Reducing the number of HCV
infections and HCV-related disease in the United States requires a number of
different prevention measures. Primary measures that reduce risks for contracting
HCV and secondary measures that reduce risks for liver and other chronic diseases
Health education programs
There is an ongoing need for comprehensive HCV health education that targets
both health and allied workers and high risk groups. Any education program
should include the following information:
- Routes of transmission
- Risk factors for infection
- Disease outcomes, the
need for medical management and treatment options
- Methods to prevent infections
and harm and risk reduction
- 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.
HCV health education program should be comprehensive and cover risks and
Dialysis center precautions
The CDC has made a number of recommendations to prevent the spread of HCV,
as well as HBV, in dialysis centers:
should be prepared in a centralized area separate from the treatment
vials should be avoided, if possible, in favor of single dose vials.
and equipment should be shared only if they are disinfected between patients,
using proper procedures.
supplies should be stored in a room or separate area from the treatment
a supply cart is used in the patient treatment area, the cart should
remain stationary in a designated area at a sufficient distance from
patient stations to avoid contamination with blood.
item taken to a patient's dialysis station should be disposed of, dedicated
for use only on a single patient, or cleaned and disinfected before being
returned to a common clean area or used for other patients.
into which priming solution from venous tubing is drained should be discarded
or cleaned and disinfected between patients.
CDC study showed that infection rates were slightly, but significantly, higher
in centers where staff returned unused supplies to a common supply cart for
use on other patients. Also, those centers that used a disposable container
to drain venous tubing and discarded it after each use had a significantly
lower rate of HCV than those that used a non-disposable container.
HCV infections from dialysis could be prevented.
Blood, plasma derivatives,
organs, tissues, and semen precautions
In order to prevent transmission of virus, programs that are currently in place
must be continued:
people are excluded from donating blood, plasma, organ, tissue or semen.
factor concentrates, and other products derived from human plasma, including
immunoglobulin products, must have viral inactivation.
plasma-derived products that do not undergo viral inactivation should
be HCV-RNA negative before release.
drug use precautions
Health care workers in all patient care settings should routinely obtain a
history that inquires about use of illegal drugs and should have information
available to give to patients regarding substance abuse programs and safe needle
practices. In an ideal world, it would be sufficient to tell people to stop
using drugs (and, by the way, don't have sex either), but this is not an ideal
world, so practical information about preventing infection is valuable. Some
states allow needle exchange programs, and all injection drug users should
be given information about any such available program, in the event that they
don't stop injecting drugs. Drug users should be advised of the following:
using and injecting drugs
and complete substance-abuse treatment, including relapse prevention
continuing to inject drugs
share syringes, needles, water, or drug preparation equipment.
only sterile syringes obtained from a reliable source, such as pharmacies.
a new sterile syringe to prepare and inject drugs.
possible, use sterile water to prepare drugs; otherwise, use clean
water from a reliable source, such as fresh tap water.
a new or disinfected container (cooker) and a new filter
(cotton) to prepare drugs.
the injection site before injection with a new alcohol swab.
dispose of syringes after one use.
using shared equipment, first clean the equipment with bleach and
rinse thoroughly with water.
Get vaccinated against hepatitis B and hepatitis
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:
sex with only one uninfected partner or no sex at all.
latex condoms correctly and every time.
vaccinated against hepatitis B, and if appropriate, hepatitis A.
and responding to percutaneous exposures to blood in health care and
All health care, emergency medical, and public safety workers should receive
education regarding risk for and prevention of bloodborne infections, including
the need for vaccination against hepatitis B. Standard protocols for universal
precautions and follow-up for percutaneous and permucosal exposures should
be in place, and any contamination immediately reported. Implementation and
maintenance of infection control practices in health care settings, including
appropriate sterilization of medical and dental equipment should be universal
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 used for any treatment or procedures that involve contact with
mucous membranes, affected skin, or body fluids or items soiled
with body fluids.
be used only once.
be discarded in a special container separate from other trash.
be done immediately after removing gloves.
be done immediately if there is a potential or actual contaminiation by blood or body fluid on hands or other body surface.
be done immediately after each contact with ANY person.
clothing (masks, goggles, gowns)
mask and eyewear should be worn during any task that may result in
exposure of mouth, nose, and eyes to blood or body fluids.
gowns or aprons should be used when blood or body fluids may contaminate clothes.
gowns or aprons should be washed according to instructions for
washing linens soiled with blood.
precautions with needles
always use disposable needles.
not recap or purposely bend needles.
discard needles in the way recommended by health care provider.
be placed in puncture-proof container, specifically marked, and
should be immediately reported to health care providers.
of waste products and washing of soiled linens
products should be disposed of in red plastic bags, double-bagged.
or clothing soiled with blood must be washed separately from other
laundry, using detergent and germicide.
for sterilization or disinfection
use chemical germicides registered with the EPA for sterilization
should be used only in recommended concentrations and only with
precautions are only necessary when caring for patients with HCV.
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.
health care facilities should have established protocols for universal
precautions and follow-up for percutaneous and permucosal exposure to blood.
Identifying people infected with Hepatitis C is one of the primary
goals in prevention. Healthcare workers need to be aware of the need for testing
be familiar with factors that put people at risk. Patients and clients
in all settings should be routinely assessed and advised to be tested if any
factors exist. Outreach should be done to reach people who might not
be seen in the primary care setting:
counseling and testing sites
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.
- 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 it
can be contaminated by the mother's blood. 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
- 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
- Recipients of
- 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 from tattooing or piercing.
However, if it is done in an unregulated manner, (e.g. sharing needles
in correctional institutions), there may be a risk.
testing of all individuals is the goal of HCV prevention.
Testing for HCV
Consent should be obtained, as for all procedures, and should include measures
to ensure confidentiality. Persons should be provided with the following
associated with the transmission of HCV, including behaviors or exposures
that might have occurred infrequently or many years ago.
test procedures and the meaning of the test results.
nature of hepatitis C and chronic liver disease.
benefits of detecting infection early.
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:
for HCV will be done
results will be kept confidential
counseling and referral will be offered if results are positive.
consent and confidentiality are important aspects of HCV testing.