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Address reprint requests to Dr. The authors summarize information about the natural history and epidemiology of hepatitis C and describe the new guidelines and novel treatment options. Centers for Disease Control and Prevention. Monina Klevens.1 this review brings dental health care providers (DHCPs) up to date with the natural history and epidemiology of HCV.ada.”4 Since then.ada. surveillance reports and practice protocols. clinical practice guidelines. the authors provide an overview of how outbreaks of health care–associated HCV are detected and prevented. JADA 2013.gov. Moorman is an epidemiologist. AB STRACT J A D A ® 2 CON 2 IO N Background and Overview. and new treatment. Practical Implications. Atlanta. STD. The article provides references and websites offering additional detail for those interested in learning more. Division of Viral Hepatitis. 2013 N U IN G ED U C HEPATITIS C: AN OVERVIEW Even before HCV was identified in the late 1980s. our understanding of the virus and the devel- Dr.144(12):1340-1347. MPH Downloaded from jada. infections. The authors include data from population-based epidemiologic surveys.org December 2013 Copyright © 2013 American Dental Association. MPH.org on November 27. Centers for Disease Control and Prevention. Anne C. Klevens. Ms. surveillance and health care–associated HCV transmission and prevention options. All Rights Reserved. Hepatitis C. National Center for HIV. The authors’ aims in this review were to create awareness of health care– associated transmission of hepatitis C and provide an update on the changes in testing and treatment. non-B hepatitis. DDS. STD. Key Words. In addition.3 (CDC). Mailstop G-37. Division of Viral Hepatitis. Centers for Disease Control and Prevention. 30333. new screening guidelines from the Centers for Disease Control and Prevention2.COVER STORY Hepatitis C virus An overview for dental health care providers R. 1600 Clifton Road. 1340 JADA 144(12) http://jada. BSN. Changes in the science of hepatitis C virus (HCV) infection and transmission in a private dental practice A 1 provide an opportunity to update dental health RT IC LE care providers about this pathogen. education in the current science of HCV infection is useful. Results. Moorman. and TB Prevention. and TB Prevention. A T P rompted by the transmission of hepatitis C virus (HCV) in a private dental practice in 2013. e-mail rmk2@cdc. Viral Hepatitis. Viral Hepatitis. the observation that not all transfusion-associated hepatitis was associated with hepatitis A or B led to the label “non-A. In the United States. Klevens is a medical epidemiologist. T I . the elevated prevalence of chronic HCV infection among baby boomers—people born during the period from 1945 through 1965—led the Centers for Disease Control and Prevention to release new national screening guidelines. Ga. Atlanta. National Center for HIV. Because dental health care professionals likely will treat people with current infection.
transmission of infecIn the United States. and the of improper infection control practices). From 2008 through 2012.org on November 27.html health care workers prevent Outpatient Settings: infections in ambulatory Minimum Expectations lead to viral clearance.18 Before 1992. because www.cdc. parenteral route. the cent concern are clusters of HCV among young host and the environment. standard precautions most isolates (about 85 www. with new toolkits and resources transmission of HCV in nondental ambulatory available (Table 16. from availability of testing to screen blood and blood patient to provider (for instance. occur at even low levels of viral contamination.20. but less than DHCP: Dental health care provider. most efficiently by the † Source: Centers for Disease Control and Prevention. CDC received for prevention of health care–associated hepanotice of 15 outbreaks of health care–associated titis infections. 6 care settings.* erogeneity within and RESOURCE WEBSITE DESCRIPTION across people. transmission of infections Investigation Guide htm during health care.13-16).org December 2013 1341 Copyright © 2013 American Dental Association.cdc.cdc. ALT: Alanine aminotransferase.4 for state and local health Transmission. and it can be detected in saliva. 