|Year : 2022 | Volume
| Issue : 2 | Page : 83-87
Serosurveillance of hepatitis C Infection among health-care workers in RIMS, Imphal
Yumlembam Bishwabati Devi, Olisha Sumer, Bidyarani Kongbrailatpam, Laitonjam Lalit Kumar, Prahllad Debnath, Robertson Sawian, Ranjana Devi Khuraijam
Department of Microbiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Submission||11-Nov-2021|
|Date of Decision||06-Jul-2022|
|Date of Acceptance||04-Aug-2022|
|Date of Web Publication||16-Nov-2022|
Prof. Ranjana Devi Khuraijam
Department of Microbiology, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Background: Alarming increase of hepatitis C infection among the general population has put a significant risk among health-care workers (HCWs). This study aims to find the prevalence of hepatitis C infection among HCWs and its importance for surveillance.
Objective: The objective of this study was to assess the prevalence of hepatitis C infection among HCWs in a tertiary care hospital.
Materials and Methods: A retrospective study was conducted in the Department of Microbiology, RIMS, Imphal, among healthy volunteer HCWs in October 2020 regardless of their COVID-19 status where blood samples were collected and tested for anti-hepatitis C virus (HCV) antibodies using enzyme-linked immunosorbent assay (Merilisa HCV).
Results: A total of 378 nonconsecutive blood samples were obtained from volunteers aged between 21 and 65 years. The majority of samples were from Imphal West district with a female preponderance of 66.93%. Two positive cases were detected with a prevalence of 0.53% belonging to occupational Category II and III. Maximum prevalence was seen in the age group of 30–39 years, with both positive cases falling in this group. One case was newly detected, while the other was known as a case of hepatitis infection.
Conclusion: Hepatitis C infection among HCWs is common. Infection control should be prioritized when dealing with patients directly or indirectly. Since no vaccine is available, HCWs require periodic screening. Thus, routine surveillance will help combat such infections among HCWs as a result of occupational exposure.
Keywords: Adult, epidemiology, female, health personnel, hepatitis C antibodies, male, occupational exposure
|How to cite this article:|
Devi YB, Sumer O, Kongbrailatpam B, Kumar LL, Debnath P, Sawian R, Khuraijam RD. Serosurveillance of hepatitis C Infection among health-care workers in RIMS, Imphal. J Med Soc 2022;36:83-7
|How to cite this URL:|
Devi YB, Sumer O, Kongbrailatpam B, Kumar LL, Debnath P, Sawian R, Khuraijam RD. Serosurveillance of hepatitis C Infection among health-care workers in RIMS, Imphal. J Med Soc [serial online] 2022 [cited 2022 Nov 28];36:83-7. Available from: https://www.jmedsoc.org/text.asp?2022/36/2/83/361279
| Introduction|| |
Infection with hepatitis C virus (HCV) is a major cause of chronic liver disease, and its global prevalence is 1% which corresponds to approximately 71.1 million people worldwide. Chronic liver disease due to HCV eventually leads to cirrhosis and hepatocellular carcinoma which has resulted in 475,000 deaths in 2015 alone., New hepatitis C infection is asymptomatic. Thirty percent of new cases spontaneously clear off the virus, whereas 70% proceed to chronic infection which leads to cirrhosis and hepatocellular carcinoma within 20 years. Thus, it is difficult to diagnose this infection early owing to its silent nature.
Transmission of HCV requires direct percutaneous exposure to blood. Different routes of parenteral transmission include sexual transmission, blood transfusion of infected blood products, intravenous drug (IVD) users, contaminated instruments (e.g., reuse of contaminated medical devices in hemodialysis, tattooing devices, acupuncture needles, razors, and manicure devices), and occupational and nosocomial exposures (e.g., needlestick injuries and exposure of exposed skin to infected blood products).,
Health-care workers (HCWs) are at high risk of HCV infection due to their constant exposure while handling blood- or blood-related–infected products. The most common mode of transmission of HCV among health workers is by percutaneous exposure and sharp injuries. This risk increases with time due to repeated performance of exposure-prone procedures which increases the chance of injuries. In addition, patients not revealing their health status to their treating medical care provider put them at further risk. Studies have reported that the chances of transmission of HCV from an infected HCW to a patient can be around 0.00036%–0.0036%.
