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Joy JB, McCloskey RM, Nguyen T, Liang RH, Khudyakov Y, Olmstead A, Krajden M, Ward JW, Harrigan PR, Montaner JSG, Poon AFY. The spread of hepatitis C virus genotype 1a in North America: a retrospective phylogenetic study. THE LANCET. INFECTIOUS DISEASES 2016; 16:698-702. [PMID: 27039040 DOI: 10.1016/s1473-3099(16)00124-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The timing of the initial spread of hepatitis C virus genotype 1a in North America is controversial. In particular, how and when hepatitis C virus reached extraordinary prevalence in specific demographic groups remains unclear. We quantified, using all available hepatitis C virus sequence data and phylodynamic methods, the timing of the spread of hepatitis C virus genotype 1a in North America. METHODS We screened 45 316 publicly available sequences of hepatitis C virus genotype 1a for location and genotype, and then did phylogenetic analyses of available North American sequences from five hepatitis C virus genes (E1, E2, NS2, NS4B, NS5B), with an emphasis on including as many sequences with early collection dates as possible. We inferred the historical population dynamics of this epidemic for all five gene regions using Bayesian skyline plots. FINDINGS Most of the spread of genotype 1a in North America occurred before 1965, and the hepatitis C virus epidemic has undergone relatively little expansion since then. The effective population size of the North American epidemic stabilised around 1960. These results were robust across all five gene regions analysed, although analyses of each gene separately show substantial variation in estimates of the timing of the early exponential growth, ranging roughly from 1940 for NS2, to 1965 for NS4B. INTERPRETATION The expansion of genotype 1a before 1965 suggests that nosocomial or iatrogenic factors rather than past sporadic behavioural risk (ie, experimentation with injection drug use, unsafe tattooing, high risk sex, travel to high endemic areas) were key contributors to the hepatitis C virus epidemic in North America. Our results might reduce stigmatisation around screening and diagnosis, potentially increasing rates of screening and treatment for hepatitis C virus. FUNDING The Canadian Institutes of Health Research, Michael Smith Foundation for Health Research, and BC Centre for Excellence in HIV/AIDS.
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Affiliation(s)
- Jeffrey B Joy
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | | | - Thuy Nguyen
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | - Yury Khudyakov
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Mel Krajden
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; BC Centre for Disease Control, Vancouver, BC, Canada
| | - John W Ward
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - P Richard Harrigan
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Art F Y Poon
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Lot F, Delarocque-Astagneau E, Thiers V, Bernet C, Rimlinger F, Desenclos JC, Chaud P, Dumay F. Hepatitis C Virus Transmission From a Healthcare Worker to a Patient. Infect Control Hosp Epidemiol 2015; 28:227-9. [PMID: 17265410 DOI: 10.1086/510807] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Accepted: 08/18/2005] [Indexed: 11/03/2022]
Abstract
We investigated the source of infection in a patient who developed acute hepatitis C virus infection after cardiothoracic surgery. A healthcare worker was found to be infected with hepatitis C virus, and molecular analysis indicated the strain was similar to that found in the patient. The exact mode of transmission was not identified; however, atopic eczema on the healthcare worker's hands may have contributed to the transmission.
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Affiliation(s)
- Florence Lot
- Departement des maladies infectieuses, Institut de veille sanitaire, Saint-Maurice, France
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3
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Henderson DK. Changing times, changing landscapes: comparing the Society for Healthcare Epidemiology of America's infected provider guidelines with the Centers for Disease Control and Prevention's Guidelines for managing providers INFECTED with hepatitis B virus. Infect Control Hosp Epidemiol 2012; 33:1152-5. [PMID: 23041815 DOI: 10.1086/668038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David K Henderson
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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4
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Turkel S, Henderson DK. Current strategies for managing providers infected with bloodborne pathogens. Infect Control Hosp Epidemiol 2011; 32:428-34. [PMID: 21515972 PMCID: PMC4772894 DOI: 10.1086/659405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND In 1991 the Centers for Disease Control and Prevention issued guidelines to reduce risks for provider-to-patient transmission of bloodborne pathogens. These guidelines, unchanged since 1991, recommend management strategies for hepatitis B e antigen-positive providers and for providers infected with human immunodeficiency virus; they do not address hepatitis C virus (HCV)-infected providers. OBJECTIVE We summarized current state practices and surveyed state health departments to determine (1) whether state policies have been modified since 1991; (2) whether state laws require prospective notification of patients and/or expert review panels to manage infected providers; (3) the frequency with which infected-providers issues come to the attention of state health departments; and (4) how state health departments intervene. METHODS We reviewed the 50 states' laws and guidelines to determine current practices and conducted a structured telephone survey of all state health departments. RESULTS Whereas only 19 states require infected providers to notify patients of the providers' bloodborne pathogen infection, these 19 states require notification under highly varied circumstances. Only 10 of 50 state health department officials identified these issues as requiring significant departmental effort. No state law or guideline incorporates information about providers' viral burdens as part of the risk assessment. Only 3 of 50 states have modified policies or laws since initial passage, and only 1 of 50 discusses the management of HCV-infected providers. CONCLUSIONS These results identify a need for incorporating contemporary scientific information into guidelines and also suggest that infected-provider issues are not occurring commonly, are not being detected, or are being managed at levels below the state health department.