2013 JADA 144(12) http://jada. In general. SHEA: tions for injection safety12 remain the foundation Society for Healthcare Epidemiology of America.html about infection control.gov/HAI/prevent/ Links to detailed documents Healthcare-Associated vary according to geoprevent_pubs. 6 13 14 15 16 Downloaded from jada. ‡ Source: Centers for Disease Control and Prevention. www. slides and campaign materials of a nonprimate animal www. greater than that with human CMS: Centers for Medicare and Medicaid Services.10 and have been associated with tattoos and piercing commercial hand antiseptics are effective in inperformed in commercial sites. Infections: Guidelines including hand hygiene and and Recommendations § graphical distribution. HCV: Hepatitis C that with hepatitis B virus. but tattoo.5 care settings for Safe Care (Outpatient There are six major Guide and Checklist) ‡ genotypes of HCV that www. Dismission is rare except with high-risk sexual infectants that inactivate hepatitis B virus also practices.21 Sexual trans8 9 months.gov/injectionsafety Continuing education Injection Safety† others include the lack documents. this transmission can ¶ Source: Centers for Disease Control and Prevention.ada. and § Source: Centers for Disease Control and Prevention. The risk of transmis15 to 20 percent of HCV infections. HIV: Human immunodeficiency virus. HCV infections that can be transmitted during health is an RNA virus with great molecular hetcare services.ada.COVER STORY opment of treatments TABLE 1 for infected people have Resources regarding viral hepatitis and other evolved rapidly. . HCV can survive in nonurban adults injecting drugs. health care transmission in the form needle sticks) or from provider to patient (for of blood transfusions was associated with about instance. 11 cent —that is. transmission of hepatitis Outbreaks Reported to htm B or C. departments HCV is transmitted * Source: Centers for Disease Control and Prevention. no documented infections will kill HCV on environmental surfaces.19 Of more resion depends on factors related to the agent. from a percutaneous injury is about 2 perCDC: Centers for Disease Control and Prevention. intended or 1b.17. as a result of products.gov/ Listing of investigations Healthcare-Associated mutations occur frehepatitis/Outbreaks/ of health care–associated Hepatitis B and C quently during replicaHealthcareHepOutbreakTable. Standard Precauvirus.and activating the virus on hands.cdc. who often the environment for 16 hours on a dry surface7 started injecting cheaper heroin when they lost and in water at low temperatures for up to five access to prescription opioids.8 The estimated risk of infection with HCV ABBREVIATION KEY.cdc.22 Likewise. immunodeficiency virus (HIV). including links to the Centers for Disease tion.gov/HAI/settings/ Integrates information Guide to Infection model and the unclear outpatient/outpatient-carefrom other sources to help Prevention for immune responses that guidelines. because with HCV infection. Viral diversity is references Control and Prevention one of the challenges to * (CDC) in 2008-2012 vaccine development. during surgery). injection drug use is tious agents in health care settings can occur the risk behavior most frequently associated from patient to patient (for instance.gov/ Step-by-step approach Viral Hepatitis percent) in the United hepatitis/Outbreaks/ to investigating possible Outbreaks: Healthcare ¶ States are genotype 1a HealthcareInvestigationGuide. All Rights Reserved.
but in only 10 percent of people infected through injection drug use. Since then. Until 2012.40 SURVEILLANCE Downloaded from jada. people with medical conditions that required dialysis or transfusions.COVER STORY piercing-associated transmissions have been documented in unregulated environments such as prisons. but for past or present disease.2 million people (1. with alcohol use screening and referral to care for infected people.30 Currently. Immunoassays can indicate whether or not a person has ever been infected with HCV. diagnosis and treatment. CDC.39 These and other therapies currently undergoing clinical trials already are revolutionizing the treatment of chronic HCV infection. defined acute HCV infection as Copyright © 2013 American Dental Association.3 HCVRNA tests can be qualitative (positive or negative) or quantitative (viral copies per milliliter).35 