Hepatitis C and Blood Awareness in the Health Care Setting

Over the past two decades, occupational transmission of blood-borne pathogens has emerged as a significant hazard for health care workers due to the identification of a number of blood-borne viruses. Needle stick injuries and blood splashes to mucous membranes such as eyes are the most common route of occupational exposure. The increasing prevalence of viruses such as hepatitis C in the patient population has raised the profile of the risk of occupational transmission. For many health care workers this has brought up a number of questions: How is hepatitis C virus (HCV) transmitted? How should workers best protect themselves against transmission of HCV? How do they protect their patients from transmission in the health care setting? Or at home? If workers have an occupational injury placing them at risk of HCV infection, what should they do? What are the rights and responsibilities of a health care worker with hepatitis C? How does a health care worker deal with a patient who is known to have hepatitis C? Transmission Hepatitis C is a blood-borne virus, predominantly spread through blood-to-blood contact. A small number of studies indicate that hepatitis C virus (HCV) has been detected at a microscopic level in body fluids, such as saliva, vaginal secretions, semen and breast milk. However, the general conclusion is that the HCV RNA is not present in sufficient amounts in saliva to cause an infection. The risk of infection through exposure to vaginal secretions, semen and breast milk is very low and virtually non-existent in a health care setting. Protection against transmission - being 'blood aware'     Universal Infection Control Precautions Universal blood and body fluid precautions were originally devised in 1985 by the US Centres for Disease Control (CDC), primarily in response to the HIV/AIDS epidemic. These precautions apply to all blood and body fluids, regardless of the person's presumed infectious status. Standard Precautions In Australia Standard Precautions With Additional Precautions have superseded Universal Precautions. They describe work practices required for the basic level of infection control. They include Universal Precautions, precautions for other body substances and some additional precautions, eg for tuberculosis management. These should be implemented with all patients. They include good hygiene practices, particularly washing and drying hands before and after patient contact, the use of protective barriers which include gloves, gowns, plastic aprons, masks, eye shields or goggles, appropriate handling and disposal of sharps and other contaminated waste and the use of aseptic techniques (NHMRC, 2002, p. 7-12). Standard precautions are recommended in the handling of: blood all other body fluids, secretions and excretions, regardless of whether they contain visible blood non-intact skin mucous membranes Standard Precautions also apply to dried blood and other body substances, including saliva. Being 'blood aware' involves adopting reasonable practices that reduce the overall risk of being exposed to a blood borne virus. Principles of standard precautions 1. The skin is the body's primary protective defence. Ensure that all cuts or abrasions are covered with a waterproof dressing. 2. Wear single-use, disposable gloves when dealing with any body fluids. 3. Wear personal protective equipment, such as protective eyewear/goggles/glasses and face masks, if there is a risk of blood or body fluid splash to the eye or mouth. This could include scrubbing to clean up blood spills. 4. Disposable materials (eg. paper towel) should be used when cleaning up body fluid spills or splashes. 5. Any environmental surfaces which have been exposed to blood or body fluids should be cleaned with detergent and water. Click here for information on the management of a blood or body fluid exposure Risk of transmission resulting from a needle stick injury Transmission of blood borne viruses following an exposure depends on a number of factors, in particular the concentration of virus in the blood or body fluid, the depth of injury and the volume of infective material the individual is exposed to. There have been a number of studies of the risk of infection or seroconversion following a needle stick injury in the health care setting. Data describing hepatitis C transmission varies to date. Some differences in the data are related to the type of testing undertaken. Often the source of the blood in the needle stick injury has been tested for HCV antibody. If positive, this indicates that the source has at some stage been infected with HCV but some may have cleared the virus and may no longer be infectious. Where the source tests positive for HCV by PCR, this demonstrates that they currently have virus circulating in their blood and, as would be expected, the transmission rate is higher than with HCV antibody testing alone. The most recent data suggests that the risk of HCV transmission is about 1 per cent when a needlestick injury occurs with a source who tests HCV antibody positive but whose current virus status is unknown increases to about 6 per cent when the source tests PCR positive for HCV, ie the person has virus circulating in their blood (MacDonald, 2001) To provide a comparison, the risk for HIV transmission is 0.3 per cent, whereas for hepatitis B the risk ranges from 2 to 40 per cent (CDC, 2001; Gerberding, 1995).   