Prevention

The United States has a national strategic plan to eliminate viral hepatitis. The number of new hepatitis C virus infections (HCV) declined for the first time in 2022 after over a decade of consecutive annual increases. However, the number of estimated new HCV infections was 67,600, well above the annual target of 36,617. A 48% reduction from the number of estimated new HCV infections in 2022 is needed to meet the 2025 goal of 35,000 estimated new infections (HHS, 2020).

U.S. strategic plan to reduce HCV has suggested the following strategies to reduce new cases of HCV to the 2025 goal:

• Supporting routine hepatitis C screening for all adults at least once in their life and for every pregnant person during each pregnancy, and testing of all perinatally exposed infants.
• Implementing periodic testing for persons with recognized exposures (such as use of injection drugs) as long as the risk persists.
• Improving access to life-saving curative treatment for all persons with hepatitis C.
• Supporting medical education and partnerships with service providers to reach people with hepatitis C.
• Building capacity within jurisdictions to collect and use a core set of surveillance data to identify outbreaks, understand transmission networks, and prioritize prevention efforts.
• Increasing access to substance use disorder treatment and medication-assisted treatment programs for disproportionately affected populations.
• Conducting research to improve prevention strategies and increase awareness of hepatitis C.
• Building and harnessing partnerships that amplify the use of effective prevention strategies in persons and places with higher rates of HCV transmission (HHS, 2020).

Health education programs

Healthcare professionals can contribute to the goal of HCV elimination by supporting comprehensive HCV health education that targets healthcare professionals allied healthcare workers and high risk groups. Effective education program should include the following information:

• Hepatitis C infection can be cured with oral medications, for most populations
• Importance of HCV screening tests
  • Every adult at least once
  • Every pregnant woman, every pregnancy
  • Everyone with risk factor
• Disease outcomes
  • Acute hepatitis
  • Chronic hepatitis
  • Cirrhosis
  • Liver cancer
• Risk factors for new HCV infection
  • Injection drug use is the highest risk
  • Healthcare acquired HCV: Inadequate sterilization of medical equipment, drug diversion, sharps injuries and needle sticks
  • Sharing personal items: razors,toothbrushes, nail clippers
  • Sexual Contact: multiple partners, STI positive partners, men with men
  • Mother to child transmission during birth is rare
  • Unsafe tattooing and body piercing
• Routes of HCV transmission
  • percutaneous
  • mucosal
  • healthcare acquired
• The importance of substance abuse treatment, when appropriate
• Sexual precautions including abstinence counseling and condom use
• Risk-reduction counseling,including not sharing drug paraphernalia
• Resources in the community available to support and sustain a reduction in risk behaviors.

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Any HCV health education program should be comprehensive and cover risks and precautions.

• Stop using and injecting drug
• Enter and complete substance-abuse treatment, including relapse prevention programs
• If continuing to inject drugs
• Never share syringes, needles, water, or drug preparation equipment.
• Use only sterile syringes obtained from a reliable source, such as pharmacies Use a new sterile syringe to prepare and inject drugs. If possible, use sterile water to prepare drugs; otherwise, use clean water from a reliable source, such as fresh tap water.
• Use a new or disinfected container (“cooker”) and a new filter (cotton) to prepare drugs.
• Clean the injection site before injection with a new alcohol swab.Safely dispose of syringes after one use.
• If using shared equipment, first clean the equipment with bleach and rinse thoroughly with water.
• Get vaccinated against hepatitis B and hepatitis A.

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Injection drug users should be advised to stop using drugs but also should receive information about using injection drugs safely.

Safe sexual practices

Health care workers in all patient care settings should routinely obtain a history that inquires about evidence of high-risk sexual practices, such as multiple partners or a history of sexually transmitted disease. Routine screening is important, as in some cases, people may have an HCV-infected partner, but otherwise not practice high-risk behavior. As with drugs, abstinence solves the problem, but for many people, abstinence is not a viable solution. All people at risk for sexual transmission should be advised of the following:

• Have sex with only one uninfected partner or no sex at all.
• Use latex condoms correctly and every time.
• Get vaccinated against hepatitis B, and if appropriate, hepatitis A.

Preventing and responding to occupational sharps injury and blood and body fluid exposure in healthcare settings

Exposure to hepatitis viruses is a recognized occupational risk for healthcare personnel (HCP), and recommendations have been established for managing occupational exposures to bloodborne pathogens, including hepatitis C virus (HCV). Employers are required to provide a workplace free from recognized hazards and to take reasonable measure to mitigate known hazards.