Not all infected people receive diagnosis and treatment.35 This regimen required weekly injections.S.24 Although about 20 percent of infections resolve spontaneously. Acute infection is symptomatic in about 50 percent of cases in studies of people not infected via injection drug use.org on November 27. screening for HCV infection was recommended for people at highest risk of infection (that is. Food and Drug Administration approval.34 However.ada. and people who received organ transplants or transfusions before 1992) or with a known exposure to HCV (that is.32 Screening. about 32 to 38 percent have been referred to care. the protease inhibitors telaprevir and boceprevir have been introduced.24 The prevalence of chronic infection is higher among people born from 1945 through 1965 (3. the routine treatment protocol consisted of pegylated interferon plus ribavirin. residents currently infected.38 In 2013. HCV is the leading indication for liver transplantation.41 working with the Council of State and Territorial Epidemiologists. there are no tests approved in the United States to detect antibodies in oral fluid. The genotype test is another type of nucleic acid test that can be performed to support decisions about clinical management. costing a median of $120.6 percent of the U.25 most infected people develop chronic infection (defined as an HCV-RNA– positive test result from plasma or serum). 7 to 11 percent have been treated and 5 to 6 percent have been cured.26 Diagnosis in public health and primary care settings begins with the detection of antibody against HCV (anti-HCV).2 million U. malaise and elevated liver function test results (alanine aminotransferase [ALT] or aspartate aminotransferase.29 Among people with chronic infection. because about 1.33 CDC expanded the risk-based screening recommendations in 2012 to include an age-based recommendation—specifically. National surveillance is conducted for two discrete HCV events: acute disease and past or present hepatitis C infection (that is. In 2012. fever.19 and of these patients. Of these.31 Deaths associated with HCV infection surpassed deaths associated with HIV infection in 2007.S. users of injection drugs.3 Rapid tests now are available that have high sensitivity and specificity.26 About 60 percent of dentists are in this cohort (baby boomers)27 and may have undetected past or current infection themselves—another reason for DHCPs to be knowledgeable about hepatitis C. DHCPs reasonably can expect to encounter patients with HCV infection. had only about a 50 percent success rate for genotype 1 and was associated with frequent adverse effects. sofosbuvir. All Rights Reserved. they still are used in conjunction with interferon and ribavirin but have greater success rates. children born to HCV-positive women and occupationally exposed people). only about 50 percent have been diagnosed. population has been infected at one time or another. these use blood from either a fingerstick capillary or whole blood from venipuncture and provide results in less than 40 minutes.37. but only a nucleic acid test to detect HCV-RNA can indicate whether a person has current infection.23 Burden of disease. Many (about 50 percent) are unaware of their infection status. an estimated 1 to 3 percent will develop hepatocellular carcinoma.28 When symptoms are present. 2013 Surveillance for HCV in the United States.36 Until 2011.36 Of the estimated 3. Researchers combined data from a CDC cohort with data from a nationally representative survey to determine the number of infected people who have been diagnosed and are receiving appropriate care.S. was submitted for U. a one-time test for all people born between 1945 and 1965. The surveillance case definition for acute disease requires a combination of symptoms and laboratory findings. . about 15 to 30 percent may experience progression to liver cirrhosis.25 percent of whom are infected). Most anti-HCV tests are immunoassays.3 percent of the total population) in the United States were HCV-RNA positive.500 per hospitalization. used in the first interferonfree treatment regimens. people with current chronic infection and people with a history of infection). only laboratory findings are required. abdominal pain. CDC estimated in 2002 that 3. they are nonspecific and can include jaundice.
