Occupational transmission of hepatitis C in healthcare workers and factors associated with seroconversion: UK surveillance data

Refocusing on work-based hazards for the anaesthesiologist in a post-pandemic era

The coronavirus pandemic has raised public awareness of one of the many hazards that healthcare workers face daily: exposure to harmful pathogens. The anaesthesia workplace encompasses the operating room, interventional radiology suite, and other sites that contain many other potential occupational and environmental hazards. This review article highlights the work-based hazards that anaesthesiologists and other clinicians may encounter in the anaesthesia workplace: ergonomic design, physical, chemical, fire, biological, or psychological hazards. As the anaesthesia work environment enters a post-COVID-19 pandemic phase, anaesthesiologists will do well to review and consider these hazards. The current review includes proposed solutions to some hazards and identifies opportunities for future research.

Sero-prevalence of hepatitis viral infections among sanitary workers across worldwide: a systematic review and meta-analysis

BACKGROUND

Sanitation or sanitary workers are exposed to hepatitis virus infections because of filthy and dangerous working conditions. The current global systematic review and meta-analysis aimed to estimate the pooled sero-prevalence of occupationally associated hepatitis virus infection among them.

METHODS

Preferred Reporting Items for Systematic Reviews (PRISMA), and Population, Intervention, Comparison, Outcome and study design (PICOS) were used for flow diagram, and review questions, respectively. Four databases other methods were used published articles from 2000 to 2022. Boolean logic (AND, OR), MeSH, and keywords were used: (Occupation *OR Job *OR Work) AND (Hepatitis A *OR Hepatitis B virus *OR Hepatitis C virus *OR Hepatitis E virus) AND (Solid waste collectors [SWCs] *OR Street sweepers [SS] *OR Sewage workers [STWs] *OR health care facilities cleaners [HCFCs)) AND (Countries). Stata MP/17 software was used for pooled prevalence analysis, meta-regression analysis (Hedges) at a 95% confidence interval (CI:95%).

RESULTS

A total of 182 studies were identified studies, a total of 28 studies were included from twelve countries. Of these, from developed (n = 7) and developing countries (n = 5). From total a of 9049 sanitary workers, 5951(66%), 2280 (25%) and 818 (9%) were STWs, SWCs and SS, respectively. Globally, the pooled sero-prevalence of occupational-related hepatitis viral infections among sanitary workers was 38.06% (95% CI: 30-0.46.12). Of this, it was 42.96% (95% CI: 32.63-53.29) and 29.81% (95% CI: 17.59-42.02) for high-income and low-income countries, respectively. Meanwhile, by sub-analysis, the highest pooled sero-prevalence of hepatitis viral infections by categories, type and year were 47.66% (95%CI: 37.42-57.90), 48.45% (95% CI: 37.95-58.96), and 48.30% (95% CI: 36.13-60.47) for SWTs, HAV, and 2000 to 2010 year, respectively.

CONCLUSION

The consistency of the evidence suggests that sanitation workers, particularly sewage workers, are susceptible to occupationally acquired hepatitis regardless of their working conditions, necessitating significant changes to occupational health and safety regulations from governmental policies and other initiatives to reduce risks among sanitary workers.

Change in hepatitis C virus positivity among needle-stick injury source patients: a 10-year experience in a Japanese tertiary hospital

Background

As a blood-borne pathogen, hepatitis C virus (HCV) has long been a major threat associated with needle-stick injuries (NSIs) mainly because no vaccine is available for HCV. Following an NSI, we usually test the source patient for HCV antibody (HCV-Ab). Since HCV-Ab positivity does not necessarily indicate current infection, HCV RNA is further examined in patients positive for HCV-Ab. Direct-acting antivirals (DAAs) have enabled us to treat most HCV-infected patients; therefore, we speculate that the rate of HCV RNA positivity among HCV-Ab-positive patients decreased after the emergence of DAAs. This cross-sectional study was performed to investigate the change in the actual HCV RNA positivity rate in source patients before and after the interferon (IFN)-free DAA era.

Methods

This was a cross-sectional study of NSI source patients at a tertiary academic hospital in Japan from 2009 to 2019. IFN-free DAA regimens were first introduced in Japan in 2014. Accordingly, we compared HCV status of NSI source patients that occurred between 2009 and 2014 (the era before IFN-free DAAs) with those that occurred between 2015 and 2019 (the era of IFN-free DAAs) in a tertiary care hospital in Japan.