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Affiliation(s)
- Sarah Turkel
- Hospital Epidemiology Service, Clinical Center, National Institutes of Health
| | - David K. Henderson
- Hospital Epidemiology Service, Clinical Center, National Institutes of Health
- Office of the Deputy Director for Clinical Care, Clinical Center, National Institutes of Health
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5
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Mohebati A, Davis JM, Fry DE. Current risks of occupational blood-borne viral infection. Surg Infect (Larchmt) 2010; 11:325-31. [PMID: 20528133 DOI: 10.1089/sur.2010.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other viruses remain occupational risks for both surgeons and patients in the operating room environment. In the past, this concern attracted great attention, but recently, this subject has been given much less attention. METHODS Review of the literature over the past 50 years on occupational risks of viral infection in the operating room. RESULTS Transmission of HIV still looms as a potential pathogen in the operating room, but no case has been documented in the United States. Infection with HBV can be prevented by a safe and effective vaccine. Chronic HCV infection is present in more than three million U.S. residents and remains a risk that can be managed only by adhering to strict infection control practices and avoiding blood exposure. CONCLUSIONS The risks of viral infection in the operating room remain the same as a decade ago even though attention to this issue has waned. The avoidance of blood exposure to prevent transmission of both known and unknown blood-borne pathogens continues to be a goal for all surgeons.
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Affiliation(s)
- Arash Mohebati
- Department of Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
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6
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Abstract
Hepatitis C (HCV) is the disease that has affected around 200 million people globally. HCV is a life threatening human pathogen, not only because of its high prevalence and worldwide burden but also because of the potentially serious complications of persistent HCV infection. Chronicity of the disease leads to cirrhosis, hepatocellular carcinoma and end-stage liver disease. HCV positive hepatocytes vary between less than 5% and up to 100%, indicating the high rate of replication of viral RNA. HCV has a very high mutational rate that enables it to escape the immune system. Viral diversity has two levels; the genotypes and Quasiaspecies. Major HCV genotypes constitute genotype 1, 2, 3, 4, 5 and 6 while more than 50 subtypes are known. All HCV genotypes have their particular patterns of geographical distribution and a slight drift in viral population has been observed in some parts of the globe.
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Affiliation(s)
- Nazish Bostan
- Department of Biological Sciences, Quaid-i-Azam University, Islamabad-45320, Pakistan
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7
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Henderson DK, Dembry L, Fishman NO, Grady C, Lundstrom T, Palmore TN, Sepkowitz KA, Weber DJ. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infect Control Hosp Epidemiol 2010; 31:203-32. [PMID: 20088696 DOI: 10.1086/650298] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This guideline provides the updated recommendations of the Society for Healthcare Epidemiology of America (SHEA) regarding the management of healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or the human immunodeficiency virus (HIV). For the reasons cited in the guideline, SHEA continues to recommend that, although some aspects of the approach to and administrative management of each of these infectious syndromes in healthcare providers are similar, separate management strategies for healthcare workers who are infected with these unrelated viruses remain appropriate. As we did in both prior iterations of this document, SHEA emphasizes the use of appropriate infection control procedures to minimize exposure of patients or providers to blood, emphasizes that transfers of blood from patients to providers and from providers to patients should be avoided, and recommends that infected healthcare providers should not be totally prohibited from participating in patient-care activities solely on the basis of a bloodborne pathogen infection. The types of procedures assessed by the panel as associated with an increased risk for provider-to-patient transmission of these pathogens are discussed in detail. For each pathogen, recommendations are graduated according to the relative viral load level of the infected provider (Tables 1 and 2). However, SHEA emphasizes that, because of the complexity of these cases, each such case will be slightly different from the next, and each should be independently considered in context.
