anti-HCV antibody detection. Whatever the risk of HCV transmission considered, the C/E ratio of this strategy was lower than the ratio of US$50 000 (about J37 000, £29 000) per QALY for dialysis for end-stage renal disease, often described as a benchmark for C/E.39 Moreover, the C/E of this strategy was less than the Gross Domestic Product (GDP) per capita of France in 2006 (ie, J30 000), designed as the threshold for considering interventions as ‘‘very cost-effective’’.40 Our results are first related to the fact that HCV RNA testing may lead to earlier detection of acute hepatitis C when compared with other strategies, and therefore to earlier initiation of anti-HCV therapy. We tested the impact of earlier diagnosis on the response to treatment, using data from the study of Kamal et al.36 This study showed that PEG-IFN therapy induces high SVR rates and prevents CHC, and that SVR varied according to timing of therapy.36 Our analysis suggested that the alternative-US strategy would lead to a slightly lower number of CHC cases than the French and European strategies. Moreover, it suggested that the alternative-US strategy would lead to a much lower number of CHC cases than the baseline- US strategy (1.9 vs 7.9 CHC among 7300 HCWs percutaneously exposed to anti-HCV antibody-positive source patients). Our results are also related to the impact of occupational exposure on the health-related quality of life of HCWs. We found that with the strategy based on early HCV RNA testing, the absence of HCV transmission to HCWs could be confirmed earlier than with the other strategies. As a result, HCW quality of life deteriorated less, because the period of waiting for the detection tests to confirm or refute transmission was shorter. One of this study’s main limitations was the lack of data on the quality of life of HCWs awaiting the results of detection tests. We used utilities associated with undiagnosed asymptomatic CHC as a substitute for estimating the quality of life of an HCW exposed to an HCV-infected source patient. We noted with interest that our conclusions were robust over a wide range of values for quality of life of HCWs during sensitivity analysis. In particular, an early HCV RNA testing strategy was associated with a reasonable C/E ratio even when we considered that the quality of life of an HCW was very moderately Table 5 Costs, QALYs and C/E ratios associated with four follow-up strategies for HCWs occupationally exposed to HCV according to low and high risk of HCV transmission Costs per HCW (J) *A weakly dominated strategy indicates a higher incremental C/E ratio than that of a more effective alternative strategy—that is, i.e. the incremental C/E ratio of the European strategy vs the baseline-US is higher than the incremental C/E ratio of the alternative-US strategy vs the European strategy (with low HCV transmission risk). {A strongly dominated strategy indicates a higher cost than that of a more effective alternative strategy—that is, the French strategy is associated with a higher cost and a lower utility compared with the alternative-US strategy (with low HCV transmission risk), and the French and baseline-US strategies are associated with higher costs and lower utilities compared with the European strategy (with high HCV transmission risk). C/E, cost-effectiveness; HCV, hepatitis C virus; HCW, healthcare worker; QALY, quality-adjusted life year. Gut 2009;58:105–110. doi:10.1136/gut.2007.145516 Strategy Low HCV transmission risk Baseline-US European Alternative-US French High HCV transmission risk European Alternative-US French Baseline-US 77.70 125.60 149.70 152.00 525.00 540.30 550.70 740.60 QALYs 23.2498 23.2551 23.2616 23.2501 23.1870 23.2090 23.1850 23.0830 Incremental C/E ratio Weakly dominated* J6102 Strongly dominated{ J695 Strongly dominant{ Strongly dominant{ Hepatology modified while they were waiting for their HCV status after an exposure. The HCV RNA testing strategy was not more cost- effective only when we assumed that the quality of life of an HCW was not modified at all while they were waiting for their HCV status, which is unlikely. In the present analysis, we did not take into account the fact that a large proportion of HCWs are lost to follow-up during the period after occupational exposure. However, the longer the follow-up period until the detection of HCV transmission, the greater the probability of loss to follow-up. The proportion of patients lost to follow-up is therefore probably lower with a strategy based on early HCV RNA testing. Again, if we had incorporated losses to follow-up in our analysis, early HCV RNA testing would probably have been even more cost-effective. Finally, we did not consider the costs of the time lost by HCWs who had to attend outpatient visits. However, all these costs weigh heavier for Strategies 1, 2 and 3 than for Strategy 4. If we had included them in the analyses, HCV RNA testing would have been even more cost-effective and perhaps even cost-saving. In conclusion, in HCWs exposed to HCV, a strategy based on HCV RNA testing leads to earlier detection of HCV transmis- sion. It is therefore proposed that anti-HCV therapy should take place earlier in these patients than with other strategies, which would result in a lower risk of progression to CHC. Moreover, a strategy based on HCV RNA testing leads to earlier confirma- tion of the absence of HCV transmission than other strategies, and therefore shortens the period during which the HCW’s quality of life deteriorates. We found that although the HCV RNA testing strategy is more expensive than the other strategies examined, it is reasonably cost-effective for all the risks of HCV transmission considered. We therefore recommend its use for occupational HCV detection. Funding: This study was supported by a grant from the Agence National de Recherches sur le SIDA (ANRS 2006-248). Competing interests: None. REFERENCES 1. RAISIN. Surveillance des Accidents avec Exposition au Sang dans les ´etablissements de sant´e fran¸cais. R´esultats ann´ee 2004: R´eseau d’Alerte, d’Investigation et de Surveillance des Infections Nosocomiales (RAISIN). Saint-Maurice, France: RAISN, 2006. 2. Pruss-Ustun A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005;48:482–90. 3. Puro V, De Carli G, Cicalini S, et al. European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus. Euro Surveill 2005;10:260–4. 4. Circulaire DGS/DH/DRT Nu99/680 du 8 d´ecembre 1999 relative aux recommandations `a mettre en oeuvre devant un risque de transmission du VHB et du VHC par le sang et les liquides biologiques. Bull Epidemiol Hebd 2000;2:1–12. 5. US Public Health Service. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001;50:1–52. 6. Lanphear BP, Linnemann CCJ, Cannon CG, et al. Hepatitis C virus infection in healthcare workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994;15:745–50. 7. Zuckerman J, Clewley G, Griffiths P, et al. Prevalence of hepatitis C antibodies in clinical health-care workers. Lancet 1994;343:1618–20. 8. Arai Y, Noda K, Enomoto N, et al. A prospective study of hepatitis C virus infection after needlestick accidents. Liver 1996;16:331–4. 9. Takagi H, Uehara M, Kakizaki S, et al. Accidental transmission of HCV and treatment with interferon. J Gastroenterol Hepatol 1998;13:238–43. 10. Hasan F, Askar H, Al Khalidi J, et al. Lack of transmission of hepatitis C virus following needlestick accidents. Hepatogastroenterology 1999;46:1678–81. 11. De Carli G, Puro V, Ippolito G. Risk of hepatitis C virus transmission following percutaneous exposure in healthcare workers. Infection 2003;31(Suppl 2):22–7. 12. Petrosillo N, Puro V, Ippolito G. Prevalence of hepatitis C antibodies in health-care workers. Italian Study Group on Blood-borne Occupational Risk in Dialysis. Lancet 1994;344:339–40. 13. Hernandez ME, Bruguera M, Puyuelo T, et al. Risk of needle-stick injuries in the transmission of hepatitis C virus in hospital personnel. J Hepatol 1992;16:56–8. 109