by Dental practices need effective infection control protocols to guard against Hepatitis C
The chances of group practices encountering patients with the hepatitis C virus (HCV) – sometimes referred to as the “silent epidemic” – is high. In fact, public health experts estimate that about 1.6 percent of the U.S. population is either currently infected or has been infected with HCV in the past. Most don’t even know it. All this is reason why practices must strictly adhere to infection control protocols at all times.
That was the message from a group of experts from the Centers for Disease Control and Prevention during a recent webinar on hepatitis C sponsored by CDC, the Academy of General Dentistry, and the Organization for Safety, Asepsis and Prevention (OSAP). The webinar was part of OSAP’s Safest Dental Visit™ campaign.
What is hepatitis C?
Hepatitis C is a contagious liver disease that ranges in severity from a mild illness lasting a few weeks, to a serious, lifelong illness that attacks the liver. There is no vaccine for HCV.
Symptoms are often non-existent – or at least not recognized – in adults with acute HCV (that is, short-term illness usually occurring within six months of infection), and are rarely present during chronic disease until liver inflammation is severe, said Anne Moorman, BSN, MPH, Division of Viral Hepatitis, CDC.
While the incidence of HCV has declined over the past 25 years, currently, at least 2.7 million people in the United States are estimated to be HCV-infected. Seventy-five percent are estimated to be baby boomers (born between 1945 and 1965). Of infected persons, only about half are estimated to have had their infection diagnosed, and of these, only up to one-third have been referred for care. Data from 2012 showed that at that time, only 11 percent had been treated, and only 6 percent cured.
Since testing to screen blood and blood products for HCV became available in 1992, new hepatitis C infection rates have declined dramatically. Even so, an estimated 30,000 new acute cases were contracted in the United States in 2013, with new cases among all age groups, but the greatest increase among young, non-urban adults injecting drugs.
Because the adverse effects of liver disease take decades to develop, the number of people with manifestations of acute hepatitis illness – and resulting hospitalization – is still rising. The rate of HCV-related hospitalizations in the United States more than doubled between 2004-5, and 2010-11. The number of deaths from HCV increased between 1999 and 2007. But even that may be under-reported. In one study, only about one-third of people known to be infected with HCV who died from end stage liver disease had HCV reported on their death certificates.
How is it spread?
The primary mode of HCV transmission is blood to blood, e.g., through an injection or break in the skin. In the environment, HCV in plasma can persist in an infectious state for 16 hours or longer, and in water at low temperatures for up to five months. In vitro studies have shown that HCV may remain infective on dry surfaces for up to six weeks. Disinfectants that inactivate hepatitis B virus will also kill HCV virus on environmental surfaces, and commercial hand antiseptics are effective in inactivating the virus on hands.
Bloodborne pathogen transmission in healthcare settings can occur from patient to patient (e.g., because of improper infection control practice), from patient to provider (e.g., as a result of needle sticks), or from provider to patient (e.g., during surgery or because of provider drug diversion). Note that approximately 60 percent of dentists are baby boomers, and so may have undetected past or current infections themselves.
Reports of transmission of hepatitis B (HBV) or C in the dental setting are rare. That said, many cases are no doubt missed by routine surveillance, given the long incubation period of HCV. In fact, only three reports of patient-to-patient transmission of HBV or HCV in the dental setting have been reported.
- In 2002, a case of patient-to-patient transmission of HBV was reported. Investigators believe that an elderly woman, who had no traditional risk factors, contracted the virus following oral surgery. It turns out that a patient with a high viral load had had a procedure earlier in the day. Presumably, a lapse in cleanup procedures following the earlier case was the cause.
- In 2009, transmissions of HBV were reported among patients and volunteers attending a portable dental clinic (a gymnasium setting). Investigators identified several infection-control breaches, including failure to heat-sterilize handpieces following use, failure to package instruments prior to sterilization, failure to adequately train volunteers on infection control protocols, and more.
- The only documented case of HCV patient-to-patient transmission in a dental setting occurred in a dental surgery practice in Oklahoma in 2013. Unsafe injection practices, improper dating and storage of multidose vials of controlled drugs, and a lack of autoclave monitoring and maintenance were all cited as potential causes.
Post-exposure management
About one person in 30 (ranging from 0 to 7 percent from various studies) whose blood has come into contact with that of an HCV-infected person is likely to contract HCV, said Jennifer Cleveland, DDS, MPH, a dental officer and epidemiologist in the Division of Oral Health within CDC. (Contrast that with HBV infection, where the risk is between 6 percent and 30 percent, or as many as one person in three; and HIV, where the risk is about 0.3 percent, or one person in 300.)
The elements of an effective post-exposure management program include:
- Clear policies and procedures
- Education of dental healthcare personnel
- Rapid access to clinical care, post-exposure prophylaxis, and testing of source patients
If the practice determines that a patient or dental healthcare worker may have been exposed to HCV, the practice should:
- Discard or sterilize the instrument or needle.
- Provide “first aid” to the exposure site, such as wound management or eyewash for blood exposures. The wound should be washed with soap and water, but not with bleach or caustic agents. Neither should the caregiver squeeze or milk the wound, or apply a tourniquet.
- Fill out an exposure report, including date and time of exposure, details of the procedure (where, how, with what device), exposure details (route, body substance involved, etc), and information about the source patient.
- Refer worker to a qualified healthcare personnel.
- Request source patient testing.
- For the exposed person, perform baseline and followup testing for HIV, HBV surface antigen, anti-HCV and liver enzyme activity.
For more information about HCV, visit the “CDC Viral Hepatitis – Hepatitis C Information” website at http://www.cdc.gov/hepatitis/HCV/index.htm.
Editor’s note: Introduced in September 2015, OSAP’s Safest Dental Visit program is an initiative designed to promote an increased commitment to infection control and safety. Clinicians, educators, speakers and consultants, product manufacturers and distributors, and others interested in patient safety are collaborating to help ensure that every patient visit is the safest dental visit. For more information, go to www.osap.org. First Impressions readers can view the hepatitis C webinar at www.agd.org/olc.