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Affiliation(s)
- David K Henderson
- National Institutes of Health Clinical Center, Bethesda, Maryland 20892-1504, USA.
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8
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Salkeld L, McGeehan S. HIV testing of health care workers in England--a flawed policy. J Health Serv Res Policy 2010; 15 Suppl 2:62-7. [PMID: 20147426 DOI: 10.1258/jhsrp.2009.009095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A new Department of Health policy in England, published in 2007, recommended changes to the pre-employment health checks performed on health care workers before taking up their employment. The policy proposed that all new health care workers should receive immunization against TB and hepatitis B and should be offered testing for hepatitis C and HIV. It also advanced a new requirement that staff who perform exposure-prone procedures must be tested for TB, hepatitis B and C and HIV and must test negative for these diseases. Essentially mandatory HIV testing has been introduced for a large number of health care workers. The aim of the recommendations is to protect patients from contracting serious communicable diseases from health care professionals. Secondary objectives of the directive are to maintain confidence in the workforce and reduce the burden of patient notification exercises. This essay explores some of the shortcomings of this policy and examines the reasons why this policy will fail to meet its objectives. The justification for this new guidance is questioned and some of the ethical issues are highlighted.
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Michelin A, Henderson DK. Infection control guidelines for prevention of health care-associated transmission of hepatitis B and C viruses. Clin Liver Dis 2010; 14:119-36; ix-x. [PMID: 20123445 DOI: 10.1016/j.cld.2009.11.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patient's circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.
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Affiliation(s)
- Angela Michelin
- NIH Clinical Center, 10 Center Drive, Bethesda, MD 20892, USA
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10
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Carlson AL, Perl TM. Health care workers as source of hepatitis B and C virus transmission. Clin Liver Dis 2010; 14:153-68; x. [PMID: 20123447 DOI: 10.1016/j.cld.2009.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Transmission of hepatitis B and C from health care workers to patients remains rare in developed medical care systems but may be more common in systems that are still developing. Since the 1970s, at least 69 health care workers infected with hepatitis B or C have been implicated in transmission of their infection. This likely underestimates the magnitude of the problem. In this article, risk factors associated with transmission are reviewed and infection prevention and control practices outlined. Management of infected providers is also discussed. National guidelines are compared, highlighting different countries' approaches to this complex challenge.
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Affiliation(s)
- Abigail L Carlson
- Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, 425 Osler, 600 North Wolfe Street, Baltimore, MD 21287, USA
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11
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Raggam RB, Rossmann AM, Salzer HJF, Stauber RE, Kessler HH. Health care worker-to-patient transmission of hepatitis C virus in the health care setting: Many questions and few answers. J Clin Virol 2009; 45:272-5. [PMID: 19477680 DOI: 10.1016/j.jcv.2009.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 04/23/2009] [Indexed: 12/12/2022]
Abstract
Hepatitis C virus (HCV) infection represents a substantial risk to both, health care workers and patients. It is of major importance to detect health care workers with HCV infection and to establish regulations how to deal with infected individuals working in specific health care settings. Currently, there are no consistent recommendations, regulations or guidelines concerning prevention of health care worker-to-patient transmission of HCV. Questions arising include: Should health care workers be screened or tested individually on HCV infection and what kind of assay(s) should be used? When and how often should health care workers be tested? How should health care workers with HCV infection be managed? Based on these questions, this article reviews the most relevant published literature. Furthermore, suggestions for establishing a future common regulatory framework are provided.
