Hep C- How Totally Unprepared and Ignorant We Really Are...

Editor’s Note:

What Doesn’t Kill You- makes You Stronger?

Sometime during the course of my third decade working as a cardiac perfusionist, I made a phone call to my wife immediately following some open-heart operation that I had just completed. In the call, I somewhat frantically relayed to her my serious concern that I had just gotten a blood spill on a raw hangnail by my fingernail- exposing me to Hep C from my patient, their blood onto what is basically an open cut on me. That’s pretty scary- and made me a lot more serious about self protection than I had been before.

Various types of exposure, to a patient’s blood is something that has happened throughout my medical career, most often accidental spills to my skin or face, micro droplets sprayed to my eyes or nasal cavity, a brief encounter of patient blood to a raw cuticle/hangnail, or more intense cases blood soaked all the way through my scrubs to actually seep and get to my skin.

In my case, I wrote it off as just another blood-contact event although in the back of my head, I was worried because there was definitely some exposure there to that hepatitis C virus. I’m not exactly sure if it was because I was tired, or just trying to avoid the administrative hassle of having to go to the emergency room or environmental health, having to write out a form explaining how the exposure happened, what I did or didn’t do to prevent it, or in my case, just a sense of fatality that many of us in healthcare especially those of us that are likely to be exposed to large amounts of shed blood (ER, OR, ICU, Paramedics etc.…) develop over time.

It’s an odd inverse relationship that diverges over time to the point that the sum of your exposures can lead to a decline of your personal vigilance even when common sense screams out to be a little more careful. A case in point, watching today’s anesthesiologist make adjustments to the patient’s arterial line, not wearing any gloves or glasses, with the entire room fully aware that this patient was definitely hep C positive, along with a very risky lifestyle that will in and of itself open the door to other optimistic infections all the way up to and including HIV.

If you work around tigers and lions long enough- eventually you might just get eaten or consumed. This is not a “you mess with the bull- you get the horns” type of dialogue. It’s more of an environmental edge-of -the- cliff thing, a lot more casual and quite a bit more alarming than the lines of- “What doesn’t kill you makes you stronger”- versus being silently introduced and ultimately subdued by the Hepatitis C virus. It will kill you- and unfortunately the answer is a resounding “no” to the “makes you stronger” portion of those lyrics to an otherwise great song.

I thought about that phone call today, as I looked at the top corner of my patients bypass record – towards the very end of the case, I noticed a small bloodstain about half the size of a dime, sitting there almost screaming out to be wiped off for the simple fact that not only did it look messy and sloppy, it was definitely a nest for the hep C virus. So once again you find yourself with an inconvenient moral and ethical consideration, confronting you with what you know you should do, versus what you actually will end up doing.

The ideal way to look at it would be asking yourself a simple question: “Would you bring home a bowl of chili from the potluck luncheon you just came back from at the local Leper colony?”

I guess for us in the perfusion world, you have to be honest with yourself and recognize what I think is a universal problem in terms of minimizing potential risks like surface bacteria or viruses sitting on our clamps, clipboards, pump-heads, pump dials, pump surfaces, and countless other things that our hands come into contact with during the course of a pump run. I can say without hesitation, that almost 100% of the time none of the above-mentioned items or contact points are sterilized or cleaned with bleach. Most often they are barely wiped down at the end of the case and if indeed they are wiped down at all- it will most likely be with a surgical towel that is soaked in common H2O.

The literature presented below enunciates clearly that hep C viruses can live on surfaces for three weeks if not months, and typically can only be destroyed/inactivated with intense heat, bleach and water, or some other anti-septic cleanser designed specifically for that purpose. In terms of the case today, did I clean my pump clamps after the case I described above? That would be yes, but only with alcohol wipes which may or may not have been effective. But typically, I don’t see many people wiping down or washing off their clamps after or between cases.

Please take the survey below and please be as honest as possible. It is a totally anonymous survey, but by elevating our global vision of what we are actually doing and comparing it to what the common standard should be, hopefully we can avoid unnecessary depletion of our working numbers and further harm to our brothers and sisters.

Please take this survey- and we shall publish results at N=200

Click Image Above to Take Survey

Westermann and her team conducted a meta-analysis of papers published from 1989-2014 to estimate the prevalence of HCV infection among healthcare workers compared to the general population. Their systematic review indicates that healthcare workers have a more than 200% higher prevalence of HCV infection than the public at large and a nearly 300% higher prevalence for some categories of workers, especially those with the most frequent exposures to blood including medical and laboratory technical professions.² With the use of engineering controls and the requirement for facilities to use safety-engineered medical devices, safe disposal practices and extensive training, this extraordinarily high prevalence seems unfathomable in a population that has greater protections in place than the general public.

