Risk of hepatitis C transmission by healthcare workers – a systematic review

Asian Pacific Association for the Study of the Liver consensus statements on the diagnosis, management and treatment of hepatitis C virus infection

Probable hepatitis C virus transmission from a seronegative blood donor via cellular blood products.

The importance of sexual transmission in the epidemiology of hepatitis C virus (HCV) infection is still controversial. To assess the risk of heterosexual HCV transmission, we examined eighty patients with chronic HCV-associated liver disease and their spouses in a cross-sectional clinical and serological cohort study. Serum samples from index patients and their spouses were assayed for HCV antibodies and HCV RNA. In the couples positive for both, further HCV genotyping was done. A questionnaire addressing points such as additional risk factors for HCV infection, sexual behaviour or duration of partnership was completed by all couples. HCV antibodies were detected in four (5%) spouses, of whom three (4%) were also positive for HCV-RNA. HCV genotyping revealed concordance (genotype 1) in two couples, indicating a risk of interspousal HCV transmission of 2.5%. Spouses of patients with HCV viraemia and chronic liver disease have a low risk for acquiring HCV. Even long-term spouses seem not to be at increased risk. We therefore suggest that the risk of HCV transmission between monogamous sex partners does not depend on the duration of sexual exposure.

EASL Clinical Practice Guidelines: Management of hepatitis C virus infection

Despite widespread concern and knowledge about the need for infection prevention and control in health care, it is clear that adherence to strict infection control procedures is not always at an optimal level (El-Masri and Oldfield, 2012). Hospital Acquired Infection (HAI) may occur when these standards break down, and HAI is a commonly discussed media topic (Bates, 2012). Alarmingly, a recent outbreak of Hepatitis C in the USA, resulting from inappropriate interference by health staff with equipment (needles) (Ramer, 2012) reminds us that even when vigilant approaches are used to combat the spread of infection, the potential for contamination from blood-borne infections remains a real possibility. Blood-borne viral infections include human immunodeficiency virus (HIV), Hepatitis C virus (HCV) and Hepatitis B virus (HBV). Taking precautions alone is not sufficient; staffs need to be knowledgeable in the disease and spread of disease. It is important to note that the risk of disease spread is to both staff and patients, although most staffs are vaccinated to prevent HBV (DoHC, 2005). While discussion papers and research studies on the topics of blood-borne diseases such as HCV, HBV and HIV/Aids are reduced in number compared with the 1980s and 1990s, current literature appears to indicate that knowledge deficits exist among nurses with regard to both HCV (Frazer et al., 2011) and HIV/Aids (Delobelle et al., 2009), and education and training specifically on these topics seems to be inconsistent and in some cases minimal (Delobelle et al., 2009; Frazer et al., 2011). This editorial discusses how blood-borne viruses (BBVs) can be best prevented in the health care setting in order to highlight the need for ongoing vigilance. An increased incidence of HBV and HCV transmission in the USA is associated with unsafe medical practices (Moore et al., 2011) particularly in those persons aged over 55 (Perz et al., 2012). These two viruses are the most prevalent in the USA with an estimated 1·4 million persons chronically infected with HBV and 3·2 million persons chronically infected with HCV (Weinbaum et al., 2008). A BBV is transmitted through contact with blood or body fluids typically through sexual or household contact, intravenous drug use or other parenteral exposures (Wise et al., 2012). Within health care settings, BBV transmission occurs through direct percutaneous inoculation of infected blood via needlestick or sharps injury or by blood splashed onto broken skin or mucous membranes (Stein et al., 2003). Health care workers (HCWs) undertaking exposure-prone procedures (EPPs) are also at risk of contracting BBVs (DoHC, 2005). The average risk of occupational HIV transmissions associated with percutaneous exposure to blood is 0·32% (approximately 1 infection in 325 documented exposures to blood from HIV-infected individuals) and for mucosal exposures it is 0·03% (approximately 1 infection for each 3300) (Henderson, 2012). The risk of occupational HBV infection following a parenteral exposure from an HBV-infected source patient with circulating e antigen is between 19% and 37% (Werner and Grady, 1982). The risk of occupational infection with HCV following parenteral exposure to blood from HCV-infected source patient is estimated at 1·9% per exposure (Henderson, 2003). In 1985, following an HIV epidemic, the Centre's for Disease Control (CDC) developed recommendations for prevention of HIV transmission in health care settings known as universal precautions (UP) (CDC, 1987). Blood was identified as the single most important source of HIV and HBV (Garner and Hospital Infection Control Practices Advisory Committee, 1996). As it is impossible to identify all patients that are sero-positive to HIV, HBV or HCV, UP dictates that all patients should be regarded as a potential biohazard (Garner and Hospital Infection Control Practices Advisory Committee, 1996; DoH