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Affiliation(s)
- Reinhard B Raggam
- Molecular Diagnostics Laboratory, Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Universitaetsplatz 4, 8010 Graz, Austria
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12
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Ross RS, Viazov S, Khudyakov YE, Xia GL, Lin Y, Holzmann H, Sebesta C, Roggendorf M, Janata O. Transmission of hepatitis C virus in an orthopedic hospital ward. J Med Virol 2009; 81:249-57. [PMID: 19107970 DOI: 10.1002/jmv.21394] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Healthcare-associated infections with hepatitis C virus (HCV) hitherto have been observed mainly in hemodialysis settings as well as in hematology and oncology wards. In this communication, molecular and epidemiologic investigations to elucidate an HCV outbreak in an orthopedic ward are reported. One hundred and thirty-five patients hospitalized in the ward and 104 staff members were tested. In addition to extensive epidemiologic reviews and hygienic inspections, direct sequencing of HCV PCR fragments and phylogenetic analysis of more than 300 partial HCV sequences obtained by end-point limiting-dilution real-time PCR assay were carried out. Six patients were infected with very closely related HCV variants. Patient-to-patient spread of the virus was inferred to have started from one patient with previous HCV infection to the other five patients during their hospital stay. Inspections did not reveal substantial breaches in basic infection control practices and did not identify a specific activity that might have led to nosocomial transmission. As a result of the investigations, the hospital corrected the documentation of all medical and nursing activities undertaken in the ward, abandoned the use of all multidose saline and other medication vials, and included explicitly recommendations for the safe preparation and administration of injectable drugs into internal infection control guidelines. Thereafter, no further nosocomial transmissions of HCV have been recorded in the orthopedic ward. The events observed suggest that nosocomial transmission of HCV is not limited to hemodialysis, hematology or oncology settings, and they also reinforce the mandatory adherence to basic infection control practices.
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Affiliation(s)
- R S Ross
- Institute of Virology, National Reference Centre for Hepatitis C, Essen University Hospital, University of Duisburg-Essen, Essen, Germany.
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13
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Outcome of an exercise to notify patients treated by a general surgeon infected with the hepatitis C virus. J Clin Virol 2008; 41:314-7. [DOI: 10.1016/j.jcv.2008.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 01/15/2008] [Indexed: 02/05/2023]
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Verbaan H, Molnegren V, Pentmo I, Rubin L, Widell A. Prospective study of nosocomial transmission of hepatitis C in a Swedish gastroenterology unit . Infect Control Hosp Epidemiol 2008; 29:83-5. [PMID: 18171195 DOI: 10.1086/524340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A prospective study of incident hepatitis C in 515 gastroenterology patients was conducted by follow-up sampling at 3-6 months after admission to the gastroenterology unit to test for antibodies to hepatitis C virus and for hepatitis C virus RNA. Universal precautions were implemented, and the use of multidose vials had been banned in this unit. Despite 5,964 exposure-days for several risk factors associated with nosocomial hepatitis C virus transmission, no incident case of hepatitis C occurred.
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Affiliation(s)
- Hans Verbaan
- Department of Medicine (H.V., L.R.),University of Lund, Malmö University Hospital, Malmö, Sweden.
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15
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Esteban JI, Sauleda S, Quer J. The changing epidemiology of hepatitis C virus infection in Europe. J Hepatol 2008; 48:148-62. [PMID: 18022726 DOI: 10.1016/j.jhep.2007.07.033] [Citation(s) in RCA: 334] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Accepted: 07/30/2007] [Indexed: 02/07/2023]
Abstract
The epidemic of hepatitis C virus (HCV) infection in Europe is continuously evolving and epidemiological parameters (prevalence, incidence, disease transmission patterns and genotype distribution) have changed substantially during the last 15 years. Four main factors contribute to such changes: increased blood transfusion safety, improvement of healthcare conditions, continuous expansion of intravenous drug use and immigration to Europe from endemic areas. As a result, intravenous drug use has become the main risk factor for HCV transmission, prevalent infections have increased and genotype distribution has changed and diversified. Hence, prevalence data from studies conducted a decade ago may not be useful to estimate the current and future burden of HCV infection and additional epidemiological studies should be conducted, as well as new preventive strategies implemented to control the silent epidemic. This review summarizes recently published data on the epidemiology of HCV infection in Europe focusing on the factors currently shaping the epidemic.
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Affiliation(s)
- Juan I Esteban
- Liver Unit, Department of Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain.
