2002 CDC SEXUAL TRANSMISSION
GUIDELINES FOR
HEPATITIS A,
B AND C
Hepatitis A, caused by infection with HAV,
has an incubation period from time of exposure to onset of symptoms of
approximately 4 weeks (range: 15–50 days). HAV replicates in the liver and is
shed in high concentrations in feces from 2 weeks before to 1 week after the
onset of clinical illness. The fecal-oral route most commonly transmits HAV.
Although viremia occurs early in infection and can persist for several weeks
after onset of symptoms, blood-borne transmission of HAV is uncommon.
HAV infection produces a self-limited
disease that does not result in chronic infection or chronic liver disease.
However, 10%–15% of patients may experience a relapse of symptoms during the 6
months after acute illness. Acute liver failure from hepatitis A is rare (0.3%
overall case-fatality rate), but occurs more frequently in older persons (1.8%
case fatality rate in adults >50 years of age) and persons with underlying
chronic liver disease. The risk for symptomatic infection is directly related
to age, with >80% of adults having symptoms compatible with acute viral
hepatitis and most children having either asymptomatic or unrecognized infection.
Antibody produced in response to HAV infection persists for life and confers
protection against re-infection.
Approximately 33% of the
Hepatitis A, like other enteric
infections, can be transmitted during sexual activity. Recent outbreaks of
hepatitis A among MSM have occurred in urban areas in the
Although Some studies have associated
having a greater number of sex partners, frequent oral-anal contact, insertive
anal intercourse, or serologic evidence of other STD’s with HAV infection,
other studies have not found specific risk factors for infection.
Unlike
persons with most other STD’s, HAV-infected persons are infectious for only a
relatively brief period of time. However, many sexual practices facilitate
fecal-oral transmission of HAV, and in-apparent fecal contamination is commonly
present during sexual intercourse. Measures typically used to prevent the
transmission of other STD’s (e.g., use of condoms) do not prevent HAV
transmission, and maintenance of “good personal hygiene” has not been
successful in interrupting out-breaks of hepatitis A. Vaccination is the most
effective means of preventing HAV transmission among persons at risk for sexual
transmission of this virus and among persons who use injection and
non-injection illegal drugs, many of whom may seek services in STD clinics.
The diagnosis of hepatitis A cannot be
made on clinical grounds alone and requires serologic testing, which is
available commercially. The presence of IgM antibody to HAV is diagnostic of
acute HAV infection. A positive test for total anti-HAV indicates immunity to
HAV infection but does not differentiate acute from past HAV infection. Tests
can be positive after hepatitis A vaccination.
Treatment
Patients with hepatitis A usually require
only supportive care, with no restrictions in diet or activity. Hospitalization
may be necessary for patients who become dehydrated because of nausea and
vomiting and for patients with signs or symptoms of acute liver failure.
Medications that might cause liver damage or are metabolized by the liver
should be used with caution among persons with HAV.
Prevention
Two products are available for the
prevention of hepatitis A: hepatitis A vaccine (Table 2) and immune globulin
(IG) for IM administration (2). Inactivated hepatitis A vaccines are prepared
from formalin-inactivated, cell-culture-derived HAV and have been available in
the United States since 1995 for persons aged >2 years. Administered in a
two-dose series, these vaccines induce protective antibody levels in virtually
all adults. By 1 month after the first dose, 94%–100% of adults have protective
antibody levels; 100% of adults develop protective antibody following a second
dose. In randomized controlled trials, the equivalent of one dose of hepatitis
A vaccine administered before exposure has been 94%–100% effective in
preventing clinical hepatitis A (3). Kinetic models of antibody decline
indicate that protective levels of antibody persist for at least 20 years.
A
combined hepatitis A and B vaccine has been developed for adults. When
administered on a 0-, 1-, 6-month schedule, the vaccine has equivalent immunogenicity to that of the monovalent vaccines.
TABLE
2.
