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Hepatitis outbreaks underscore ongoing transmission risk to health care workers
IC failures may reflect an overall lack of safety
Recent outbreaks of hepatitis C are a wake-up call to boost infection control practices, particularly in outpatient settings. But they also underscore the prevalence of HCV and the continued occupational risk to health care workers.
A review of investigations by the Centers for Disease Control and Prevention revealed that health care facilities have contacted more than 60,000 patients and asked them to be tested for hepatitis B due to the failure of health care workers to follow proper infection control practices. There were 33 outbreaks in outpatient clinics, hemodialysis centers, and long-term care facilities, resulting in transmission of HCV or hepatitis C to 450 people.1
The outbreak scenarios included cases in which health care workers reused syringes on multiple patients or contaminated multidose vials by reusing a syringe. This spring, Veterans Affairs centers in Florida, Tennessee, and Georgia began notifying and testing thousands of patients for hepatitis B and C and HIV who had been exposed to endoscopy equipment that was not properly disinfected.
Infection control lapses raise concern about an overall lack of safety. "If you've got a facility that's not practicing according to basic standards of safety and infection control, in terms of patient-to-patient transmission, then the chances are probably pretty good that they're not attending to worker safety either," says Jane Perry, MA, associate director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville.
There have been no recent prevalence studies of health care workers and hepatitis C, although past studies did not show an elevated rate. But a recent CDC analysis of death certificates indicates that health care workers have an occupational risk. Twenty years of data (1984 to 2004) from the National Occupational Mortality Surveillance System found that female health care workers have a 20% greater risk of dying from hepatitis C than women in other occupations. Male health care workers have a 50% elevated risk.2
"Our data doesn't link any of these deaths to specific occupational incidents," says Sara Luckhaupt, MD, medical officer in the surveillance branch of the Division of Surveillance, Hazard Evaluation and Field Studies at the National Institute for Occupational Safety and Health in Cincinnati.
But the consistency of the HCV finding was telling. "Since we found the association for both males and females [with HCV], it made us more suspicious that there was an occupational risk," she says.
'Hidden' epidemic of HCV
An estimated 4 million Americans have a chronic hepatitis C infection, but because many of them aren't aware of the infection, HCV has been called "the hidden epidemic." The National Health and Nutrition Examination Survey (NHANES), which had about 15,000 participants from 1999 to 2002, found a peak prevalence in the 40 to 49 age group. Almost two-thirds (63%) of those who tested positive for HCV RNA said they had never been told they had "any kind of liver condition."3
In some settings, the prevalence of HCV may be significantly higher than the national estimate of 1.6%. For example, a VA study of 1,288 veterans in 20 medical centers found a prevalence of 5.4%.4
CDC needs to do more prevalence studies of HCV, including studies of health care workers and their patients, asserts Robert T. Ball Jr., MD, MPH, infectious disease epidemiologist with the South Carolina Department of Health and Environmental Control in Charleston. Health care workers also need to understand the relative risks of bloodborne pathogen exposure, he says.
Although studies show a seroconversion rate of about 0.5% after an exposure to HCV, the higher prevalence is a concern, he says. "Anytime a health care worker gets an exposure from a splash or a stick, the overall likelihood of the source having hepatitis C is five times greater than the source having HIV," says Ball.
Because there is no vaccine (as there is for hepatitis B) and no post-exposure prophylaxis (as there is for HIV), "we really stress prevention," says Tara MacCannell, PhD, health care epidemiologist in the Division of Healthcare Quality and Performance at CDC.
New CDC database offers sharps benchmarking
NHSN adds modules on needlesticks, flu shots
In a major boost for employee health benchmarking, the Centers for Disease Control and Prevention is launching new modules for data collection of bloodborne pathogen exposures and health care worker influenza immunization.
The National Healthcare Safety Network (www.cdc.gov/nhsn) currently collects patient safety data from more than 2,200 hospitals. The bloodborne pathogen module will comply with U.S. Occupational Safety and Health Administration reporting requirements and will enable facilities to track their own exposures as well as compare their data to other facilities, says Tara MacCannell, PhD, health care epidemiologist in the Division of Healthcare Quality and Performance at CDC.
NHSN will use number of workers as a denominator for benchmarking purposes. CDC's previous database, the National Surveillance System for Healthcare Workers (NaSH) did not have a denominator. It was discontinued in December 2007.
CDC hopes to attract many of its current hospitals that use the NHSN to monitor health care-associated infections. It also will be open to other health care facilities, such as ambulatory and long-term care.
"For the first time in a long time, facilities can start to look at these rates fairly objectively and initiate prevention strategies with tailored data that is specific to their own region," says MacCannell.
The EPINet Sharps Injury Surveillance System, maintained by the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville, also provides benchmarking information for hospitals. Many of its member hospitals are part of the PHTS, a risk management alliance based in Columbia, SC. EPINet data are reporting for teaching and nonteaching facilities.
The U.S. Occupational Safety and Health Administration requires annual training on bloodborne pathogens. Health care-related transmissions underscore the importance of that training, which should include information about HCV.
CDC has vowed to conduct better surveillance of HBV and HCV and to support educational outreach. The Safe Injection Practices Coalition, a group that includes organizations representing nurse anesthetists, infection control professionals, ambulatory surgery centers, and patients, is promoting the One & Only Campaign to emphasize the single use of syringes and needles.
Being proactive is critical, says MacCannell. Due to the nature of HCV infection, "it may be years before you detect that there are deficiencies in training or workplace practices," she says.
At the same time, it is critical to include needle safety in the education about safe injection practices, says Ball. "Remind health care workers that their needlestick risk [of contracting HCV] is significant," he says.
1. Thompson N, Perz JF, Moorman AC, and Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009; 150:33-39.
2. Luckhaupt S, Calvert G. Deaths due to bloodborne infections and their sequelae among health care workers. Am J Ind Med 2008; 51:812-814.
3. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006; 144:705-714.
4. Dominitz JA, Boyko EJ, Koepsell TD, et al. Elevated prevalence of hepatitis C infection in users of United States veterans medical centers. Hepatology 2005; 41:88-96.