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16
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Nosocomial transmission of hepatitis C virus during contrast-enhanced computed tomography scanning. Eur J Gastroenterol Hepatol 2008; 20:73-8. [PMID: 18090995 DOI: 10.1097/meg.0b013e32825b07b0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
We have investigated two cases of acute hepatitis C that occurred in patients who underwent digestive endoscopy and contrast-enhanced computed tomography (CT) scanning at two different centers. Investigations to identify the sources of infection included an on-site review of diagnostic procedures, interview of the involved healthcare staff, serological testing of the patients who underwent the procedures before and after the index cases and a molecular analysis of viral isolates from the patients and from potential viremic sources. In both cases, the epidemiological investigation identified a chronic hepatitis C virus (HCV) carrier who had been subjected to CT-scanning immediately before the index patient. Genetic distance and molecular phylogenetic analyzes of HCV sequences showed a close relationship between the isolates from these carriers and those from the acute-hepatitis patients, strongly suggesting that patient-to-patient transmission had occurred during CT. This is the first report describing two well documented cases of HCV nosocomial patient-to-patient transmission during contrast-enhanced CT scanning.
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Bruguera M, Torres M, Campins M, Bayas JM, Segura A, Barrio JL, Esteban R, Gatell JM, Martínez M, Monés J, Plans A, Planas R, Serra C, Tural C, Villalbí JR. [Risk of transmission of HIV or hepatitis B or C viruses from an infected physician. Preventive measures]. Med Clin (Barc) 2007; 129:309-13. [PMID: 17878027 DOI: 10.1157/13109120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Miquel Bruguera
- Servicio de Hepatología, Hospital Clínic, Barcelona, España.
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18
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Shemer-Avni Y, Cohen M, Keren-Naus A, Sikuler E, Hanuka N, Yaari A, Hayam E, Bachmatov L, Zemel R, Tur-Kaspa R. Iatrogenic transmission of hepatitis C virus (HCV) by an anesthesiologist: comparative molecular analysis of the HCV-E1 and HCV-E2 hypervariable regions. Clin Infect Dis 2007; 45:e32-8. [PMID: 17638183 DOI: 10.1086/520014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Accepted: 04/05/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Transmission of hepatitis C virus (HCV) from infected health care workers to patients rarely occurs. In 2003, a cluster of patients with HCV infection was identified at a medical center in Israel. All patients had a common history of various surgical procedures performed during the period 2001-2003. All patients had been anesthetized by an anesthesiologist who was an injection drug user and was infected with genotype 2a HCV. Screening was initiated by the hospital to identify newly infected patients with HCV infection and to determine the source of the iatrogenic HCV infection outbreak using comparative molecular analysis of the HCV E1 and HCV E2 hypervariable regions (HVR1 and HVR2). METHODS A total of 1200 patients who were anesthetized by the anesthesiologist (the related group) and 873 hospital personnel and patients anesthetized by other anesthetists (the unrelated group) were examined. Serum samples were screened for anti-HCV antibodies, HCV RNA, and genotype. Sequence analysis of HVR1 and HVR2 was performed after reverse-transcriptase polymerase chain reaction. RESULTS HCV type 2a was found in 33 patients in the related group but in only 1 patient in the unrelated group. The differences between the sequences isolated from the related group serum samples and the sequences isolated from genotype 2a control group serum samples (obtained from 15 patients) were highly statistically significant. The genetic distances from the anesthesiologist sequence were 1.4%-4.4% in the HVR1 and 0%-3% in the HVR2 in the related group serum samples, whereas in the HCV genotype 2a control group serum samples, the genetic distances were 22%-45% and 10%-35%, respectively. CONCLUSIONS Molecular analysis revealed sequence similarity of HVR1 and HVR2 in the related group, suggesting that the anesthesiologist with chronic HCV infection may have transmitted HCV to 33 patients.
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Affiliation(s)
- Yonat Shemer-Avni
- Clinical Virology Unit, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel.
