1.Overview
(A) The epidemiology of hepatitis C and the current status of nosocomial infection
Hepatitis C is a disease that poses a great risk to the health and life of patients. 50%-80% of HCV (hepatitis C virus) infected patients will progress to a chronic state, and 20%-30% of them will develop cirrhosis or liver cancer, which is one of the most important causes of end-stage liver disease in Europe, America and Japan. The number of new cases of hepatitis C in China is increasing year by year, and there have been outbreaks of hepatitis C epidemics in many places. The diagnosis rate and antiviral treatment rate of HCV infection in China are low due to the insidious symptoms of hepatitis C patients, so there are more hidden sources of infection in the population.
Hepatitis C is a disease transmitted mainly by blood, and the use of unregulated endoscopes, dental instruments, syringes, needles, hemodialysis machines, and occupational exposure of medical personnel during the use and handling of medical devices are important routes of HCV transmission in hospitals. The Hep-Net (The German Network of excellence for viral hepaLitis) database for acute hepatitis C shows that 15% of acute HCV infections are caused by medical procedures and another 13% by needle stick.
In hospital infections, clinical staff are also at high risk for HCV infection. A survey of 310 departments in 5 hospitals in northern China found that the overall HCV infection rate among medical staff was 2.5%, mainly in surgery and obstetrics and gynecology, with the highest rate of infection in the 51-60 age group, 3.2%, which was much higher than the rate of infection in the general population, 0.43%.
Although there is no effective vaccine for hepatitis C, it is still a preventable and treatable disease. Strengthening HCV screening and providing effective treatment for hepatitis C patients as early as possible are important measures to interrupt the medical transmission of HCV. This guideline was developed by the Hospital Infection Control Branch of the Chinese Society of Preventive Medicine, based on the current situation in China and the latest guidelines and research results of hepatitis C prevention and treatment at home and abroad, with the aim of cutting off the transmission of HCV in hospitals, reducing the incidence of hepatitis C, and further enhancing the protection of patients and medical personnel.
(A) Diagnosis and treatment of hepatitis C
1.Diagnosis of hepatitis C
(1) Diagnosis of acute hepatitis C:.
①Epidemiological history: history of blood transfusion, application of blood products or clear history of HCV exposure.
(2) Clinical manifestations: general malaise, loss of appetite, nausea and pain in the right quadrant, a few with low-grade fever, mild hepatomegaly, some may present with splenomegaly, and a few may present with jaundice. Some patients have no obvious symptoms and show insidious infection.
(iii) Laboratory tests: ALT is mostly mildly or moderately elevated, and anti-HCV and HCV RNA are positive. HCV RNA often turns negative before ALT returns to normal, but there are cases where ALT returns to normal but HCV RNA remains positive.
The above ①+②+③ or ②+③ can be diagnosed.
(2) Diagnosis of chronic hepatitis C
HCV infection for more than 6 months, or the onset H period is unknown, no history of hepatitis, but the histopathological examination of liver is consistent with chronic hepatitis and positive for anti-HCV and HCV RNA.
2.Treatment of hepatitis C.
(1) Acute hepatitis C: IFNa treatment significantly reduces the rate of chronicity of acute hepatitis C. IFNa monotherapy can be initiated at 8- 16 weeks post-infection for 24 weeks for genotype 1 and 12 weeks for genotype 2 or 3. In patients with acute hepatitis C receiving PEG-IFNa or IFNa, the combination of ribavirin does not increase SVR.(SVR: sustained virologic response)
(2) Chronic hepatitis C.
① Those with HCV RNA gene type l, or HCV RNA quantification ≥ 2×10^6 copies/ml, can be treated with PEG-IFNa or IFNa combined with ribavirin until HCV RNA is detected at l2 weeks.
a) Consider discontinuation if HCV RNA decreases by <2 log orders;< p="">
b) If the qualitative HCV RNA test is negative or below the minimum detection limit of the quantitative method, continue treatment until 48 weeks;
c) If HCV RNA does not turn negative, but decreases ≥ 2 log levels, continue treatment until 24 weeks; if HCV RNA turns negative at U24 weeks, continue treatment until 48 weeks; if it still does not turn negative at 24 weeks, discontinue the drug for observation.
②HCV RNA gene is non-l type, and/or HCV RNA quantification <2×l0^6 copies/ml, can be treated with PEG-IFNa or IFNa combined with ribavirin for 24 weeks.