malaise or Health Care Providers Clinical Laboratories abdominal pain) and jaundice or elevated serum ALT levels (> 400 international units per liter). including.42 Flow of surveillance information. in an investigation of HCV tection and investigation.44 For example. an unexpectedly high number of infections in a but in practice. HCV frequently begins with a telephone call from an infection is a reportable condition in most astute clinician who diagnoses HCV infection in states. Downloaded from jada. especially in the area of laboratory support.COVER STORY illness with discrete onset of symptoms (such as nausea. employment in the medical or CDC from 2008 through 2012. and tors assess all potential exposures within the submit these reports to CDC each week (Figure). acute case. characteristics of infected populations. fever. Among at-risk people have been notified of the need the potential exposures. health departments to seek HCV testing because of their possible collect history of accidental needlesticks. Local and weeks compared with no cases for months). departments pursue supplemental clinical and Once the report is received.org on November 27.org December 2013 1343 Copyright © 2013 American Dental Association. most cases are identified first short period (such as two to three cases in two from laboratory-initiated reporting.000 to six months before symptom onset). laboratory-initiated reporting to conduct routine surveillance for viral hepatitis Figure. molecular JADA 144(12) http://jada. health department demographic data for him or her.18 With advances Centers for Disease Control in information technology. a When a person with HCV infection is deterrelative measure of the risk of potential transmined to represent a new. Investigators also assess infection control practices. and dental a Healthcare Investigation Guide to support treatment or oral surgery. facilities and laboratories a person with no behavioral risk factors or sees usually are required to report potential cases. At state health departments receive the reports the health department. Then surveillance investigareports. Flow of information in hepatitis C surveillance.17 Providers. in officials face many barriers to conducting inpractice. health mission of HCV during health care delivery. Hospital and Commercial anorexia. cases more efficiently. however.17 Health care–associated outbreak deness. outpaassociation with the 16 outbreaks reported to tient injections. CDC and Health department personnel often work in health departments disseminate reports online collaboration with CDC during HCV investigaand in scientific venues to guide prevention and tions. resources frequently limit the number vestigations.43 typically begins by confirming whether infection Health departments conduct investigations of indeed occurred. follow-up of potential and check to determine whether the case was health care–associated transmission of HCV reported previously or represents a new case. An investigation transmission in an endoscopy clinic.ada. health departments in their efforts to quickly Data from HCV surveillance are used in identify transmission of infection and to control public health to describe burden of disease and any unsafe clinical practices (Table 16. More than 90. if appropriate. They also set Maintain database Local Health Departments forth an option of identifyInvestigate new cases Classify ing a new seroconversion as Analyze an acute case. hospitalization.ada. incubation period. patients potentially risk factors for infection by identifying expoexposed during the at-risk period are notified sures during the incubation period (two weeks of the need to seek testing.6 CDC16 developed dental field.13-16). depending on available resources. All Rights Reserved. surgery.44 If the investigators identify risky of cases investigated. Genetic sequencing is used to assign virus help health care policymakers plan for health isolated from different individuals into related care resource needs at the state and national clusters according to their degree of relatedlevels. this requires only one positive test result State Health Departments with a previous negative result within the previous six months. and Prevention most health departments have developed electronic. 2013 .
Five of these outbreaks likely were associated with syringe reuse. these outbreaks involved 160 confirmed outbreak-associated infections. resource and legal barriers may prevent state and local health departments from investigating clusters thoroughly and reporting them to CDC. three were associated with drug diversion (that is. leading to underreporting of cases to the health department and difficulty in identifying a health care encounter during which transmission may have taken place. how or what to report. Standard Precautions remain the foundation of protection against transmission of HCV and other infectious agents during patient care in the dental setting.44 There also is underrecognition of the potential for health care as a risk factor for viral hepatitis transmission.org on November 