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Hepatitis C Infected Health Care Workers

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HEPATITIS C INFECTED HEALTH CARE WORKERS

Introduction

1 This guidance is intended to assist in implementation of Health Department Letter (HDL) (2002)75 'Hepatitis C Infected Health Care Workers'. It is also available on the Executive's web site at:
http://www.show.scot.nhs.uk/sehd/hdl.asp

Summary of HDL (2002)75

2 HDL (2002)75 builds upon previous advice from the Advisory Group on Hepatitis that hepatitis C infected health care workers associated with transmission of infection to patients should no longer perform exposure prone procedures. 1 It recommends that employers put arrangements in place as soon as possible so that:

  • the HDL and this guidance are brought to the attention of all health care workers who perform, or who may perform, exposure prone procedures;

  • health care workers who already know themselves to have been infected with hepatitis C (i.e. who have antibodies to hepatitis C virus) and who carry out exposure prone procedures should be tested for hepatitis C virus RNA. This testing is not necessary for health care workers who are already known to be hepatitis C virus RNA positive. Those found to be carrying the virus (i.e. who are hepatitis C RNA positive) should not be allowed to perform exposure prone procedures in future;

  • health care workers who are intending to undertake professional training for a career that relies upon the performance of exposure prone procedures should be tested for antibodies to hepatitis C virus and, if positive, for hepatitis C virus RNA. Those found to be hepatitis C virus RNA positive should be restricted from starting such training whilst they are carrying the virus;

  • health care workers who perform exposure prone procedures and who believe that they may have been exposed to hepatitis C infection should promptly seek and follow confidential professional advice (e.g. from an occupational health physician) on whether they should be tested for hepatitis C. They should cease performing exposure prone procedures if they are carrying the virus;

  • hepatitis C infected health care workers who have responded successfully to treatment with antiviral therapy should be allowed to resume exposure prone procedures, or to start professional training for a career that relies upon the performance of exposure prone procedures. Successful response to treatment is defined as remaining hepatitis C virus RNA negative 6 months after cessation of treatment. Successfully treated health care workers will be allowed to return to performing exposure prone procedures at that time. As a further check, they should be shown still to be hepatitis C virus RNA negative 6 months later;

  • staff are provided with information and training about measures to reduce the risk of occupational exposure to hepatitis C infection (e.g. safe handling and disposal of sharps and measures to reduce risks during surgical procedures).

Previous advice and scope of new guidance

3 The Advisory Group on Hepatitis (AGH) recommended in 1995 that hepatitis C infected health care workers associated with transmission of infection to patients should no longer perform exposure prone procedures. 2 However, there have now been five incidents in the UK in which hepatitis C infected health care workers have transmitted infection to 15 patients, and the AGH has made further recommendations to protect patients. HDL (2002)75 introduces additional restrictions based on the AGH's recommendations.

4 The guidance applies to all health care workers in NHSScotland who carry out exposure prone procedures, including independent contractors such as general dental and medical practitioners (and relevant staff); independent midwives; students; locums and agency staff and visiting health care workers. NHS Trusts/Island NHS boards that arrange for NHS patients to be treated by private sector hospitals should ensure that this guidance is observed by health care workers who perform exposure prone procedures on NHS patients. The independent healthcare sector is required to have appropriate infection control procedures. Under the national care standards for this sector these should reflect relevant professional guidance. The guidance applies to the independent health care sector. 3

Transmissions to patients from hepatitis C infected health care workers

5 The first reported incident in the UK was in 1994 in which a health care worker infected with hepatitis C transmitted infection to a single patient. 4 The four other incidents in the UK which have occurred since then have been reported in the Public Health Laboratory Services' CDR Weekly. 5 There had been one previous incident reported in Spain. 6 There have since been two reports from Germany 7 and an incident from the US involving a cardiac surgeon is currently being investigated. 8 Hepatitis C can cause serious liver disease leading to cirrhosis and in a small proportion of cases, primary liver cancer.