Results

In total, 1435 NSIs occurred, and 150 HCV-Ab-positive patients were analyzed. The proportion of HCV RNA-positive patients significantly changed from 2009 through 2019 (p = 0.005, Cochran–Armitage test). Between 2009 and 2014, 102 source patients were HCV-Ab-positive, 78 of whom were also positive for HCV RNA (76.5%; 95%CI, 67.4–83.6%). Between 2015 and 2019, 48 patients were HCV-Ab-positive, 23 of whom were also positive for HCV RNA (47.9%; 95%CI, 34.5–61.7%; p = 0.0007 compared with 2009–2014). In the era of IFN-free DAAs, 9 of 23 HCV RNA-negative patients (39.1%) and 2 of 22 HCV RNA-positive patients (9.1%) were treated with an IFN-free combination of DAAs (p = 0.0351). Regarding the departments where NSIs occurred, HCV RNA-negative patients were predominant in departments not related to liver diseases in the era of IFN-free DAAs (p = 0.0078, compared with 2009–2014).

Conclusions

Actual HCV RNA positivity in source patients of NSIs decreased after the emergence of IFN-free DAAs. IFN-free DAAs might have contributed to this reduction, and HCV RNA-negative patients were predominant in departments not related to liver diseases in the era of IFN-free DAAs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06117-4.

Seroconversion after needlestick injuries - analyses of statutory accident insurance claims in Germany

Objective: After a needlestick injury (NSI) with contaminated blood, there is a risk of seroconversion. Statutory accident insurance (SAI) claims data were used to determine the numbers of seroconversions for hepatitis B and C viruses (HBV, HCV) and for HIV.

Materials and methods: Cases of HBV, HCV or HIV infection recognised as occupational diseases between 2006 and 2015 were selected from the BGW (Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege) database. Cases where an NSI was reported to the accident insurer before the diagnosis of the infectious disease was made were included in the analysis. The causal link between the infection and the NSI identified was estimated based on diagnostic findings in medical case files.

Results: In total, 566 cases with an occupation-related HBV, HCV or HIV infection were identified, including 44 cases where an NSI had been reported before diagnosis. Data on file indicated a possible causal link in 34 cases. In 16 of the 34 cases, seroconversion after the NSI was proven by diagnostic findings; in 13 of the 34 cases, seroconversion was possible but not proven because of the lack of initial findings. The index case was known in 23 of the 34 cases. The injuries occurred most often during waste disposal and high-risk procedures such as taking blood samples. The injuries were most often caused by cannulas for intravenous puncture. Subcutaneous devices were involved in two NSIs but there was no information on the initial serology or known index case.

Conclusions: It is possible to identify seroconversion in SAI claims data. However, data on the injured person’s initial infection status is often incomplete and this makes it difficult to assess any causal link. The incidence of seroconversions resulting from injuries from subcutaneously applied devices is apparently low; this is consistent with the literature.

Chronic Hepatitis C Screening, Evaluation, and Treatment Update in the Age of Direct-Acting Antivirals

Globally, hepatitis C virus (HCV), the cause of one of the most common infectious diseases, infects approximately 4 million to 5 million Americans with approximately half of infected individuals undiagnosed. Some workplaces screen employees for HCV exposure and other bloodborne pathogens (BBP) after needlestick injuries, but it is not well known whether employers screen employees for HCV without an occupational exposure. New guidelines from the Centers for Disease Control and Prevention (CDC) recommend that all individuals born between 1945 and 1965 should be screened for HCV regardless of risk; this provides an opportunity at the worksite for HCV outreach to employees, dependents, and retirees. To understand this recommendation, the management of HCV in the age of direct-acting antivirals (DAAs) should be reviewed. Now that new DAA treatment can cure HCV, occupational health nurses should identify potential HCV-positive individuals at the worksite via HCV education, screening, testing, and, if positive, linking to specialists for treatment.

Seroconversion rates among health care workers exposed to hepatitis C virus-contaminated body fluids: The University of Pittsburgh 13-year experience

BACKGROUND

Hepatitis C virus (HCV) transmission to health care personnel (HCP) after exposure to a HCV-positive source has been reported to occur at an average rate of 1.8% (range, 0%-10%). We aimed to determine the seroconversion rate after exposure to HCV-contaminated body fluid in a major U.S. academic medical center.

METHODS

A longitudinal analysis of a prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at the University of Pittsburgh Medical Center was performed. Data collected include type of injury and fluid, injured body part, contamination of sharps, resident physicians' involvement, and patients' hepatitis B virus (HBV), HCV, and HIV status.