UK, 1998). However, body substance isolation precautions (aimed at regarding all moist and body substances as potentially infectious) are familiar to all nurses as they are in use since 1987 (Garner and Hospital Infection Control Practices Advisory Committee, 1996). CDC then produced a two tier isolation precaution system known as standard precautions (SP) (Garner and Hospital Infection Control Practices Advisory Committee, 1996; Siegel et al., 2007). The first tier is designed for the care of all patients in hospitals, regardless of diagnosis or presumed infection status. The second tier, ‘Transmission-Based Precautions’ is for patients known or suspected to be infected by a transmissible infection (Garner and Hospital Infection Control Practices Advisory Committee, 1996; Siegel et al., 2007). SP principles include hand hygiene, patient isolation, personal protective equipment (PPE), personal and environmental hygiene, appropriate management of linen and health care waste, including sharps. Hand hygiene is the most important principle to prevent the spread of infection (WHO, 2009; HPSC, 2011a, 2011b). Hand hygiene includes hand-washing with soap (or antimicrobial soap) and water or alcohol gel. It also prescribes that cuts and abrasions are covered with waterproof dressings (WHO, 2009; HPSC, 2011a, 2011b). Stein et al. (2003) illustrated that while doctors understood the importance of hand hygiene, only 7 in 10 followed it frequently in practice. Patients with a BBV should be risk assessed to determine the type of isolation required. Patients that are actively bleeding or with large open wounds require contact precaution isolation (Siegel et al., 2007). Signs alerting staff to the type of isolation should be placed on the door and appropriate PPE should be available. PPE such as gloves and/or apron are required in the event of exposure to blood or body fluids (Siegel et al., 2007). Seventy-one percent of doctors do not wear gloves when taking blood despite 83% believing it important (Stein et al., 2003). Masks are not usually necessary unless to protect from other active infectious diseases, e.g. a patient with pulmonary tuberculosis. The environment should be cleaned daily with detergent and water and disinfected in the event of blood or body fluid spill. Blood spills require appropriate action, e.g. use of spill kits with PPE; appropriate disinfection agents to kill any viruses present; disposable scoops and yellow health care waste bags. Blood spills must be managed and decontaminated to prevent persons becoming contaminated (Siegel et al., 2007). The environment and instruments can also become contaminated with blood. This can lead to infection outbreaks such as the case of podiatry instruments that were the source of an outbreak of HBV in a long-term care facility (Wise et al., 2012). Health care waste is divided into health care risk waste and health care non-risk waste (DoHC, 2010). Health care risk waste includes any item contaminated with blood. Blood-stained products must be appropriately discarded in the yellow health care risk waste stream. If blood is in liquid form, a yellow rigid spill-proof container is used. Needles and sharps should be discarded in designated sharps containers (DoHC, 2010). Needlestick injuries (NSI) or sharps injuries must be managed appropriately. US surveillance indicates more than 380 000 parenteral annual exposures to blood. This equates to nearly 1 in 10 US HCWs receiving a needlestick exposure annually (Panlilio et al., 2004). Alarmingly, Delobelle et al.'s figure (as reported by the nurses themselves in response to survey) was as high as 7 of 10. The discrepancies in figures could be due to underreporting of NSI, which does occur in health care, and it is believed that doctors are least likely to report NSI (Stein et al., 2003). It is very important for nurses in critical care who are exposed to an NSI to perform first-aid to the injury and report to their supervisor and Occupational Health /Emergency Department. Occupational exposure should be assessed and treated accordingly, for example by immunization, hepatitis B immune globulin and post exposure chemoprophylaxis for exposure to HIV. There are also emotional effects of such exposure such as stress (Henderson, 2012) which need to be dealt with as well as financial implications. The cost of management of occupational exposures to blood and body fluids can vary from $71 to $4838 per exposure (O'Malley et al., 2007). An EU directive (2010/32/EU) was published in May 2010 (Council Directive, 2010). Its objective is to achieve the safest possible work environment for HCWs through the prevention of sharps injuries. All health care organizations must comply with this directive, which becomes legally binding on 11 May 2013 (European Biosafety Network, 2010). Perz et al. (2012) determined that unsafe injection practices account for a proportion of HBV acquisitions in health care settings (e.g. use of multi-dose vials; incorrect administration of injections resulting in microscopic quantities of blood contaminating the environment). An outbreak of HCV was identified in an outpatient's clinic where myocardial perfusion imaging was undertaken (Moore et al., 2011). It was determined that a nuclear medicine technologist routinely drew flushes of saline solution from multi-dose vials using the same needle and syringe as had previously been used to administer radiopharmaceutical doses (Moore et al., 