HCV may pose greatest risk for needlesticks

South Carolina, Florida begin education programs

When health care workers suffer a needlestick injury, their greatest concern may be contracting HIV. But they may actually have more to fear from hepatitis C, a virus that is more prevalent, has a higher seroconversion rate, and can lead to severe liver disease or cancer.

That is why the states of South Carolina and Florida have set up special programs to educate health care workers, providers, and the general public about HCV. A lack of funds for testing and a lack of awareness plagues HCV treatment, says Robert Ball, MD, MPH, infectious disease/HIV consultant epidemiologist for the South Carolina Department of Health and Environmental Control in Columbia.

"This is HIV in the mid-’80s all over again," says Ball, referring to a time when authorities were slow to combat HIV transmission with widespread education, testing, and prevention programs.

"We have to maintain vigilance against this bloodborne pathogen," says Steven Wiersma, MD, MPH, deputy state epidemiologist for the Florida Department of Health in Tallahassee. "It’s a lot more virulent than hepatitis B and HIV in terms of needlestick injuries."

The Florida Legislature appropriated $2.5 million to the Florida Hepatitis and Liver Failure Prevention and Control Program, which will allow the creation of a hepatitis registry. Health officials plan to target four to eight counties with high at-risk populations for intensive screening, testing, prevention, and liver wellness programs.

The South Carolina Hepatitis C Coalition is acting as a clearinghouse for HCV information and resources and is initially focusing education efforts on health care workers and providers. PHT Services Ltd. of Columbia, which provides workers’ compensation insurance and risk management services to hospitals in the state, is coordinating the coalition.

"The Hepatitis C Coalition is trying to get all or virtually all South Carolina health care facilities to incorporate the latest CDC guidelines [on bloodborne pathogens]," says Ball. (For a summary of CDC guidelines, see story in Hospital Employee Health, December 1999, p. 136.)

About four million people nationwide are infected with HCV, making it the most common chronic bloodborne pathogen, according to the Centers for Disease Control and Prevention in Atlanta.

Only 1% to 2% of health care workers are infected with HCV, but 2% to 4% of all acute HCV infections that have occurred annually from 1991 to 1996 occurred in health care workers exposed occupationally, the CDC found.1 The use of safer needle technology to protect health care workers became an imperative with an updated compliance directive from the U.S. Occupational Safety and Health Administration this fall. The National Institute for Occupational Safety and Health also issued an alert on preventing needlestick injuries. (See article on p. 21.) OSHA is considering rewriting its bloodborne pathogens standard to include language about safer sharps technology.

HCV carriers may not even realize they are infected; they may have no symptoms or only mild symptoms. But unlike HBV, chronic infection develops in 75% to 85% of patients, with active liver disease developing in 70%. Of the patients with active liver disease, 10% to 20% develop cirrhosis, and 1% to 5% develop liver cancer.

Seroconversion after a needlestick injury averages 1.8% — six times greater than the average seroconversion in needlestick injuries involving HIV exposure.

Postexposure prophylaxis for HIV has prompted hospitals to respond quickly with rapid blood tests after needlestick injuries. (See article on p. 20.) However, there is no recommended postexposure prophylaxis for HCV, although trials with interferon or Rebetron indicate that the virus may be put into remission in some cases, Ball says.

Given those statistics, health care workers need to be aware of their risks, says Ball. And current guidelines need to be followed closely, he says.

"Often we find health care workers may be considered at risk for HIV and HCV, and [in some cases] HCV isn’t even in the exposure control plan," he says.

Ball estimates that about 10% of the time, South Carolina patients and health care workers aren’t considered for testing for HCV after a needlestick, with percentages possibly greater in other states. The figure should be 0%, he says.

The South Carolina Hepatitis C Coalition is conducting seminars that target infection control professionals, employee health, and emergency departments. The coalition includes nurses, physicians, and state chapters of specialty groups, such as the Association of Professionals in Infection Control and Epidemiology and the Association of Occupational Health Nurses.

With new funding, Florida is taking the lead in widespread testing for HCV. Wiersma hopes to learn more about the prevalence of HCV in the state and which populations are at greatest risk. If Florida’s HIV rates are any indication, the state will have a higher HCV prevalence than the nation overall, he says.

The Florida Department of Health conducts an annual telephone survey of 5,000 respondents each year. In addition to questions about behavioral risk factors, this year’s survey will ask respondents if they are willing to take a home test for HCV.

The kit involves a simple blood collection at home that is mailed to an independent company. Participants receive pre-test and post-test counseling and are assured of confidentiality.

Meanwhile, people at high risk for HCV infection, including those who use illegal injection drugs and have multiple sexual partners, will be urged to go to their local health departments for testing. "[We want to] let those people benefit from the new advances, new drugs, and information on how to maintain liver wellness," he says.

Health care workers also will have easy access to HCV information with interactive learning materials the state plans to release on the Internet and in a CD-ROM version.

Reference

1. National Institute for Occupational Safety and Health. "Alert: Preventing Needlestick Injuries in Health Care Settings." DHHS (NIOSH) Publication 2000-108. Washington, DC; November 1999.