RESULTS

A total of 1,361 cases were included in the study. Most exposures were caused by percutaneous injuries (65.0%), followed by mucocutaneous injuries (33.7%). Most (63.3%) were injuries to the hand, followed by the face and neck (27.6%). Blood exposure accounted for 72.7%, and blood-containing saliva accounted for 3.4%. A total of 6.9% and 3.7% of source patients were coinfected with HIV and HBV, respectively. The HCV seroconversion rate was 0.1% (n = 2) because of blood exposure secondary to percutaneous injuries.

CONCLUSIONS

This study provides the largest and most recent cohort from a major U.S. academic medical center. The seroconversion rates among HCP exposed to HCV-contaminated body fluids was found to be lower than most of the data found in the literature.

Hepatitis C Virus Postexposure Prophylaxis in the Healthcare Worker: Why Direct-Acting Antivirals Don't Change a Thing

Currently, 380 000-400 000 occupational exposures to blood-borne pathogens occur annually in the United States. The management for occupational HIV or hepatitis B virus exposures includes postexposure prophylaxis (PEP) when necessary; however, PEP is not recommended for hepatitis C virus (HCV) exposures. Recent approval of HCV direct-acting antivirals (DAAs) has renewed discussions as to whether these therapies could be used to prevent infection after exposure. There are no published studies addressing this question, but the prescribing of DAAs for PEP has been reported. We will discuss the differences in transmission of the 3 most common blood-borne pathogens, the natural history of early HCV infection, and the scientific rationale for PEP. In particular, we will discuss how the low feasibility of conducting an adequately powered clinical trial of DAA use for PEP and the low cost-effectiveness of such an intervention is not supportive of targeting limited resources for such use.

HCV prevalence can predict HIV epidemic potential among people who inject drugs: mathematical modeling analysis

BACKGROUND

Hepatitis C virus (HCV) and HIV are both transmitted through percutaneous exposures among people who inject drugs (PWID). Ecological analyses on global epidemiological data have identified a positive association between HCV and HIV prevalence among PWID. Our objective was to demonstrate how HCV prevalence can be used to predict HIV epidemic potential among PWID.

METHODS

Two population-level models were constructed to simulate the evolution of HCV and HIV epidemics among PWID. The models described HCV and HIV parenteral transmission, and were solved both deterministically and stochastically.

RESULTS

The modeling results provided a good fit to the epidemiological data describing the ecological HCV and HIV association among PWID. HCV was estimated to be eight times more transmissible per shared injection than HIV. A threshold HCV prevalence of 29.0% (95% uncertainty interval (UI): 20.7-39.8) and 46.5% (95% UI: 37.6-56.6) were identified for a sustainable HIV epidemic (HIV prevalence >1%) and concentrated HIV epidemic (HIV prevalence >5%), respectively. The association between HCV and HIV was further described with six dynamical regimes depicting the overlapping epidemiology of the two infections, and was quantified using defined and estimated measures of association. Modeling predictions across a wide range of HCV prevalence indicated overall acceptable precision in predicting HIV prevalence at endemic equilibrium. Modeling predictions were found to be robust with respect to stochasticity and behavioral and biological parameter uncertainty. In an illustrative application of the methodology, the modeling predictions of endemic HIV prevalence in Iran agreed with the scale and time course of the HIV epidemic in this country.

CONCLUSIONS

Our results show that HCV prevalence can be used as a proxy biomarker of HIV epidemic potential among PWID, and that the scale and evolution of HIV epidemic expansion can be predicted with sufficient precision to inform HIV policy, programming, and resource allocation.

HCV epidemiology in high-risk groups and the risk of reinfection

Injecting risk behaviours among people who inject drugs (PWID) and high-risk sexual practices among men who have sex with men (MSM) are important routes of hepatitis C virus (HCV) transmission. Current direct-acting antiviral treatment offers unique opportunities for reductions in HCV-related liver disease burden and epidemic control in high-risk groups, but these prospects could be counteracted by HCV reinfection due to on-going risk behaviours after successful treatment. Based on existing data from small and heterogeneous studies of interferon-based treatment, the incidence of reinfection after sustained virological response range from 2-6/100 person years among PWID to 10-15/100 person years among human immunodeficiency virus-infected MSM. These differences mainly reflect heterogeneity in study populations with regards to risk behaviours, but also reflect variations in study designs and applied virological methods. Increasing levels of reinfection are to be expected as we enter the interferon-free treatment era. Individual- and population-level efforts to address and prevent reinfection should therefore be undertaken when providing HCV care for people with on-going risk behaviour. Constructive strategies include acknowledgement, education and counselling, harm reduction optimization, scaled-up treatment including treatment of injecting networks, post-treatment screening, and rapid retreatment of reinfections.