2011). In addition, Fischer et al. (2010) highlighted HCV transmission resulting from contamination of single-use medication vials used on multiple patients during anaesthesia administration. As a consequence, more than 50 000 persons required follow-up by Public Health. This investigation highlighted breaches in aseptic technique and deficiencies in oversight within outpatient settings. BBV outbreaks have also been caused through blood glucose monitoring. Five instances of HBV in UK care homes resulted from poor infection control practice in blood glucose testing (Duffell et al., 2011). HBV outbreak was also noted in a long-stay facility where blood glucose monitoring devices were not decontaminated between patients. This resulted in HBV transmission to at least six residents (Schaffzin et al., 2012). HCV has also been transmitted by shared spring-triggered capillary blood glucose monitoring (Desenclos et al., 2001). Recently, Perz et al. (2012) identified haemodialysis as another risk factor in blood-borne pathogen transmission, while several documented cases of patient-to-patient HCV transmission via colonoscope exist (González-Candelas et al., 2010). Most occupational exposures occur on wards (36%), operating theatres account for 17% of incidents (HPA, 2008). Once a BBV is diagnosed in a health care setting, a local investigation is necessary to determine whether the infection is considered as nosocomial. Under the Infectious Disease Regulations (1981) the Department of Public Health must be notified of HBV and HCV infections. A patient notification exercise (PNE) is undertaken using ‘Guidance on the management and investigation of potential exposure to BBVs in health care setting’ (DoHC, 2005). Surveillance is a key performance indicator in the management of HCAI. Early identification of outbreaks and active surveillance of occupational exposures is also necessary. Occupational exposures include percutaneous exposures, where skin has been broken by a needle or sharp, human scratches or bites and mucotaneous exposures (HPA, 2008). Between 1997 and 2008, 3773 occupational exposures to blood or other high risk body fluids were reported to the Health Protection Agency in the UK (HPA, 2008). Feedback from surveillance and good communication informs staff of risks and of appropriate precautions. A study by Donohue et al. (2012) included recommendations such as enhanced surveillance of BBV notifications; sufficient laboratory resources; improved hospital information systems; the establishment of a national register of possible incidents of BBV transmission and that findings of investigations should be published. These would contribute to the further prevention of BBV within the health care setting. Transmission of BBVs in health care settings was believed to occur most frequently during EPPs; however, there is growing evidence of patient-to-patient transmission via other routes (Donohue et al., 2012) including deficient policies and procedures, improper hand hygiene, preparation of medication in blood processing areas, blood glucose monitoring, common-use saline bags, reuse of syringes, reuse of single-dose vials and use of multi-dose drug vials (Kermode et al., 2005; Greeley et al., 2011; Donohue et al., 2012). Perz et al. (2012) concluded that health care exposures may represent an important source of new HBV and HCV infections among older adults especially in ambulatory care settings through reduced oversight and fewer infection control resources. Strategies associated with injury prevention include avoidance of unnecessary needle use; unnecessary insertion of intravenous catheters; use of needleless or protected needle infusion systems and use of safer needles (Henderson, 2012). Health care associated infections and outbreaks of BBV have occurred in health care settings therefore it is necessary that a good infection control programme is in place (HIQA, 2009). Hand hygiene and adherence to SP are important in the prevention of spread of infections (SARI, 2005; Siegel et al., 2007). Reducing occupational exposure will reduce occupational infections with BBVs (Henderson, 2012). Education of staff is essential. Stein et al. (2003) observed the attitudes and compliance of medical staff to UP and recorded reasons for non-compliance. It concluded that while 86% of nurse's s attested to UP compliance, only 41% of doctors did. Education, monitoring, sufficient resources and disciplinary action for poor compliance are all necessary to improve infection control in hospitals (Stein et al., 2003). Although safety-engineered devices have been designed to cover sharps and eliminate all ‘after-use’ injuries, NSI still occur if these devices are used incorrectly. Thorough training and monitoring of the correct use of these safety devices is required (Perry et al., 2004). This training, together with regular education on blood-borne diseases, and infection prevention and control policies and procedures in the critical care unit lead to better management and prevention of BBV and increased safety for both staff and patients. Where direct educational update on the topics is not readily available, critical care nurses may take the initiative to perform independent learning on the topic in line with the development of their professional portfolio. Professional literature and readings on the topic are widely available and act as a good resource for the nurse looking to explore this topic within their portfolio.

