T Thomas

Risk factors for hepatitis C virus transmission to health care workers after occupational exposure: A European case-control study

BACKGROUND Factors that influence the risk for HCV infection after occupational exposure to hepatitis C virus (HCV) have not yet been determined. The objective of this study was to assess potential risk factors for Hepatitis C seroconversion after occupational exposure to HCV. METHODS We conducted a European matched case-control study from 01/01/1991 through 31/12/ 2002. Cases were Health Care Workers (HCWs) who were HCV seronegative at the time of exposure, sustained a documented exposure to HCV, and present documented HCV seroconversion temporally associated with the exposure. Controls-HCWs had a documented exposure to HCV, were HCV seronegative at the time of exposure, and remained so at least 6 months later. Controls were matched to cases for the center and the time period of the exposure occurrence. RESULTS 60 cases and 204 controls were included. All cases were exposed to HCV-infected materials through percutaneous injuries. Those for whom information was available (61.6%) were exposed to viremic source patients. Multivariate conditional logistic regression analysis, in which HCV viral load was not introduced because of missing values, identified needle placed in the source patients vein or artery (Odds Ratio [OR]=100.1; 95% Confidence Interval [CI]=7.3-1365.7), deep injury (OR=155.2; 95%CI=7.1-3417.2), and HCWs gender (M vs. F: OR=3.1; 95%CI=1.0-10.0) as risk factors for HCV infection. In univariate unmatched analysis the risk of HCV transmission was increased 11-fold (C195%=1.1-114.1) in HCWs exposed to sources with a viral load>6 log10 copies/mL when compared to sources with a HCV viral load<4 log10 copies/mL. CONCLUSION The risk of HCV transmission after percutaneous exposure increases with a larger volume of blood, and, a higher titer of HCV in the source patients blood. The role of HCWs gender need to be further investigated. The results of this study have important implications for counselling and follow-up of HCWs after exposure.

European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus

Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, >10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs >50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs >10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

Post-Exposure Prophylaxis of HIV Infection in Healthcare Workers: Recommendations for the European Setting

The European Commission funded a project for the standardisation of the management of occupational exposures to HIV/blood-borne infections and antiretroviral post-exposure prophylaxis (PEP) in Europe. Within this project, the following recommendations and rationale were formulated by experts representative of participating countries. Based on assessment of the exposure, material, and source characteristics, PEP should be started as soon as possible with any triple combination of antiretrovirals approved for the treatment of HIV-infected patients; initiation is discouraged after 72 hours Rapid HIV testing of the source could reduce inappropriate PEP. HIV testing should be performed at baseline, 4, 12, and 24 weeks, with additional clinical and laboratory monitoring of adverse reactions and potential toxicity at week 1 and 2. HIV resistance tests in the source and direct virus assays in the exposed HCW are not recommended routinely. These easy-to-use recommendations seek to maximise PEP effect while minimising its toxicity and inappropriate use.

Facteurs de risque de transmission accidentelle du VHC au personnel soignant au décours d’un accident exposant au sang : une étude cas-témoins européenne

Position de probleme Aucune etude sur les facteurs de risque de transmission du virus de l’hepatite C (VHC) au personnel soignant n’a ete recensee a ce jour. L’objectif de cette etude est de determiner les facteurs de risque de transmission accidentelle du VHC au personnel de sante au decours d’un accident exposant au sang (AES). Methodes La recherche a repose sur la realisation d’une enquete cas-temoins europeenne. Les cas etaient les personnels soignants non infectes par le VHC, contractant un AES dans la periode du 01/01/1993 au 31/12/2002 avec un patient source infecte par le VHC et presentant une seroconversion au virus de l’hepatite C. Les temoins etaient les personnels soignants non infectes par le VHC contractant un AES avec un patient source infecte par le VHC et ne presentant pas de seroconversion au VHC dans les 6 mois suivant l’accident. Les cas et les temoins ont ete apparies sur le centre et sur la periode de survenue d’un AES. Resultats Soixante cas et 204 temoins ont ete inclus. L’ensemble des cas etait contamine a la suite d’un accident percutane. 37 des 60 cas pour lesquels les donnees etaient disponibles etaient exposes a des patients sources viremiques. Dans l’analyse multivariee, les facteurs de risque de la transmission accidentelle du VHC au personnel soignant etaient: procedure intraveineuse, intra-arterielle (Odds Ratio [OR] = 100,1; Intervalle de confiance [IC]95 % = 7,3-1365,7), piqure profonde (OR = 155,2 ; IC95 % = 7,1-3 417,2), et le sexe (soignant homme vs. femme : OR = 3,1; IC95 % = 1,0-10,0). La charge virale du patient source n’etait pas introduite dans le modele multivarie compte tenu des donnees manquantes. Dans l’analyse univariee non appariee, le risque de transmission du VHC etait multiplie par 11 chez les soignants exposes a des patients sources ayant une charge virale > 6 log10 copies/mL (IC95 % = 1,1-114,1) par rapport a ceux exposes a des patients ayant une charge virale Conclusion Le risque de transmission du virus de l’hepatite C apres un accident percutane est lie a la tache en cours, la profondeur de la blessure et la charge virale chez le patient source. Les resultats de cette etude vont nous permettre d’elaborer des recommandations adaptees en terme de suivi apres un AES.