When a needlestick injury occurs   Management of a needlestick or blood accident If the skin is penetrated, wash the area well with soap and water, as soon as possible. Cover the wound with a waterproof dressing to prevent further exposures. If eyes are contaminated, rinse the area with water or normal saline. If blood gets in the mouth, spit it out and then rinse the mouth with water. Report the accidental exposure to the Infection Control Practitioner or other designated manager, who will follow the organisation's protocol. This will involve ordering the relevant tests for both the health care worker exposed and the person who is the source of the exposure and providing support and counselling. A referral to a blood borne virus medical specialist (eg, infectious diseases physician) should be made for further follow up and support. Testing protocols Serological testing protocols after a blood or body fluid exposure may differ between health care institutions. Any queries relating to an exposure should be directed to the Infection Control Department within the hospital/institution. Each hospital or health care institution will have its own protocol. The Commonwealth Government draft recommendation [Appendix 8 http://www.health.gov.au/pubhlth/strateg/communic/review/draft.htm ] is that the testing procedure should be performed at baseline (as soon as possible, preferably within one week), then at three and six months from the time of exposure, although some institutions extend follow up to twelve months. For example, testing could involve PCR (polymerase chain reaction - virus detection), HCV antibody and liver function tests (LFT) as soon as possible after the exposure, followed by repeat HCV antibody and LFT at three and six months. The person who is the source of the blood or body fluid exposure will usually be asked to participate in baseline serology tests to establish their hepatitis C status. If the source is hepatitis C negative, this will help to alleviate the health care worker's anxiety. Being tested It takes time to be tested for hepatitis C and to receive the results. Waiting can be stressful for the person who has had an occupational exposure. Many people get support during this time from family, partners, friends and colleagues. Some people may also find it useful to talk through the issues with a professional counsellor either face to face or over the telephone. Click here for information on counselling services . What do the test results mean? HCV antibody positive - this result indicates that the person has been infected with hepatitis C in the past, but does not indicate that the person is still infected. Approximately 15-30% of people infected with hepatitis C will clear the virus. However, they will remain HCV antibody positive. HCV PCR positive/hepatitis C RNA positive - this test result indicates the presence of hepatitis C virus in the blood. This person is said to have hepatitis C. Treatment options There is no post exposure prophylaxis (treatment to prevent a person from developing infection) currently available for people who have had occupational exposures to hepatitis C. Treatment should not be considered unless the person becomes hepatitis C RNA positive as detected by a PCR (virus detection) test and the ALT (test indicating liver inflammation) begins to rise. There have been a number of recent studies investigating treatment of individuals with acute hepatitis C with interferon monotherapy (Jaeckel,2001; Hoofnagle, 2001; Poynard, 2002; Marinos, Pirola and Locarnini,1999). In light of this new research, therapy for acute hepatitis C should be considered and discussed with the specialist physician caring for the person. Personal and domestic issues While waiting for results, after a needlestick or blood/body fluid accident, health care workers may have concerns about the potential for hepatitis C transmission in their personal or home lives. What about sexual relationships? Hepatitis C is not classified as a sexually transmissible infection in Australia. Studies of long term heterosexual partners