Fasten your seat belts: Hospitals face a bumpy ride as hepatitis C cases peak

HCV to replace HIV as prime occupational threat

(Editor’s note: In our last issue, we discussed the emerging debate about using combination therapy for hepatitis C virus to provide post-exposure prophylaxis for health care workers. We continue our coverage this month with a discussion of projections that the number of HCV patients seeking care is expected to increase dramatically over the next two decades.)

The nation’s hospitals face a growing wave of late-stage hepatitis C virus patients that will peak sometime during the next two decades, as hundreds of thousands of people, many of whom do not even realize they are infected today, will develop serious liver disease and seek treatment and transplants, experts advise Hospital Infection Control.

"The people who were infected 20 to 30 years ago — their end-stage liver disease is just starting to show up now," says Toni Mitchell, MD, MBA, chief HCV consultant for the Department of Veterans Affairs in Washington, DC. "For the next 10 to 15 years, we are probably going to be in for a bumpy ride."

The projections raise important infection control issues regarding patient and worker testing, compliance with precautions, needle safety, and post-exposure prophylaxis (PEP) of health care workers as HCV replaces HIV as the prime occupational threat of infection. With a patient population considered at higher risk for bloodborne infections, the VA has taken the lead in trying to identity and treat HCV cases in its national hospital system. Facing an HCV patient prevalence rate of 8% to 10% — at least four times that of the general population — the effort may foreshadow what other hospitals will face as the number of serious cases of HCV increases.

"The VA is probably on the bleeding’ edge in trying to identify these folks," Mitchell says. "While our [situation] may be exceptional, since the prevalence rate is so much higher, I still think it is a preview of what is to come for other people."

The total VA patient population base is somewhere between 3.5 and 4 million, which means as many as 400,000 veterans currently may be HCV positive. "Positive only means that when you run a test, they have antibodies," she says. "It doesn’t necessarily mean that they have active disease. So you have to start breaking it down from there. Our estimates indicate at the present time that, probably out of the total number, some 20% are eligible’ and encouraged for treatment."

Calls for testing and treatment

Indeed, the overall projections — coupled with a 41% cure rate using current combination therapy — have heightened calls for more widespread testing and treatment of patients and initiation of PEP regimens for health care workers.¹ However, the side effects of the treatment may be debilitating or contraindicated for some patients, and public health officials are reluctant to recommend PEP with the current drugs.

Moreover, even widespread testing doesn’t necessarily clear the complex picture. Unlike HIV and hepatitis B virus, the amount of circulating HCV is not necessarily reflective of the severity of infection, Mitchell notes. "You are going to have people with very high counts and not a lot of liver damage, and others with low counts and a lot of damage," she says. "We don’t understand the natural history of the disease enough to make the kind of predictions that we would like to make, in terms of who is going to respond well to treatment, and who is going to accelerate and get sicker faster."

Similarly, national numbers are somewhat difficult to project, because any one HCV case can progress along several lines for years to end in benign infection or deadly liver cancer. But like a balloon payment that is finally coming due, several projections see HCV worsening over time in a large group of those previously infected.

Of the estimated 4 million Americans who have HCV antibodies, about 2.7 million have active infection. Most HCV cases are believed to have been contracted before 1990, but about 30,000 new cases still occur annually. Research indicates there was a large increase in the incidence of HCV infections from the late 1960s to the early 1980s. Annual incidence went from 45,000 infections to 380,000 infections a year in the 1980s.²

As members of that huge group of previously infected people develop latter-stage hepatitis, liver-related deaths and demand for transplants will continue to increase to a peak in 2018. In that year, compared with 1998, liver-related deaths will have more than tripled, and demand for transplants will have increased sevenfold, one study projects.³ The economic impact could be huge, as the HCV surge will result in rising costs to the health care systems that could peak in 2021 at $26 billion a year, according to an actuarial study by the firm of Milliman & Robertson Inc. in New York City.⁴

Overall, the increasing demand on hospital resources to provide care for patients with HCV complications will parallel the demand for AIDS care in the 1980s, says Robert Ball, MD, an infectious disease physician at the University of South Carolina in Columbia and an epidemiologist at the state department of health. "Hospitals were under increasing pressure to care for sick and dying AIDS patients," he says. "The average cost per AIDS patient was almost purely hospital based, over $100,000 per patient. Now it’s almost all outpatient, [with treatment costing] $10,000 a year and dropping. The same scenario is repeating itself [for HCV]. As Yogi Berra would say, It’s deja vu all over again.’"