Hepatitis C virus (HCV) infection is a leading cause of chronic liver disease with an estimated global prevalence of >120 million individuals (1). Of those who are exposed to the virus, an estimated 50–80% will develop chronic infection that can ultimately lead to hepatic fibrosis, hepatocellular carcinoma, and cirrhosis. As the virus is most effectively transmitted via blood, the majority of prevalent infections can be attributable to injection drug use or blood transfusions administered before 1990. Among incident HCV infections in the United States in 2005, the most frequently reported risk factors were injection drug use (50%), multiple sex partners (23%), surgery (14%) and percutaneous injury (10%) (2). Interestingly, no identifiable risk factors were reported by 26% of the participants. In at least some of the HCV-infected individuals without identifiable risk factors, noninjection drug use might be the mechanism of viral acquisition. As 8% of the US population engages in illicit substance use monthly (3), HCV transmission via noninjection drug use may be a common, yet under-appreciated, public health problem. Although most incident HCV infections occur among injection drug users, noninjection drug use is increasingly recognized as an emerging risk factor. Several recent studies have reported that the prevalence of HCV among noninjection drug users (NIDUs), estimated to range from 2 to 35%, is greater than that observed in the general population (4). The wide variability in the prevalence estimates among NIDUs results from differences in the primary aims and in the quality of the data obtained in individual studies. In the majority of these studies, HCV risk factor assessment among NIDUs was a secondary aim as the investigation of HCV transmission among injection drug users (IDUs) was their primary objective. Additional weaknesses of these studies include limited data regarding the likely time of HCV exposure and possible false-negative HCV antibody measurements due to waning serological markers, as HCV antibodies have been shown to disappear in a significant percentage of individuals 20 years after spontaneous resolution of the infection. Additionally, several studies did not use the recombinant immunoblot assay or HCV RNA quantitation to confirm positive serologic results. Misclassification and recall bias is another potential limitation of studies of both noninjection as well as injection drug use, as these studies largely rely on risk factor assessment based upon patient self-report. Misclassification might occur if prior injectors are erroneously classified as NIDUs. Recall bias, the inability to remember episodes of high-risk behavior, may have occurred from the effect of mind-altering substances or patient reluctance to report specific instances. Consequently, the specific behaviors among NIDUs that result in increased HCV seroprevalence and their relative importance toward the establishment of HCV infection remain unclear. How might NIDU behaviors result in HCV transmission? Most likely, two factors are required, exposure to HCV RNA in biological fluids and mucous membrane disruptions permissive for blood–virus interaction. HCV RNA has been detected in saliva from chimpanzees (5) and in up to 52% of humans with chronic HCV infection (6, 7). Injection of saliva derived from an HCV-infected chimpanzee into a second chimpanzee resulted in HCV infection (5). Similar observations have been noted in humans where a skin bite from an HCV-infected individual resulted in productive HCV infection (8). Other body fluids besides saliva also harbor HCV and may be vehicles of viral transmission. For example, HCV RNA has been detected in 59% of gingival crevicular fluid (GCF) specimens, and the detection of HCV RNA in GCF required a minimum plasma level of 100 000 copies/ml (7). In this study, only patients with measurable HCV RNA in GCF had detectable HCV RNA in saliva suggesting that GCF may be a potential viral reservoir. Additionally, secretions from other body compartments may also transit HCV. As the virus has also been detected in nasal sections of an NIDU (9), intranasal cocaine use could lead to HCV infection. Thus, sharing of inhalational equipment contaminated by either intranasal or oral fluids could permit viral transfer among individuals. The other factor required for the development of HCV infection is direct interaction between the virus and the host's blood. Among NIDUs, chronic substance abuse can lead to mucous membrane disruptions. For example, through its vasoconstricting effects as well as irritation from substances with which the drug is diluted (i.e. talc), cocaine can be locally irritating to the thin respiratory epithelium of the nasal cavity resulting in nasal septum perforations of both the cartilaginous and bony tissues. In the oral cavity, persistent cocaine use can result in ischaemic mucosal ulceration, rapid gingival recession, and dental erosions (10). In addition, individuals with chronic substance abuse display high rates of dental abnormalities, including decay and periodontal disease, which could further facilitate interaction between the virus and the host. Consequently, blood or saliva on inhalation equipment in combination with cocaine-induced lesions of oral or nasal mucous membranes is a mechanism by which noninjection drug use could result in productive HCV infection. In this issue of Liver International, Macias et al. (11) assessed risk factors for HCV acquisition in 182 NIDUs. Study participants were recruited from a drug abuse treatment center, and detailed information on previous drug addiction behaviors was available. Subjects underwent a structured interview that included detailed questions on potential routes of exposure, substance abuse patterns, and behaviors that increase the likelihood of HCV transmission. A study physician subsequently examined all subjects for signs of skin perforation such as evidence of recent venipuncture, tattoos and body piercings. Serological testing for human immunodeficiency virus, hepatitis B virus and HCV as well as measurement of HCV RNA levels was subsequently performed on each individual. The authors report an HCV prevalence of 12.6%, and they observed that age ≥34 years, the presence of tattoos, and sharing of crack cocaine inhalation equipment were independently associated with HCV infection in NIDUs. These results, which are corroborated by those of prior studies (12–17) (Table 1), suggest that HCV transmission can occur via shared crack cocaine inhalation equipment. The authors hypothesize that blood (from oral ulcerations) or saliva contamination of inhalational equipment could transmit quantities of virus sufficient to surpass the critical threshold, estimated to be 20 viral copies/ml in chimpanzees (18), necessary for productive infection. Macias et al. also found that tattoos were significantly associated with HCV transmission. Tattooing, especially when performed by a friend or relative, has been reported to be an independent risk factor for HCV transmission among high-risk individuals (12–14, 16, 17) (Table 1). Unprofessional tattooing, especially among incarcerated individuals, can be performed using a paperclip, staple or other sharp objects to break the surface of the skin, which is then pigmented with ink commonly from a ballpoint pen. HCV transmission might occur as a consequence of the same object being used on more than one individual and the fact that these implements are infrequently sterilized between insertions. Besides noninjection drug use and tattooing, other risk factors for HCV include incarceration (13, 19), altercations that result in traumatic injury (20), and sharing the same electric shears among many prisoners (20). How does this study rate in comparison with other studies that have assessed risk factors for HCV acquisition among NIDUs? A recent meta-analysis of 28 studies of NIDUs reported mean and median scores of 7.11 and 7.00, respectively, on an objective quality measurement scale (4). Using these criteria, we calculated a score of 10 for the Macias et al. study. Strengths of the present study are the inclusion of a relatively large sample, the fact that physicians experienced in drug addiction management conducted patient interviews and physical examinations, the fact that a comprehensive ascertainment of prior noninjection drug use behaviors was performed, and the analysis of the data using multivariate techniques. Of note is the fact that study participants did not receive payment for their involvement. The exclusion of IDUs from this study is an additional advantage. Recall bias, especially because patients may have been reluctant to report or did not recall specific high-risk behaviors, is a potential limitation of the study as it is with all studies that rely on patient self-report. This important study by Macias et al. identifies potential modes of HCV transmission in NIDUs, and it underscores the importance of noninjection drug use as a potential mechanism of viral acquisition. The exclusion of IDUs may permit detection of the weaker association between NIDU behaviors and HCV. Several factors concerning the mechanism of viral transmission, such as the relative contribution of blood versus salivary contamination and the minimum viral quantity required for human oral transmission, remain to be investigated. With an enhanced understanding of the factors that promote viral transmission in NIDUs, effective infection control interventions may be implemented.