II. Hospital infection prevention and control measures
(I) Screening
l. People who need to be screened for hepatitis C and the time of screening
(l) The population and timing of screening for patients
① Screening at the time of consultation.
a) Those who have a history of blood transfusion or blood product application, especially those who had blood transfusion or blood product application before l993;
b) People who have injected or are injecting drugs, including those who have injected only once and do not consider themselves drug addicts;
c) Persons who have received a solid organ transplant or donated solid organs or blood, including blood component donors, who have not been screened for hepatitis C;
d) Sexual partners of hepatitis C patients or family members with whom they share toothbrushes, razors, nail clippers, etc.;
e) Those who have broken skin or mucous membranes contaminated with blood, blood stains, cotton balls or other utensils from wounds of HCV-infected patients;
f) HIV-infected persons, HIV-positive partners, male homosexuals and persons with multiple sexual partners;
g) Those with a history of unsafe needle therapy, tattooing, or skin piercing;
h) Unexplained elevated transaminases.
②Patients undergoing surgical and invasive diagnostic operations should be screened for anti-HCV before the operation.
③Patients on hemodialysis should be screened for hepatitis C before the first hemodialysis and regularly (six months) on hemodialysis towels.
④Infants born to HCV-infected mothers should be screened for hepatitis C and checked for HCV RNA: 1 month after birth.
(2) Screening population and timing for medical personnel
Medical personnel, first responders or public safety personnel who have been stabbed by syringe needles or other sharp instruments contaminated with HCV blood or body fluids, or whose mucous membranes have been exposed to HCV-positive blood should be promptly tested for HCV RNA, and the need for subsequent follow-up surveillance should be determined based on the results of the first test. People exposed to HCV who are at risk of hospital transmission, such as surgeons who are stabbed with contaminated needles or sharp instruments, need to be tested for HCV RNA at 2-4 weeks and checked for anti-HCV and liver function at 12 and 24 weeks.
2. Screening methods.
(¨ Anti-HCV detection: Screening for hepatitis C shall be performed by enzyme-linked immunoassay or chemiluminescent immunoassay (enzyme or chemiluminescent immunoassay EIA or CIA) of the 3rd or 4th generation to detect anti-HCV.
(2) Detection of HCV RNA: sensitive molecular biology (PCR method) techniques for detection of HCV RNA.
(2) Management of screening-positive patients and medical personnel
1.Clinical procedures for screening positive patients
(1) Outpatients/inpatients: HCV RNA test for anti-Hcv positive patients will be prescribed by the doctor, and HCV RNA positive patients are recommended to be transferred to specialist for antiviral treatment after this consultation; repeat the test after several weeks for those with HCV RNA test attached, if HCV RNA is still negative, it means that hepatitis C has been self-healed. If positive, referral to a specialist for antiviral treatment is recommended. (See Appendix 1)
(2) Medical personnel: If the source of exposure is clearly a hepatitis C patient after occupational exposure during medical operations, HCV RNA testing will be performed within 4 weeks, and antiviral treatment is recommended for those who are positive for HCV RNA; those who are negative for HCV RNA will be repeatedly tested for anti-HCV and ALT at 12 father J and 24 posts after exposure, respectively, for follow-up management. (See Appendix 2)
2. Medical staff job adjustment: If HCV RNA positive, anti-disease per treatment is recommended, and temporary avoidance and transfer from clinical work related to invasive operations until HCV RNA turns negative and still HCV RNA negative after 6 months re-test before resuming clinical work, regular liver function and HCV RNA tests are recommended.
3. Reporting and privacy protection.
(1) For patients with anti-HCV positive screening results: It is recommended that the laboratory report patient information to the hospital infection management department through the LIS system, and the hospital infection management department will conduct daily information verification and summary, and supervise and promptly follow up the confirmation of diagnosis and treatment for patients who are anti-HCV positive but have not been tested for HCV RNA. The patient’s test report should only be communicated to the patient himself/herself or his/her legal guardian (if the patient is a minor or incapacitated), and do not communicate the patient’s test results to non-relevant persons.
(2) For medical personnel with positive HCV RNA after occupational exposure: It is recommended to take the initiative to report to the hospital infection management department or the relevant authorities. It is advisable to inform them of the test report, and it is recommended not to inform non-relevant personnel of their test results. The medical personnel involved and the relevant personnel have the responsibility and obligation to protect the personal privacy of anti-HCV-positive medical personnel.
(C) Prevention of blood-borne infections
1. Strictly enforce standard prophylaxis
Standard prevention means that the patient’s blood, body fluids, secretions and excretions are considered to be infectious and need to be isolated. Regardless of whether there is obvious blood, contamination, whether contact with non-intact skin and mucous membranes, those who come into contact with the above substances must take preventive measures. Implement two-way protection to prevent the spread of disease in both directions. Standard precautions include wearing isolation gowns, double gloves, face masks, goggles and masks, and washing hands or wiping hands with disgusting hand disinfectant after removing gloves and isolation gowns. Use the “hands-free” technique during surgical operations to minimize the chance of being stabbed or cut by needles, sutures, blades and other sharp instruments.