have shown a very low rate of transmission from one partner to another. Your treating specialist will discuss this with you in more detail. Preventing transmission in the home Transmission of blood borne viruses can theoretically occur in the home. Health care workers can be active in educating their own households. Implementing the principles of blood awareness at home will prevent exposure to potentially infectious blood. Therefore always clean up your own blood spills, cover all cuts and abrasions and avoid sharing toothbrushes, razor blades or manicuring equipment. Ensuring that all blood is treated as potentially infectious will reduce the risk of exposure and subsequent transmission to other household members. Cleaning up a blood spill in the home The same principles of Standard Precautions should be used at home as they are in the workplace when cleaning up after a blood or body fluid spill. 1. Ensure that any non-intact skin is covered, preferably with a waterproof dressing and put gloves on 2. Initially cover the spill with paper towel, to remove the blood from the environment and therefore reduce the risk of exposure 3. Mop up and wash any surface that has been exposed to blood with warm water and detergent 4. Discard materials used to wipe up the blood or body fluid, in a plastic bag 5. If any clothes were splashed with blood, remove them and wash, first in cold water so that it doesn't stain and then as normal 6. Wash hands after removing the gloves Being blood aware in the home does not mean being fanatical about avoiding contact with other people's blood and body fluids. It involves implementing precautions to ensure that the risks of being exposed to a disease are reduced. Donating blood and body tissue During the follow-up period after an occupational exposure health care workers should not donate blood, semen, body tissue or organs. This applies until a negative result has been received.     Rights and responsibilities   Disclosure An individual with hepatitis C does not have to tell anyone their status. In some circumstances you are legally required to disclose your status. However, you can choose to avoid these situations if you wish. These situations include: donating blood or body organs performing exposure prone medical procedures as a health care worker(click here for more information ) joining the armed forces applying for health or life insurance, if the question is asked If disclosure is requested outside these situations, seek legal advice or contact the Equal Opportunity Commission. National Health and Medical Research Council (NHMRC) guidelines recommend: Standard infection control procedures in the workplace treat all blood as infectious and protect both workers and clients/patients from infection. They also protect the confidentiality of workers and clients as disclosure in these circumstances is not necessary and not recommended, except in high risk procedures. Health care workers with blood borne viruses are not excluded from roles and activities they can perform safely in their job. It is the employer's responsibility to ensure that standard infection control procedures are followed. If you find you are hepatitis C positive, take time to decide which people you will tell. Think through the consequences of telling them. How and when will you tell them? You may wish to seek advice from a counsellor, an anonymous telephone counselling service such as Hepatitis C Helpline or, in some cases, a legal advice service. If you are a health care worker, you may wish to consult an experienced medical practitioner outside your workplace to separate occupational health issues and documentation of your care. The NHMRC recommends that, after confidential clinical assessment and counselling, hepatitis C positive health care workers should be encouraged to report their status to their employers and their professional or advisory boards. This is not a legal obligation. The employer and professional board must also maintain the confidentiality of the worker. Reponsibilities Health care workers do have a legal obligation to care for the safety of others in the workplace (both fellow workers and patients/clients). This means: Health care workers who perform exposure prone procedures have a professional and ethical responsibility to know their status in regard to blood borne viruses. These workers are encouraged to seek routine testing if they believe there is a risk associated with their occupation or lifestyle. Exposure prone procedures are procedures where there is the potential for direct contact between the skin (usually finger or thumb) of the health care worker and sharp surgical instruments, needles or sharp tissues (bone or teeth) in body cavities or in poorly visualised or