Medical procedures as a risk factor for HCV infection in developed countries: Do we neglect a significant problem in medical care?
Authors: Katja Deterding, Johannes Wiegand, Norbert Grüner, Heiner Wedemeyer
Journal: Journal of Hepatology (2008)

It is with great interest that we read the article by the Spanish Acute HCV study group identifying hospital admission as a significant risk factor for acquiring HCV infection in Spain [[1]Martinez-Bauer E. Forns X. Armelles M. Planas R. Sola R. Vergara M. et al.Hospital admission is a relevant source of hepatitis C virus acquisition in Spain.J Hepatol. 2008; 48: 20-27Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar]. While it is well known that the transmission of HCV may occur through medical procedures in countries with a low or medium human development index [[2]Prati D. Transmission of hepatitis C virus by blood transfusions and other medical procedures: a global review.J Hepatol. 2006; 45: 607-616Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar], infection with HCV during inpatient or ambulatory treatment is thought to be uncommon in the developed countries. This is supported by the fact that HCV is by far less infectious than HBV. Moreover, we have recently reported that the risk of acquiring HCV by a needlestick injury is an extremely rare event and that the risk of acute HCV infection after injury with an HCV-contaminated needle in Europe is below 0.5% [[3]Kubitschke A. Bader C. Tillmann H.L. Manns M.P. Kuhn S. Wedemeyer H. Injuries from needles contaminated with hepatitis C virus: how high is the risk of seroconversion for medical personnel really?.Internist (Berl). 2007; 48: 1165-1172Crossref PubMed Scopus (35) Google Scholar]. At first view, these data are in contrast to the rather high proportion of nosocomial HCV acquisition of 67% reported by the Spanish Acute HCV study group. Although this high proportion might be partially explained by the fact that patients were referred for antiviral treatment, the data are in line with other reports from Italy [[4]Santantonio T. Medda E. Ferrari C. Fabris P. Cariti G. Massari M. et al.Risk factors and outcome among a large patient cohort with community-acquired acute hepatitis C in Italy.Clin Infect Dis. 2006; 43: 1154-1159Crossref PubMed Scopus (97) Google Scholar], France [[5]Morin T. Pariente A. Acute hepatitis C: a retrospective study of 62 cases.Gastroenterol Clin Biol. 2002; 26: 994-1000PubMed Google Scholar], and the USA [[6]Corey K.E. Ross A.S. Wurcel A. Schulze Zur W.J. Kim A.Y. Lauer G.M. et al.Outcomes and treatment of acute hepatitis C virus infection in a United States population.Clin Gastroenterol Hepatol. 2006; 4: 1278-1282Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]. We have analyzed the data of the German National Acute HCV studies I [[7]Jaeckel E. Cornberg M. Wedemeyer H. Santantonio T. Mayer J. Zankel M. et al.Treatment of acute hepatitis C with interferon alfa-2b.N Engl J Med. 2001; 345: 1452-1457Crossref PubMed Scopus (776) Google Scholar] and II [[8]Wiegand J. Buggisch P. Boecher W. Zeuzem S. Gelbmann C.M. Berg T. et al.Early monotherapy with pegylated interferon alpha-2b for acute hepatitis C infection: the HEP-NET acute-HCV-II study.Hepatology. 2006; 43: 250-256Crossref PubMed Scopus (217) Google Scholar] and the currently ongoing acute HCV-III study for the possible sources of HCV infection. We also included the data of 31 patients who did not fulfil the inclusion criteria for therapy in the Hep-Net Acute-HCV-III study. Overall, the Hep-Net cohort consists of 254 patients with acute hepatitis C (November 15, 2007). Among those, hospital admission was a less important risk factor as compared to the Spanish experience. Only 38 (15%) of our acute hepatitis C patients reported a medical procedure as the most likely risk factor for having acquired HCV. The table lists the type of procedures in these cases. The majority of those consisted of hospital admissions for surgery (n = 30 cases). Other invasive procedures including dental treatment were present in only 4 cases. Medical procedures were significantly more often the probable cause of infection in patients older than 30 years of age (p = 0.002 vs. patients younger than 30 years) but not associated with disease severity or time from exposure to the onset of symptoms. Another, somewhat worrying finding was that still more than 25% of patients were not aware of any obvious source of infection (see Table 1).Table 1Potential sources of HCV infection in 254 patients with acute hepatitis recruited in the Hep-Net acute HCV-databaseRisk factorNo. (%) of patientsIntravenous drug abuse41 (16%)Medical procedure38 (15%) Hospitalization1 Surgery30 Blood transfusion2 Dental treatment1 Other invasive procedures3 Acupuncture1Needlestick injury34 (13%)Tattoo and/or body piercing6 (2.3%)Sexual contact/promiscuity56 (22%)Other9 (3.5%)Unknown68 (27%) Open table in a new tab Although medical procedures as a risk factor for HCV infection seem to be less important in Germany than in Spain, our findings are still alarming. Screening for HCV infection should not only be recommended for patients at risk such as patients under haemodialysis. The available data suggest that all the individuals undergoing invasive medical procedures should be tested for anti-HCV since 0.5% to 1.5% of the European population is infected with HCV and thus representing a potential source for HCV transmission. As up to one-third of chronic hepatitis C patients with significant HCV viremia do present with normal liver enzymes, only testing for anti-HCV will be sufficient to identify HCV-infected individuals. In summary, medical treatment per se represents a significant risk factor for HCV infection – even in well developed countries. Thus, we strongly support the conclusions by the Spanish Acute HCV Study Group that the strict adherence to universal precaution guidelines is urgently warranted.