OCCUPATIONAL RISK TO NEEDLESTICKS AND SHARPS INJURIES ARE STILL UNACCEPTABLY HIGH

The International Safety Center’s Exposure Prevention Information Network (EPINet^®) data supports that occupational risk to needlesticks and sharps injuries are still unacceptably high. The 2013 sharps injury summary data from a network of 30 US hospitals illustrates that more than 50% of injuries are from devices that are not a safety design despite regulations from OSHA to use them. It also indicates, that of the safety devices that were used, more than 70% did not have safety features activated to protect the users from the contaminated sharp.³

NUMBER OF TOTAL EXPOSURES IS GRAVELY UNDER-ESTIMATED

In addition, surveillance systems should be put in place that track HCV infections back to a specific occupational exposure, so that future infections can be prevented. Based on what limited data CDC does collect voluntarily, data from 2013 indicates that there were 52 confirmed cases of HCV infection from needlesticks but this dataset shows an incomplete picture. Follow-up data (HCV infection status) was not available from 1,459 out of 2,138 needlesticks. This could mean that HCV infections following needlesticks from hospitals submitting data to CDC are actually higher and since neither CDC, NIOSH, nor OSHA require healthcare facilities to report needlesticks, the number of total exposures is gravely under-estimated.

Do You Employ these Preventive measures?

Hepatitis B and Hepatitis C

The Hepatitis virus infection is the most common chronic bloodborne infection in the United States. CDC staff estimate that during the 1980s, an average of 230,000 new infections occurred each year. Most of these persons are chronically infected and might not be aware of their infection because they are not clinically ill. Infected persons can serve as a source of transmission to others.

The Hepatitis virus is extremely hearty. It is able to survive the body’s highly acidic digestive tract and can live outside the body for months. High temperatures, such as boiling or cooking food or liquids for at least one (1) minute at 185°F (85°C) will kill the virus, although freezing temperatures do not.

The following information has been developed in accordance with current applicable infection control and regulatory guidelines. It is intended for use as a guideline only. At no time should this information replace existing documents established by the facility unless written permission has been obtained from the responsible facility manager.

BASIC PROTOCOL

Appropriate personal protection should be taken for those responsible for the decontamination of a room or area.
1. Disposable gloves. Gloves should be changed as required, i.e., when torn, when hands become wet inside the glove, and between rooms.
2. Household gloves can be worn, but they must be discarded when the cleaning is complete.
3. Protective eyewear (e.g., goggles, face shield, or mask with eye protection) should be worn at all times.
4. Masks (e.g., surgical or procedural masks) should also be worn.
5. Coveralls should be worn over clothing.
Gather all equipment, cleaning solutions, and materials required to clean the room.
Wash your hands and put gloves on prior to entering the room. Personal protective equipment should be changed between rooms or if it is torn or soiled.
Place a wet floor sign at the room entrance.
Pick up garbage in the room and place it in regular garbage bag.
Visible or gross soil present and/or blood or body fluid spills must be removed prior to cleaning.
Clean all furniture, bedding, night tables, sink basins, all bathroom fixtures, all high touch areas, such as knobs and light switches, and everything that is touched by the hepatitis-infected person, ensuring that clean cloths and solutions do not become contaminated (NO DOUBLE DIPPING) with the cleaning solution. Allow surfaces to remain wet for 10 minutes.
Spot wipe all walls from high to low.
Mop floors with a disinfectant cleaner.
Soiled rags should be placed in a regular plastic bag and then taken to the appropriate disposal area.
Remove and discard gloves.
WASH hands prior to leaving room

This information is from the Public Health Agency of Canada.

yOU gOT eXPOSED… What Are We Gonna Do Now ???

For percutaneous (needlestick), ocular, or mucous-membrane exposure to blood known to contain HBsAg and for human bites from HBsAg carriers that penetrate the skin, a single dose of HBIG (0.06 ml/kg or 5.0 ml for adults) should be given as soon as possible after exposure and within 24 hours if possible. HB vaccine 1 ml (20 ug) should be given IM at a separate site as soon as possible, but within 7 days of exposure, with the second and third doses given 1 month and 6 months, respectively, after the first (Table 1). If HBIG is unavailable, immunoglobulin (IG {formerly ISG or “gamma globulin”}) may be given in an equivalent dosage (0.06 ml/kg or 5.0 ml for adults). If an individual has received at least two doses of HB vaccine before an accidental exposure, no treatment is necessary if serologic tests show adequate levels (> 10 S/N by RIA) of anti-HBs. For persons who choose not to receive HB vaccine, the previously recommended two-dose HBIG regimen may be used (1).