confined body sites (including the mouth) (NHMRC, 1996, p. 106 http://www.health.gov.au/nhmrc/publications/synopses/ic6syn.htm ). Health care workers with a blood borne virus should not perform exposure prone procedures where there is an evidence-based risk of transmitting infection from the worker to the patient. Risk: There is a reasonable risk of transmitting infection if the worker tests PCR positive to hepatitis C and these workers should not perform exposure prone procedures. However, workers with indeterminate or uncertain results should not be excluded on the basis of test results alone. These workers should be clinically assessed by an experienced physician over a reasonable period of time for signs of current infection. Where there is not sufficient evidence to determine current infection, the treating doctor or the worker concerned should seek the advice of an advisory panel or professional board. Health care workers with a blood borne virus are responsible for having an assessment with their treating medical practitioner to ensure they are able to perform their tasks adequately to the accepted professional standard they practise recommended techniques they comply with Standard Precautions they adhere to approved recommendations for sterilisation and disinfection Discrimination Discrimination in the health care setting can occur against both health care workers and patients. It is against the law in Victoria to discriminate against a person because they Are hepatitis C positive Are assumed to be hepatitis C positive Are an associate of someone who is (or is assumed to be) hepatitis C positive Discrimination may take many forms and may be direct or indirect. In employment Health care workers with blood borne viruses can continue to carry out roles and functions they can perform safely in their job. It is unlawful to discriminate against people employed by an organisation or seeking a job with that organisation on the basis of their hepatitis C status. This means that an employer cannot sack or demote someone, fail to give them a promotion, training or a job because they are hepatitis C positive. The only issue of relevance is whether the worker can fulfil the requirements of the position. Health care workers who test hepatitis C PCR positive should not perform exposure prone procedures as there is a reasonable risk of transmission. Who decides what is safe? Or whether the worker can still meet the needs of their role? According to the NHMRC guidelines: Workers with blood borne viruses should consult a medical practitioner with experience in hepatitis C. This doctor assesses the worker's health and practices and then makes the recommendation about the worker's continued involvement in patient care. If there is any uncertainty, the worker or the medical practitioner may ask for confidential advice from a relevant professional or advisory board. The board may be given information about the medical and occupational context but not about the identity of the worker. If you are concerned about any of these issues, you may wish to contact the Hepatitis C Council or the Hepatitis C Enquiry Line for Health Care Workers for further support and advice. Patients In standard precautions, all patients are treated as though they may be infectious. Therefore a patient with hepatitis C is managed in the health care setting no differently to any other patient. It is only lawful to to treat someone differently because of their hepatitis C positive status where it is reasonably necessary to protect the health and safety of another person. This exception applies in very few situations (eg, the blood donation of a person with hepatitis C will not be accepted). It is important to good health care practice to provide the patient with respectful, non-discriminatory care. Protecting the patient's confidentiality is an essential part of this. Examples of inappropriate and discriminatory practices are: Rescheduling or cancelling of surgery due to the patient's hepatitis C status Labelling of the patient's history or door with coloured stickers to indicate their hepatitis C status. This is also a breach of confidentiality Inappropriate practices are often the result of ignorance. They may also occur with allied health, dental support, ward support, cleaning and reception staff. If you see inappropriate or discriminatory practices happening in your workplace, consider discussing the need for further education with your Infection Control Consultant or your supervisor.   