Hepatitis C Virus Still Unacceptably High Risk for Healthcare Workers

Abstract:

Background: A recently published study describes that the prevalence of occupational hepatitis C virus (HCV) infection is higher than the general population.  This study provides insights into the risk associated with virus acquisition from other surveillance systems that quantify needlestick and other blood and body fluid exposure incidents among the healthcare workforce.

Significance: For decades, healthcare facilities have focused on preventing occupational exposure to bloodborne pathogens using universal and standard precautions, and adhering to federal regulations. Based on occupational incident surveillance data (EPINet), it seems that this may not still be the case.  As HCV infections among healthcare workers are still unacceptably high and occupational incident data confirms that exposures are still occurring and can be prevented, this article provides evidence for suggesting that policies at the national, local, and facility level need to be improved in order to decrease transmission of bloodborne pathogens.

Main Article:

With workplace controls for bloodborne pathogens having been solidly in place in healthcare settings for decades, a new study reveals that we may need to drastically improve our focus in order to protect healthcare workers from ongoing exposures to viruses like hepatitis C virus (HCV).  HCV causes Hepatitis C that is a chronic liver infection that can cause long-term health effects and even death.  There is currently no cure. Hepatitis C is transmitted via blood and today most people in the general population become infected with the virus by sharing needles or other equipment to inject drugs.  It is a risk to healthcare workers who get stuck with needles, sharp instruments, blood or body fluids from patients that are infected with HCV.  The Centers for Disease Control and Prevention (CDC) estimates that HCV infection has increased 150% from 2010 to 2013 and many people do not know they are infected.¹

A recently published study in Occupational and Environmental Medicine authored by Claudia Westermann and her research team in Germany, illustrate that we need to do better to control and prevent occupational exposures to HCV.

Westermann and her team conducted a meta-analysis of papers published from 1989-2014 to estimate the prevalence of HCV infection among healthcare workers compared to the general population.  Their systematic review indicates that healthcare workers have a more than 200% higher prevalence of HCV infection than the public at large and a nearly 300% higher prevalence for some categories of workers, especially those with the most frequent exposures to blood including medical and laboratory technical professions.²  With the use of engineering controls and the requirement for facilities to use safety-engineered medical devices, safe disposal practices and extensive training, this extraordinarily high prevalence seems unfathomable in a population that has greater protections in place than the general public.

occupational risk to needlesticks and sharps injuries are still unacceptably high

The International Safety Center’s Exposure Prevention Information Network (EPINet^®) data supports that occupational risk to needlesticks and sharps injuries are still unacceptably high.  The 2013 sharps injury summary data from a network of 30 US hospitals illustrates that more than 50% of injuries are from devices that are not a safety design despite regulations from OSHA to use them.  It also indicates, that of the safety devices that were used, more than 70% did not have safety features activated to protect the users from the contaminated sharp.³

In the US, we clearly have more work to do.  Actually, only a handful of countries have requirements in place to use safety engineered devices, which begs the question; if countries like the US have regulations in place to protect healthcare workers from bloodborne pathogens like HCV, but compliance is still lower than ideal, how much higher is the risk in countries around the world that do not have regulations in place?

Based on Westermann et al data from around the world, the risk of infection can be much higher!  In some countries like Italy, Saudi Arabia, Egypt, and Nigeria, odd ratios (ORs) can range from higher than 2.0 to up to 17.0.  That means essentially that healthcare workers in some countries are 200% to more than 1,700% more likely to be infected with HCV despite having bloodborne pathogens training that the general population does not typically have access to.

There are no required or mandatory national or international surveillance/reporting systems that track occupational seroconversion to HCV or other bloodborne pathogens following a needlestick, sharp object injury, or splatter.  Westermann’s paper in conjunction with EPINet data may support the implication that injuries from sharps and other blood and body fluid splashes and splatters can cause cases of occupational HCV, despite the use of post-exposure prophylaxis. This amplifies the need for CDC, National Institute for Occupational Safety and Health (NIOSH), and the Occupational Safety and Health Administration (OSHA) to provide updated information on preventing HCV transmission (Note: CDC’s last published guidance for occupational exposure to bloodborne pathogens like HCV was in 2001).⁴

Number of total exposures is gravely under-estimated

In addition, surveillance systems should be put in place that track HCV infections back to a specific occupational exposure, so that future infections can be prevented.  Based on what limited data CDC does collect voluntarily, data from 2013 indicates that there were 52 confirmed cases of HCV infection from needlesticks but this dataset shows an incomplete picture. Follow-up data (HCV infection status) was not available from 1,459 out of 2,138 needlesticks.  This could mean that HCV infections following needlesticks from hospitals submitting data to CDC are actually higher and since neither CDC, NIOSH, nor OSHA require healthcare facilities to report needlesticks, the number of total exposures is gravely under-estimated.⁵

How can we possibly combat emerging infectious disease threats, when the traditional, long-standing ones are still a problem? The outlook appears grim.  However, motivation is often elicited through evidence, knowledge and understanding.

References:

1. Centers for Disease Control and Prevention (CDC). Viral Hepatitis Surveillance.  United States, 2013.  http://www.cdc.gov/hepatitis/statistics/2013surveillance/pdfs/2013hepsurveillancerpt.pdf.  Accessed December 30, 2015.
2. Westermann, C. et al. The prevalence of hepatitis C among healthcare workers: a systematic review and meta-analysis. Occup Environ Med 2015;0:1–9. http://oem.bmj.com/content/early/2015/10/05/oemed-2015-102879.full.pdf+html Accessed December 29, 2015.
3. International Safety Center. Exposure Prevention Information Network, Sharp Object Injury Summary Data 2013.  http://internationalsafetycenter.org/wp-content/uploads/2015/08/Official-2013-NeedleSummary.pdf.  Accessed December 29. 2015
4. Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR).  Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.  http://www.cdc.gov/mmwr/pdf/rr/rr5011.pdf .  Accessed December 29, 2015.
5. Centers for Disease Control and Prevention (CDC). Acute Hepatitis C reports by risk/behavior, United States 2013.  http://www.cdc.gov/hepatitis/statistics/2013surveillance/pdfs/hcv_surv-2013_figure4.6b.pdf.  Accessed December 29, 2015.