Recommended regimens: dose and schedule for hepatitis A vaccines
|
Vaccine |
Age
(yrs) |
Dose* |
Volume
(ml) |
Two-dose
schedule (months)☺ |
|
HAVRIX (SKB Biologicals) |
2-18 |
720
(EL.U.) |
0.05 |
0,
6-12 |
|
>18 |
1,440
(EL.U.) |
1.0 |
0,
6-12 |
|
|
|
|
|
|
|
|
VAQTA (Merck & Co., Inc.) |
2-18 |
25
(U) |
0.5 |
0,
6-12 |
|
>18 |
50
(U) |
1.0 |
0,
6-12 |
*
EL.U=Enzyme-linked immunosorbent assay (ELISA) units;
U=Units.
0
months represent timing of the initial dose; subsequent numbers represent
months after the initial dose.
IG is a sterile solution of concentrated immunoglobulins prepared from pooled human plasma processed
by cold ethanol fractionation. In the
Persons
in the following groups should be offered hepatitis A vaccine:
z MSM, including those who report having
minimal or no current sexual activity;
z illegal drug users (both injection and
non-injection drug users);
and persons with
chronic liver disease, including persons with chronic HBV and HCV infection who
have evidence of chronic liver disease.
Hepatitis A vaccine currently is available
for children and adolescents aged <19 years through the Vaccines for
Children (VFC) program (tel: 800-232-2522).
Pre-vaccination
Serologic Testing for Susceptibility
Screening for HAV infection may be
cost-effective in populations where the prevalence of infection is likely to be
high (e.g., older persons and persons born in areas of high HAV endemically).
The potential cost-savings of testing should be weighed against the likelihood
that testing will interfere with initiating vaccination. Vaccination of a
person who is already immune is not harmful.
Post-vaccination serologic testing is not indicated because
most persons respond to vaccine. In addition, the commercially available
serologic test is not sensitive enough to detect the low, but protective,
levels of antibody produced by vaccination.
Post-exposure
Prophylaxis.
Previously unvaccinated persons exposed to
HAV (e.g., through household or sexual contact or by sharing illegal drugs with
a person who has hepatitis A) should be administered a single IM dose of IG
(0.02 mL/kg) as soon as possible, but not >2 weeks after exposure. Persons
who have had one dose of hepatitis A vaccine at least 1 month before exposure
to HAV do not need IG. If hepatitis A vaccine is recommended for a person
receiving IG, it can be administered simultaneously at a separate anatomic
injection site. The use of hepatitis A vaccine alone is not recommended for
post-exposure prophylaxis.
Limited data indicate that vaccination of
HIV-infected persons results in lower seroprotection rates and antibody
concentrations (3). Antibody response may be directly related to CD4+ levels.
Hepatitis B is caused by infection with HBV.
The incubation period from time of exposure to onset of symptoms is 6 weeks to
6 months. HBV is hepatotropic, is found in highest concentrations in the blood,
and is found in lower concentrations in other body fluids (e.g., semen, vaginal
secretions, and wound exudates). HBV infection can be self-limited or chronic.
In adults, only 50% of acute HBV infections are symptomatic and about 1% of
cases result in acute liver failure and death. Risk for chronic infection is
associated with age at infection: about 90% of infected infants and 60% of
infected children aged <5 years become chronically infected compared with
2%–6% of adults. Among persons with chronic HBV infection, the risk of death
from cirrhosis or Hepatocellular carcinoma is 15%–25%.
In the United States, an estimated 181,000
persons were infected with HBV in 1998, and about 5,000 deaths occurred from
HBV-related cirrhosis or Hepatocellular carcinoma. An estimated 1.25 million
people are chronically infected with HBV, serve as a reservoir for infection,
and are at increased risk for death from chronic liver disease. HBV is
efficiently transmitted by percutaneous or mucous membrane exposure to
infectious body fluids. Sexual transmission among adults accounts for most HBV
infections in the United States. In the 1990s, transmission among heterosexual
partners accounted for about 40% of infections, and transmission among MSM
accounted for another 15% of infections. The most common risk factors for
heterosexual transmission include having multiple sex partners (i.e., more than
one partner in a 6-month period) or a recent history of an STD. Risk factors
for infection among MSM include having multiple sex partners, engaging in
unprotected receptive anal intercourse, and having a history of other STD’s. Changes
in sexual practices among MSM to prevent HIV infection have resulted in a lower
risk for HBV infection than that observed in the late 1970s, when studies found
up to 70% prevalence of HBV markers among adult MSM. Recent surveys of young
MSM (aged 15–22 years) indicated that 6%–13% of participants had evidence of
HBV infection, whereas 3%–27% had evidence of having been immunized against
hepatitis B.
