Hepatitis C (Acute Case)

Transcription

1 Hepatitis C (Acute Case) Revisin Dates Case Definitin Reprting Requirements Remainder f the Guideline (i.e., Etilgy t References sectins inclusive) January 2013 July 2018 January 2011 Case Definitin Cnfirmed Case: Acute r Recent Infectin Cnfirmed detectin f hepatitis C virus antibdies (anti-hcv) r hepatitis C virus RNA (HCV RNA) in a persn with discrete nset (A) f any symptm r sign f acute viral hepatitis (B) within the previus 6 mnths f current psitive test. AND Negative anti-hav IgM and negative anti-hbc IgM r HBsAg test* AND Serum alanine amintransferase (ALT) greater than 2.5 times the upper nrmal limit. OR OR OR Cnfirmed detectin f hepatitis C virus antibdies (anti-hcv) r HCV RNA in a persn with a dcumented anti-hcv negative test within the preceding 12 mnths Detectin f hepatitis C virus RNA (HCV RNA) in a persn with a dcumented HCV RNA negative test within the preceding 12 mnths, excluding thse underging HCV treatment r therapy. Individuals wh have had a sustained virlgic respnse (SVR) fr six mnths psttreatment and becme HCV RNA psitive within 12 mnths f SVR shuld be cnsidered as having an acute r recent infectin fr surveillance purpses, even thugh sme f these cases may be pst-treatment relapses. * If nly HBsAg was tested fr and was psitive, this shuld nt autmatically rule ut an acute hepatitis C infectin (the persn culd be c-infected). (A) Onset may be discrete but is mre ften insidius. Disease flares in chrnic HCV infectin may present similar symptms and signs. Mre than 90% f acute infectins are asymptmatic. (B) Clinical symptms and signs f acute viral hepatitis include anrexia, abdminal discmfrt, nausea, vmiting, malaise, fatigue, dark urine, pale stls and jaundice. 1 f 12

2 Hepatitis C (Acute Case) Labratry Cmments: If diagnsis is based n anti-hcv alne, it shuld be cnfirmed by HCV RNA, immunblt, a secnd manufacturer s EIA, r based n an EIA signal t cut-ff rati predictive f a psitive immunblt. If diagnsis is based n HCV RNA alne, a repeat test is recmmended. It is recmmended that the samples be taken at tw separate time pints. Anti-HCV testing shuld nt be perfrmed in infants under 18 mnths f age since a psitive anti-hcv result may represent maternal antibdy. Since vertical transmissin f HCV infectin usually ccurs arund the time f birth, if testing fr HCV RNA is cnsidered, it shuld be delayed fr 4 12 weeks pst-partum t avid false negative result. Crd bld may be cntaminated by maternal bld and shuld nt be used fr anti-hcv r HCV RNA testing. The HCV sercnversin windw perid is apprximately 5 10 weeks; it is estimated that 30% f acute infectins may be missed if anti-hcv is the nly marker f infectin used during this time perid. HCV RNA is detectable within 2 3 weeks f infectin and, in the cntext f clinical illness, can identify acute HCV infectin even in the absence f anti-hcv. In immuncmprmised individuals, sercnversin can be delayed fr up t ne year, and sme may never develp anti-hcv. These individuals may need t underg HCV RNA testing. Individuals wh have had a sustained virlgic respnse (SVR) fr six mnths pst-treatment and becme HCV RNA psitive within 12 mnths f SVR shuld be cnsidered as having a new recent infectin fr surveillance purpses, even thugh sme f these cases may be pst-treatment relapses. Apprximately 25% (range, 15 45%) f HCV infectins will reslve spntaneusly. These individuals will typically demnstrate anti-hcv withut detectable HCV-RNA. As such, these individuals wuld be cnsidered t be nn-infectius (exceptin: Screening fr rgan transplants and Canadian Bld Services) Gvernment f Alberta 2 f 12

