Management of healthcare workers exposed to hepatitis B virus or hepatitis C virus

Dr. Walid Y. Farah

Definition of exposure – The CDC has defined "exposure" to blood, tissue, or other body fluids that may place a HCW at risk for HIV infection and therefore requires consideration of postexposure prophylaxis (PEP) as:
· A percutaneous injury (eg, a needlestick or cut with a sharp object)
· Contact of mucous membrane or nonintact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis)

Body fluids of concern include: semen, vaginal secretions, or other body fluids contaminated with visible blood that have been implicated in the transmission of HIV infection, and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids, which have an undetermined risk for transmitting HIV. In addition, any direct contact (ie, without barrier protection) to concentrated HIV in a research laboratory or production facility is considered an "exposure" that requires clinical evaluation and consideration of PEP. This definition should also be used for providing postexposure evaluation for HBV and HCV.

General guidelines

All potential exposures to blood or contaminated body fluids as defined above should be promptly evaluated. The following information should be obtained by trained medical personnel:

• Name and identification of the source
• Time and date of the exposure
• Nature of the exposure (ie, nonintact skin, mucosal, or percutaneous exposure, human bite); type of fluid (ie, blood, blood contaminated fluid, or other contaminated fluid)
• Body location of the exposure and contact time with the contaminated fluid
• Infective status of the source (ie, HIV, HCV, HBsAg), if known, including date of test
• For percutaneous injuries, a description of the injury (depth of wound, solid versus hollow needle, sharp use in source patient)

The injured HCW should be questioned about the circumstances of the exposure (activity, time, device type, availability of PPE). The following information should be obtained from the injured person and verified from their medical/occupational health record:

• Dates of hepatitis B immunizations
• Postimmunization titer, if known
• Previous testing (if available) for HIV, HBV, and HCV
• Tetanus immunization status
• Current medications
• Current or underlying medical conditions that might influence drug selection (eg, pregnancy, breast feeding, renal or hepatic disease)

All information should be recorded on the injured HCWs medical/occupational health record. Many healthcare facilities regard information obtained on HCWs as confidential and place it in a separate medical record accessible only to the occupational health physician or nurse. Use of code numbers instead of names for all laboratory tests and medical prescriptions will aid in protecting confidentiality.

All source cases should be tested for HBsAg, HCV, and HIV, unless the source is known to be infectious. If feasible, a system should be devised to allow HIV test results to be obtained possible (ie, within 24 hours). The rapid HIV test (SUDS) may be used to make an initial determination of the source patient's HIV status, and has the advantage that results are available in less than 60 minutes. All positive tests should be confirmed by ELISA and Western blot. Negative tests do not require confirmation. Determination of HBsAg status should be obtained as soon as possible, but not later than 7 days. Local and state laws regarding consent and counseling prior to HIV testing should be followed.

Testing the injured employee is based upon the results of the source patient tests (see below).

HBV infection – Postexposure prophylaxis with HBIG and/or vaccine should be used when indicated (eg, after percutaneous or mucous membrane exposure to blood known or suspected to be HBsAg positive). Needlestick or other percutaneous exposures of unvaccinated HCWs should lead to initiation of the series regardless of the HBV status of the source patient. Postexposure prophylaxis should be considered for any percutaneous, ocular, or mucous membrane exposure to blood in the workplace and is determined by the HBsAg status of the source and the vaccination and vaccine-response status of the exposed person.

If the source patient is HBsAg positive and the exposed person is unvaccinated, HBIG also should be administered as soon as possible after exposure (preferably within 24 hours) and the vaccine series started. The effectiveness of HBIG when administered more than seven days after percutaneous or permucosal exposures is unknown. If the exposed person had an adequate antibody response (>10 mIU/mL) documented after completion of an HBV vaccination series, no testing or treatment is needed, although some experts would consider administration of a booster dose of vaccine. When the source is unavailable but is at high risk for HBV infection (eg, current or former injecting drug user), some clinicians would assume that the source is HBsAg positive and provide postexposure prophylaxis based on this assumption.

HCV infection – Healthcare professionals who provide care to persons exposed to HCV in the occupational health setting should be knowledgeable about the risk for HCV infection and appropriate counseling, testing, and medical follow-up. A National Institutes of Health (NIH) consensus conference recommended that persons exposed to an HCV-positive source have the following baseline and follow-up testing:

• Baseline testing for anti-HCV, HCV RNA, and alanine aminotransferase (ALT)
• Follow-up testing for anti-HCV, HCV RNA, and ALT between 2 and 8 weeks after exposure (usually performed at 4 weeks)

Testing asymptomatic persons for HCV should conform to current recommendations. When an enzyme immunoassay is positive for HCV antibodies, supplemental testing is recommended to confirm true positivity.

Currently, there is no proven effective postexposure prophylaxis for persons exposed to HCV blood or contaminated body fluids. Immunoglobulin (Ig) and antiviral agents are not recommended for postexposure prophylaxis of HCV. When HCV infection is identified early, the individual should be referred for medical management to a specialist knowledgeable in this area.