European hepatitis B/C PEP guidelines for healthcare workers published

European guidelines for healthcare workers occupationally exposed to hepatitis B virus (HBV) and/or hepatitis C virus (HCV) have been published in the October edition of Eurosurveillance Monthly, available online here. These guidelines complement 2004 European guidelines to manage HIV exposure in healthcare workers who have been exposed occupationally.

The prevalence of both HBV and HCV in the general population varies throughout Europe but is thought be in the range of 0.3% to 3% for HBV and 0.5% to 2% for HCV. The World Health Organisation (WHO) estimates that each year approximately 300,000 healthcare workers are exposed to HBV, 150,000 are exposed to HCV, and 22,000 are exposed to HIV through accident subcutaneous exposure to sharps, also known as needlestick injuries.

WHO also estimates that the probability of acquiring a bloodborne infection following an occupational exposure has been estimated to be on average 18%-30% for HBV, 0.5% for HCV and less than 0.3% for HIV, depending on the type of exposure, the body fluid involved, and the infectivity of the index case.

The United States have produced guidelines for the management of occupational exposure for HBV and HCV, most recently updating them in 2001. In order to implement and standardise a rational management of occupational exposures to HBV and HCV among healthcare workers in Europe, representatives of nine European countries participated in a project funded by the European Commission, and developed a comprehensive set of recommendations.

The guidelines include the following general recommendations:

• Prevention of exposure is the primary strategy to reduce the risk of occupational bloodborne pathogen infections.
• Comprehensive education should be provided to all healthcare workers regarding the possible risks and prevention of bloodborne infections after an occupational exposure, as well as the principles of post-exposure management and the importance of seeking urgent advice following any occupational exposure immediately after it occurs.

The following recommendations are made regarding HBV:

• All healthcare workers should be vaccinated against HBV, and the combined hepatitis A/ HBV vaccine is recommended for healthcare workers with chronic HCV infection, or other liver problems.
• When necessary, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin (HBIG) or both should be started within 24 hours and no later than one week after exposure.
• HBsAg-positive healthcare workers should receive clinical evaluation and their serostatus, as well as risk for hepatitis D, should be assessed.
• Serological follow-up is not recommended when post-exposure management is managed according to these recommendations.

The following recommendations are made regarding HCV:

• Currently, there is no available vaccine for HCV.
• It is unclear whether treating acute HCV infection (with pegylated or unpegylated interferon with or without ribavirin) is more effective than treating early chronic HCV infection.
• HCV antibody and liver function tests should be done at exposure, and either three or six months later.
• Follow-up with HCV viral load testing if liver function tests are abnormal.

The guidelines authors say that “these recommendations must be considered dynamic documents. Indeed, scientific evidence appearing in the literature after the consensus meetings was also included in these documents, and recommendations may change in the future with further research and scientific information, as some issues remained unresolved or controversial.”

This includes a disagreement over the exact antibody titre levels that are considered protective against HBV, and whether treatment for HCV during the acute period is necessary or cost-effective.

“In the meantime,” they conclude, “it is important to maintain surveillance of occupationally exposed healthcare workers, and to promote a widespread implementation of preventive strategies such as standard precautions, education on exposure risk, better sharps disposal systems, personal protective equipment, and safety-engineered sharp devices to ensure a safer working environment in the healthcare setting.”