Among persons with acute hepatitis B, up
to 70% have previously received care in settings where they could have been
vaccinated (e.g., STD clinics, drug treatment programs, and correctional
facilities). A 1997 survey of STD clinics demonstrated that hepatitis B vaccine
was routinely offered in only 5% of these settings.
The diagnosis of acute or chronic HBV
infection cannot be made on clinical grounds, but requires serologic testing
(Table 3). Hepatitis B surface antigen (HBsAg) is
present in either acute or chronic infection. The presence of IgM anti-body to
hepatitis B core antigen (IgM anti-HBc) is diagnostic of acute HBV infection.
Antibody to HBsAg (anti-HBs) is produced following a
resolved infection and is the only HBV antibody marker present following
immunization. The presence of HBsAg with a negative
test for IgM anti-HBc is indicative of chronic HBV infection. The presence of
anti-HBc may indicate either acute, resolved, or chronic infection.
Table 3. Serologic markers in different stages
of hepatitis B virus (HBV) infection
|
Stages of HBV Infection |
HbsAg (Hep B Surface Antigen) |
Anti-HBs
(Antibodies to hepatitis B surface antigen) |
Anti-HBc (Antibodies to hepatitis B core antigen) |
Total
IgM (The total anti-HBc assay detects both
IgM and IgG antibody) |
|
Late
Incubation Period |
+ |
- |
- |
+/- |
|
Acute |
+ |
- |
+ |
+ |
|
Chronic |
+ |
- |
+ |
- |
|
|
(+
rarely) |
|
|
|
|
Recent
(<6 months) Window period |
- |
+/- |
+ |
+ |
|
|
|
|
|
|
|
Distant
(>6 months); |
|
|
|
|
|
Resolved** |
- |
+ |
+ |
- |
|
Immunized |
- |
+ * |
- |
- |
* Anti-HBs >10mIU/ml
**
“Resolved” indicates that the patient no longer has the disease
Laboratory testing should be used to
confirm suspected acute or chronic HBV infection, and infected persons should
be referred for medical follow-up and possible treatment of chronic infection.
In addition, contacts should be vaccinated (see Exposure to Persons who have
Acute Hepatitis B) and receive post-exposure prophylaxis. No specific therapy
is available for persons with acute HBV infection; treatment is supportive.
Antiviral agents (i.e., alpha-interferon
or Lamivudine) are available for treatment of persons with chronic hepatitis B.
To determine the likelihood of response to treatment, an initial evaluation is
required to determine the status of the chronic HBV infection and the extent of
liver disease. For this reason, health-care professionals should offer
treatment with experience in the treatment of hepatitis B.
Prevention
Two products have been approved for hepatitis
B prevention: hepatitis B immune globulin (HBIG) and hepatitis B vaccine. HBIG
is prepared from plasma known to contain a high titer of anti-HBs and is used
for post-exposure prophylaxis. The recommended dose of HBIG for children and
adults is 0.06 mL/kg. The dose is 0.5 mL to prevent perinatal HBV infection
among infants born to HbsAg-positive mothers.
Hepatitis
B vaccine uses HbsAg produced in yeast by recombinant DNA technology and
provides protection from HBV infection when used for both pre-exposure
immunization and post-exposure prophylaxis. The two available monovalent
hepatitis B vaccines for use in adolescents and adults are Recombivax HB ®
(Merck and Co., Inc.) and Engerix-B (SmithKline Beecham Biologicals).
The recommended vaccine dose varies by
product and age of recipient (Table 4). Vaccine should be administered IM in
the deltoid muscle and can be administered simultaneously with other vaccines.
Many vaccination schedules have been used for both adults and adolescents. A
two-dose schedule has been approved for adolescents aged 11–15 years using the
adult dose of Recombivax HB ® . If the vaccination series is interrupted after
the first or second dose of vaccine, the missed dose should be administered as
soon as possible. The series does not need to be restarted if a dose has been
missed.