Minimising the risk of occupational exposure to hepatitis C infection

6 There is no vaccine to protect against hepatitis C infection. Therefore health care workers remain at risk of infection because of occupational injuries that may expose them to the blood of infected patients. It is therefore essential that employers provide staff with information and training about measures to reduce the risk of occupational exposure to hepatitis C such as safe handling and disposal of sharps, measures to reduce risks during surgical procedures, and decontamination and waste disposal. The Scottish Executive Health Department publication Needlestick Injuries: sharpen your awareness placed a requirement on NHSScotland employers to provide specific good practice needlestick injury awareness and avoidance courses based on the educational needs of particular staff groups. It recommended that all staff likely to have access to needles or sharps should attend. The UK Health Department's publication Guidance for clinical health care workers: protection against infection with blood-borne viruses provides relevant advice. 9

Restriction on practice of hepatitis C infected health care workers

7 The Advisory Group on Hepatitis has assessed that the risk of transmission of hepatitis C from a health care worker of unknown hepatitis C status during exposure prone procedures is low. It does not, therefore, advise that all health care workers doing exposure prone procedures should be routinely tested for hepatitis C. However, it has recommended the following precautionary measures to reduce the risk of infection to patients:

Health care workers who know that they have been infected with hepatitis C and who carry out exposure prone procedures

(a) Health care workers who know that they have been infected with hepatitis C (i.e. who have antibodies to hepatitis C virus) and who carry out exposure prone procedures, should be tested for the hepatitis C virus RNA. Health care workers in this position should take account of their regulatory bodies' statements on professional responsibilities in relation to communicable disease. This testing is not necessary for health care workers who are already known to be hepatitis C virus RNA positive. Those found to be carrying the virus (i.e. who are hepatitis C virus RNA positive) should be restricted from performing exposure prone procedures in future, unless they have responded successfully to treatment (see paragraph 12). Occupational Health Departments will have a role to play in identifying such health care workers and bringing this guidance to their attention. Health care workers who have antibodies to the hepatitis C virus and are hepatitis C RNA negative should be allowed to continue performing exposure prone procedures.

Health care workers intending to begin professional training for a career that relies upon the performance of exposure prone procedures

(b) Health care workers intending to embark upon careers that rely upon the performance of exposure prone procedures should be tested for antibodies to hepatitis C virus and, if positive, for hepatitis C virus RNA. Those found to be hepatitis C virus RNA positive should not commence training for such careers unless they have a sustained virological response to treatment (see paragraph 12). It will obviously be to the advantage of health care workers to establish their hepatitis C status early as they make their career choices. The time for testing may vary depending upon the particular chosen career, but the following are considered appropriate:

  • junior doctors entering all surgical specialities, including obstetrics and gynaecology, should be tested before their first SHO post (this will include those posts in accident & emergency where doctors may be called upon to perform exposure prone procedures and GP trainees, if they are to carry out minor surgery in general practice);

  • prospective dental students should be tested before entry into dental school, as exposure prone procedures form an integral part of their training and in the work of dentists;

  • prospective midwifery students should be tested before embarking on midwifery courses; if they are hepatitis C virus RNA positive, they should only be allowed to proceed with training on the understanding that they will not be able to perform exposure prone procedures, and hence not be able to undertake the full ranges of activities in the specialty;

  • nurses should be tested before they move to specialised areas of work where they may be required to perform exposure prone procedures, e.g. operating theatre and accident & emergency nursing;

  • ambulance staff should be tested before they embark on training as paramedics or technicians;

  • podiatrists should be tested before they commence training in podiatric surgery.

This list covers the major specialties but is not intended to be exhaustive.

It is not currently considered necessary for medical students to be tested for hepatitis C routinely, as those embarking on careers that involve exposure prone procedures will be tested at SHO level (see above). However, an expert ad hoc group has just completed an assessment of the potential health risk posed to patients from health care workers new to the NHS, infected with serious communicable diseases (in particular HIV, hepatitis B virus, hepatitis C virus and TB). 10 Further guidance will follow on this.