Ultra-short duration direct acting antiviral prophylaxis to prevent virus transmission from hepatitis C viremic donors to hepatitis C negative kidney transplant recipients.

Transmission of Hepatitis C Virus Associated with Surgical Procedures—New Jersey 2010 and Wisconsin 2011: February 27, 2015 / 64(07);165-170

In February 2007, a general surgeon in Charlottetown, Prince Edward Island, tested positive for hepatitis C virus (HCV). The surgeon's infection onset date could not be determined; however, episodic hepatic enzyme elevations were first detected in November 2004 and again in February 2007. HCV transmission during surgery, alhough rare, has been documented. A phased look-back HCV screening program was conducted to detect HCV transmission from this surgeon to patients who underwent the highest-risk procedures in the three years before his positive test. Highest-risk procedures were defined as exposure-prone procedures (EPP) in which exposure to the surgeon's blood was most likely. EPP patients from January 2004 to February 2007 were identified using hospital and administrative records. Linkages with the provincial notifiable disease for HCV was performed, and death records for deceased EPP patients were reviewed. Eligible patients were invited for screening. Of 6248 patients seen in phase 1, 272 (4.4%) were identified to be EPP. Of the 272 patients, 248 (91.1%) were invited for HCV testing and 24 (8.8%) were deceased. To date, 231 of 248 (93.1%) patients have presented for screening. Two patients (one alive, one deceased) were HCV positive before their EPP. Viral sequence of the surgeon's isolate is unrelated to the first patient; the second individual has a resolved infection (polymerase chain reaction negative). No new transmission events were identified in the screened patients. The 95% CI of the transmission probability was estimated to be 0 to 0.016. HCV transmission from the surgeon during a 38-month look back was unlikely. In the absence of protocols for investigating HCV transmission from infected health care workers, screening was initially prioritized to the highest-risk patients. The investigation has been satisfactorily terminated based on these results.

