Prevention of hepatitis B virus and hepatitis C virus infection among healthcare providers
- David J Weber, MD, MPH
David J Weber, MD, MPH
- Professor of Medicine, Pediatrics and Epidemiology
- University of North Carolina Schools of Medicine and Public Health
- William A Rutala, PhD, MPH
William A Rutala, PhD, MPH
- Research Professor of Medicine
- University of North Carolina School of Medicine
- Joseph Eron, MD
Joseph Eron, MD
- Professor of Medicine
- University of North Carolina School of Medicine
Many pathogens can be transmitted to healthcare personnel (HCP) following exposure to blood or body fluids. The most important of these are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
The epidemiology and management of occupational exposures to HBV and HCV in HCP will be reviewed here. The prevention of HIV and other pathogens in HCP is discussed separately. (See "Management of healthcare personnel exposed to HIV" and "Immunizations for health care providers" and "Prevention and control of varicella-zoster virus in hospitals".)
EPIDEMIOLOGY OF BLOODBORNE EXPOSURES
Statistics on exposures — The Centers for Disease Control and Prevention (CDC) estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others . Although the focus on post-exposure management is on HIV, HBV, and HCV, more than 30 different pathogens have caused documented occupational infection following exposure to blood or body fluids in healthcare personnel (HCP) or hospital laboratory personnel (table 1) .
All occupational exposure to blood and other potentially infectious material place HCP at risk for infection with bloodborne pathogens. The Occupational Safety and Health Administration (OSHA) defines blood to mean human blood, blood components, and products made from human blood . Other potentially infectious material includes body fluids such as: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva associated with dental procedures, and body fluid that is visibly contaminated with blood. All body fluids should be considered infectious in situations where it is difficult or impossible to differentiate between bloody fluids. Any unfixed tissues or organs (other than intact skin) from a human (living or dead) are also considered potentially infectious material. For laboratory personnel, other potentially infectious material includes HIV-containing cell or tissue cultures, organ cultures, HIV- or hepatitis virus-containing culture medium or other solutions, as well as blood, organs, or tissues from experimental animals infected with HIV, HBV, or HCV.
The main occupational risk for acquiring a bloodborne pathogen is a percutaneous sharps injury with a contaminated object. Mucous membrane exposure to blood or other potentially infectious material can also transmit HIV, HBV, and HCV. Reports regarding the frequency of such occupational risks are as follows:
- Occupational Safety and Health Administration. Bloodborne pathogens and needlestick prevention. https://www.osha.gov/SLTC/bloodbornepathogens/recognition.html (Accessed March 25, 2014).
- Tarantola A, Abiteboul D, Rachline A. Infection risks following accidental exposure to blood or body fluids in health care workers: a review of pathogens transmitted in published cases. Am J Infect Control 2006; 34:367.
- Centers for Disease Control and Prevention. The STOP STICKS campaing: Sharps injuries. http://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html (Accessed March 25, 2014).
- International Healthcare Worker Safety Center, University of Virugina. 2011 EPINet Report: Needlestick and sharp-object injuries. http://www.healthsystem.virginia.edu/pub/epinet/epinetdatareports.html (Accessed March 25, 2014).
- Henderson DK. Management of needlestick injuries: a house officer who has a needlestick. JAMA 2012; 307:75.
- Perry J, Parker G, Jagger J. EPINet Report: 2006 percutaneous injury rates. Intern Healthcare Worker Safety Center, 2009; 1-4.
- International Healthcare Worker Safety Center, University of Virugina. 2011 EPINet Report: Bood and body fluid exposures. http://www.healthsystem.virginia.edu/pub/epinet/epinetdatareports.html (Accessed March 25, 2014).
- Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013; 62:1.
- Fisman DN, Harris AD, Rubin M, et al. Fatigue increases the risk of injury from sharp devices in medical trainees: results from a case-crossover study. Infect Control Hosp Epidemiol 2007; 28:10.
- Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA 2006; 296:1055.
- Makary MA, Al-Attar A, Holzmueller CG, et al. Needlestick injuries among surgeons in training. N Engl J Med 2007; 356:2693.
- Askarian M, Yadollahi M, Kuochak F, et al. Precautions for health care workers to avoid hepatitis B and C virus infection. Int J Occup Environ Med 2011; 2:191.
- Centers for Disease Control and Prevention. The STOP STICKS campaing: Campaign user’s guide and resources. http://www.cdc.gov/niosh/stopsticks/. Accessed 25 March 2014.
- Centers for Disease Control and Prevention. Workbook for designing, implementing and evaluating a sharps injury prevention. http://www.cdc.gov/sharpssafety/resources.html (Accessed March 25, 2014).
- Occupational exposure to bloodborne pathogens--OSHA. Final rule. Fed Regist 1991; 56:64004.
- Tan L, Hawk JC 3rd, Sterling ML. Report of the Council on Scientific Affairs: preventing needlestick injuries in health care settings. Arch Intern Med 2001; 161:929.
- Alvarado-Ramy F, Beltrami EM, Short LJ, et al. A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a multicenter study, 1993-1995. Infect Control Hosp Epidemiol 2003; 24:97.