Health care workers who perform exposure prone procedures and who may have been exposed to hepatitis C infection

(c) Health care workers, who perform exposure prone procedures and who believe that they may have been at risk of acquiring hepatitis C, should promptly seek and follow confidential professional advice on whether they should be tested for hepatitis C. Testing should be for antibodies to hepatitis C virus, and if positive, for hepatitis C virus RNA. Health care workers should take account of their regulatory bodies' statements on professional responsibilities in relation to communicable disease. The major risk factors for hepatitis C in the general population are:

  • receipt of a blood transfusion prior to the introduction of screening of all donations in September 1991;

  • use of blood clotting factors prior to the introduction of heat treatment process to protect against hepatitis C and other viruses. In Scotland heat treated Factor VIII and IX were available in 1987 and 1985 respectively;

  • the sharing of injecting equipment whilst misusing drugs.

(d) Additionally the following risk factors also apply to health care workers:

  • having been occupationally exposed to the blood of patients known to be infected, or deemed to be at high risk of infection, with hepatitis C by sharps or other injuries (see paragraphs 17-21 on the management of blood exposure incidents);

  • involvement as a health care worker or patient in invasive medical, surgical, dental or midwifery procedures in parts of the world where infection control precautions may have been inadequate, or with populations with a high prevalence of HCV infection.

8 Occupational health departments should be available to discuss with health care workers whether they may have been exposed to hepatitis C infection occupationally or otherwise; whether they should be tested for hepatitis C; and the implications of a positive test. Health care workers who are found to be carrying the virus should be restricted from carrying out exposure prone procedures unless they have shown a sustained virological response to treatment (see paragraph 12).

Testing for hepatitis C virus RNA

9 Qualitative testing for hepatitis C virus RNA should be carried out in accredited laboratories which are experienced in performing such tests, and which participate in appropriate external quality assurance schemes. Two samples taken a week apart should be tested for each health care worker. The assays used should have a minimum sensitivity of 50 IU per ml. Health care workers do not need to cease performing exposure prone procedures whilst testing is carried out, provided this is done promptly.

Use of identified and validated samples

10 Those commissioning tests for hepatitis C antibodies or hepatitis C virus RNA should ensure that samples tested are from the health care worker in question. Health care workers should not provide their own specimens. The following standards for occupational health data recording have been agreed with the Association of NHS Occupational Physicians (ANHOPS) and the Association of NHS Occupational Health Nurse Advisors (ANHONA):

  • laboratory test results required for clearance for undertaking exposure prone procedures must be derived from an identified, validated sample (IVS). Results should not be recorded in occupational health records if not derived from an IVS;

  • an IVS is defined according to the following criteria:

  • the health care worker should show a proof of identity with a photograph - Trust identity badge, new driver's licence, some credit cards or passport, when the sample is taken;

  • the sample of blood should be taken in the occupational health department;

  • samples should be delivered to the laboratory in the usual manner, not transported by the health care worker;

  • when results are received from the laboratory, check that the sample was sent by the occupational health department.

11 On request, occupational health departments may wish to arrange testing for health care workers who are currently not employed. Trusts are not expected to meet the costs of testing for these individuals, unless such testing forms parts of pre-employment assessment. If it does not, Trusts may wish to seek reimbursement of the testing costs from individual health care workers, or in the case of doctors employed by a locum agency, from the agency itself in accordance with the national contract specification. NHS boards have received funding to provide an occupational health and safety service through the local occupational health service to general medical and dental practitioners and their staff. As a priority the occupational health service has been asked to provide:

  • pre-employment checks on all prospective employees;

  • screening programmes;

  • immunisation programmes;

  • accidental blood exposure treatment programme.

NHS boards will wish to ensure that occupational health boards locally are offering and providing the service to general medical and dental practitioners and their staff, particularly where individuals are performing exposure prone procedures