The understanding of the epidemiology, routes of transmission, and prevalence of HCV infection has developed over the years. In turn, such knowledge has helped understand the substantial risks posed against HCWs during any exposure-prone procedure by infected blood and body fluids and thus take precautions to avoid such mishaps.
As per the Centers for Disease Control and Prevention, HCWs are defined as all paid and unpaid persons providing health care, or working or training in health-care settings, who have reasonably anticipated risks for exposure to infectious materials, including blood or body fluids, contaminated medical supplies and equipment, or contaminated environmental surfaces. HCW includes physicians, nurses, nurse practitioners, physician assistants, therapists, technicians, emergency medical services personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, health-care students and trainees, contractual staff not employed by the health-care facility, and persons not directly involved in patient care but with potential exposure to infectious agents that can be transmitted between patients and health-care providers (e.g., housekeeping, laundry, security, maintenance, and volunteers).
In this study, we aim to assess the prevalence of hepatitis C infection among HCWs and impress on the importance of surveillance not only for high-risk patients but also among high-risk population groups such as health-care providers.
| Materials and Methods|| |
Our study is a retrospective study conducted in the Department of Microbiology in October 2020. For the purpose of this study, samples were collected from all volunteer HCWs working in different departments in RIMS Hospital regardless of their COVID-19 status. With full precautionary measures, a phlebotomist drew 2 mL of whole blood aseptically by venous puncture and collected it in sterile plain vials prelabeled with relevant personal details such as patient ID, name, age, gender, and name of the test to be done. Samples were then transported to the Serology Section in Microbiology Department where the test was performed.
Nonconsecutive samples were centrifuged at 3000 rpm for 10 min and then placed in sterile serum storage vials maintaining all universal precautions. Serum samples were stored at +4°C before analysis for a maximum of 1 week or transferred to deep freezers (−20°C) if required to be stored longer than 1 week. Samples were then tested with enzyme-linked immunosorbent assay, (ELISA) (Merilisa HCV) using standard protocol and following the manufacturer's instructions. A sample was considered positive according to the manufacturer's specifications. All testing and reading procedures were done under steady lighting.
In brief, Merilisa HCV kit utilizes the principle of sandwich ELISA where anti-HCV antibodies in patient's serum bind to precoated antigens present in ELISA wells, thereby forming antigen–antibody complexes. This complex in turn binds to the conjugate (anti-human immunoglobulin G labeled with an enzyme, horseradish peroxidase) which reacts with the substrate producing bluish green color. The absorbance value was read with the help of an ELISA reader, and positive results were declared according to the manufacturer's guidelines.
For the purpose of this study, HCWs have been divided into three categories based on their contact with patients [Table 1].
| Results|| |
Out of 378 samples collected, 125 (31.48%) were males and 253 (66.93%) were females [Figure 1]. Maximum contribution of volunteers was seen in the age group 30–39 years (n = 148, 39.16%), followed by age groups 40–49 years (n = 110, 29.10%), 20–29 years (n = 15.87%), and 50–59 years (n = 54, 14.28%). The least contributors belonged to the age group of 60–69 years (n = 6, 1.58%).
The majority of the samples were contributed by the housekeeping staff (n = 120, 31.74%) belonging to the Center for Research on Environmental Development (CRED).
[Figure 2] shows the distribution of the volunteers from different districts in Manipur. As our tertiary care hospital is located in the Imphal West district, the majority of volunteers (n = 286, 46%) were seen to be contributed from the same district, followed by Imphal East (n = 67, 18%).