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Abstract
Bloodborne pathogens continue to be a source of occupational infection for healthcare workers, but particularly for surgeons. Over 1 per cent of the U.S. population has one or more chronic viral infections. Hepatitis B is the infection that has the longest known role as an occupational pathogen, but infection with this virus is largely preventable with the use of the effective hepatitis B vaccine. Hepatitis C affects the largest number of people in the United States, and there is no vaccine available for the prevention of this infection. HIV infection still has not been associated with a documented transmission in the operating room environment, but six cases of probable occupational transmission have been reported. A total of 57 healthcare workers have had documented occupational infection since the epidemic of HIV infection began. Infection of blood-borne pathogens to patients from infected surgeons remains a concern. Surgeons who are e-antigen-positive for hepatitis B have been well documented to be an infection risk to patients in the operating room. Only four surgeons have been documented to transmit hepatitis C, although other transmissions have occurred in the care of patients when practices of infection control have been violated. No surgical transmission of HIV to a patient has been identified at this time. Prevention of occupational infection requires use of protective barriers, avoidance of exposure risk by modification of techniques, and a constant awareness of sharp instruments in the operating room. Blood exposure in the operating room carries risk of infection and should be avoided. It is likely that other infectious agents will emerge as operating room threats. Surgeons must maintain vigilance in avoiding blood exposure and percutaneous injury.
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Affiliation(s)
- Donald E. Fry
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Kretzschmar E, Chudy M, Nübling CM, Ross RS, Kruse F, Trobisch H. First case of hepatitis C virus transmission by a red blood cell concentrate after introduction of nucleic acid amplification technique screening in Germany: a comparative study with various assays. Vox Sang 2007; 92:297-301. [PMID: 17456153 DOI: 10.1111/j.1423-0410.2007.00903.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Pooled nucleic acid amplification techniques (NAT) and donor screening for anti-hepatitis C virus (HCV) have reduced the diagnostic window period of HCV infection in the blood donor population from about 12 to 1 or 2 weeks. During that time, HCV RNA is hardly detectable by pooled or individual donation NAT. Here we describe a case of transfusion-acquired HCV infection from an extremely low-titre donation. After a repeat donor tested positive for HCV, a look-back procedure was initiated. A recipient of a red cell concentrate from the previous donation was identified and found to be infected with HCV as well. We compared several commercial NAT systems for their ability to detect the viraemic plasma. MATERIALS AND METHODS Molecular analyses of HCV in donor and recipient samples were performed. The HCV-transmitting plasma was tested using different commercially available qualitative and quantitative NAT assays. RESULTS HCV transmission was verified by molecular analyses and was assigned to genotype 2b. NAT with various commercial HCV assays detected the infection erratically in individual donations. However, the detection rate was not directly related to the claimed sensitivity of some HCV NATs. CONCLUSIONS HCV transmission can be caused by donations that escape NAT detection even when tested in an individual donation. Comparison of different assays led to results that did not necessarily reflect the expected sensitivities. The need for standard materials representing further HCV genotypes is discussed.
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Affiliation(s)
- E Kretzschmar
- Institute for Clinical Haemostaseology, Duisburg, Germany.
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Abstract
Hepatitis C virus (HCV) is a leading cause of chronic blood-borne infection and chronic liver disease. The global epidemic of HCV infection emerged in the second half of the 20th century, and several lines of evidence indicate that it was primarily triggered and fed iatrogenically by the increasing use of parenteral therapies and blood transfusion. In developed countries, the rapid improvement of healthcare conditions and the introduction of anti-HCV screening for blood donors have led to a sharp decrease in the incidence of iatrogenic hepatitis C, but the epidemic continues to spread in developing countries, where the virus is still transmitted through unscreened blood transfusions and non-sterile injections. This article reviews the published literature concerning HCV transmission through blood transfusions and other unsafe medical procedures. Given the substantial difference in current disease transmission patterns between the northern and southern hemispheres, the situation in developed and developing countries is separately analysed.
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Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: a double standard. Am J Infect Control 2006; 34:313-9. [PMID: 16765212 DOI: 10.1016/j.ajic.2006.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Accepted: 01/04/2006] [Indexed: 11/30/2022]
Abstract
US policy regarding health care worker-to-patient transmission of bloodborne pathogens, issued in 1991, is flawed. We review current evidence of such nosocomial infections and conclude that a standardized national policy is needed, which includes improved surveillance and follow-up of blood exposures to patients and targeted practice restrictions for infected practitioners performing exposure-prone procedures.
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Affiliation(s)
- Jane L Perry
- Division of Infectious Diseases, International Healthcare Worker Safety Center, UVA Health System, PO Box 800764, Charlottesville, VA 22908-0764, USA.