Controlling exposures to hazards in the workplace is vital to protecting workers. The hierarchy of controls is a way of determining which actions will best control exposures. The hierarchy of controls has five levels of actions to reduce or remove hazards. The preferred order of action based on general effectiveness is:

• Elimination
• Substitution
• Engineering controls
• Administrative controls
• Personal protective equipment (PPE) (NIOSH 2023)

The Exposure Prevention Information Network surveillance system (EPINet) is a sharps injury and blood and body fluid exposure surveillance research group that publishes occupational exposure date for the participating healthcare facilities.

Their 2022 report surveyed 40 US hospitals and facilities reporting a total needle or sharp object injury rate of 29.2 per 100 average daily census (ADC).  The rate for teaching hospitals was nearly double (34.4/100 ADC) that of non-teaching hospitals (18.4/100 ADC). Nurses had the highest exposure (40.6%) compared to the attending staff with the second highest rate of 17.2% of sharp injuries. The sharp item was contaminated in 88.1% of injuries. Disposable needle and syringe was the most common item involved (23%). Less than one third of the items were known to be caused by a shielded, recessed, retractable, or blunted needle or blade (30.4%). In 66% of the injuries their safety mechanism was not activated.

Standard precautions (health care settings)

The Centers for Disease Control (CDC) defines Standard Precautions as: “A set of precautions designed to prevent transmission of HIV, Hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care. Under standard precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other blood borne pathogens" The following precautions should be taken:

• Gloves
  • Should be used for any treatment or procedures that involve contact with mucous membranes, affected skin, or body fluids or items soiled with body fluids.
  • Should be used only once.
  • Should be discarded in a special container separate from other trash.
• Hand washing
  • Should be done immediately after removing gloves.
  • Should be done immediately if there is a potential or actual contaminiation by blood or body fluid on hands or other body surface.
  • Should be done immediately after each contact with ANY person.
• Protective clothing (masks, goggles, gowns)
  • Surgical mask and eyewear should be worn during any task that may result in exposure of mouth, nose, and eyes to blood or body fluids.
  • Disposable gowns or aprons should be used when blood or body fluids may contaminate clothes.
  • Cloth gowns or aprons should be washed according to instructions for washing linens soiled with blood.
• Safety precautions with needles
  • Should always use disposable needles.
    
  • Should not recap or purposely bend needles.
    
  • Should discard needles in the way recommended by health care provider.
    
  • Should be placed in puncture-proof container, specifically marked, and not overfilled.
    
  • Needlesticks should be immediately reported to healthcare employer.
• Disposal of waste products and washing of soiled linens
  • Waste products should be disposed of in red plastic bags, double-bagged.
  • Linens or clothing soiled with blood must be washed separately from other laundry, using detergent and germicide.
• Guidelines for sterilization or disinfection
  • Should use chemical germicides registered with the EPA for sterilization or disinfection.
  • Chemicals should be used only in recommended concentrations and only with proper ventilation.

Home healthcare professionals overseeing patients receiving home infusion therapy should ensure that families and caregivers are informed of potential risk for infection and taught adequate infection control practices. The family's ability to follow these practices should be assessed. There are currently no recommendations to restrict HCV-infected health care workers, but they should follow strict aseptic techniques and standard precautions. Some authorities advise the practice of double-gloving.

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Increased testing

Identifying people infected with Hepatitis C is one of the primary goals in prevention. Healthcare workers need to be aware of the risks and benefits of testing and be familiar with factors that increase risk. Patients and clients in all settings should be routinely assessed and advised to be tested if any risk factors exist. Outreach should be done to reach people who might not be seen in the primary care setting:

• Correctional facilities
• HIV counseling and testing sites
• Substance abuse programs
• Programs for people with sexually transmitted diseases A coordinated program for testing needs to be established so that people who test positive can receive counseling and referral for medical management.

A coordinated program for testing needs to be established so that people who test positive can receive counseling and referral for medical management.