3 Hepatitis C (Acute Case) Reprting Requirements 1. Physicians, Health Practitiners and Others Physicians, health practitiners and thers shall ntify the Medical Officer f Health (MOH) (r designate) f the zne, f all cnfirmed cases in the prescribed frm by mail, fax r electrnic transfer within 48 hurs (tw business days). 2. Labratries All labratries shall reprt all psitive labratry results by mail, fax r electrnic transfer within 48 hurs (tw business days) t the: Chief Medical Officer f Health (CMOH) (r designate), and MOH (r designate) f the zne. 3. Alberta Health Services and First Natins and Inuit Health Branch The MOH (r designate) f the zne where the case currently resides shall frward the initial Ntifiable Disease Reprt (NDR) f all cnfirmed cases t the CMOH (r designate) within fur weeks f ntificatin and the final NDR (amendment) within ten weeks f ntificatin. Fr ut-f-prvince and ut-f-cuntry reprts and/r cntacts, the fllwing infrmatin shuld be frwarded t the CMOH (r designate) by phne, fax r electrnic transfer within 48 hurs (tw business days): name, date f birth, ut-f-prvince health care number, ut-f-prvince address and phne number, psitive labratry reprt, and ther relevant clinical / epidemilgical infrmatin. Fr ut-f-prvince and ut-f-cuntry cntacts the fllwing infrmatin shuld be frwarded t the CMOH (r designate) as sn as pssible: name, date f birth, and ut-f-prvince / cuntry cntact infrmatin. 4. Additinal Reprting Requirements Canadian Bld Services (CBS): All persns testing psitive must be reprted by the MOH (r designate) t CBS within tw business days if: the persn has a histry f dnating bld/bld prducts r the persn received bld/bld prducts in Canada when bld transfusin is the nly risk factr identified. A cpy f the psitive test result must accmpany the Transmissible Disease Ntificatin (TDN) frm, and all infrmatin shuld be sent fr Lkback/Traceback t the TDN Department by: Fax OR Scan & t: TDntificatins@bld.ca T speak t a TDN Specialist regarding any questins r cncerns please call: (506) r ext Gvernment f Alberta 3 f 12

4 Etilgy Hepatitis C (HCV) is an envelped RNA virus. It is a member f the Flaviridae family, genus Hepacivirus. At least 6 majr gentypes and apprximately 100 subtypes exist.(1) Types 1a and 1b are the mst cmmn types fund in Nrth America.(2) Althugh the predminant type f hepatitis C in Canada is gentype 1, all types have been reprted in Canada. Gentypes appear t vary in pathgenicity and in hw they respnd t antiviral therapy.(3) Clinical Presentatin Mst peple (mre than 90%) infected with HCV have either n symptms r exhibit nly mild symptms f illness, such as anrexia, vague abdminal discmfrt, nausea and vmiting. In acute infectins, the mst cmmn symptms are fatigue and jaundice.(3;4) A persn with acute disease may have elevatins in serum ALT levels, ften in a fluctuating pattern.(2) Althugh initial illness may be asymptmatic r mild, a high percentage (50 80%) develp chrnic HCV infectin.(1) Up t 70% f individuals with chrnic HCV infectin have evidence f active liver disease, hwever, the majrity f these individuals may nt be aware f their infectin because they are nt clinically ill,(5) and symptms are ften nn-specific.(6) Chrnic infectin can be marked by fluctuatins in clinical symptms and liver enzyme tests such as serum transaminases. Many peple cmplain f chrnic r intermittent fatigue, which can be debilitating. The degree f fatigue is ften nt crrelated with the severity f liver disease. Althugh mst peple shw few physical signs f the disease during the first 20 years f infectin(2), f thse chrnically infected with HCV, abut half will eventually develp cirrhsis r hepatcellular carcinma (HCC).(1;7) Lng-term cmplicatins (e.g., cirrhsis and HCC) generally ccur mre than 20 years after infectin, althugh mre rapid prgressin des ccur.(8) HCV is the leading cause fr liver transplants wrldwide.(6) Alchl cnsumptin, lder age at time f infectin (>40 years ld), male gender, and c-mrbidities including besity, c-infectin with hepatitis B, and c-infectin with HIV are factrs that accelerate liver disease prgressin in peple with HCV infectin.(9) It is estimated that apprximately 20% f HIV-psitive peple in Canada are c-infected with HCV(10) and the risk fr cirrhsis in these individuals is nearly twice that in persns with HCV infectin alne.(5) Diagnsis In Alberta, serlgy and nucleic acid testing (NAT) fr HCV is dne at the PrvLab. A HCV infectin diagnsis is based n psitive antibdies t HCV (anti-hcv) and/r psitive HCV NAT results. A psitive NAT is an indicatin f viremia i.e., HCV is detected in the bld indicating viral replicatin. NAT des nt distinguish between acute r chrnic infectin with HCV. Frm the clinical assessment and management perspective, HCV PCR is an imprtant test, as nly individuals wh are viremic will be cnsidered fr antiviral treatment. Mrever, HCV NAT is a useful diagnstic tl in immuncmprmised individuals wh might nt munt an antibdy respnse. Fr nenates brn t HCV psitive mthers, physicians can determine if vertical transmissin has ccurred by perfrming HCV antibdy after 18 mnths f age when maternal antibdies are cleared. If cnfirmatin f a diagnsis that will impact infant management prir t 18 mnths is required, NAT is indicated. (G. Zahariadis, persnal cmmunicatin, Nvember 22, 2009). Epidemilgy Reservir Humans Gvernment f Alberta 4 f 12