Two volunteers were found to be positive for anti-HCV antibodies (0.53%) with an equal distribution of male and female (1:1) [Figure 3]. The two positive cases reported were of a laboratory technician and a housekeeping staff (CRED) belonging to Category II and III, respectively [Table 2].
| Discussion|| |
Lack of hepatitis C vaccine has made early diagnosis of the infection a priority, especially among HCWs who are in constant exposure to HCV-infected patients and blood-related products.
The result of this study shows an overall low prevalence of hepatitis C infection (0.52%) among HCWs which correlates with other studies done in other parts of the world such as France (0.7%), Belgium (0.4%), Turkey (0.3%), Denmark (0.2%), and Albania (0.7%). This finding is also in correlation with studies done in other parts of India such as Tamil Nadu, Telangana, Maharashtra, and Chandigarh (0%, 0%, 0.1%, and 0.87%, respectively).,,,
Few studies in India have reported 0% seroprevalence of anti-HCV antibodies among their HCWs, while other studies in India have reported anti-HCV antibodies positivity rate of up to 4%,,,
Studies by Kalaskar and Kumar in Tamil Nadu, Malkappa and Sreekanth in Telangana, and Ganju and Goel did not report any positive anti-HCV antibodies among their HCWs despite including personnel from various professions (e.g., doctors, nurses, students, laboratory technicians, laboratory attendants, ayas, radiology technicians, and clerical staff). However, they did observe a considerable degree of hepatitis B surface antigen positivity rate of 1.13%, 1.37%, and 5%, respectively. Although hepatitis B was not included in our study, the risk for this infection cannot be neglected in our HCWs.
In studies conducted by Ansari and Dixit and Jindal et al., they reported a relatively high prevalence rate of hepatitis C infection among their HCWs compared to our study. Ansari and Dixit in a tertiary health-care hospital in Uttar Pradesh reported a 4% seroprevalence of anti-HCV antibodies among their health-care providers. The highest rate was among the laboratory technicians (50%) having more than 30 years of experience in the medical field. The high risk of needlestick injury was attributed to be one of the causes for their high prevalence rate.
Similarly, in a tertiary care hospital in New Delhi, Jindal et al. conducted a study in 100 HCWs for anti-HCV antibodies and reported a seroprevalence of 4%. The duration of working experience was not statistically significant, and the maximum cases reported were from the hemodialysis unit of the hospital.
Hepatitis C infection in HCWs has been observed all over the world, and its importance is reiterated for the safety of the health workers as well as the patients. Their prevalence varies from place to place as evident from several studies that have been conducted in various countries from 1991 to 2002 where the prevalence ranged from as low as 0% (Italy, Spain, UK, Kuwait, and the Netherlands) to as high as 22.2% (USA).
In a study by Thorburn et al., HCWs were divided into five categories based on their degree of patient exposure _ staff conducting exposure-prone procedures, staff in contact with patient and body fluids, laboratory medical and technical staff, staff with patient contact only, and staff without any patient contact. A total of 0.28% HCV seroprevalence was seen among the HCWs with the highest prevalence of 0.64% seen among the staff without any patient contact which included administrative, catering, clerical, security, and catering staff.
Similarly, in our study, we included volunteers from medical backgrounds such as doctors, dentists, nurses, paramedical staff, and housekeeping staff and divided them into three Categories (I–III) based on their exposure to patients [Table 1]. This study detected two positive cases one each from Category II and III which correlates with other studies showing a higher prevalence of HCV infection in laboratory technicians and housekeeping staff.
In a study conducted in 135 participants at Rishikesh, HCV antibodies were detected in 1.5% of their HCWs. One positive case was a student whose reason for contracting the infection was not known, while the other was a resident doctor with a history of road traffic accidents which was presumed to be the source of contracting the infection. In both their cases, the reason for contracting the infection was not related to health-providing services.