Table
4. Recommended regimen: doses and schedules of currently licensed hepatitis B
vaccines for adolescents and adults
|
Group |
Recombivax |
Engerix-B |
Schedule |
|
Adolescents |
5
0.5 |
10
0.5 |
0,
1, 6, or |
|
Adolescents |
10
1.0 |
|
0,4 |
|
Adults |
10
1.0 |
20
1.0 |
0,
1, 6 or |
* Eligible persons < 19 years can receive free vaccine
under the Vaccines for Children (VFC) program
**
This schedule has been used for persons requiring rapid protection (e.g.
international travelers)
In adolescents and healthy adults aged
<40 years, approximately 50% develop a protective antibody response
(anti-HBs >10 mIU/mL) after the first vaccine dose, 70% after the second,
and >90% after the third dose. Because relatively high rates of protection
are achieved following each vaccine dose, hepatitis B vaccination should be
initiated even if completion of the series cannot be ensured. Because most
fully vaccinated persons have long-lasting protection from HBV infection,
periodic testing to determine antibody levels in immune competent persons is
not necessary, and booster doses of vaccine are not recommended.
Hepatitis B vaccine has been shown to be
safe; more than 20 million adolescents and adults have been vaccinated in the
United States. The vaccine is well tolerated by most recipients. Pain at the
injection site or low-grade fever is reported by a minority of recipients.
Anaphylaxis is estimated to occur in one in 600,000 doses of vaccine
administered; no deaths have been reported following anaphylaxis. Hepatitis B
vaccine has not been associated with multiple sclerosis, diabetes, or other
auto-immune or neurologic diseases in any controlled epidemiologic study.
Vaccine is contraindicated in persons with a history of anaphylaxis after a
previous dose of hepatitis B vaccine and in persons with a known anaphylactic
reaction to yeast.
CDC’s national immunization strategy to
eliminate transmission of HBV infection includes a) prevention of perinatal
infection through maternal HBsAg screening and
post-exposure prophylaxis of at-risk infants, b) universal infant immunization,
c) universal immunization of previously unvaccinated adolescents aged 11–12
years (99), and d) vaccination of adolescents and adults at increased risk for
infection (100). Although high immunization coverage rates have been achieved
among infants and younger adolescents, hepatitis B incidence rates remain high
because most infections now occur in adults. Although the cost of vaccine
remains a barrier to adult vaccination, vaccine purchase and provider
reimbursement should not be a barrier for vaccination of adolescents aged
<19 years, who may be eligible for free vaccine under the Vaccines for
Children (VFC) program (Tele: 800-232-2522).
Hepatitis B vaccine is recommended for all
persons who attend STD clinics who have not been previously vaccinated. In the
non-STD clinic setting, the following persons should be vaccinated: a) persons
with history of an STD, persons who have had multiple sex partners, those who
have had sex with an injection-drug user, and sexually active MSM; b) persons
engaging in illegal drug use; c) household members, sex partners, and
drug-sharing partners of a person with chronic HBV infection; and d) persons on
hemodialysis, persons receiving clotting factor concentrates, or persons who
have occupational exposure to blood. In addition, hepatitis B vaccine should be
offered to all persons who have not been previously vaccinated who receive
services in drug treatment programs and long-term correctional facilities.
Based on the current cost of hepatitis B
vaccine, revaccination serologic testing may be cost-effective in adult
populations with a high prevalence of HBV infection (>2% HBsAg
positive or >30% anti-HBc positive). However, pre-vaccination testing is not
cost-effective in any adolescent populations. Adult populations with high
prevalence of HBV infection include injection-drug users, MSM, sexual contacts
of persons with chronic HBV infection, and persons from countries with endemic
HBV infection. When testing is performed, anti-HBc is the test of choice.
Testing should not be a barrier to vaccination of susceptible persons,
especially in populations that are difficult to access, and the first dose of
vaccine should be administered at the same time that serologic testing is
initiated.
As
hepatitis B vaccination becomes more widespread, more persons will present with
a history of vaccination and most will not have a personal vaccination record.
