Hepatitis C: Approach to the Health-Care Worker with a Potential Exposure

ABSTRACT & COMMENTARY

Synopsis: This article outlines minimum guidelines with regard to the hepatitis C virus should a health care worker receive a percutaneous or mucosal exposure to blood.

Source: Centers for Disease Control and Prevention. JAMA 1997;278:1056-1057.

The cdc, in collaboration with the hospital infection control Practices Advisory Committee, has outlined some minimum guidelines with regard to the hepatitis C virus (HCV) should a health care worker (HCW) receive a percutaneous or mucosal exposure to blood. They are: 1) baseline anti-HCV testing for the source patient; 2) baseline and six-month testing for the exposed individual for anti-HCV and alanine aminotransferase; 3) confirmatory testing if either the source or exposed individuals are found to be repeatedly positive for anti-HCV; 4) recommendation against postexposure prophylaxis with immune globulin or interferon; and 5) continued educational efforts regarding bloodborne infection and the HCW.

Several of these points are augmented 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 8-10 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 post-exposure 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 HCW 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

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 1-5% develop hepatoma.2 It is essential for us to obtain the appropriate demographic data and blood studies from the source patient and the exposed HCW, with chart documentation being paramount. Importantly, but unfortunately, there is no medicinal therapy we can offer the HCW who has suffered an exposure to HCV-contaminated blood. I feel conservative recommendations are best initially regarding precautions against transmission from a potentially-infected HCW to others. A long-term approach, especially with regard to safe-sex practices, can be devised in light of blood test results and after the patient has had time to digest and reflect upon the event. (Dr. Harrigan is Assistant Professor of Medicine, Temple University School of Medicine, Philadelphia, PA.) v

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.

Gemfibrozil treatment of post-CABG patients with isolated low HDL has been associated with marked reduction in subsequent clinical events despite lack of any demonstrated angiographic benefit.

When a health care worker receives a percutaneous exposure to hepatitis C-contaminated blood:

a. immune globulin should be administered.

b. interferon should be administered.

c. immune globulin and interferon should be administered.

d. neither immune globulin nor interferon should be administered.

Fibromyalgia and Hepatitis C: Is There an Association?

ABSTRACT & COMMENTARY

Synopsis: Serologic evidence of hepatitis C infection was reported to be more than six times more prevalent in patients with fibromyalgia than in an age- and sex-matched group of patients with rheumatoid arthritis.

Source: Rivera J, et al. Br J Rheumatol 1997;36:981-985.

What causes fibromyalgia? many patients and their physicians are anxious, if not quite dying, to know. Rivera and colleagues have not provided a definitive answer to that perplexing question, but they have reported evidence that supports an association between hepatitis C virus (HCV) infection and fibromyalgia. They present two case control studies, the first of which compared a group of patients who received a diagnosis of fibromyalgia while attending a rheumatology clinic at a tertiary care hospital with a gender- and age-matched group of patients with rheumatoid arthritis (RA) at the same center. Both groups had HCV screening enzyme linked immuno-adsorbent assays (ELISA) which, if positive, were followed by confirmatory recombinant immunoblot assay (RIBA) and polymerase chain reaction (PCR) assays for HCV ribonucleic acid (RNA). Of the 112 patients in the fibromyalgia group, 15.2% had a positive HCV ELISA, while only 5.3% of the 112 with RA had a positive ELISA for HCV. In the fibromyalgia group, 93% of those with a positive ELISA had a positive RIBA, and 76% had positive PCR for HCV RNA. In the RA group, false-positive ELISA for HCV were more common, with 66% having confirmatory positive RIBAs, while only 33% of those with RA who were ELISA-positive had a positive PCR for HCV RNA. The difference in the prevalence of active HCV infection as indicated by PCR was 11.6% for fibromyalgia vs. 1.8% for RA and was statistically significant at the P < 0.01 level.

In the second case-control study, a group of 32 patients with documented HCV infection, who were being considered for interferon alpha treatment, were compared with a group of gender- and age-matched controls selected from patients awaiting elective surgery. Although 53% of those with HCV reported generalized arthralgia, only six (18.7%) met American College of Rheumatology criteria for fibromyalgia. The control group had only one patient (3.1%) who met fibromyalgia criteria. The difference between these two groups was statistically significant at the P < 0.001 level.

COMMENT BY JERRY M. GREENE, MD, FACR

The idea that a chronic infection with HCV is linked to fibromyalgia in some causative fashion is attractive, but there are some methodological issues with the study by Rivera et al that make me hesitate to agree that the association is proven. The most important of these issues is that the examinations for tender points, upon which the diagnosis of fibromyalgia is largely based, were made by one examiner, and it is not stated in the methods section of the article that he was blinded to the HCV serologic test results. If he were aware of the HCV status of the subjects, there is a possibility of unintentional bias, since determination of tender points by palpation is more of a qualitative determination than a truly quantitative measure. Another issue is that in the group with fibromyalgia and evidence of HCV infection, roughly half the patients had abnormal transaminase enzyme levels. Although hepatitis is not specifically an exclusion criterion for fibromyalgia, it is often associated with arthralgia and myalgia. I would be hesitant about making a diagnosis of fibromyalgia in a patient with elevated hepatic enzymes. Finally, the only currently available treatment for HCV infection, interferon alpha, is associated with a high rate of post-treatment relapse, and there is no evidence of which I am aware that even successful treatment, with clearance of HCV RNA as determined by PCR, has any effect on fibromyalgia symptoms. However, if the findings of Rivera and colleagues are confirmed, screening for HCV infection in patients with fibromyalgia, even those with normal transaminase enzyme levels, may be prudent, since more effective therapy for HCV may be available in the future. Identifying patients who have been exposed to HCV may also identify patients whose behavior puts them at risk for other infectious diseases, such as hepatitis B and HIV, for which immunization, counseling, and antiviral therapy may be helpful to prevent or treat these other potentially fatal illnesses.

Gemfibrozil treatment of post-CABG patients with isolated low HDL has been associated with marked reduction in subsequent clinical events despite lack of any demonstrated angiographic benefit.

Evidence of active hepatitis C infection was indicated by detection of hepatitis C ribonucleic acid by polymerase chain reaction in what percentage of patients with fibromyalgia?

a. 1.8 %

b. 5.2 %

c. 11.6%

d. 18.7%