27. . medication vials should not be entered with a used syringe or needle. proper use of personal protective equipment (that is. HCV infections might not be reported to the health department because clinicians might not understand when. Even if diagnosed. specifically in an oral surgery practice.1 CDC maintains an updated list of viral hepatitis outbreaks associated with health care. when a prescription medication is used by an infected health care worker with subsequent contamination of the medication vial or syringe) and six occurred in hemodialysis settings. no identified lapses in infection control were observed during the investigation. The tool contains basic information as a general reference from which more detailed documents can be accessed quickly and easily.49 Postexposure care of health care workers. including continuing education for health care providers and materials to use in educating staff members in infection control.46. If. even if the needle is changed. proper use of medical equipment and drug delivery systems (such as reusable versus single-use). CDC received notice of 16 outbreaks of health care–associated transmission of HCV. Original CDC infection control guidelines for dental offices were published in 2003. CDC has developed numerous tools and questionnaires to support health departments in investigating potential outbreaks of health care–associated infections. gloves. Briefly. Further detail is available online. masks and gowns). CDC provides many resources for DHCPs in these areas (Table 16. despite prevention efforts. safe handling of sharps and safe injection practices. 2013 Copyright © 2013 American Dental Association. These include hand hygiene. environmental cleaning. conducted and the results interpreted as a component of a larger epidemiologic investigation.14 Table 212 summarizes the Standard Precautions for dental and other outpatient settings. it is likely that only a fraction of such outbreaks have been detected. Personnel. The Oklahoma Health Department is collaborating with CDC in investigating the first transmission of HCV in a dental setting. Therefore. In other words. CDC14 developed a tool outlining the minimum expectations for safe care in outpatient settings.45 Laboratory analyses are. CDC’s recommended follow-up for exposed health care workers consists of baseline HCV Downloaded from jada.COVER STORY characterization confirmed a high degree of similarity between two source patients with chronic HCV infection and seven patients infected at the clinic.6 Combined. Furthermore. Reported health care–associated HCV outbreaks. Injection safety. or the clinician might not suspect HCV infection. even people with HCV-related symptoms might not recognize them and seek medical attention.48 and these are the same basic principles and evidence base for infection control in all outpatient settings. on a website. in one outbreak. Medications never should be administered to more than one patient by means of the same syringe. Safe injection practices are a part of the Standard Precautions. 15 of these were in ambulatory care settings. Most HCV transmissions in outpatient health care settings have been attributed to syringe reuse or other practices that led to contamination of the solution or medication intended to be injected49 (such as fentanyl or propofol). Single-use vials should never be used for more than one patient.47 PREVENTION There is no vaccine for primary prevention of hepatitis C. many cases are missed by routine surveillance. Asymptomatic infections frequently go undetected for many years.13-16). All Rights Reserved. as well as links to toolkits for investigation of health care–associated infections. and must be. so the numbers reported to CDC likely lead to underestimation of the number of outbreak-associated cases and the number of at-risk people notified of the need for screening. In 2011. and respiratory hygiene and cough etiquette (that is.46 Because of the long incubation period (up to six months) and typically asymptomatic course of acute HCV infection. a needlestick or other exposure to HCV occurs.ada. it is important to have a protocol to follow in responding. From 2008 through 2012. use of measures to contain respiratory secretions of symptomatic people and education of health care workers to prevent spread of respiratory secretions).