Hospital housekeepers: Victims of ineffective hospital waste management

Improper waste management exposes hospital housekeepers to biological risk. The objectives of this study were to identify the frequency and profile of exposure incidents, classify the role of sharps waste, and compare the first and last occurrences for hospital housekeepers with multiple exposure incidents. A retrospective epidemiological study using Brazilian records from 1989 to 2012 was conducted. Data analyzed included hospital treatment records and the state notification database. Probabilistic linkage was performed using LinkPlus and data analysis using SPSS. There were 996 (11.6%) injuries, with 57 (6.1%) workers reporting multiple occurrences, for a total of 938 workers. These were primarily needlestick injuries (98.5%), involving blood (85.6%), caused by hypodermic needles (75.1%), and improper sharps disposal (70.8%). The number of workers completing vaccination after their first injury and before their last injury was statistically significant. Additional efforts to prevent and manage exposure incidents are needed.

Review article: treatment as prevention - targeting people who inject drugs as a pathway towards hepatitis C eradication

BACKGROUND

Hepatitis C virus (HCV) is a leading cause of chronic liver disease worldwide. HCV predominates in people who inject drugs; a group in whom anti-viral therapy has previously been withheld on the basis of chaotic lifestyles and associated risks of reinfection. New research has emerged which suggests that by specifically targeting HCV-infected people who inject drugs for treatment, the pool of HCV would deplete, thus reducing overall transmission and eventually leading to HCV eradication.

AIM

To outline the requirements for HCV eradication and review the evidence that this is achievable.

METHODS

Expert review of the literature.

RESULTS

The achievement of HCV eradication using 'treatment as prevention' is supported by numerous epidemiological modelling studies employing a variety of models in several contexts including people who inject drugs, men who have sex with men and prisoners. More recent studies also incorporate the newer, more efficacious direct-acting anti-viral drugs. These drugs have been shown to be safe and effective in people who inject drugs in clinical trials. There is no empirical evidence of the impact of treatment as prevention strategies on population prevalence.

CONCLUSIONS

This review highlights the efforts to control HCV and evaluates the possibilities of achieving eradication of HCV. Currently, the technologies required to achieve HCV eradication exist, but the infrastructure to deliver them is not generally available or of insufficient scale outside of specific areas. Such areas are yet to demonstrate that elimination is possible, but results of studies in these areas are awaited. Such a demonstration would be proof of principle for eradication. Although we are aspiring towards HCV eradication, elimination is the more realistic prospect.

Cost-effectiveness of screening for hepatitis C in Canada

BACKGROUND

The seroprevalence of hepatitis C virus (HCV) infection among Canadians is estimated at 0.3% to 0.9%. Of those with chronic HCV infection, 10% to 20% will experience advanced liver disease by 30 years of infection. Targeted screening seems a plausible strategy. We aimed to estimate the health and economic effects of various screening and treatment strategies for chronic HCV infection in Canada.

METHODS

We used a state-transition model to examine the cost-effectiveness of 4 screening strategies: no screening; screen and treat with pegylated interferon plus ribavarin; screen and treat with pegylated interferon and ribavarin-based direct-acting antiviral agents; and screen and treat with interferon-free direct-acting antivirals. We considered Canadian residents in 2 age groups: 25-64 and 45-64 years of age. We obtained model data from the literature. We predicted deaths related to chronic HCV infection, costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios.

RESULTS

We found that screening and treating would prevent at least 9 HCV-related deaths per 10,000 persons screened over the lifetime of the cohort. Screening was associated with QALY increases of 0.0032 to 0.0095 and cost increases of $124 to $338 per person, which translated to an incremental cost-effectiveness ratio of $34,359 to $44,034 per QALY gained, relative to no screening, depending on age group screened and antiviral therapy received.

INTERPRETATION

A selective one-time HCV screening program for people 25-64 or 45-64 years of age in Canada would likely be cost-effective. Identification of silent cases of chronic HCV infection and the offer of treatment when appropriate could extend the lives of Canadians at reasonable cost.