- Trim JC, Elliott TS. A review of sharps injuries and preventative strategies. J Hosp Infect 2003; 53:237.
- Trim JC. A review of needle-protective devices to prevent sharps injuries. Br J Nurs 2004; 13:144, 146.
- Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll Surg 2004; 199:462.
- Mamoun JS, Ahmed MK. Preventing sharps, splash, and needlestick injuries in dentistry: a comprehensive overview. Gen Dent 2005; 53:188.
- Cleveland JL, Barker LK, Cuny EJ, et al. Preventing percutaneous injuries among dental health care personnel. J Am Dent Assoc 2007; 138:169.
- Cullen BL, Genasi F, Symington I, et al. Potential for reported needlestick injury prevention among healthcare workers through safety device usage and improvement of guideline adherence: expert panel assessment. J Hosp Infect 2006; 63:445.
- Vaughn TE, McCoy KD, Beekmann SE, et al. Factors promoting consistent adherence to safe needle precautions among hospital workers. Infect Control Hosp Epidemiol 2004; 25:548.
- Lamontagne F, Abiteboul D, Lolom I, et al. Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals. Infect Control Hosp Epidemiol 2007; 28:18.
- Whitby M, McLaws ML, Slater K. Needlestick injuries in a major teaching hospital: the worthwhile effect of hospital-wide replacement of conventional hollow-bore needles. Am J Infect Control 2008; 36:180.
- Haiduven DJ, Phillips ES, Clemons KV, Stevens DA. Percutaneous injury analysis: consistent categorization, effective reduction methods, and future strategies. Infect Control Hosp Epidemiol 1995; 16:582.
- Akduman D, Kim LE, Parks RL, et al. Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery. Infect Control Hosp Epidemiol 1999; 20:110.
- Laine T, Aarnio P. Glove perforation in orthopaedic and trauma surgery: a comparison between single, double indicator gloving and double gloving with two regular gloves. J Bone Joint Surg 2004; 86-B:898.
- Naver LP, Gottrup F. Incidence of glove perforations in gastrointestinal surgery and the protective effect of double gloves: a prospective, randomised controlled study. Eur J Surg 2000; 166:293.
- Kovavisrach E and Seedadee C. Randomized controlled trial for glove perforation in single and double-gloving methods in gynaecologic surgery. Aust NZ J Obstet Gynaecol 2002; 42:519.
- MacCannell T, Laramie AK, Gomaa A, Perz JF. Occupational exposure of health care personnel to hepatitis B and hepatitis C: prevention and surveillance strategies. Clin Liver Dis 2010; 14:23.
- Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000; 13:385.
- U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001; 50:1.
- Strasser M, Aigner E, Schmid I, et al. Risk of hepatitis C virus transmission from patients to healthcare workers: a prospective observational study. Infect Control Hosp Epidemiol 2013; 34:759.
- Medeiros WP, Setúbal S, Pinheiro PY, et al. Occupational hepatitis C seroconversions in a Brazilian hospital. Occup Med (Lond) 2012; 62:655.
- Tomkins SE, Elford J, Nichols T, et al. Occupational transmission of hepatitis C in healthcare workers and factors associated with seroconversion: UK surveillance data. J Viral Hepat 2012; 19:199.
- Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after drying and storage for one week. Lancet 1981; 1:550.
- Kamili S, Krawczynski K, McCaustland K, et al. Infectivity of hepatitis C virus in plasma after drying and storing at room temperature. Infect Control Hosp Epidemiol 2007; 28:519.
- Occupational Safety and Health Administration. Enforcement procedures for the occupational exposure to bloodborne pathogens. Directive CPL 202.69, issued November 27, 2001.
- Cleveland JL, Cardo DM. Occupational exposures to human immunodeficiency virus, hepatitis B virus, and hepatitis C virus: risk, prevention, and management. Dent Clin North Am 2003; 47:681.
- Henderson DK. Managing occupational risks for hepatitis C transmission in the health care setting. Clin Microbiol Rev 2003; 16:546.
- Krawczynski K, Alter MJ, Tankersley DL, et al. Effect of immune globulin on the prevention of experimental hepatitis C virus infection. J Infect Dis 1996; 173:822.
- Corey KE, Servoss JC, Casson DR, et al. Pilot study of postexposure prophylaxis for hepatitis C virus in healthcare workers. Infect Control Hosp Epidemiol 2009; 30:1000.
- EPIDEMIOLOGY OF BLOODBORNE EXPOSURES
- Statistics on exposures
- Risk of exposure by profession
- Devices associated with exposure
- Minimizing risk
- Risk of acquisition following exposure
- - HBV infection
- - HCV infection
- PRE-EXPOSURE PROPHYLAXIS
- Hepatitis B
- Hepatitis C
- POST-EXPOSURE MANAGEMENT
- Definition of exposure
- Initial management
- - Wound care
- - Obtaining Information
- HBV exposure
- - HCP with evidence of prior HBV infection
- - HCP who are vaccine responders
- - HCP who are vaccine nonresponders
- - HCP who have unknown vaccine response
- - HCP who have not received or completed the vaccine series
- - Follow-up testing after exposure
- - Hepatitis B Immune Globulin (HBIG)
- HCV exposure
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS