CDC omits safer devices as HCV prevention strategy

HCW safety advocates dismayed by omission

New U.S. Centers for Disease Control and Prevention recommendations for preventing and managing hepatitis C virus (HCV) infection reiterate previous guidelines for health care workers, but fail to point out that safer needle devices could help prevent the percutaneous injuries that expose workers to the life-threatening bloodborne pathogen.

The recently released guidelines expand upon the CDC’s 1991 guidelines for screening and following up blood, plasma, tissue, organ, and semen donors for evidence of hepatitis B and C.1 The current report includes broader guidelines for preventing HCV transmission; identifying, counseling, and testing people at risk; and providing appropriate medical evaluation and management of HCV-infected individuals. Testing for HCV is recommended for health care workers only after a specific exposure to HCV-positive blood, along with baseline and follow-up testing for alanine aminotransferase (ALT) activity.2 (See related story, p. 5, for specific recommendations.)

In sections relating particularly to HCWs, the document repeats recommendations issued in the agency’s 1997 guidelines for follow-up after occupational exposure to HCV.3 (See Hospital Employee Health, September 1997, pp. 103-105.) The 1997 guidelines were essentially the same as those published in another CDC document in 1995.4

While the CDC’s general recommendations for preventing HCV infection among HCWs may not have changed much over the last several years, a new piece of information emerged from one of the agency’s own studies: the fact that safer needle devices can help prevent percutaneous injuries. In 1997, the CDC published the results of an evaluation of safety devices intended to reduce the risk of needlestick injuries to HCWs during phlebotomy procedures. Results showed that the use of safety needles reduced worker injuries by up to 76% without significant patient complications.5 (See Hospital Employee Health, April 1997, pp. 37-43.)

In an editorial note accompanying the study, the CDC supported the use of safer needle devices to help protect HCWs from blood exposures, yet the CDC’s current hepatitis C recommendations — which note that "a history of unintentional needlestick injury [is] the only occupational risk factor independently associated with HCV infection" — do not mention or cite the agency’s own findings.

Health care worker safety experts see that as a serious omission.

"It’s astonishing that the CDC doesn’t even reference its own research on the significant reduction of needlestick injuries achieved with safer devices," says Janine Jagger, PhD, MPH, director of the International Health Care Worker Safety Research and Resource Center at the University of Virginia in Charlottesville. "Why wouldn’t they reference their own research showing the effectiveness of a very relevant prevention strategy? Safer devices prevent the type of exposures most likely to transmit hepatitis C."

Hepatitis C is the major pathogen’

Jagger notes that hepatitis C accounts for the greatest number of bloodborne pathogens infections among HCWs per year.

"HIV results in many fewer cases, and hepatitis B is plummeting because of the vaccine, so hepatitis C is the major pathogen that will most frequently infect health care workers," she points out.

Susan Wilburn, RN, MPH, occupational safety and health specialist with the Washington, DC-based American Nurses Association (ANA), says failure to emphasize safer needle devices for preventing HCV exposures is "disappointing."

"It’s terrible because the best method of preventing an exposure is a safer device," she says, "but it’s not surprising."

Wilburn says the ANA had asked the CDC to recommend the use of safer needle devices in its recently updated guidelines for infection control in health care personnel,6 but no such recommendation was included. (See Hospital Employee Health, October 1998, p. 121.)

However, the ANA is optimistic that congressional language included in a 1999 federal spending bill will provide a "strong suggestion" to the CDC and other agencies that needlestick issues must be addressed with information about safer devices. (See related story, p. 6.)

The CDC did not respond to questions about Congress’ directive, nor did the agency have an answer about why the new hepatitis C guidelines failed to include information about using safer needle devices to help prevent HCW exposures.

References

1. Centers for Disease Control and Prevention. Public Health Service inter-agency guidelines for screening donors of blood, plasma, organs, tissues, and semen for evidence of hepatitis B and hepatitis C. MMWR 1991; 40 (No. RR-4):1-17.

2. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47 (No. RR-19):1-39.

3. Centers for Disease Control and Prevention. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. MMWR 1997; 46:603-606.

4. Centers for Disease Control and Prevention. Risk of acquiring hepatitis C for health care workers and recommendations for prophylaxis and follow-up after occupational exposure. Hepatitis Surveillance Report No. 56. Atlanta: U.S. Department of Health and Human Services, Public Health Service; 1995, pp. 3-6.

5. Centers for Disease Control and Prevention. Evaluation of safety devices for preventing percutaneous injuries among health care workers during phlebotomy procedures — Minneapolis-St. Paul, New York City, and San Francisco, 1993-1995. MMWR 1997; 46:21-25.

6. Bolyard EA, Tablan OC, Williams WW, et al. Guidelines for infection control in health care personnel, 1998. Am J Infect Control 1998; 26:289-354; Infect Control Hosp Epidemiol 1998; 19:407-463.