5 Transmissin Hepatitis C is primarily transmitted thrugh parenteral expsure t HCV infected bld.(8) Transmissin is mst efficient thrugh large r repeated percutaneus expsures t bld, such as transfusin f bld frm unscreened dnrs r thrugh injectin drug use (IDU). Althugh less efficient, ccupatinal, perinatal, and sexual expsures can als result in transmissin f HCV.(5) Current r past IDU accunts fr mre than 58% f all reprted cases f HCV in Canada(11), and between 70 80% f all newly acquired HCV infectins acquired in Canada are related t IDU(12), thrugh sharing f injectin equipment(13) (sharing needles, syringes, spns, filters, water, turniquets, and swabs).(14) Nn-injectin drug use als pses a risk fr HCV transmissin. It has been established that HCV can be transmitted thrugh sharing straws and crack pipes when snrting r smking drugs. Other activities invlving needles, such as tatting, piercing, electrlysis and acupuncture may pse a risk f HCV transmissin if nt carried ut using new needles fr each prcedure, r if equipment is nt prperly sterilized.(14) Any bdy fluid cntaminated with HCV-infected bld can be a surce f infectin.(15) Husehld (nn-sexual) transmissin has been reprted thrugh sharing sharp instruments/persnal hygiene equipment with an infected persn (e.g., tthbrushes, nail scissrs and clippers, and razrs).(14;16;17) Sexual transmissin is lw (prbably less than 5%), but can ccur if bld is present, either visibly r thrugh micrscpic cuts r tears in the skin and/r mucsa.(14) Ppulatins identified as being at increased risk f sexual transmissin f HCV include men wh have sex with men (MSM), sex trade wrkers r sexually prmiscuus grups, persns attending a sexually transmitted infectin (STI) clinic, persns and their partners with HIV, sexual partners f HCV-infected hemphiliac men, and sexual partners f patients with chrnic hepatitis.(17) Sexual transmissin (in lw prevalence cuntries) amng lng-term sexual partners is relatively lw (<5%). The risk f transmissin increases with multiple sexual partners.(8;18) The risk f vertical transmissin (mther t baby) has been estimated t be between 1 6% f HCV-infected. Maternal c-infectin with HIV is assciated with an increased risk f transmissin.(15) Maternal risk factrs that increases the risk f transmissin f HCV include HIV c-infectin, histry f IDU, and high maternal viremia (>10 6 cpies/ml).(19) Breastfeeding is cnsidered safe as lng as nipples are nt cracked and bleeding. Transmissin thrugh breast milk is unlikely.(14) In Canada, since the early 1990s, the risk f transmissin frm screened and dnated bld, manufactured bld prducts, and transplanted rgans has been minimal due t screening and prcessing f bld prducts. The current risk fr HCV transmissin frm bld transfusin is very lw and is thught t be less than 1:3,100,000 units f bld dnated.(20) Individuals wh were expsed t cntaminated bld, bld prducts r transplantatin prir t 1992 in Canada may be at risk f having HCV infectin. HCV is nt transmitted efficiently thrugh ccupatinal expsures t bld. The average incidence f anti-hcv ser-cnversin after accidental percutaneus expsure frm an HCV psitive surce is 1.8% (range 0 7%).(18) Gvernment f Alberta 5 f 12

6 A mre detailed descriptin f HCV transmissin is available in the Canadian AIDS Sciety publicatin, HIV Transmissin: Guidelines fr Assessing Risk, 5 th ed., These guidelines nw include a sectin, Assessing Risk f Hepatitis C Transmissin (pp ).(14) Incubatin Perid The incubatin perid ranges frm 14 days t 6 mnths, cmmnly 6 9 weeks.(1) After expsure, HCV RNA can be detected in plasma within days, ften 1 4 weeks befre liver enzymes rise.(8) There is nrmally a time lapse f 6 7 weeks between the expsure t the HCV and any symptms that may result. Perid f Cmmunicability Hepatitis C is cmmunicable frm ne r mre weeks befre the nset f symptms,(21;22) up t lifelng.(22) Peaks in virus cncentratin appear t crrelate with peaks in liver ALT activity. Peple wh are psitive fr HCV antibdy may, frm a medical perspective, clear the virus fllwing treatment. Hst Susceptibility Susceptibility is universal. The degree f prtective immunity fllwing infectin is nt knwn but repeated infectins with HCV have been demnstrated in experimental chimpanzee mdels and human case reprts.(23) Occurrence General Hepatitis C is a majr public health cncern arund the wrld. It is estimated that apprximately 3% f the wrld s ppulatin, r 180 millin persns wrldwide are infected, 130 millin f whm are chrnic HCV carriers at risk f develping liver cirrhsis and/r liver cancer. In additin, it is estimated that 3 4 millin peple wrldwide are newly infected with HCV each year.(7) Disease prevalence is cnsidered lw (<1%) in Canada, Australia, and nrthern Eurpe, and is apprximately 1% (medium endemicity) in the USA and mst f Eurpe. Many cuntries in Africa, Latin America, and Central and Sutheastern Asia are cnsidered high endemicity (>2%), with sme cuntries in these areas reprting prevalence rates between 5 and 10%.(7) Canada Prir t 1989, when hepatitis C was first identified, it was knwn that there was sme factr causing hepatitis amng peple wh received bld transfusins r bld prducts. It was riginally knwn as nn-a, nn-b hepatitis.(3) A test fr hepatitis C was intrduced in Canada in 1990.(4) As f December 2007, it is estimated that 242,500 peple in Canada (apprximately 0.7% f the Canadian ppulatin) were infected with HCV, with an estimated 7,900 individuals newly infected in 2007, mstly thrugh IDU.(11) In Canada, apprximately 20% f reprted HCV infectins are in the immigrant cmmunity. HCV infectins frm transfusin f bld prducts accunts fr nly (apprximately) 13% f all cases.(13) The number f cases diagnsed has increased dramatically since 1992, in part due t imprved awareness and recgnitin f the infectin(3), hwever, it estimated that perhaps nly 65% f the estimated cases in Canada have been identified.(13) Many individuals culd be in the lng asymptmatic stage f the illness and are unaware f their infectin.(6) Gvernment f Alberta 6 f 12

7 Reprted HCV infectin rates vary acrss Canada. In 2008, the highest rates were fund in the Yukn (84.5 per 100,000), fllwed by Saskatchewan (69.3 per 100,000) and B.C. (56.6 per 100,000). The lwest rates were fund in Newfundland (19.5 per 100,000) and Nunavut (6.4 per 100,000). Alberta s rate in 2008 (33.3 per 100,000) was lwer than the natinal average (35.5 per 100,000).(24) Alberta Nn-A/nn-B hepatitis (hepatitis C) became reprtable in 1983, and there were 10 cases reprted that year. In 1997, hepatitis C was designated as a ntifiable disease. Between 1998 and 2006, the rate f newly diagnsed cases f HCV declined substantially in the prvince. The rate f newly diagnsed cases f HCV has cnsistently been higher in males than females in Alberta; apprximately duble in recent years. In 2006, there were 911 new cases f HCV in males (54.0 per 100,000 males) and 464 new cases amng females (27.5 per 100,000 females). HCV rates are much higher in First Natins individuals than in nn-first Natins individuals. Between 1998 and 2006, First Natins individuals represented 13.6% f HCV cases, while representing nly 4.7% f the ppulatin.(25) Between 1998 and 2006, the peak rate f newly diagnsed cases f HCV was at an lder age fr males (40 59 years) than fr females (30 39 years). Rates f newly diagnsed HCV were higher fr males in mst age grups, with the exceptin being in the age grup (16.0 per 100,000 fr females, and 7.2 per 100,000 fr males).(25) Key Investigatin Single Case/Husehld Cluster Determine the reasn fr the test (frm the case r physician). Assess risk factrs fr ptential surce f infectin including: IDU (pririty fllw-up), needle sharing, recent incarceratin, receipt f bld/tissue/rgan between 1978 and 1990, receipt f bld/tissue/rgan at any time in a develping cuntry, skin piercing prcedures e.g., tatting, bdy piercing, acupuncture, wrkplace r nn-ccupatinal expsure, and recent invasive medical r dental prcedures e.g., hemdialysis. Assess sexual relatinships and high-risk sexual behavirs. Ascertain status f c-infectin with ther bld brne infectins (BBIs). Ascertain c-infectin with STI. If female, determine pregnancy status. Determine dnatin f bld, tissue, r rgans. Identify husehld and ther intimate cntacts fr ptential bld expsure frm the case. Cntacts include: needle sharing partners, persns wh share persnal use items e.g., razrs, tthbrushes, lng term and shrt term sexual partners, and ther persns with an identified expsure t the bld r ther bdy fluids capable f prducing HCV infectin Gvernment f Alberta 7 f 12

8 Cntrl Management f a Case Public health persnnel may cntact the physician t make them aware f the need fr: public health fllw-up including client educatin, fllw-up f cntacts, prvisin f resurces, additinal epidemilgic infrmatin, and the pssibility f testing fr ther types f hepatitis (t determine the need fr hepatitis A and B vaccine). Discussin f healthy lifestyle and infrmatin t minimize liver damage e.g., avid intake f alchl and hepattxic drugs, eating a well balanced diet, and having regular medical checkups. Educatin abut the mdes f transmissin and reducing the risk f transmissin t thers. Referral t a specialist fr medical management. Prvide infrmatin abut cmmunity supprt agencies. HIV and hepatitis B testing is recmmended fr clients invlved in relevant risk activities. Determine the need fr hepatitis A and hepatitis B vaccine. Testing may have been requested by the physician. Persns wh are anti-hcv psitive and are nt already immune t hepatitis A and hepatitis B, are eligible fr prvincially funded vaccine as per the current Alberta Immunizatin Manual. Treatment f a Case Treatment (e.g., antivirals) is determined n an individual basis, is generally based n gentype and severity f liver disease, and may prevent prgressin f liver disease r develpment f HCC. Criteria fr initiating treatment are cmplex and shuld be dne in cnjunctin with a medical specialist. Respnse t treatment and duratin f therapy depends n the hepatitis gentype. Gentype 1 is mst cmmn in Canada and respnds prly t current treatment ptins. Management f Cntacts Persns wh are identified as cntacts f IDUs shuld be given pririty fr fllw-up by public health persnnel and shuld be ntified f pssible expsure t HCV by the case r by public health persnnel. Shrt-term sexual cntacts shuld be assessed fr risk behavirs and apprpriate testing fr STIs, hepatitis C and ther BBIs shuld be recmmended. They shuld be ntified by the case r by public health persnnel. Mst lng-term sexual partners f HCV psitive persns test anti-hcv negative, hwever, they may elect t be assessed by their physician. Infants brn t HCV psitive mthers shuld be fllwed up by a pediatric infectius disease physician r an expert in hepatitis C infectin. Preventive Measures Injectin Drug Use (IDU) The identificatin f injectin drug users, with harm reductin cunseling and educatin abut the infectin, is critical fr preventin. Harm reductin effrts may include participatin in needle-exchange prgrams, participatin in addictin prgrams and drug substitutin. Street-based and prisn-based prgrams are imprtant fr identifying and educating highrisk persns Gvernment f Alberta 8 f 12

9 Research shws the need t direct hepatitis C preventin strategies twards peple wh are just beginning t inject drugs r cntemplating injectin. Mre than half f thse new injectin drug users becme psitive fr HCV within 6 12 mnths.(26) Users f drugs that are nt injected shuld be cunseled in the danger f infectin frm equipment such as straws, which culd be cntaminated with infected bld. Skin Piercing Prcedures Anyne cnsidering tatting, bdy piercing, r acupuncture shuld be cunseled t ensure that these practices are carried ut with sterile equipment, preferably ne-time-use equipment. Occupatinal Expsure Health care and emergency wrkers shuld all be trained in the risk and preventin f bldbrne infectins and shuld reprt any percutaneus r permucsal expsure t their respective ccupatinal health and safety (OHS) representative fr apprpriate management. Prevalence f HCV infectin amng health care wrkers is abut 1 2%, which is the same as amng the general ppulatin.(27) Nn-Occupatinal Expsure Refer t the current Alberta Guidelines fr Nn-Occupatinal, Occupatinal and Mandatry Testing and Disclsure Act Pst-Expsure Management and Prphylaxis: HIV, Hepatitis B, Hepatitis C and Sexually Transmitted Infectins, AH. Sexual Activity Transmissin frm partner t partner in a lng-term relatinship is relatively lw, hwever, the risk f transmissin increases with multiple sexual partners, c-infectin with HIV, and high-risk sexual behavir (i.e., where bld is present). The infected persn shuld infrm (r public health persnnel can ntify) sexual partners. Testing shuld be ffered t the partners. Recmmend use f cndms in shrt-term sexual relatinships. Infected wmen shuld avid unprtected sex during menstruatin, as the virus may be present in menstrual bld. Vertical Transmissin Transmissin f HCV frm mther t baby can ccur at the time f birth. It remains uncertain whether delivery by elective caesarian prevents transmissin. This interventin is nt currently recmmended. Breastfeeding is recmmended in general because f its prven health benefits and because the risk f HCV transmissin by this means is nly theretical. Wmen wh wish t take n risk may chse t use alternative feeding methds. If the nipples are bleeding r cracked, it is recmmended that breastfeeding be suspended until they are healed. Husehld Expsure Peple with HCV shuld be advised nt t share persnal articles such as razrs, nail scissrs r clippers, and tthbrushes because f the pssibility they may be cntaminated with small amunts f bld cntaining the HCV. Cuts and pen sres n the skin shuld be cvered up, and cunseling n hw t manage accidental spills f bld shuld be prvided. After a bld spill, remval f rganic material must ccur fllwed by cleaning with an apprpriate disinfectant (usually 1:10 dilutin f husehld bleach).(28) Screening fr HCV Early detectin f HCV infectin is imprtant s that treatment may be initiated if indicated, and s that infected persns may be given the pprtunity t initiate lifestyle changes t Gvernment f Alberta 9 f 12

10 reduce ther risks that might lead t liver damage. Respnse t treatment may als be enhanced in persns with a shrter duratin f infectin. Persns with significant risk factrs (e.g., ever injected drugs [even nce], histry f incarceratin, tatts, ear r bdy piercing, rgan transplant r a transfusin f bld r bld prducts befre 1990, and health care wrkers wh have injuries frm needlesticks r sharps) shuld be screened fr HCV. Persns with liver dysfunctin f unknwn etilgy r chrnic liver disease shuld als be screened. In Canada, the risk f infectin thrugh bld transfusin has been reduced but nt eliminated by the testing f dnrs fr HCV. The incidence f pst-transfusin hepatitis C in the mid 1980s was 3.1%. The rate had fallen t 1.3% by the late 1980s. The current risk fr HCV transmissin frm bld transfusin is very lw and is thught t be less than 1:3,100,000 units f bld dnated.(20) All bld dnatins are screened by the CBS fr HCV. Persns wh are fund t be psitive in this manner are referred t the MOH (r designate) fr the zne in which the dnr lives, fr apprpriate fllw-up. All dnatins f bld, bld prducts, tissues, rgans, and semen are screened fr HCV, and peple infected with HCV shuld be cunselled nt t dnate. Health Care Wrkers In any situatin in which a wrker wh is HCV psitive, is uncertain abut the ptential transmissin risks f HCV r prper practices t minimize the risk t clients, he r she shuld cnsult with emplyee health r an infectin cntrl practitiner r patient safety grup respnsible fr the quality f care fr the clients. In additin, HCWs wh are HCV psitive shuld cntact the Zne MOH r designate t discuss the ptential risks f transmissin t clients. Upn assessment by the Zne MOH, a wrker may r may nt be referred t the Alberta Expert Review Panel fr Bld Brne Viral Infectins in Health Care Wrkers fr further assessment services, if indicated. The Panel is established t review circumstances f HCWs wh are fund t have a bld brne viral infectius disease. The panel may receive referrals frm MOHs regarding HCWs wh perfrm expsure-prne prcedures when there is uncertainty as t whether cntinued r mdified prfessinal practice is indicated Gvernment f Alberta 10 f 12