However, serologic testing in persons with a history of previous hepatitis B
vaccination may not be helpful because of the loss of detectable antibody.
Without a vaccination record, obtaining a careful history (e.g., number of
doses, schedule, and age at immunization) is the only way to determine if the
person most likely received the complete hepatitis B vaccine series.
Administration of additional doses of vaccine beyond the three-dose series is
not harmful.
Sex Contacts
Previously unvaccinated sex partners of
persons with acute hepatitis B should receive post-exposure immunization with
HBIG and hepatitis B vaccine within 14 days after the most recent sexual
contact. HBIG has been shown to be required for effective post-exposure
protection in this setting. Administration of vaccine with HBIG in this setting
confers long-term protection in the event the person with acute hepatitis B
becomes chronically infected; simultaneous administration of HBIG and hepatitis
B vaccine does not reduce vaccine effectiveness. Testing sex partners for
susceptibility to HBV infection (anti-HBc) can be considered if it does not
delay post-exposure immunization beyond 14 days.
Non-sexual Household Contacts. Non-sexual
household contacts of patients who have acute hepatitis B are not at increased
risk for infection unless they have other risk factors or are exposed to the
patient’s blood (e.g., by sharing a toothbrush or razor blade). However,
vaccination of household contacts is encouraged, especially for children and
adolescents. If the patient with acute hepatitis B becomes chronically infected
(i.e., remains HBsAg-positive after 6 months), all
household contacts should be vaccinated.
Exposure
to Persons Who Have Chronic HBV Infection
Most HBsAg-positive
persons are identified during routine screening (e.g., blood donation and
prenatal evaluation) or clinical evaluation. Active post-exposure prophylaxis
with hepatitis B vaccine alone is recommended for sex or needle-sharing
partners and non-sexual household contacts of persons with chronic HBV
infection. Because identifying the time of the last contact can be difficult,
hepatitis B vaccination provides both pre-exposure and post-exposure
protection. Although the effectiveness of active post-exposure immunization has
not been evaluated for sex contacts of persons with chronic HBV infection, it
provides high-level protection (90%) against perinatal HBV infection, where the
intensity of exposure is greater than that among household or sex contacts of
chronically infected persons.
Post-vaccination
testing (anti-HBs) should be considered for sex partners of persons with
chronic HBV infection. Although most persons are expected to respond to
vaccination, those found to be antibody-negative should receive a second,
complete vaccination series. Those persons found to be antibody-negative after
revaccination should be counseled about abstinence and the use of other methods
to protect them from sexual HBV transmission.
Special
Considerations
All pregnant women receiving STD services
should be tested for HBsAg, regardless of whether
they have been previously tested. If positive, this test result should be
reported to state perinatal immunization or HBV prevention programs to ensure
proper case management of the mother and appropriate post-exposure immunization
of her at-risk infant. HBsAg-negative pregnant women
seeking STD treatment who have not been previously vaccinated should receive
hepatitis B vaccine, as pregnancy is not a contraindication to vaccination.
HBV infection in HIV-infected persons is
more likely to result in chronic HBV infection. HIV infection also can impair
the response to hepatitis B vaccine. Therefore, HIV-infected persons who are
vaccinated should be tested for anti-HBs 1–2 months after the third vaccine
dose. Revaccination with three more doses should be considered for persons who
do not respond initially to vaccination. Those who do not respond to additional
doses should be advised that they might remain susceptible to HBV infection and
should be counseled in the use of methods to prevent HBV infection.
Studies have not determined the frequency
with which HBV infection occurs following sexual abuse or rape. Fully
vaccinated victims of sexual assault are protected from HBV infection and do
not need further doses. For a victim who is not fully vaccinated, the vaccine
series should be completed as scheduled. Unvaccinated persons in this setting
should be administered active post-exposure prophylaxis (i.e., vaccine alone)
upon the initial clinical evaluation. Unless the offender is known to have
acute hepatitis B, HBIG is not required. Because sexual abuse of children
frequently occurs over a prolonged period of time, the last exposure is often
difficult to determine. However, when sexual abuse is identified, hepatitis B
vaccination should be initiated in previously unvaccinated children.