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Leao JC, Teo CG, Porter SR. HCV infection: aspects of epidemiology and transmission relevant to oral health care workers. Int J Oral Maxillofac Surg 2006; 35:295-300. [PMID: 16487681 DOI: 10.1016/j.ijom.2004.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Accepted: 09/15/2004] [Indexed: 10/25/2022]
Abstract
Hepatitis C virus (HCV) infection is a common worldwide problem, giving rise to long-term viral carriage and risk of chronic hepatic disease, hepatic malignancy and a wide spectrum of immunologically mediated disorders. The present report describes relevant data suggesting that nosocomial transmission to oral health care workers is unlikely, but in view of medical and occupational consequences of such infection, and the absence of long-term effective treatment or vaccine, the oral surgery profession must continue to be vigilant and to maintain the highest standards of infection control procedures to minimize the possible acquisition of HCV during dental treatment.
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Affiliation(s)
- J C Leao
- Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Recife, Brazil.
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24
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Schäfer A, Scheurlen M, Felten M, Kraus MR. Physician-patient relationship and disclosure behaviour in chronic hepatitis C in a group of German outpatients. Eur J Gastroenterol Hepatol 2005; 17:1387-94. [PMID: 16292094 DOI: 10.1097/00042737-200512000-00019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES In chronic hepatitis C infection, the doctor-patient relationship can be burdened for various reasons. Factors associated with the doctor-patient relationship and self-disclosure of hepatitis C virus (HCV) status have not so far been investigated systematically. The goal of the study was to examine self-disclosure of HCV positivity, perceived stigmatization, and potential predictor variables in a German outpatient group. METHODS In a cross-sectional single-centre study, we included a volunteer sample of 103 HCV outpatients. Patient recruitment was between March 2003 and September 2004. Data were obtained from a fully standardized face-to-face interview [HCV disclosure behaviour (main interview variable), stigmatization, doctor-patient relationship] and psychometric self-assessment questionnaires [Hospital Anxiety and Depression Scale, German version; Symptom Checklist-90 Revised (global severity index); Inventory of Interpersonal Problems (total score)]. RESULTS The overall general disclosure rate was 44.7% (with respect to all physicians). However, 75% stated revealing their positive serostatus in future physician appointments (P < 0.05). With respect to family/friends, disclosure rates were clearly higher (permanent partner, 99%; average, 76.7%). Patients' disclosure behaviour could not be predicted by sociodemographic variables or personality factors (binary logistic regression, P > 0.05). Similarly, the Hospital Anxiety and Depression Scale and Symptom Checklist-90 subscales were not substantially associated with HCV disclosure. Experiences of stigmatization (rate 38.8%) were more frequent in women (P = 0.014) and patients with higher depression scores (P = 0.029). CONCLUSIONS There is a need for education in the field of chronic hepatitis C in order to improve the physician-patient relationship. HCV disclosure rates might thus be increased and the frequency of problematic contacts reduced. Importantly, the data show that physicians should explicitly ask for the patients' HCV status because unrequested disclosure cannot be taken for granted.
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Affiliation(s)
- Arne Schäfer
- Medizinische Klinik und Poliklinik II, Würzburg University, Department of Gastroenterology and Hepatology, Germany.
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25
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Izopet J, Sandres-Sauné K, Kamar N, Salama G, Dubois M, Pasquier C, Rostaing L. Incidence of HCV infection in French hemodialysis units: a prospective study. J Med Virol 2005; 77:70-6. [PMID: 16032714 DOI: 10.1002/jmv.20415] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A large prospective study was carried out from 1997 to 2000 in 25 French hemodialysis units including 1,323 patients to determine the incidence of hepatitis C virus (HCV) infection. Monthly testing of alanine aminotransferase (ALT) activity, and assessment of HCV RNA and anti-HCV antibodies if the ALT activity was elevated, identified 14 new infections in 7 different units, giving an incidence of 0.4% new HCV infections per year. Molecular analyses and epidemiological data indicated that five patients became infected with HCV outside the unit where they were dialyzed, while the nine remaining patients acquired HCV from infected patients on dialysis during the same shift at the same unit. HCV was cleared in six of the seven (85.7%) patients with acute hepatitis C who were given standard doses of alpha-interferon (alpha-IFN). The persistence of nosocomial transmission of HCV in hemodialysis units emphasizes the need to implement infection control practices. Identifying new infections is crucial because alpha-IFN treatment results in long term clearance of HCV RNA in a large proportion of patients.
