Infectious Diseases

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Hepatitis C

General Description: Hepatitis C is a relatively common viral infection that causes an inflammation of the liver. The initial (acute) infection frequently goes undetected, as jaundice occurs in only one in four cases. In the U.S., 2% of the adult population has hepatitis C infection; world-wide, 170 million persons have a long-term (chronic) infection. Unlike hepatitis A and B, there is no vaccine for hepatitis C.

Mode of Transmission: In the U.S., most frequently via high-risk sexual contact or intravenous drug use involving shared needles. Transmission through blood transfusion has been greatly reduced since the blood supply has been screened for hepatitis C beginning in the early 1990s. LEOs are at risk of percutaneous exposure during blind searches for contraband. Experimental studies have demonstrated that hepatitis C virus can survive in syringes with detachable needles for up to 9 weeks.

Efficiency of Transmission/Attack Rate: The risk of contracting the infection from a person depends upon the concentration of virus in the source patient, but appears to be rare in exposures occurring in health care personnel. In a report reviewing exposures occuring in the period 2002-2015, among 885 health care personnel (HCP) with percutaneous exposure to blood that tested positive for HCV antibodies, the estimated risk was estimated to be 0.2% (2/885). Among 458 HCP with mucocutaneous exposure, the risk was 0%.c

Period of Communicability: 1 or more weeks before onset of symptoms; patients may remain infectious indefinitely.

Effect on LEO Fitness for Duty: The symptoms of acute hepatitis C can be debilitating and therefore can compromise physical capability and situational awareness. The spectrum of chronic hepatitis C infection ranges from an asymptomatic carrier state to liver failure requiring transplant and multi-system impairment and disability. Direct acting antiviral (DAA) therapy for chronic hepatitis C can be curative and has supplanted interferon/ribavirin for management of this disease.10 DAAs are generally well tolerated and should not require monitoring for the side effects seen with interferon therapyd (see Medications chapter).

HCV-positive LEO and Defensive Tactics Training

The potential for the LEO or recruit to sustain bleeding injuries exists in both the training facility and the routine work environment. Portals of entry for bloodborne pathogens are abrasions, other wounds, mucous membranes, or conjunctiva. The portals of entry of bloodborne pathogens are abrasions, other wounds, mucous membranes, or conjunctiva. However, the absolute risk of transmission is unknown in the absence of ongoing serosurveillance. Decontamination of training facility equipment should be performed on a routine basis (see Appendix A).

Based on the likelihood of the LEO bleeding and the person being exposed having non-intact skin or a mucous membrane exposure; the Task Group has stratified risk of transmission into the three categories below. This list is meant to be exemplary only and is not intended to be a complete inventory of possible activities that can be considered.

Category I: Activities with no risk of bloodborne virus transmission:

  • Motor vehicle operation
  • Interviewing a non-violent, compliant subject
  • Searching a non-violent, compliant subject

Category II: Activities where bloodborne virus transmission is theoretically possible, but unlikely:

  • Physical training
  • Administering first aid
  • Use of duty weapons
  • Exposure to chemical agents – e.g., oleo-capsicum (OC) and/or orthocholorobenzal-malonotrite (CS)

Category III: Activities where there is definite risk of bloodborne virus transmission:

  • Defensive tactics training
  • Handcuffing
  • Restraining subjects
  • Administering first aid to violent subjects
  • Administering first aid to subjects having a seizure

Each risk assessment should be individualized. The evaluating physician may consider referring to the risk matrices cited in the 2021 updated Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions.8

In this document, risk is stratified by the viral load (expressed as genome equivalents) and the degree to which an activity related to patient care could result in an exposure.

Although there are no studies to support which activities can be performed at specific viral load, it is the consensus of the Task Group is that the LEO with hepatitis C could safely perform all essential job tasks with a viral load of <2000 IU/mL.

Treatment of chronic hepatitis C infection with nucleoside regimens have demonstrated high rates of cure, defined as a sustained virologic response and undetectable viral load, 24 weeks after discontinuing therapy. LEOs who have been cured of their Hepatitis C infection as defined above do not require ongoing monitoring.

In addition to these categories, the Task Group recommends that persons known to be infected with hepatitis C, be excluded from intentional skin breaching or puncturing (e.g., receiving a TASER discharge with darts).

LEO-specific Clinical Studies and Reports:
Abel S, Césaire R, Cales-Quist D, Béra O, Sobesky G, Cabié A. Occupational transmission of human immuno-deficiency virus and hepatitis C virus after a punch. Clin Infect Dis. 2000;31(6):1494-5.

Rischitelli G, Lasarev M, McCauley L. Career risk of hepatitis C virus infection among US emergency medical and public safety workers. J Occup Environ Med. 2005;47:1174-81.

Hales T, Boal WL, Ross CS. Hepatitis C virus infection among public safety workers. J Occup Environ Med. 2002;44:221-3.

 

 


c“For approximately 885 HCP with percutaneous exposure to anti-HCV-positive blood (72.7% of exposures) or body fluids (27.3% of exposures) during 2002-2015 in the U.S., the estimated risk for HCV infection was reported as approximately 0.2% (two of 885; 95% confidence interval [CI]: 0%-0.52%) HCV RNA status of the anti-HCV positive source patients was not described. Among 458 HCP with mucocutaneous exposure, the risk for HCV infection was 0% (95% CI: 0%-0.6%). Recently published studies have reported similar infection risks with percutaneous exposure, although risks ranging from 0% to 10% have been reported from studies published earlier; variability might be explained in part by mechanism of injury, sensitivity of the test used to detect infection, and HCV RNA status of anti-HCV–positive source patients.” Ref Moorman #9

 

dThe choice of medical therapy for hepatitis C is individualized by the treating physician. In the past, interferon plus ribavirin was the standard treatment to treat hepatitis C infections. However, this regimen can cause behavioral changes, particularly depression, with onset of symptoms as early as 2 weeks after initiation of treatment. Therefore, LEOs undergoing treatment with interferon needed to be closely monitored on a weekly basis for behavioral changes for the first 12 weeks of therapy, and less frequently thereafter until therapy is completed. Until the treating physician could document that the officer was clinically stable and not manifesting depressive symptoms, cognitive impairment, or fatigue, it was recommended that the LEO be excluded from patrol. Evaluation tools such as the Beck Depression Index-23 or the Center for Epidemiologic Studies Depression Scale (CES-D)4,5 were used to assess the officer. Selective serotonin reuptake inhibitor- and serotonin norepinephrine reuptake inhibitor-class anti-depressants (SSRIs and SNRIs) were frequently used to prevent or treat interferon-associated depression, and the LEO was monitored for side effects of these medications as well.