HCV infection is the most common chronic
blood-borne infection in the United States; an estimated 2.7 million persons
are chronically infected. More than two thirds of all infected persons are aged
<50 years. Persons with acute HCV infection typically are either
asymptomatic or have a mild clinical illness. The average time from exposure to
sero-conversion is 8–9 weeks, and antibodies to HCV (anti-HCV) can be detected
in >97% of persons by 6 months after exposure. Chronic HCV infection
develops in most persons (75%–85%) after acute infection; 60%–70% have evidence
of active liver disease. Most infected persons may not be aware of their
infection because they are not clinically ill. However, infected persons serve
as a source of transmission to others and are at risk for chronic liver disease
or other HCV-related chronic diseases for at least 2 decades after infection.
HCV is most efficiently transmitted by
direct percutaneous exposure to infected blood (e.g., by receipt of blood
transfusion from an infected donor or through use of injection drugs). Although
less efficient, occupational, perinatal, and sexual exposures also can result
in transmission of HCV. No association has been documented between HCV and
military service or HCV and exposures resulting from medical, dental, or
surgical procedures; tattooing; acupuncture; ear piercing; or foreign travel.
The greatest variation in prevalence of
HCV infection occurs among persons with different risk factors for infection.
The highest prevalence of infection is found among those with substantial or
repeated direct percutaneous exposures to blood (e.g., IUD’s, persons with
hemophilia treated with clotting factor concentrates produced before 1987, and
recipients of transfusions from HCV positive donors). Moderate prevalence is
found among persons with frequent but limited direct percutaneous exposures
(e.g., long-term hemodialysis patients). Lower prevalence occurs among persons
with in-apparent percutaneous or mucosal exposures or sexual exposure and among
those with limited, sporadic percutaneous exposures (e.g., health-care
workers). Lowest prevalence of HCV infection is found among persons with no
high-risk characteristics (e.g:blood donors).
Although the role of sexual activity in
the transmission of HCV remains controversial, results from several types of
studies indicate that sexual activity is associated with HCV transmission
(103,104). These studies reported independent associations between HCV
infection and a) exposure to an infected sex partner, b) increasing numbers of
partners, c) failure to use a condom, d) history of STD, e) heterosexual sex
with a male IDU, and f) sexual activities involving trauma.
In contrast, a low prevalence (average:
1.5%; range: 0%–4.4%) of HCV infection has been demonstrated in studies of
long-term spouses of patients with chronic HCV infection who had no other risk
factors for infection. One study has found an association between HCV infection
and male homosexual activity, and at least in STD clinic settings, the
prevalence rate of HCV infection among MSM generally has been similar to that
of heterosexual’s. Because sexual transmission of blood-borne viruses is more
efficient among homosexual men compared with heterosexual men and women, it is
unclear why HCV infection rates are not substantially higher among MSM compared
with heterosexuals. This observation and the low prevalence of HCV infection
observed among the long-term steady sex partners of persons with chronic HCV
infection have raised doubts about the importance of sexual activity in the
transmission of HCV. Unacknowledged percutaneous exposures (i.e., illegal
injection-drug use) might contribute to increased risk for HCV infection among
such persons.
Although inconsistencies exist between
studies, data indicate overall that sexual transmission of HCV can occur and
accounts for up to 20% of HCV infections (102). The substantial contribution of
sexual transmission to the disease burden in the United States relative to the
inefficiency with which the virus appears to be spread in this manner can be
explained. Because sexual activity with multiple partners is a common behavior
among chronically infected persons and because of the substantial number of
these persons, multiple exposure opportunities exist. However, more data are
needed to determine the risk for, and factors related to, transmission of HCV
between sex partners, including whether other STD’s promote the transmission of
HCV by influencing viral load or modifying mucosal barriers.
Increased HCV viral load or co-infection
with HIV (known to increase perinatal transmission of HCV) may increase the
risk for sexual transmission. A recent study involving hemophilic men
demonstrated that dually infected men had a higher HCV load than those infected
with HCV alone, and that a higher HCV load was associated, though not
significantly, with an increased risk for HCV transmission to female partners
(106).
