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New CDC HCV Postexposure Guidelines

The CDC has revised their guidelines for follow-up after occupational exposure to hepatitis C virus (HCV) that include consideration of baseline testing of the source patient for anti-HCV and baseline and 6 month follow-up testing of the person exposed for anti-HCV and ALT (alanine aminotransferase) activity. In these revised guidelines, the CDC cites risk of both occupational and nosocomial transmission of HCV.

In summarizing the results of follow-up studies of healthcare workers who sustained percutaneous exposures to blood from anti-HCV positive patients, the CDC cites the incidence of anti-HCV seroconversion (based on second-generation testing) averaged 3.5% (range 0% to 7%) and in the one study that used polymerase chain reaction (PCR) to measure HCV infection by detecting HCV RNA, the incidence was 10%. In the summary on nosocomial transmission.

The CDC also notes that hospitalized patients may serve as the reservoir for transmission--the prevalence of anti-HCV among patients has been reported to range from 2% to 18%. A number of nosocomial outbreaks were also summarized. In one reported cited from Australia, four patients that had outpatient surgery on the same day became infection with HCV of the same genotype as a chronically infected patient who underwent surgery just prior to the cases. In a report from Spain, five open heart surgery patients acquired HCV infection from a cardiovascular surgeon with chronic HCV.

In the absence of post exposure prophylaxis, there are multiple issues that need to be considered in deciding if there should be a defined protocol for the follow-up health care workers (HCWs) for HCV infection after occupational exposure. These include the limited data on the risk of transmission, the limitations of available serological testing for detecting infection and determining infectivity, the poorly defined risk of transmission by sexual, household, and perinatal exposures, the limited benefit of therapy for chronic disease (e.g. alpha interferon), the medical-legal implications, and the cost of follow-up. CDC has estimated the nationwide cost of providing post-exposure follow-up testing is estimated at $2 to $4 million; the cost per person for each person who benefits from therapy is estimated at $200,000.

Even in the absence of both available postexposure prophylaxis and limited specific measures for disease prevention, the CDC is now recommending that individual institutions should consider implementing policies and procedures for follow-up after percutaneous or per mucosal exposure to anti-HCV positive blood to address individual workers' concerns about their risks and outcome. Above all, institutions should ensure education of HCWs regarding the risk and prevention of bloodborne infections in the occupational setting, including hepatitis C, and such information should be routinely updated to ensure accuracy.

In the summary of recommendations, it states that no postexposure prophylaxis is available for hepatitis C and immune globulin is not recommended because it does not appear to be effective in preventing hepatitis C . The CDC recommends that institutions should provide health care workers (HCWs) with accurate and up-to-date information on the risk and prevention of all blood-borne pathogens, including hepatitis C. In addition, institutions should consider implementing policies and procedures for follow-up of HCWs after percutaneous or per mucosal exposure to anti-HCV positive blood. Such policies might include baseline testing of the source patient for anti-HCV and baseline and 6 month follow-up testing of the persons exposed for anti-HCV and ALT activity. All anti-HCV results should be confirmed by supplemental anti-HCV testing.

The issue of the HCV-infected HCW is also addressed and the guidelines state that the risk of transmission from an infected worker to a patient appears to be very small and that there are currently are no recommendations regarding restriction of HCWs with Hepatitis C. As recommended for all HCWs, those who are anti-HCV-positive should follow strict aseptic technique and standard (universal) precautions, including appropriate use of handwashing, protective barriers, and care in the use and disposal of needles and other sharp instruments.

A copy of this document can be obtained from the CDC Hepatitis Surveillance Branch (telephone: 404-639-3408).

FROM: CDC. Issues and Answers: What is the risk of acquiring hepatitis C for health care workers and what are the recommendations for prophylaxis and follow-up after occupational exposure to hepatitis C virus? CDC: Hepatitis Surveillance Report: No. 56; April 1996.

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