Hepatitis C virus (HCV) is transmitted most efficiently by large or repeated percutaneous exposures to blood, such as through the transfusion of blood or blood products from infectious donors or the sharing of contaminated needles among injection drug users. Other bloodborne viruses, such as the hepatitis B virus, are transmitted not only by overt percutaneous exposures, but by mucous membrane and inapparent parenteral exposures as well. Although these types of exposures are prevalent among healthcare workers, the risk factors for HCV transmission in this occupational setting are not well defined. A case-control study of patients with acute non-A, non-B hepatitis conducted prior to the discovery of HCV found a significant association between acquiring disease and healthcare employment, specifically patient care or laboratory work.1 Seroprevalence studies have reported antibody to HCV (anti-HCV) rates of 1% among hospital-based healthcare workers in Western countries and 4% among such workers in Japan.2 In the one study that assessed risk factors for infection, a history of accidental needlesticks was associated independently with anti-HCV positivity.3 Case reports have documented the transmission of HCV infection from anti-HCV-positive patients to healthcare workers as a result of accidental needlesticks or cuts with sharp instruments.2 In the study reported by Lanphear et al in this issue4 on the follow-up of healthcare workers who sustained a variety of different types of exposures to blood from anti-HCV-positive patients, 3 (6%) of 50 with needlestick exposures seroconverted to anti-HCV on the basis of second-generation enzyme immunoassays (EIA) and supplemental testing. A fourth healthcare worker who sustained a scalpel laceration from an anti-HCV-positive source contracted clinical non-A, non-B hepatitis without anti-HCV seroconversion. Among patients with HCV infection, the secondgeneration EIAs detect anti-HCV in approximately 90%2; thus, in about 10% of persons with HCV infection, the diagnosis can be made only with researchbased detection methods, such as polymerase chain reaction (PCR) testing for HCV RNA. If we assume that the fourth healthcare worker also contracted hepatitis C, then the risk of HCV infection after a total of 57 exposures to needlesticks or sharps was 7%; 2 of the 4 infected healthcare workers developed clinical hepatitis. These results are consistent with a similar study reported from Japan.5 In this study, five of 76 healthcare workers with needlestick exposures to anti-HCV-positive patients seroconverted to anti-HCV for an incidence of 7%; however, an additional two infections were detected by PCR for an overall incidence of 9%. When exposures only to HCV RNApositive source patients were included (68 of 76), the overall incidence of HCV infection was 10%. Liver enzyme elevations developed in 4 of the 7 infected healthcare workers. Although no infections were detected among the small number of healthcare workers who sustained mucous membrane or open skin lesion exposures in the study by Lanphear et al, a recent case report has documented the transmission of HCV from a blood splash to the conjunctiva.6

Concern is increasing in both the medical community and among the general public about the possible transmission of hepatitis C virus (HCV) from infected health care workers to their patients. Until now, no reliable estimates for the risk of such transmission exist. To estimate the probability of HCV transmission from a surgeon to a susceptible patient during invasive procedures. A model consisting of 4 probabilities was used: (A) the probability that the surgeon is infected with HCV, (B) the probability that the surgeon might contract percutaneous injuries, (C) the probability that an HCV-contaminated instrument will recontact the wound, and (D) the probability of HCV transmission after exposure. Values for the calculations were taken from published studies. When the surgeon's HCV status is unknown, the risk of HCV transmission during a single operation is 0.00018% +/- 0.00002% (mean +/- SD). If the surgeon is HCV RNA positive, this risk equals 0.014% +/- 0.002%. The likelihoods of transmission in at least 1 of 5000 invasive procedures performed by a surgeon during 10 years are 0.9% +/- 0.1% (HCV status unknown) and 50.3% +/- 4.8% (HCV RNA positive), respectively. The calculated risks for HCV transmission from a surgeon to a susceptible patient during a single invasive procedure are comparable to the chance of acquiring HCV by receiving a blood transfusion. These figures could provide a basis for further discussions on this controversial subject and might also be relevant for future recommendations on the management of HCV-infected health care workers.