Per-event probability of hepatitis C infection during sharing of injecting equipment

Background

Shared injecting apparatus during drug use is the premier risk factor for hepatitis C virus (HCV) transmission.

Aims

To estimate the per-event probability of HCV infection during a sharing event, and the transmission probability of HCV from contaminated injecting apparatus.

Methods

Estimates were obtained using a maximum likelihood method with estimated IDU and sharing events obtained from behavioural data.

Settings

Cohort study in multiple correction centres in New South Wales, Australia

Participants

Subjects (N = 500) with a lifetime history of injecting drug use (IDU) who were followed up between 2005 and 2012. During follow-up, interviews for risk behaviours were taken and blood sampling (HCV-antibody and RNA testing) was performed.

Measurements

Self-reported frequencies of injecting drugs and sharing events, as well as other risk behaviours and details on the nature of injecting events.

Findings

The best estimate of the per-event probability of infection was 0.57% (CI: 0.32–1.05%). A sensitivity analysis on the likely effect of under-reporting of sharing of the injecting apparatus indicated that the per event infection probability may be as low as 0.17% (95% CI: 0.11%–0.25%). The transmission probability was similarly shown to range up to 6%, dependent on the presumed prevalence of the virus in injecting equipment.

Conclusions

The transmission probability of HCV during a sharing event is small. Hence, strategies to reduce the frequency and sharing of injecting equipment are required, as well as interventions focused on decreasing the per event risk.

Risk of transmission associated with sharing drug injecting paraphernalia: analysis of recent hepatitis C virus (HCV) infection using cross-sectional survey data

Sharing injecting paraphernalia (containers, filters and water) poses a risk of transmitting the hepatitis C virus (HCV). The prevalence of, and risk of HCV from, such behaviour has not been extensively reported in Europe. People who inject drugs (PWID) were recruited in cross-sectional surveys from services providing sterile injecting equipment across Scotland between 2008 and 2010. Participants completed a questionnaire and provided a blood spot for anonymous testing. Logistic regression was used to examine the association between recent HCV infection (anti-HCV negative and HCV-RNA positive) and self-reported measures of injecting equipment sharing in the 6 months preceding interview. Twelve per cent of the sample reported sharing needles/syringes, and 40% reported sharing paraphernalia in the previous 6 months. The adjusted odds ratios (AOR) for sharing needles/syringes (+/- paraphernalia), and sharing only paraphernalia in the last 6 months were 6.7 (95% CI 2.6-17.1) and 3.0 (95% CI 1.2-7.5), respectively. Among those who reported not sharing needles/syringes, sharing containers and filters were both significantly associated with recent HCV infection (AOR 3.1, 95% CI 1.3-7.8 and 3.1, 95% CI 1.3-7.5, respectively); sharing water was not. We present the first study to apply a cross-sectional approach to the analysis of the association between sharing paraphernalia and incident HCV infection and demonstrate consistent results with previous longitudinal studies. The prevalence of paraphernalia sharing in our study population is high, representing significant potential for HCV transmission.

HCV transmission in industrialized countries and resource-constrained areas

HCV is a blood-borne virus transmitted by percutaneous exposure to infected blood or blood-derived body fluids. The main routes of transmission are blood transfusions, medical procedures and injection drug use. In industrialized countries, HCV transmission through blood transfusions has been virtually eliminated and iatrogenic transmission occurs only sporadically during local breaches of infection control procedures. As most new cases originate from injection drug use, harm-reduction programmes (including opiate substitution, needle exchange and health education) can greatly reduce HCV transmission. Currently, the main approach to reduce the HCV disease burden is by increasing awareness of both the public and health-care providers to hepatitis C, enhancing screening opportunities and treatment of the infected population. In resource-limited countries, the priority is reducing transmission through blood transfusions and invasive medical procedures. This approach requires training of health-care providers and also structural changes and financial investments in countries where antibody screening, disposable materials and effective sterilization procedures are not routinely available. In these countries, reducing the HCV burden has been hampered by limited access to treatment, largely owing to the cost of drugs. Access to treatment is moving up on the agenda of international and non-governmental organizations in conjunction with the future availability of highly efficacious oral drug regimens.

Novel drugs in the management of difficult-to-treat hepatitis C genotypes

Background

Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States, with approximately 3.2 million Americans being chronically infected. Rates of HCV-related end-stage liver disease and its associated morbidity and mortality have yet to peak, so there is a pressing need for more effective and tolerable HCV treatment. HCV genotypes 1, 4, 5, and 6 are considered difficult to treat, and the need for improved therapies is especially great for persons infected with these genotypes.