Hepatitis C and Employment

yOU gOT eXPOSED… Can You Still Work in HealthCare ???

Should a person infected with the hepatitis C virus be restricted from working in certain jobs or settings?

CDC’s recommendations for prevention and control of the hepatitis C virus infection state that people should not be excluded from work, school, play, child care, or other settings because they have hepatitis C virus infection.

There is no evidence that people can get hepatitis C from service providers without blood-to-blood contact.

An Ethical Morass or Morality? An Essay…

He wrote, “What aggravates me the most about it is that most of these dedicated medical professionals where infected doing their job. Many were infected when precautionary measures were not as stringent as they are today. They understood the risks when undertaking and committing to the profession, and simply took it as part of being in the line of duty…to prevent them from continuing to pursue their career due to their viral infection is just WRONG!”

I said I would write the article, and then I didn’t. I procrastinated because it is a tough subject. The public is afraid. My experience with some patients is that they don’t trust health care professionals. Look at what we did to the health care workers who returned after doing a stint with Ebola – the toughest medical job there is. The press dogged them; we tried to ostracize them. Kaci Hickox, the nurse who defied the ridiculous New Jersey quarantine, was called the “Ebola nurse.” She never had Ebola.

As a nurse, I have been publicly attacked for “exposing patients to hepatitis C.” For the record, patients were never at risk of acquiring hepatitis C from me. However, I don’t need to defend myself. The evidence speaks for itself. The U.S. Centers for Disease Control and Prevention (CDC) does not recommend restrictions for HCV-infected health care workers. The CDC recommends that we follow good infection control practices. It isn’t legal to terminate health care workers with hepatitis C who perform their jobs safely. However, we all know that terminations are conducted in a variety of ways, and the reasons can be covered up.

So, why did it take me so long to write this? There is another side—the dirty side of medicine that we in health care don’t want to acknowledge—medical harm. Sometimes our medical system fails us. If you spend any time reading news on the Internet, you probably heard about the oral surgeon in Tulsa, OK who may have exposed as many as 5,000 patients to HIV, hepatitis B and hepatitis C. Or, perhaps you read about the travelling health care technician, David Kwiatkowski, who left a trail of hepatitis C infections behind him. Kwiatkowski was a hepatitis C-positive injection drug user who helped himself to potent pain and anesthesia drugs meant for patients. He refilled the syringes with sterile saline. Not only did he expose patients to hepatitis C, he also put them at risk of insufficient pain relief or anesthesia.

I read these stories and I understand why patients are afraid. The world is a scary place, and the one place we want a guarantee of safety is in health care. I have been on both sides of this debate, as both nurse and as patient. As a patient, I was the victim of a lab technician who reused needles. I already had hepatitis C. I was more concerned about anyone who had their blood drawn after me than I was by what I could have contracted from those who were before me.

References

Centers for Disease Control and Prevention (CDC). Viral Hepatitis Surveillance. United States, 2013. https://www.cdc.gov/hepatitis/statistics/2013surveillance/pdfs/2013hepsurveillancerpt.pdf. Accessed December 30, 2015.
Westermann, C. et al. The prevalence of hepatitis C among healthcare workers: a systematic review and meta-analysis. Occup Environ Med 2015;0:1–9. https://oem.bmj.com/content/early/2015/10/05/oemed-2015-102879.full.pdf+html Accessed December 29, 2015.
International Safety Center. Exposure Prevention Information Network, Sharp Object Injury Summary Data 2013. https://internationalsafetycenter.org/wp-content/uploads/2015/08/Official-2013-NeedleSummary.pdf. Accessed December 29. 2015
Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. https://www.cdc.gov/mmwr/pdf/rr/rr5011.pdf . Accessed December 29, 2015.
Centers for Disease Control and Prevention (CDC). Acute Hepatitis C reports by risk/behavior, United States 2013. https://www.cdc.gov/hepatitis/statistics/2013surveillance/pdfs/hcv_surv-2013_figure4.6b.pdf. Accessed December 29, 2015.