2. Pay attention to the safe use of blood
The transmission of HCV in medical institutions is mainly blood-borne transmission. If patients have blood transfusion or use blood products, the safety of blood products should be ensured.
3.Block mother-to-child transmission
Mother-to-child transmission is an important way of HCV transmission. For HCV RNA-positive mothers, avoid invasive examination of mothers or damaging the baby’s skin during delivery as much as possible to reduce the chance of contaminating the baby with viral blood. Postpartum HCV RNA mothers with high viral load avoid breastfeeding as much as possible can effectively reduce perinatal HCV infection.
4. Post-exposure emergency treatment procedures
Exposed mucous membranes should be flushed with plenty of water, including the conjunctiva of the eyes. If there is a puncture wound, immediately after exposure occurs, squeeze next to the wound, and squeeze should be from the proximal end to the distal end; then rinse the exposed wound or non-intact skin with running water, but do not scrub hard, then disinfect the wound with disinfectant (iodophor or alcohol), and the exposed person should immediately report the hospital infection or relevant authorities (emergency contact numbers should be established) and obtain further testing and tracking.
5. Post-exposure prophylaxis
Since there is no vaccine for HCV, close follow-up is recommended for those who have been occupationally exposed.
6. Handling of positively exposed items and instruments.
Hepatitis C patients’ reusable items and instruments should be disposed of in accordance with the “People’s Republic of China Health Industry Standard” WS310.2-2009 – Hospital Disinfection and Supply Towel Heart Part 2: Cleaning, Disinfection and Sterilization Technical Practice.
Items discarded after use by hepatitis C patients should be classified and disposed of in accordance with the requirements of the Regulations on the Management of Medical Waste and the Methods for the Management of Medical Waste in Medical and Health Institutions.
(IV) Education and training
In view of the current status of the hepatitis C epidemic and its serious consequences, medical institution towels should conduct systematic education and training for people at high risk of hepatitis C infection and medical personnel, which is also an important means of hospital infection prevention and control.
1. Patient education.
The purpose of hepatitis C prevention and control for patients is to standardize the screening of high-risk groups and promote HCV RNA confirmation for those who are anti-HCV positive thereby increasing the treatment rate of hepatitis C and improving the prognosis of hepatitis C infected patients.
(l) Public education
Hospitals should make full use of the waiting room, ward publicity gallery and other spaces to promote patients, for example, through posters, coloring pages, wall-mounted TVs and other means to regularly cycle through the waiting room to broadcast knowledge about the dangers of HCV infection, transmission routes, clinical characteristics, scientific prevention and control.
(2) Face-to-face education
Medical staff should introduce to anti-HCV-positive patients the hazards of hepatitis C, the importance of timely HCV RNA testing and the necessity of treatment.
Medical personnel should introduce to HCV RNA-positive patients knowledge of the dangers of hepatitis C, the necessity of treatment, etc.
2.Medical staff training
Blood-borne exposure is one of the main risks in the occupational injury towel of medical staff. Due to the insidious nature of hepatitis C, the risk of HCV infection among medical personnel after occupational exposure is significantly increased. In order to prevent patients and medical staff from medical-acquired infection with HCV, training and education of medical staff on blood-borne exposure is especially important.
(1) Pre-service training
Include prevention of bloodborne occupational exposure in the training of new arrivals to medical institutions.
(2) Continuing education
Include relevant training in the mandatory annual continuing education curriculum for healthcare facility employees to ensure that each employee receives training annually.
(3) Specialized education
Hold special training on the topic of occupational exposure to HCV infection.
Medical source infection is one of the important ways of HCV transmission, and its harm to patients and medical staff cannot be ignored. Early screening, early diagnosis and early treatment are effective measures to interrupt the transmission of HCV. For medical personnel.
Strict implementation of standard precautions can effectively reduce the risk of occupational exposure; mastering post-exposure emergency treatment procedures has the potential to minimize the harm after HCV exposure. We hope that the release of this guideline can raise the attention of medical staff to the prevention and control of HCV hospital infection, further standardize the screening of high-risk groups, and provide timely and effective treatment for hepatitis C patients, so as to reduce the medical transmission of HCV and protect the safety of patients and medical staff. We hope that all hospital infection management professionals will do a good job in preventing and controlling hepatitis C hospital infection according to the guidelines in their daily work.