Diagnosis
and Treatment
The diagnosis of HCV infection can be made
by detecting either anti-HCV or HCV RNA. Anti-HCV is recommended for routine
testing of asymptomatic persons and should include use of both EIA to test for
anti-HCV and a supplemental antibody test (i.e., recombinant immuno-blot assay
[RIBA]) for all positive anti-HCV results. In settings where clinical services
for liver disease are provided, use of reverse transcriptase Polymerase chain
reaction (RT-PCR) to detect HCV RNA might be appropriate to confirm the
diagnosis of HCV infection (e.g., in patients with abnormal alanine
amino-transferase [ALT] levels or with indeterminate supplemental anti-HCV test
results), although RT-PCR assays are not currently FDA-approved. Current
approved therapy for HCV-related chronic liver disease includes alpha
interferon alone or in combination with the oral agent ribavirin for a duration
of 6–12 months. Because of advances in the field of antiviral therapy for
chronic hepatitis C, standards of practice might change, and clinicians should
consult with specialists knowledgeable about this virus. The National
Institutes of Health Consensus Development Conference Panel recommended that
therapy for hepatitis C be limited to those patients with persistently elevated
ALT levels, detectable HCV RNA, and histologic evidence of progressive disease
(as characterized by liver biopsy findings indicating either portal or bridging
fibrosis or at least moderate degrees of inflammation and necrosis).
No vaccine for hepatitis C is available,
and prophylaxis with immune globulin is not effective in preventing HCV
infection after exposure. Reducing the burden of HCV infection and disease in
the United States requires implementation of both primary and secondary prevention
activities. Primary prevention reduces or eliminates HCV transmission;
secondary prevention activities reduce liver and other chronic diseases in
HCV-infected persons by identifying them and providing appropriate medical
management and antiviral therapy, if necessary. Persons seeking care in STD
clinics or other primary-care settings should be screened for risk factors for
HCV infection, and those with the following risk factors should be offered
counseling and testing:
1. illegal injection
drug use, even once or twice many years ago;
2. blood transfusion
or solid organ transplant before July 1992;
3. receipt of
clotting factor concentrates produced before1987;
4.
long-term hemodialysis.
Regardless of test results, persons who
use illegal drugs or have multiple sex partners should be provided with
information regarding how to reduce their risk for acquiring blood-borne and
sexually transmitted infections and how to avoid transmitting infectious agents
to others (e.g., through vaccination against hepatitis B and, if appropriate,
hepatitis A). Persons who inject drugs should be counseled to stop using and
get into a treatment program. If they are found at any follow-up visit to be
continuing the use of these drugs, they should be counseled on how to inject safely
(i.e., use of sterile, single-use equipment, including needles, syringes,
cookers, cottons, and water each and every time they inject). Persons with
multiple sex partners should be counseled regarding how to reduce the
transmission of STDs (e.g., through abstinence or by decreasing the number of
sex partners).
Persons who test negative for HCV who had
a previous exposure should be reassured that they have not been exposed.
Persons who test positive for HCV infection should be provided information regarding
how to protect their liver from further harm, how to prevent transmission to
others, and the need for medical evaluation for chronic liver disease (CLD) and
possible treatment. To protect their liver from further harm, HCV-positive
persons should be advised to avoid alcohol, avoid taking any new medicines
(including over-the-counter and herbals) without checking with their doctor,
and become vaccinated against hepatitis A or hepatitis B if they are not
immune. To reduce the risk for transmission to others, HCV-positive persons
should be advised not to donate blood, body organs, other tissue, or semen and
not to share any personal items that may have blood on them (e.g., toothbrushes
and razors). HCV-positive persons with one long-term, steady sex partner do not
need to change their sexual practices. They should discuss the low but present
risk for transmission with their partner and discuss the need for counseling
and testing. HCV-positive women do not need to avoid pregnancy or
breastfeeding.
Post-exposure
follow-up
No post-exposure prophylaxis is effective
against HCV. Testing to determine whether HCV infection has developed is
recommended for health-care workers after percutaneous or
Permucosal
exposures to HCV-positive blood and for children born to HCV-positive women.
To
view the entire guidelines, please go to
http://www.cdc.gov/std/treatment/rr5106.pdf