The trend does not bode well for health care workers, who already face a much higher HCV prevalence among their patients than they would encounter in the general public, Ball adds. HCV prevalence of about 5% was found in a survey of South Carolina hospitals, and patient prevalence as high as 10% has been reported in surveillance of sentinel hospitals by the Centers for Disease Control and Prevention, he says. "Whether it is 5% or 10%, it is severalfold higher than the general population, which means health care workers are at risk. And as more and more of these HCV patients get diagnosed and discovered — and are coming into hospitals for both in- and outpatient treatment — there is going to be increased risk to health care workers. Standard precautions notwithstanding, needlesticks are still going to occur."

In that regard, the threat of HCV might be the final impetus needed to push the widespread implementation of needle safety devices to protect health care workers. "Since HIV is now regarded as a more manageable, chronic treatable condition with PEP available for needlesticks, it is going to take an additional fear or concern on the part of the workers to further reduce the still unacceptably high level of needlesticks," Ball says.

A spiral of workers’ comp cases

Indeed, part of the dire economic projection is that the increasing numbers of HCV patients heighten the risk to health care workers, which in turn could set off an expensive spiral of workers’ compensation claims.

"As the population ages and the disease progresses, you will see patients who have more severe forms of hepatitis in the hospital; there will be an increase in HCV inpatient bed days," says Sherrie Dulworth, RN, lead author of the Milliman & Robertson study and a health care management consultant with the firm. "If hospitals don’t take action to prevent new incidents, at the current level of needlesticks, there will be increased claims."

Given such a scenario, the actuarial study projected that every dollar spent on combination therapy would save $4 in subsequent medical expenses. "Under workers’ comp programs, the [insurer] is responsible for the health care costs associated with hepatitis for the rest of the person’s life," says Bruce S. Pyenson, FSA, MAAA, an actuary and co-author of the study. "The costs associated with that are potentially huge. From an insurance company standpoint, we are coming up with a range of $200,000 to $700,000 for each person who gets infected. We think there are something like a thousand new cases per year among health care workers. We estimate that 2% of those each year go on to develop cirrhosis. It is a potentially devastating cost for the health care industry."

Some wonder if infection control and other hospital support programs may suffer as HCV wrings billions of dollars in patient treatment and workers’ compensation claims out of a health care industry that has been struggling in recent years.

"I think the biggest impact is going to be on HMO-type organizations, where you fund the care," says Ona Montgomery, RN, BSN, MSHA, CIC, infection control coordinator at the VA Medical Center in Amarillo, TX. "If it is going to be a resource issue, is the money going to go to treatment or support processes?"

Regardless, ICPs are likely to become increasingly involved with HCV post-exposure prophylaxis of workers, as drug issues are resolved and formal recommendations eventually issued. "It could change the volume of PEP cases that we see that require a real timely intervention," says Montgomery.

Likewise, more hospitals may begin assessing risk factors and offering HCV testing on admission, an approach that is already being taken by VA hospitals like Montgomery’s. (See testing algorithm, p. 132.) "The only reason to do that would be to [identify] people who could benefit from treatment," she says. "That is what is going on in the VA. We are trying to identify infected veterans who can potentially benefit from treatment and therefore reduce the lifelong impact of the disease. If hospitals do start testing more aggressively, it will have a workload effect on infection control programs, at least in larger facilities."

Ball says more hospitals are increasing screening of patients for HCV, often even if a single abnormal liver test is found. However, many facilities are still not testing source patients after exposures, an approach he advocates over screening by risk factors on admission. "[Patients] don’t think it is relevant or pertinent, or they are just simply going to deny, so going on risk factors is not a good way." With the wave of incoming patients projected, HCV testing of source patients will become increasingly routine and should withstand confidentiality challenges, he adds.

"Most hospital admission consent forms allow additional testing for bloodborne pathogens in the event of a health care worker exposure," he says. "You don’t have to give permission every time your doctor orders an X-ray, do you?"

References

1. Liang JT, Rhermann, Seeff, et al. NIH conference: Pathogenesis, natural history, treatment, and prevention of hepatitis C. Ann Intern Med 2000; 132:296-305.

2. Davis GL, Albright JF, Cook S, et al. Projecting the future health care burden from hepatitis C in the United States. Abstract 909. Hepatology 1998; 390A.

3. Armstrong GL, Alter MJ, McQuillan GM, et al. The past incidence of hepatitis C virus infection: Implications for the future burden of chronic liver disease in the United States. Hepatology 2000; 31:777-782.

4. Dulworth S, Patel Sunit, Pyenson BS. The hepatitis C epidemic: Looking at the tip of the iceberg. Research Report. New York City: Milliman & Robertson, Inc.; April 2000.