• Procedures should be established to notify people who might have become infected with HCV through transfusion of blood or blood components. There are targeted approaches that notify people who received a transfusion from recipients who tested positive after screening tests were implemented. A general approach is to notify all people that they should be tested, if they received transfusions before July 1991. There are advantages to a general education program because it does not depend on donor testing status and availability of records. It potentially reaches people who received infected blood from donors who tested falsely negative on the less sensitive early tests, as well as from donors before testing was available. The same approaches can be used for those who received organ or tissue transplants.
• Children born of HCV positive mothers should be routinely tested. Testing of infants for antigens should be done no earlier than 12 months of age, when the passively received antigens from the mother declines below detectable levels. HCV RNA tests can be done between 1 to 2 months, if earlier diagnosis is desired. Umbilical cord blood should not be used for testing because the mother's blood can contaminate it. If positive, children should be evaluated for the presence or development of liver disease and those with a persistently elevated liver enzyme test (ALT) should be referred to a specialist for medical management.
  
• Post exposure follow-up for healthcare workers, emergency medical, and public safety works for HCV should include the following:
  • Source: baseline testing for HCV antigen (anti-HCV)
  • Person exposed: baseline and follow-up testing:
    • >Baseline testing for anti-HCV and ALT
    • Follow-up testing for anti-HCV at 4-6 months and ALT activity
    • HCV RNA may be performed at 4-6 weeks if early diagnosis desired
      
• Confirmation of positive results with supplemental testing.
• Some people do not need to be referred for routine testing unless there are risk factors involved:
  • Health care, emergency medical, and public safety workers.
  • Pregnant women
  • Household (non-sexual) contacts of HCV-positive persons
  • General population.
• There are other persons for whom HCV testing is of uncertain need and should be individually evaluated:
  • Recipients of transplanted tissue
  • Intranasal cocaine or other non-injecting illegal drug users
  • Persons with a history of tattooing or body piercing.
  • Persons with a history of multiple sex partners or sexually transmitted diseases.
  • Long-term steady sex partners of HCV-positive persons.
• While there has been HCV infection from tissue transplants, the risks are quite low. Some have suggested an association of HCV with intranasal cocaine from the sharing of nasal straws, but this is inconclusive. In the United States, there is no documentation of people being infected by tattooing or piercing. However, if it is done in an unregulated manner (e.g. sharing needles in correctional institutions), there may be a risk.
• Tissue transplants infected with HCV have occurred, but the risks are quite low.
• Use of intranasal cocaine by sharing of nasal straws has been suggested to be associated with transmission of HCV, but this is inconclusive.
• Tattooing and body piercing have not been documented to have transmitted HCV in the United States. However, unsafe and unregulated practices (e.g. sharing needles in correctional institutions), may be a risk.

Testing for HCV

Consent should be obtained, as for all procedures, and measures should be taken to ensure confidentiality. Persons should be provided with the following information:

• Exposures associated with the transmission of HCV, including behaviors or exposures that might have occurred infrequently or many years ago.
• The test procedures and the meaning of the test results.
• The nature of hepatitis C and chronic liver disease.
• The benefits of detecting infection early.
• Available medical treatment.
• Potential adverse consequences of testing positive, including disrupted personal relationships and possible discriminatory action (loss of employment, insurance, educational opportunities).

Ideally, comprehensive information about hepatitis C should be provided before testing, but if that is not practical or possible, the person should be informed of 3 things:

• Testing for HCV will be done
• Individual results will be kept confidential
• Appropriate counseling and referral will be offered if results are positive (Schillie et al., 2020).

References

EPINet Report for Needlestick and Sharp Object Injuries (2022). International Safety Center. Acccessed 4/15/2024 from https://internationalsafetycenter.org/exposure-reports/

The National Institute for Occupational Safety and Health (NIOSH)- Hierarchy of Controls (Reviewed 2023). Accessed 4/19/2024 from https://www.cdc.gov/niosh/topics/hierarchy/default.html

Nguyen, D. B., Bixler, D., & Patel, P. R. (2019). Transmission of hepatitis C virus in the dialysis setting and strategies for its prevention. Seminars in dialysis, 32(2), 127–134. https://doi.org/10.1111/sdi.12761

Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020. Last Reviewed March 17, 2023. MMWR Recomm Rep 2020;69(No. RR-2):1–17. DOI: http://dx.doi.org/10.15585/mmwr.rr6902a1

U.S. Department of Health and Human Services. 2020. Viral Hepatitis National Strategic Plan for the United States: A Roadmap to Elimination (2021–2025). Washington, DC.
https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf