HCV infection diagnostic and

health care worker infection

management
Herniah Asti Wulanjani
KSM Patologi Klinik RSUP dr Kariasi/
Bagian Patologi Klinik FK UNDIP
 HCV infection Epidemiology
Mortality number WHO
1990 333.000
2010 499.000

2013 704.000

HCV chronic infection 2015 in the world 150.000.000

(3%) > Chirrotic and Hepatic carsinoma

RISKESDAS 2013 HCV infection is 2.5% from 1.2 % Indonesian people , this Less than
HBV infection (21.8%)

CDC Information estimated HCV infection 25.000-30.000 case per years

With 60% IDUs, <10% sexual transmited,
 High-risk HCV infection
• HIV infection
• Sharing drug abuse iv (history)
• History Transfusion and transplantation (not
equiped HCV screening )
• History Prolong hemodialisa
• Persisten elevated serum ALT
• Sharing intranasal/inhalasi therapy
• Tattos with non aceptic
• High risk sexual relation HCV infection (long time)
• State or came from high prevalence HCV
 HCV infection diagnostic
• Acute HCV infection rare to detection (<30%)
• More Patients came with the complication
dissease :
– Esentiale mixed cryoglobulinemia
– Membrane Proliferation Glumerulonephritis
– Glumerulonephritis membranosa
– Leukocytoplastic vasculitis
– Lichen plannus
– Porpiria cutanea tarda.
– Chirrosis Hepatis (Biopsi) and Carcinoma
Hepatocelluler
 Antibody HCV EIA Methode
• Enzyme immunoassay
• 1990 : FDA Recommendation Ortho DX;Abbot
Laboratories .
• Blood donor screening ( acute infetion HCV
and Chronic)
• High number with false positive (50%-70%)
• 1992 EIA 2 with multy antigen is
recommended FDA
• Antigen core regions NS3 and NS4 ( c33c,
c100-3 combinations of c200)
• Sensitivity and spesivisity higher in low and
high prevalence population,
• Seroconversion 16-19 week (short time)
• 1997 second generation ( EIA 3.0; Ortho
Diagnostic systems)
• For screening in more Laboratories
• Core NS3 antigen, NS5 antigen
• EIA2 that similar with EIA 3.0 but
seroconversion 20-34 days, (everage 26 day)
 Table of EIA HCV assay

Source : American study of liver disease , IDSA, HCV

Guidance 4
 When we continue to Recombinant
immunoblot assay (RIBA)

• EIA high false (+) in low risk

• Test to comparred specivicity and non
specivicity reactivity (immunoassay strips
RIBA-1 ; Chiron corp. or RIBA-2 with four
antigen RIBA HCV 2.0 strip immunoassay ;
Chiron corp )
 RIBA-2 Assay ?

• 4 antigent with Superoxide dismutase (SD):

– Positive 2-4 band, no band in SD : Positivity
– One band : Indeterminate
– 1-4 band with SD band : Indeterminate
 RIBA 3 Assays
• Blood bank
• Rare result indeterminate (compare RIBA 2)
• Well corelated to positivity with viremia
positive
• More sensitivity with modification added c33
c100 antigent (compare if only with NS5
antigent)
 Nucleic acid
• Diagnostic : HCV RNA in Serum or plasma
• Qualitative and Quantitative HCV RNA assay
• Positive in 8-10 days after exposure
• ALT serum : plateau phase in 40-60 days after
exposure
 HCV RNA tes Qualitative
• Used to convirmed positive EIA
• Not necessary if evidence of their dissease and obvious
risk factors for HCV
• Test should have a lower of detection of 50 IU/ml = 100
viral genes/ml
• Specificity >95%
• Determines if virus present in the blood : Pesitive or
Negative
Single +ve : convirm infection
-ve : May just be below the level of
detection
Coversion from IU/mL to Copies
 Quantitative HCV RNA
• Determines the amount of virus in 1 ml of
blood
< 400.000 IU/ml (low)
< 2.000.000 copies/ml (low)
Cann’t be measured < 10 IU/ml
No upper limit

Source : Naggie S et all

Limit detection HCV RNA (UI/mL)
Source : Sine DM 8
 Genotyping assay HCV
• To Determine therapy
• More methode , high accuracy is Direct sequencing and
phylogenetic analisis. This labor intensive methode and impractical
for large scale
• Developed : methode restricted fragment length polymorphism
(RFLP) ; used restricted enzymes to determined . (INNO-LiPA;
Innogenetics;Belgium)
• Amplified 5’UTR PCR product to type specific probes
• Detected new sub type : 1a, 1b, 2ato c, 3a to c, 4a to h, 5a, 6a.
• Concordance beetwen assay high : 94%-100%
• Limitations is : 10% case point mutation detected but do not
represent true genotype.
• 5-10% can not distiguish between 1a/1b , 2a/2c
Distribution sub genotype in southeast Asia (type 1)
Indonsesia type 1b

Source : Guidelines CDC Genotype Distribution 2

 Monitoring during HCV treatment
What to monitor
• HCV RNA Quantitative
• HCV RNA qualitative
• Other Laboratory test
– CBC with differencial, Liver
panel, biochemistry, TSH,
CD4, cell count, HIV viral load
and AFP if Cirrotic
When to monitor
• Teleprevir : week 0,1,8 and 11
Boceprevir : week 0, 11
• Teleprevir : week 24 and 48
Boceprevir : week 24 and 48
• CBC weekly for the first 4 week,
every other until week 11 and
every month thereafter. Use
clinical judgenment. Liver panel,
CD4 count, boichemistry and TSH
monhtly.
HIV load every 4-12 week, AFP
every 6 months if Chirrotic
a. Acute HCV
infection
clear HCV RNA in
36 weeks
with Normal ALT

b. Chronic HCV
infection
Persisten HCV RNA
with increase level
ALT
 Management HCV infection in Health care
worker
• Estimation CDC : 2 of 100 health care worker had
HCV infection from patient (Similar with HBV or
HIV infection)
• Recomendation Sociaty for Healthcare
Epidemiology of America (SHEA) :
HCV infection = virus in circulation ≥ 104 GE/mL
– Routinaly used double glowing for all invasive
procedure, contact mocous membran or non intact
skin, all patient care with glowing. (Category III
procedure)
 Virus burden less than 104 GE/mL

• Not Detected transmited infection

• Obtain Advice expert review panel
• Follow up routinely occupational medicine
• Follow up expertis in management HCV infection
cosult with an infection control expert about
recommended procedure ( routine use double
glowing in procedure II/III, Compromise glove
integrity )
• Agrees to information in or sign contract or letter
from expert review panel responsibilities.
Summary recommendation managing
healthcare provider ( HBV, HCV, HIV)
Continue…
Test alogaritm HCV infection
source : WHO gudelines HCV
Category prosedure of level risk for blood borne
pathogen transmission
Category I:
• Procedures with de minimis risk of bloodborne virus
transmission
– Regular history-taking and/or physical or dental examinations,
including gloved oral examination with a mirror and/or tongue
depressor and/or dental explorer and periodontal probe
– Routine dental preventive procedures (eg, application of
sealants or topical fluoride or administration of prophylaxisa ),
diagnostic procedures, orthodontic procedures, prosthetic
procedures (eg, denture fabrication), cosmetic procedures (eg,
bleaching) not requiring local anesthesia
– Routine rectal or vaginal examination
– Minor surface suturing
– …………..
 Category II:

Procedures for which bloodborne virus transmission is

theoretically possible but unlikely
• Locally anesthetized ophthalmologic surgery
• Locally anesthetized operative, prosthetic, and endodontic
dental procedures
• Periodontal scaling and root planingd
• Percutaneous cardiac procedures (eg, angiography and
catheterization)
• Percutaneous and other minor orthopedic procedures
• Subcutaneous pacemaker implantation
• ……………..
 Category III:

Procedures for definite risk of bloodborne virus transmission

or that have been classified previously as “exposure-prone”
• Orthopedic procedures, including total knee arthroplasty,
total hip arthroplasty, major joint replacement surgery,
open spine surgery, and open pelvic surgery
• Extensive plastic surgery, including extensive cosmetic
procedures (eg, abdominoplasty and thoracoplasty)
• Transplantation surgery (except skin and corneal
transplantation)
• Trauma surgery, including open head injuries, facial and jaw
fracture reductions, extensive soft-tissue trauma, and
ophthalmic trauma
• ……………..
 Legal issue
For legal perspective
• Relative unsupported infected health care provider. (problem that does
not Exist)
The practitioners was sued for inflicting mental anguish for causing ‘pain
suffering’, comply with the ‘duty of warn’, patient risk, or variuos legal
issue
UK guidelines :
HCV infected provider who have circulating HCV RNA may not konduct
exposure prone Invasive procedure (there is for trainees ). Receive anty viral
treatment became HCV RNA negative for periode 6 month, procedure
invasive (+), retest 6 months later to confirm durability of the response
The European Consortium
Could not reach consensus for healthcare infected HCV , similarly
HBV infection to prevention board respect HBV, to supdressed before
escape mutant virus emerged ( also aply to chronicaly HCV RNA)
Thanks for Attention