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Affiliation(s)
- Jacques Izopet
- Laboratoire de Virologie, Variabilité virale EA2046-IFR30, Hôpital Purpan, CHU Toulouse, France.
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26
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Bracho MA, Gosalbes MJ, Blasco D, Moya A, González-Candelas F. Molecular epidemiology of a hepatitis C virus outbreak in a hemodialysis unit. J Clin Microbiol 2005; 43:2750-5. [PMID: 15956393 PMCID: PMC1151931 DOI: 10.1128/jcm.43.6.2750-2755.2005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We analyzed a hepatitis C virus (HCV) transmission case in the hemodialysis unit of a private clinic by sequencing two genome regions of virus isolates from a number of patients attending this unit and some external controls. The analysis of 337 nucleotides (nt) in the NS5B region did not provide enough resolution to ascertain which patients were actually involved in the outbreak and the potential source. Nevertheless, this region allowed the exclusion of several patients as putative sources of the transmission case based on their genotypes and phylogenetic relationships. On the other hand, the analysis of several 472-nt-long clone sequences per sample in a more rapidly evolving region of the HCV genome, coding for the envelope proteins and encompassing hypervariable region 1, allowed us to establish the existence of at least two independent transmission events involving two different source patients and three recipients. The direction of the transmissions was further corroborated by different measures of genetic variability within and among samples.
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Affiliation(s)
- Maria Alma Bracho
- Institut Cavanilles de Biodiversitat i Biologia Evolutiva, Universitat de València, València, Spain
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27
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Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004; 38:1592-8. [PMID: 15156448 DOI: 10.1086/420935] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2003] [Accepted: 01/28/2004] [Indexed: 01/22/2023] Open
Abstract
In the United States, transmission of viral hepatitis from health care-related exposures is uncommon and primarily recognized in the context of outbreaks. Transmission is typically associated with unsafe injection practices, as exemplified by several recent outbreaks that occurred in ambulatory health care settings. To prevent transmission of bloodborne pathogens, health care workers must adhere to standard precautions and follow fundamental infection-control principles, including safe injection practices and appropriate aseptic techniques. These principles and practices need to be made explicit in institutional policies and reinforced through in-service education for all personnel involved in direct patient care, including those in ambulatory care settings. The effectiveness of these measures should be monitored as part of the oversight process. In addition, prompt reporting of suspected health care-related cases coupled with appropriate investigation and improved monitoring of surveillance data are needed to accurately characterize and prevent health care-related transmission of viral hepatitis.
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Affiliation(s)
- I T Williams
- Epidemiology Branch, Division of Viral Hepatitis, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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28
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Henderson DK. Managing occupational risks for hepatitis C transmission in the health care setting. Clin Microbiol Rev 2003; 16:546-68. [PMID: 12857782 PMCID: PMC164218 DOI: 10.1128/cmr.16.3.546-568.2003] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hepatitis C virus (HCV) infection is a significant contemporary health problem in the United States and elsewhere. Because it is primarily transmitted via blood, hepatitis C infection presents risks for both nosocomial transmission to patients and occupational spread to health care workers. Recent insights into the pathogenesis, immunopathogenesis, natural history, and treatment of infection caused by this unique flavivirus provide a rationale for the use of new strategies for managing occupational hepatitis C infections when they occur. This article reviews this developing information. Recently published data demonstrate success rates in the treatment of "acute hepatitis C syndrome" that approach 100\%, and although these studies are not directly applicable to all occupational infections, they may provide important clues to optimal management strategies. In addition, the article delineates approaches to the prevention of occupational exposures and also addresses the difficult issue of managing HCV-infected health care providers. The article summarizes currently available data about the nosocomial epidemiology of HCV infection and the magnitude of risk and discusses several alternatives for managing exposure and infection. No evidence supports the use of immediate postexposure prophylaxis with immunoglobulin, immunomodulators, or antiviral agents. Based on the very limited data available, the watchful waiting and preemptive therapy strategies described in detail in this article represent reasonable interim approaches to the complex problem of managing occupational HCV infections, at least until more definitive data are obtained.
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Affiliation(s)
- David K Henderson
- Warren G. Magnuson Clinical Center, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland 20892, USA.
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