Should you screen all new employees for HCV?

Answer may differ based on community rates

A longtime employee develops symptoms of liver disease and tests positive for hepatitis C. Although there has been no recent needlestick, she insists that the exposure was occupational. After all, testing for HCV after needlesticks only recently became routine. There’s another risk factor, a previous blood transfusion, but the occupational risk still leaves you liable. Your hospital, self-insured for workers’ compensation, pays all her bills for a liver transplant and lost wages. The total cost tops half a million dollars.

That nightmare scenario has propelled some hospitals to begin screening new employees for hepatitis C. However, such routine screening remains controversial, as some employee health professionals say it is not cost-effective.

Whether HCV screening of new employees makes sense for your hospital depends on the prevalence of the disease in the surrounding community and the structure of state workers’ compensation laws, employee health experts say.

"Every state is a little different. According to case law in Florida, the burden of proof is really on the employer when it comes to hepatitis B and hepatitis C," says JoAnn Shea, MSN, ARNP, director of employee health and wellness at Tampa (FL) General Hospital. "Because health care workers have a significant occupational risk, it would be difficult for us to prove they didn’t acquire it here."

Since Tampa General began screening new employees for HCV in 1995, 85 have tested positive. In most cases, the employees proceeded into the positions for which they were hired. In a few cases involving surgical technicians and surgical nurses who perform exposure-prone cases, a hospital committee determined that their employment in that position would compromise patient safety, Shea says.

Uncovering unknown cases of HCV is a double-edged sword. While it may burden an employee with job restrictions, it also can save an employee’s life. "Hepatitis C is insidious. You don’t know you have it," says Gary Rischitelli, MD, JD, MPH, assistant scientist at the Center for Research on Occupational and Environmental Toxicology at Oregon Health & Science University in Portland. "A lot of people don’t recall they had any risk factors."

Early treatment and changes in lifestyle, such as limiting alcohol intake, can dramatically impact the course of the disease, Rischitelli notes.

Yet for some hospitals, screening hundreds of new employees for the rare case of hepatitis C just doesn’t make sense. Others offer screening on a voluntary basis for employees who want to know their HCV status. Employee health professionals at three hospitals in different geographic regions shared their perspectives on HCV screening with Hospital Employee Health:

Four nurses at Tampa General are being treated for hepatitis C, which is presumed to be occupationally acquired. One had never even reported an exposure, but claimed unreported needlesticks and the occupational exposure cannot be ruled out.

Meanwhile, the number of patients with hepatitis C is growing steadily. Last year, 41 source patients tested positive for HCV after an employee exposure, compared with 19 in 1997.

Those facts, along with the reported benefits of early treatment,1 influenced the hospital to begin testing all new hires for hepatitis C. Since 1995, the hospital has had 85 new employees test positive during pre-employment screening.

Tampa General now conducts 500 to 600 HCV screening tests a year for employees who could have a bloodborne-pathogen exposure, including housekeeping staff, nurses, and surgical techs. The expense of the screening is outweighed by the potential costs of lifelong care for an HCV patient. "You can spend 10 times on one case what we spend on screening people," Shea notes.

Yet there is a humanitarian aspect, as well, she points out. "We’ve identified many people within the group in which treatment is recommended, and they never knew they had hepatitis C," she says. "Some of them may be one of the fortunate ones to clear the virus with treatment."

Current employees receive an HCV test at baseline in the case of a bloodborne pathogen exposure, or they can request a test if they want to know their HCV status. In addition to the 85 employees who were positive on hire, Tampa General has identified 43 current employees with hepatitis C following baseline exposure testing or via routine visits. "We believe [screening] has given us the ability not only for early identification so they can get early intervention, but I do believe we protected the hospital against some future liability," Shea says.

The prevalence of HCV among health care workers is roughly the same as the general population (1% to 2%).2 Anytime you conduct widespread screening on a low prevalence population, you will end up with false positives, notes Anthony Burton, MD, MPH, medical director of employee health services at St. Joseph Mercy Health System in Ann Arbor, MI.

Each positive result requires confirmatory testing, Burton says. "You’re looking at antibodies, you’re not looking at infection. If you do confirm that the person has hepatitis C antibodies, you don’t know if [it’s an] ongoing infection or if it’s a cleared infection. That requires further testing."

The low likelihood of detecting cases of hepatitis C and the burden — emotionally for the employee and financially for the hospital — of dealing with false positives has convinced Burton that wide-spread screening isn’t beneficial. Instead, hospitals could provide an information sheet outlining the risk factors for HCV and suggesting that new employees take a screening test or be tested by their personal physicians.

"If you reserve hepatitis C testing for those who have risk factors, you increase the positive predictive value of the test," he says.

You also need to have a clear plan of what you will do if cases of hepatitis C are detected. "You’ve now uncovered a problem," he says. "You need to make sure they get follow-up."

Georgia Thomas, MD, MPH, director of employee health at the University of Texas M.D. Anderson Cancer Center in Houston, recalls two unrelated phone calls from nurses who had worked at the center in the 1970s. They both had hepatitis C, and they both recalled needlesticks that could have been the source of infection.

Thomas found the old records, but still couldn’t help them determine the source of their infection. HCV testing wasn’t available at the time of their exposures. But the calls made her think about the hidden cases of HCV and the impact on employees’ lives.

Now, the cancer center tells new employees at orientation that they can receive voluntary tests for HCV. While about half of them take a slip to order the test, more than a third of them fail to show up for screening, she says.

"At any point of time, we have a large number of individuals where we’re waiting for at least a month to see if they’re going to get a test," she says. "They’ve got to go across the street to the main hospital lab to get their blood drawn."

For Thomas, the testing isn’t influenced by concerns about potential liability for undetected, pre-existing cases of hepatitis C. In Texas, an employee must link a bloodborne infection to a specific occupational exposure to be covered by workers’ compensation. "If you haven’t reported a needlestick, as far as we’re concerned, legally, it didn’t happen," she says.

Last year, out of 436 screening tests, five new employees tested positive for HCV. The cancer center has 11,000 employees.

"Our positivity rate is somewhere between 0.7% and 1.1%," Thomas says. "That is simply the initial hepatitis C test that is positive. We did not start doing confirmation tests until this year. Once we got the initial positive, we felt that individual ought to be referred out to his or her own physician. We decided that since the number of positive tests is relatively low, we would do confirmatory testing. I would expect our confirmed positive rate is going to be below 1%."

Thomas views the HCV testing as a service for employees. "If we are able to identify and help that individual intervene successfully in what can be a very chronic and very difficult disease to manage, I think that’s valuable," she says.

References

1. Jaeckel E, Cornberg M, Wedemeyer H, et al. Treatment of acute hepatitis C with interferon alfa-2b. N Engl J Med 2001; 345:1,452-1,457.

2. Centers for Disease Control and Prevention. Recom-mendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47(RR-19):1-39.