face shield Gown Proper Use of Equipment and Drug Delivery Systems Soiled patient-care equipment RECOMMENDATIONS FOR USE Perform after touching blood. excretions.COVER STORY TABLE 2 Summary of Standard Precautions to prevent transmission of infectious agents during patient care in outpatient settings. do not enter a medication vial with a used needle or syringe. CDC developed an infection control audit tool to help ambulatory surgical centers prepare for CMS audits. body ﬂuids. observe hand hygiene after soiling of hands with respiratory secretions. secretions. cleaning and disinfection of environmental surfaces. The Centers for Medicare and Medicaid Services (CMS) requires periodic reports of quality measures from many facilities that receive reimbursement for services (such as ambulatory surgical centers and hemodialysis facilities). use tissues and dispose in no-touch receptacle. wear gloves if visibly contaminated. Administration of immunoglobulin is not recommended for postexposure protection. bend. eye protection. secretions Wear during procedures and patient-care activities when contact of clothing or exposed skin with blood or body ﬂuids. four to six months after exposure. excretions. CDC collaborates with CMS because both agencies are concerned with patient safety and preventing health care–associated infections (such as vaccination coverage for hepatitis B among patients receiving hemodialysis and among health care workers). perform hand hygiene after handling Develop procedures for routine care.org on November 27.org December 2013 1345 Copyright © 2013 American Dental Association. All Rights Reserved.51 Oversight of infection control practices. immediately after removing gloves. use safety features when available. JADA 144(12) http://jada. for example. body ﬂuids. place used sharps in a puncture-resistant container Never administer medications from the same syringe to more than one patient. According to SHEA guidelines.11 CDC’s50 2012 recommendations for the management of the care of health care workers infected with hepatitis B did not address the issue of HCV-infected health care workers. between patient contacts Wear when touching blood. .* COMPONENT Hand Hygiene Personal Protective Equipment Gloves Mask. Testing for HCV-RNA also may be done at four to six weeks postexposure if earlier diagnosis is desired. more than three feet if possible Downloaded from jada. wear when touching mucous membranes and nonintact skin Wear during procedures and patient-care activities likely to generate splashes or sprays of blood. However. contaminated items. The Society for Healthcare Epidemiology of America (SHEA) recommends that HCVinfected health care workers with high circulating viral burden (≥ 104 genome equivalents/ mL) follow certain precautions and abstain from performing certain invasive procedures.ada. break or hand-manipulate used needles.12 antibody testing of both the exposed health care worker and the source patient. never use singledose vials for more than one patient. contaminated items. 2013 Environmental infection control Textiles (linen and laundry) Needles and other sharps Injection safety Respiratory Hygiene and Cough Etiquette * Adapted from Siegel and colleagues. body ﬂuids. wear surgical mask if tolerated or maintain spatial separation from other people. HCV-infected health care workers with less than 104 genome equivalents/mL of circulating virus should undergo routine follow-up with a personal physician and maintain consultation with an infection control expert to ensure that they continue to use appropriate infection control practices.11 In addition. follow proper infection control practices during administration of injected medications Instruct a symptomatic person to cover his or her mouth and nose when sneezing or coughing. the health care worker should receive a baseline assessment of ALT activity. Follow-up testing of the exposed health care worker should be performed at. especially frequently touched surfaces in patient-care areas Handle in a manner that prevents transfer of microorganisms to others and to the environment Do not recap.ada. CMS routinely conducts audits and surveys of facilities through regional offices. No such oversight exists for monitoring infection control practices in dental settings. secretions. For example. secretions and excretions is anticipated Handle in a manner that prevents transfer of microorganisms to others and to the environment. Facilities that demonstrate adherence to CDC infection control guidelines receive CMS financial incentives.
Public Health Service. knowledge of hepatitis C. Klevens RM. HCV transmission in health care settings is preventable through the use of Standard Precautions. 23.204(6):825-831. Hepatology 2012.gov/hepatitis/ Outbreaks/HealthcareInvestigationGuide. Klevens RM. Healthcareassociated hepatitis B and C outbreaks reported to the Centers for Disease Control and Prevention (CDC) in 2008-2012. Ly KN. Holmberg SD. McQuillan GM. 2009. Barral S. most are asymptomatic. Moyer LA.62(18):362-365.epa. 33.28(5):519-524.cdc. MMWR Recomm Rep 2012. www. 2013. Castro A. Feinstone SM. 16. Diagnosis. Smith BD. 30. Centers for Disease Control and Prevention. 2013. McCaustland K. 19.htm.pdf. List D: EPA’s registered antimicrobial products effective against human HIV-1 and hepatitis B virus. Klevens RM. Infectivity of hepatitis C virus in plasma after drying and storing at room temperature. Hepatitis C. 7th ed. et al. 24. 1. Jewett A. MMWR Recomm Rep 2001.org/news/public-health-responsesituation-update-22. 5. Evolving epidemiology of hepatitis C virus in the United States. Centers for Disease Control and Prevention. 