unfortunately, there is no medicinal therapy we can offer the health care worker who has suffered an exposure to HCV-contaminated blood. I feel conservative recommendations are best initially regarding precautions against transmission from a potentially infected health care worker to others. A long-term approach, especially with regard to safe-sex practices, can be decided upon in consultation with the health care worker’s follow-up physician. That plan can be devised in light of blood test results and after the patient has had time to digest and reflect upon the event.

References

1. Alter MJ. Epidemiology of hepatitis C in the West. Semin Liver Dis 1995; 15:5-14.

2. Tice A. NIH consensus on management of hepatitis C. Emerg Med Alert 1997; 4:30-31.

DeMaria PL, Gertzen J, Weinstein RA. Nosocomial infections in human immunodeficiency virus-infected patients in a long-term-care setting. Clin Infect Dis 1997; 25:1,230-1,232.

Rates of hospital-acquired infections were high among HIV-infected patients in a long-term care setting, with many patients infected with common nosocomial bacteria and infections overall contributing to a significant number of deaths, the authors report.

Because patients with AIDS are living longer, it is expected that more of them will require long-term care, and nosocomial infections will probably contribute to an increase in morbidity, mortality, and cost of care. In addition, the occurrence of antibiotic-resistant bacteria is likely to be a problem in such a high-risk population

For 13 months, researchers observed HIV-infected patients (50 men and 15 women) in a dedicated 21-bed unit in a long-term-care facility to determine the rate of nosocomial infections. The mean age of the patients was 39 years (range, 22-78 years); 74% of the patients had CD4 cell counts of less than 200/mm3. There was a total of 152 infections (24 infections per 1,000 long-term-care days). The factors associated with the occurrence of a nosocomial infection were low CD4 cell counts, poor functional status, and longer duration of stay at the facility. The three most common infections were Clostridium difficile-associated diarrhea, primary bacteremia, and urinary tract infection. More than 50% of the cases of bacteremia were due to multidrug-resistant organisms.

Patients with HIV infection who require long-term subacute nursing care have many risk factors for infection including immunosuppression, the presence of invasive devices, and use of antibiotics. The mortality rate among patients on the unit was high (52%), but this finding was not unexpected given that many of the patients were referred for terminal care, the authors noted. Infections contributed to more than 40% of the deaths.