In contrast, the positive cases detected in our study were of a laboratory technician and a housekeeping (CRED) staff who are in constant exposure to blood and blood-related products or articles contaminated with infected blood which could have been the source of their infection. The laboratory technician is a known case of hepatitis C infection and asymptomatic at the time of testing. He showed a detectable level of hepatitis C viral load (>34 IU/mL). He is currently under treatment and undergoing routine viral load testing simultaneously. He has a work experience of more than 10 years in the medical field with no history of any needle prick or any exposure-prone procedures. However, he has a history of IVD use which could have been the source of his infection. On the other hand, the housekeeping staff is a newly diagnosed case and also asymptomatic at the time of testing. Unlike the other case, she has a work experience in the medical field for around 3 years and gave no history of any accidental exposure to infected blood or blood-infected articles. She gave a family history of her husband's demise as a result of a liver-related condition, but unfortunately, she could not verify if the disease was of viral origin. Most probably, a young man dying of liver disease at a young age could have been due to hepatitis C infection. The source of her infection still remains ambiguous. Following her anti-HCV antibodies positive result, she was advised for hepatitis C viral load testing. No detectable level of HCV RNA viral load was seen and was therefore advised for further follow-up. Despite taking detailed medical history of both cases, the source of infection remained ambiguous. This study was unable to specify if the cause of the infection was occupationally or otherwise acquired.
Chances of community-acquired infection cannot be ruled out as evidenced from studies conducted by Abdelwahab et al. and Sulotto et al. Abdelwahab et al. observed a prevalence of 16.6% (one in six) among their HCWs with the highest positivity rate seen in the older age group, males, and rural inhabitants. Occupation and duration of employment did not provide significant risks, thus signifying a community-acquired infection. Similarly, Sulotto et al. found that 1.97% of their HCWs were anti-HCV positive with a significant correlation with nonoccupation risk factors.
As opposed to other studies,,, where higher anti-HCV antibodies positives were seen in older age groups (more than 45 years), we observed that both our positive cases belonged to a younger age group (30-39)years.
Since HBV and HCV share similar modes of transmission, HCWs who are at risk may become infected with both viruses. HCWs co-infected with HBV and HCV are more likely to suffer from severe histological liver disease than those infected with only one of the blood-borne pathogens. As apparent from previous studies, although HCV infection among the HCWs in India is low as compared to hepatitis B infection, the risks of contracting the disease from occupational exposure still remain. Vaccination is a saving grace in the medical community for the health-care providers, but owing to the lack of vaccines for hepatitis C, it is vital that surveillance becomes a significant aspect under infection and control strategies to safeguard the health of the medical community.
The small sample size and the inability to include varied volunteers from departments that are involved in more exposure-prone practices is the main drawback of our study.
Despite evidence of HCV infection among HCWs, there are still not as much studies being published in India. This is the first study conducted in Northeast India where hepatitis C infection has been screened among health-care providers.
| Conclusion|| |
The risk of infection in HCWs by blood-borne viral infections is more than the general public due to occupational exposure, which is preventable as long as proper infection control measures and good universal practices are followed. Infection prevention strategies and means of regular screening and testing should be formulated and revised periodically to reduce the substantial risk of patient-to-provider infection.
Financial support and sponsorship
National Viral Hepatitis Control Program supported the study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. WHO Global Hepatitis Report 2017. Geneva: World Health Organization; 2017.
Blach S, Zeuzem S, Manns M, Altraif I, Duberg AS, Muljono DH, et al
. Global prevalence and genotype distribution of hepatitis C virus infection in 2015: A modelling study. Lancet Gastroenterol Hepatol 2017;2:161-76.
Te HS, Jensen DM. Epidemiology of hepatitis B and C viruses: A global overview. Clin Liver Dis 2010;14:1-21.
Henderson DK. Managing occupational risks for hepatitis C transmission in the health care setting. Clin Microbiol Rev 2003;16:546-68.