3. Smith BD. and CONCLUSIONS The first documented HCV transmission in a dental setting serves as a reminder of the need to educate DHCPs about hepatitis C. Acute hepatitis C virus infection in young adult injection drug users: a prospective study of incident infection. Friesland M.33(1):201-206. Accessed Nov.60(42):1457-1458. Accessed Nov. 29. 9. Holmberg SD. Jiles R. 2010 Survey of Dental Practice. Mast EE. 26.201(12): 1859-1866.101(1-2):29-35. 2011. Prospects for prophylactic and therapeutic vaccines against hepatitis C virus. Updated U.gov/HAI/settings/outpatient/outpatientcare-guidelines. Kim WR. and medical followup among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008.cdc. Seeff LB. Simard EP.html. 21. MMWR Morb Mortal Wkly Rep 2013. 15. eds. American Association for the Study of Liver Diseases.S.org on November 27. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965 (published correction appears in MMWR Recomm Rep 2012. Gross JB Jr. Notes from the field: risk factors for hepatitis C virus infections among young adults—Massachusetts. Kuhnert WL. Ward JW. Atlanta. Liu S. Jiles RB. 2007 guideline for Downloaded from jada.cdc.12(1):13-26. Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus. J Infect Dis 2011. Ann Intern Med 2006. 20.61(RR-4):1-32. Wasley A. Tulsa Health Department. 2011. 34. 2013. Centers for Disease Control and Prevention. Viral hepatitis outbreaks: healthcare investigation guide. Hermida M.47(RR19):1-39. J Infect Dis 2009. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007 (published correction appears in Ann Intern Med 2012. Dolin R. Centers for Disease Control and Prevention. American Dental Association.55(suppl 1):S3-S9. November 2004-April 2007. Jiles R. Testing for HCV infection: an update of guidance for clinicians and laboratorians. Centers for Disease Control and Prevention. www.364(25):2429-2438. www. Alter MJ. 4. Public health response: situation update 22.S. N Engl J Med 2011. Rosen HR. Denniston MM. Bennett JE. Infect Dis Clin North Am 1998. May 2011. Centers for Disease Control and Prevention.S. J Virol Methods 2002. 28. Ciesek S. 11. www.gov/injectionsafety. Detection of HCV RNA in saliva of patients with hepatitis C virus infection by using a highly sensitive test.COVER STORY isolation precautions: preventing transmission of infectious agents in health care settings. Chicago: American Dental Association. Centers for Disease Control and Prevention (CDC).35(10 suppl 2): S65-S164. Klevens and Ms. 4. Dr.S. n Disclosure. 17. Hahn JA. Screening for hepatitis C virus infection in adults: U. Li X. Evans J. Diz Dios P. Accessed Nov. Margolis HS. In press. Health Care Infection Control Practices Advisory Committee. Armstrong GL. Holmberg SD. education in the evolving science of HCV infection could be of substantial value. Surveillance for viral hepatitis: United States.55(suppl 1):S25-S32. 6. 8. 2013. McQuillan GM.gov/oppad001/list_d_hepatitisbhiv. Injection safety. Ray SC. 2013. Public Health Service guidelines for the management of occupational exposures to HBV. Environmental Protection Agency Office of Pesticide Programs. Ann Intern Med 2012.200(8):1216-1226. www. Accessed Oct. Alter MJ. 2013 Copyright © 2013 American Dental Association. Major ME. 22. All Rights Reserved. Laredo R.55(6):1652-1661. Jiles RB. Preventive Services Task Force. New tools are available to support health departments in conducting investigations and to give health care providers easy access to information about infection control. Centers for Disease Control and Prevention. 4. Morgan RL. Thomas DL. which improved the manuscript of this article.159(5): 349-357. 1999 through 2002. 7. et al. Ann Intern Med 2013. 18. and Bennett’s Principles and Practice of Infectious Diseases. and reinfection. Centers for Disease Control and Prevention. 35. 6. Holmberg S. Infect Control Hosp Epidemiol 2007. Holmberg SD. Clin Infect Dis 2012. 32. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Moyer VA. Klevens RM. Douglas. Page K. Accessed Oct.52(4):1497-1505. MMWR Morb Mortal Wkly Rep 2008. Hu DJ.gov/hepatitis/ Statistics/2011Surveillance/index. and HIV and recommendations for postexposure prophylaxis.S. Guide to infection prevention for outpatient settings: minimum expectations for safe care.ada. Strader DB. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease: Centers for Disease Control and Prevention. Awareness of infection. 2013. Steinmann J. Clin Infect Dis 2012. Thomas DL. 4.156:840). Am J Infect Control 2007.144(10):705-714. January 9.htm.cdc. Healthcareassociated infections: guidelines and recommendations. Accessed Nov. 31. www. 2. . 1. Hu DJ. Xing J.tulsa-health. Preventive Services Task Force recommendation statement. J Infect Dis 2010. 21. Estimating acute viral hepatitis infections from reported cases. Chiarello L. Alter MJ. Clinical practice: chronic hepatitis C infection. U. Transmission of hepatitis C virus infection through tattooing and piercing: a critical review. Use of enhanced surveillance for hepatitis C virus infection to detect a cluster among young injection-drug users: New York. Clin Infect Dis 2012. non-B viral hepatitis and hepatitis C. Centers for Disease Control and Prevention.html. Roberts H. 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