With the development of effective therapies against human immunodeficiency virus (HIV), hepatitis C virus (HCV) infection has become a major cause of morbidity and mortality among patients with both infections (coinfection). In addition to the high prevalence of chronic HCV, particularly among HIV-infected injection drug users, the rate of incident HIV infections is increasing among HIV-infected men who have sex with men, leading to recommendations for education and screening for HCV in this population. Liver disease is the second leading and, in some cases, a preventable cause of death among coinfected patients. Those at risk for liver disease progression are usually treated with a combination of interferon (IFN) and ribavirin (RBV), which is not highly effective; it has low rates of sustained virologic response (SVR), especially for coinfected patients with HCV genotype 1 and those of African descent. Direct-acting antivirals might overcome factors such as immunodeficiency that can reduce the efficacy of IFN. However, for now it remains challenging to treat coinfected patients due to interactions among drugs, additive drug toxicities, and the continued need for combination therapies that include pegylated IFN. Recently developed HCV protease inhibitors such as telaprevir and boceprevir, given in combination with pegylated IFN and RBV, could increase the rate of SVR with manageable toxicity and drug interactions. We review the latest developments and obstacles to treating coinfected patients.

All-cause and liver-related mortality in hepatitis C infected drug users followed for 33 years: A controlled study

Although it is well documented that bloodborne viruses (BBVs), including human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) have been transmitted from patients to healthcare workers (HCWs), there has also been reported transmission from HCWs to patients during the provision of health care. With remarkable progress in infection prevention, diagnosis tools, treatment regimens and major improvements in guideline development methodology, there was a need to develop an evidence-based guideline to replace the 1998 Canadian consensus document for managing HCWs infected with BBVs. This article summarizes the Canadian Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Settings. A Guideline Development Task Group was established and key questions developed to inform the guideline content. Systematic reviews were conducted to evaluate the risk of HCW-to-patient transmission of HIV, HCV and HBV. Environmental scans were used to provide information on Expert Review Panels, disclosure of a HCW's serologic status and lookback investigations. Federal, provincial and territorial partners and key stakeholder organizations were consulted on the Guideline. The risk of HCW-to-patient BBV transmission was found to be negligible, except during exposure-prone procedures, where there is a risk that injury to the HCW may result in exposure of a patient's open tissues to the HCW's blood. Risk of ensuing transmission and the rate of transmission varied by BBV, and were lowest with HIV and highest with HBV. The Guideline provides key content, including recommendations regarding criteria to determine if a procedure is an exposure-prone procedure, management of HCWs infected with a BBV, including considerations for the HCW's fitness for practice, Expert Review Panels, HCW disclosure obligations and right to privacy and lookback investigations. This new Guideline provides a pan-Canadian approach for managing HCWs infected with a BBV, with recommendations related to preventing HCW-to-patient transmission of BBVs during the provision of care.

BackgroundStudies of the molecular epidemiology and risk factors for hepatitis C virus (HCV) in health care workers (HCWs) of Peshawar, Khyber Pakhtunkhwa region are scarce. Lack of awareness about the transmission of HCV and regular blood screening is contributing a great deal towards the spread of hepatitis C. This study is an attempt to investigate the prevalence of HCV and its possible association with both occupational and non-occupational risk factors among the HCWs of Peshawar.ResultsBlood samples of 824 HCWs, aged between 20-59 years were analysed for anti-HCV antibodies, HCV RNA and HCV genotypes by Immunochromatographic tests and PCR. All relevant information was obtained from the HCWs with the help of a questionnaire. The study revealed that 4.13% of the HCWs were positive for HCV antibodies, while HCV RNA was detected in 2.79% of the individuals. The most predominant HCV genotype was 3a and 2a.ConclusionA program for education about occupational risk factors and regular blood screening must be implemented in all healthcare setups of Khyber Pakhtunkhwa province in order to help reduce the burden of HCV infection.