Deuffic-Burban S, Delarocque-Astagneau E, Abiteboul D, Bouvet E, Yazdanpanah Y. Blood-borne viruses in health care workers: Prevention and management. J Clin Virol 2011;52:4-10.
Prüss-Ustün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005;48:482-90.
Ozsoy MF, Oncul O, Cavuslu S, Erdemoglu A, Emekdas G, Pahsa A. Seroprevalences of hepatitis B and C among health care workers in Turkey. J Viral Hepat 2003;10:150-6.
Schillie S, Murphy TV, Sawyer M, Ly K, Hughes E, Jiles R, et al.
CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013;62:1-19.
Djeriri K, Fontana L, Laurichesse H, Peigue-Lafeuille H, Henquell C, Chamoux A, et al.
Seroprevalence of markers of viral hepatitis A, B and C in hospital personnel at the Clermont-Ferrand University Hospital Center. Presse Med 1996;25:145-50.
Moens G, Vranckx R, De Greef L, Jacques P. Prevalence of hepatitis C antibodies in a large sample of Belgian healthcare workers. Infect Control Hosp Epidemiol 2000;21:209-12.
Fisker N, Mygind LH, Krarup HB, Licht D, Georgsen J, Christensen PB. Blood borne viral infections among Danish health care workers-frequent blood exposure but low prevalence of infection. Eur J Epidemiol 2004;19:61-7.
Kondili LA, Ulqinaku D, Hajdini M, Basho M, Chionne P, Madonna E, et al.
Hepatitis B virus infection in health care workers in Albania: A country still highly endemic for HBV infection. Infection 2007;35:94-7.
Kalaskar A, Kumar M. Prevalence of hepatitis B and hepatitis C viruses among nurses and nursing students in a medical college hospital in southern Tamil Nadu, India. Int Res J Microbiol 2012;3:10-3.
Malkappa SK, Sreekanth B. Hepatitis B and C in healthcare workers: Prevalence, relation to vaccination and occupational factors. J Evol Med Dent Sci 2014;3:3919-23.
Shah DK, Jain SS, Khot AA, Gharat AR, Rajadhyaksha GC, Rathi PM. Low prevalence of hepatitis B and C infections among the healthcare workers despite low vaccination coverage for hepatitis B in Mumbai. Indian J Med Sci 2017;69:8-12.
Duseja A, Arora L, Masih B, Singh H, Gupta A, Behera D, et al.
Hepatitis B and C virus-prevalence and prevention in health care workers. Trop Gastroenterol 2002;23:125-6.
Ansari AM, Dixit S. Hepatitis C infection in health care workers: A clinical study. Int J Med Health Res 2017;3:41-3.
Jindal N, Jindal M, Jilani N, Kar P. Seroprevalence of hepatitis C virus (HCV) in health care workers of a tertiary care centre in New Delhi. Indian J Med Res 2006;123:179-80.
Ganju SA, Goel A. Prevalence of HBV and HCV infection among health care workers (HCWs). J Commun Dis 2000;32:228-30.
Thorburn D, Dundas D, McCruden EA, Cameron SO, Goldberg DJ, Symington IS, et al.
A study of hepatitis C prevalence in healthcare workers in the West of Scotland. Gut 2001;48:116-20.
Gupta P, Kaistha N, Omar B. HBV and HCV in health care workers and students of a newly established tertiary care hospital at Rishikesh: Prevalence and immunity status. Indian J Community Health 2020;32:454-7.
Abdelwahab S, Rewisha E, Hashem M, Sobhy M, Galal I, Allam WR, et al.
Risk factors for hepatitis C virus infection among Egyptian healthcare workers in a national liver diseases referral centre. Trans R Soc Trop Med Hyg 2012;106:98-103.
Sulotto F, Coggiola M, Meliga F, Bosio D, Martina C, Isaia R, et al.
Degree of hepatitis C infection risk in the health care setting. Med Lav 2002;93:34-42.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]