Information and Telephone Support Services for Victoria     Hepatitis C Council of Victoria Inc. (Information, Education, Support, Advocacy) (03) 9380 4644 Country 1800 703 003 www.hepcvic.org.au Hepatitis C Helpline (Telephone Counselling, Information and referral service) (03) 9349 1111 Country 1800 800 241 TTY 1800 032 665 www.aidshep.org.au Hepatitis C Enquiry Line for Health Care Workers (Jacqui Richmond) (03) 9288 3586 0407 865 140 Access Information Centre at The Alfred (Resources, referral) (03) 9276 6993 www.accessinfo.org.au Melbourne Sexual Health Centre (03) 9347 0244 www.mshc.org.au National Needlestick Injury and other Exposures Hotline (for health care workers only - NSW based) 1800 804 823 VIVAIDS (Drug User Group) (03) 9381 2211 Victorian Counselling Services   Hepatitis C Counsellor, located at The Alfred. Referrals through the Hepatitis Clinics at The Alfred and Royal Children's Hospital and through the Hepatitis C Council. Contact the Hepatitis C Council for more information. Ph: (03) 9380 4644 Toll Free: 1800 703 003 Positive Counselling, The Bouverie Centre. Clinics on Fridays. 50 Flemington St, Flemington 3031 Ph (03) 9376 9844 www.positivecounselling.org.au Hepatitis C Helpline (Telephone Counselling, Information and referral service) (03) 9349 1111 Country 1800 800 241 TTY 1800 032 665 www.aidshep.org.au Haemophilia Foundation Victoria. Ph: (03) 9276 3061 Liver and Hepatitis clinics around Victoria   Country Ballarat Liver Clinic (Mair St) - (03) 5332 9210 Ballarat North (Dr Jon Watson) - (03) 5331 8289 Geelong Hospital - (03) 5226 4355 Sale Liver Clinic -(03) 5144 4555 Wodonga - Dr Tim Shanahan - (02) 6024 5255 Melbourne Metropolitan Alfred Hospital , Prahran - (03) 9276 2223 Austin / Repatriation Medical Centre, Heidelberg - (03) 9496 3498 Barkly St Clinic (St Vincents), St Kilda - (03) 9534 0531 Bayside Gastroenterology, Frankston - (03) 9781 4434 Bayside Hepatitis Clinic, Cheltenham - (03) 9276 2223 (appointments via Alfred clinic) Box Hill Hospital - (03) 9895 3353 Cabrini Private Hospital, East Malvern - (03) 9508 1862 (Melbourne Gastrointestinal Investigations Unit) Knox Private Hospital (St Vincents) - (03) 9210 7300 Maroondah Hospital Liver Clinic, Ringwood East - (03) 9871 3333 Mercy Hospital (St Vincents), Werribee - (03) 9216 8633 Monash Medical Centre, Clayton - (03) 9594 5545 Northern Hospital Liver Clinic, Epping - (03) 9219 8335 Royal Melbourne Hospital, Parkville - (03) 9342 7212 Springvale Community Health Centre (Monash Med Centre) - (03) 9594 5545 (appointments via Monash clinic) St. Vincent's Hospital, Fitzroy - (03) 9288 3580 Western Hospital, Footscray - (03) 9319 8456 References CDC (Centers for Disease Control and Prevention). 2001. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR, Jun 29 2001; 50 (RR-11) Gerberding, JL. 1995. Management of occupational exposures to blood-borne viruses. NEJM, 332(7):444-451. Jaeckel, E et al. 2001. Treatment of acute hepatitis C with interferon Alfa-2b. NEJM, 345(20):1452-7. Hoofnagle, JH. 2001. Therapy for acute hepatitis C. NEJM, 345(20):1495-7. Commonwealth Dept of Health and Ageing/Communicable Diseases Network of Australia. 2002. Infection control guidelines for the prevention of infectious diseases in the health care setting [draft]. Canberra: Commonwealth Dept of Health and Ageing. [http://www.health.gov.au/pubhlth/strateg/communic/review/draft.htm ] MacDonald, M, Crofts, N, Wodak, A and Kaldor, J. 2001. Transmission of the hepatitis C virus infection. In: Crofts, N, Dore, G and Locarnini, S (eds) 2001. Hepatitis C: an Australian perspective. Melbourne: IP Communications. Marinos, G, Pirola, R and Locarnini, S. 1999. Acute hepatitis C, Australian Family Physician, 28(Special Issue). National Health and Medical Research Council/Australian National Council on AIDS. 1996. Infection control in the health care setting. Canberra: Commonwealth Dept of Health and Family Services. [http://www.nhmrc.gov.au/publications/synopses/ic6syn.htm ] Poynard, T et al. 2002. Interferon for acute hepatitis C (Cochrane Review). In: The Cochrane Library 1, 2002. Oxford: Update Software. Victorian Government. Equal Opportunity Act 1995.
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Prepared by Jacqui Richmond, Victorian Hepatitis C Educator, St Vincent's Hospital Suzanne O'Callaghan, Co-ordinator, Access Information Centre At The Alfred Reviewed by The Alfred Sue Borrell and Tess Benedict, Infection Control Consultants Dr Stuart Roberts, Deputy Director, Gastroenterology Dept Sandy Breit, Hepatitis C Counsellor Rosey Cummings, Bloodborne Viruses/STIs Health Educator, Infectious Diseases Unit Dr Margaret Hellard, Infectious Diseases Physician/Epidemiologist, Burnet Institute St Vincent's Hospital Jo Cox, Infection Control Co-ordinator Assoc Prof Paul Desmond, Director of Gastroenterology Jenny Flynn, Clinical Research Nurse Victorian Infectious Diseases Reference Laboratory Rhonda McCaw, Senior Scientist, Molecular Microbiology

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