Current strategies for HCV treatment

Current therapy for genotype 1 HCV infection includes triple therapy with pegylated interferon, ribavirin, and a NS3/4A protease inhibitor. Sustained virologic response (SVR) rates with triple therapy range from 42% to 75%, a vast improvement over pegylated interferon and ribavirin therapy alone. However, response rates remain suboptimal, and triple therapy is associated with significant adverse effects and is only indicated for genotype 1 HCV infection.

Novel drugs for HCV treatment

HCV drug development is proceeding at a rapid pace to meet this need. Novel direct acting antiviral agents in several classes, including new NS3/4A serine protease inhibitors, NS5A replication complex inhibitors, NS5B polymerase inhibitors, interferon lambda, and microRNAs, are in varying stages of development. These new therapeutic agents promise SVR rates of up to 100% with durations as short as 12 weeks and, often, fewer adverse effects.

Conclusion

New drug development in HCV is proceeding at an unprecedented pace. Novel agents promise higher SVR rates, shorter duration of therapy, and fewer adverse effects than have been possible with HCV therapy to date.

Occupational exposure to hepatitis C virus: early T-cell responses in the absence of seroconversion in a longitudinal cohort study

BACKGROUND

T-cell responses have been described in seronegative patients who test negative for hepatitis C virus (HCV) RNA despite frequent HCV exposure. However, the cross-sectional design of those studies did not clarify whether T cells were indeed induced by low-level HCV exposure without seroconversion or whether they resulted from regular acute infection with subsequent antibody loss.

METHODS

Over a 10-year period, our longitudinal study recruited 72 healthcare workers with documented HCV exposure. We studied viremia and antibody and T-cell responses longitudinally for 6 months.

RESULTS

All healthcare workers remained negative for HCV RNA and antibodies. However, 48% developed proliferative T-cell response and 42% developed responses in interferon-gamma enzyme-linked immunosorbent spot assays, with 29 healthy HCV-unexposed controls used to define assay cutoffs. The response prevalence was associated with the transmission risk score. T-cell responses peaked at week 4 and returned to baseline by week 12 after exposure. They predominantly targeted nonstructural HCV proteins, which are not part of the HCV particle and thus must have been synthesized in infected cells.

CONCLUSIONS

Subclinical transmission of HCV occurs frequently, resulting in infection and synthesis of nonstructural proteins despite undetectable systemic viremia. T-cell responses are more sensitive indicators of this low-level HCV exposure than antibodies.

Hepatitis C virus and human immunodeficiency virus transmission routes: Differences and similarities

Bouare et al found that hepatitis C virus (HCV) infection in Malian women is mainly transmitted through medical procedures with contaminated supplies, and that human immunodeficiency virus (HIV) transmission is predominantly sexual. The results of this study confirm those of a recent case-control study in New York and Oregon which demonstrated that healthcare exposures represent an important source of new HCV infections in United States. HCV seroprevalence was only 0.2% in pregnant, young Malian women, indicating that hygiene improved in healthcare facilities over time. Heterosexual transmission of HCV is exceptional, and can occur, from males to females, in extremely rare occasions in case of vaginal mucosal damage or less rarely through anal intercourse. The Malian study did not show an association between HIV infection and hospitalization, transfusion, tattoo, dental care. Transmission by needle-stick injury occurs in 0.9%-2.2% of exposures from HCV-infected subjects and in 0.1%-0.3% of exposures from HIV-infected individuals. HCV is therefore more transmissible through percutaneous exposure.

Public health issues of hepatitis C virus infection

Hepatitis C virus (HCV) is a leading cause of liver disease worldwide, as 130-170 million individuals are chronically infected and 350,000 patients die every year from HCV infection. The HCV prevalence varies widely among countries being highest in several African and Eastern Mediterranean countries. The incidence of new HCV infections may be declining in developed countries, but there is still a large reservoir of chronic infections. The most important mode of HCV transmission has been injecting drug use in developed countries with low prevalence and unsafe therapeutic injections in developing countries with moderate-high prevalence. Since there are no systematic screening policies, most patients remain undiagnosed. Even among diagnosed patients, a minority receives treatment due to several barriers to therapy. Given the high efficacy of treatment, public health authorities should recognise the importance of HCV and make resources available for the implementation of effective primary prevention, screening and management policies.