11 References (1) American Public Health Assciatin. Viral hepatitis C. In: D.L.Heymann, editr. Cntrl f Cmmunicable Diseases Manual. 19 ed. Washingtn: American Public Health Assciatin; p (2) Canadian Liver Fundatin. Hepatitis C: Medical infrmatin update. Canadian Jurnal f Public Health 2000; 91, Supplement 1:S4-S9. (3) Canadian Nurses Assciatin (CNA). Hepatitis C: A Nursing Guide. Ottawa: Canadian Nurses Assciatin; (4) Rath A, Alvarad L. Hepatitis C: Strategic Issues Twards a Glbal Awareness Campaign (5) Wrkwski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006: Hepatitis C. MMWR 2006 Aug; 55(RR11):1-94. (6) Dinner K, Dnaldsn T, Ptts J, Sirna J, Wng T. Hepatitis C: A public health perspective and related implicatins fr physicians. Ryal Cllege Outlk 2005; 2(3):20-2. (7) Wrld Health Organizatin (WHO). Viral Cancers Available frm: (8) Thmas DL, Ray SC, Lemn SM. Hepatitis C. In: G.L.Mandell, J.D.Bennell, R.Dlin, editrs. Principles and Practice f Infectius Diseases. 6 ed. Philadelphia: Elsevier; p (9) Mre L. Treatment and Preventin Update HIV and Hepatitis C: Enhancing Care f the Cinfected Patient (10) Côté P, Baril JG, Hébert MN, Klein M, Lalnde R, Pliquin M, et al. Management and treatment f hepatitis C virus in patients with HIV and hepatitis C cinfectin: A practical guide fr health care prfessinals. Canadian Jurnal f Infectius Disease and Medical Micrbilgy 2008; 18(5): (11) Public Health Agency f Canada (PHAC). A Renewed Public Health Respnse t Address Hepatitis C: A Summary Reprt f the Pririty-Setting Prcess and a Strategic Framewrk fr Actin (12) Public Health Agency f Canada (PHAC). Epidemilgy f Acute Hepatitis C Infectin in Canada Results frm the Enhanced Hepatitis Strain Surveillance System (EHSSS) Available frm: (13) Sherman M, Shafran S, Burak K, Ducette K, Wng W, Girgrah N, et al. Management f chrnic hepatitis c: Cnsensus guidelines. Canadian Jurnal f Gastrenterlgy 2007; 21, Suppl C:25c-34c. (14) Canadian AIDS Sciety. HIV Transmissin: Guidelines fr Assessing Risk Available frm: Gvernment f Alberta 11 f 12

12 (15) American Academy f Pediatrics. Hepatitis C. In: L.K.Pickering, C.J.Baker, D.W.Kimberlin, D.W.Lng, editrs. Redbk: 2009 Reprt f the Cmmittee n Infectius Diseases. 28 ed. Elk Grve, IL: American Academy f Pediatrics; p (16) Public Health Agency f Canada (PHAC). Hepatitis C: Quick Facts Available frm: (17) Wng T, Lee SS. Hepatitis C: A review fr primary care physicians. CMAJ 2006; 174(5): (18) Centers fr Disease Cntrl and Preventin (CDC). Updated U.S. public health service guidelines fr the management f ccupatinal expsures t HBV, HCV, and HIV and recmmendatins fr pst-expsure prphylaxis. MMWR 2001; 50(RR-11):43-4. (19) Zu SM, Frrester L, Giulivi A. Hepatitis C update. Canadian Jurnal f Public Health 2003; 94(2): (20) Canadian Bld Services. Clinical Guide t Transfusin Available frm: (21) Public Health Agency f Canada (PHAC). Ntifiable Diseases On-Line: Hepatitis C Available frm: dsl-smed.phac-aspc.gc.ca/dsl-smed/ndis/diseases/hepc_e.html (22) Webber R. Hepatitis C. Cmmunicable Disease Epidemilgy and Cntrl. 3 ed. Cambridge: Cambridge University Press; p (23) Backmund M, Myer K, Edlin B. Infrequent reinfectin after successful treatment fr hepatitis C virus infectin in injectin drug users. Clinical Infectius Diseases 2004; 39: (24) Public Health Agency f Canada (PHAC). Reprted Cases f Hepatitis c frm January 1 t December 31, 2007 and January 1 t December 31, 2008 and Crrespnding Rates fr January 1 t December 31, 2007 and (25) Alberta Bld -brne Pathgens and Sexually Transmitted Infectins Surveillance Wrking Grup Alberta Bld-Brne Pathgens and Sexually Transmitted Infectins Surveillance Reprt Available frm: (26) Public Health Agency f Canada. Hepatitis C Preventin: An Examinatin f Current Internatinal Evidence Available frm: (27) Patrick DM, Buxtn JA, Bigham M, Mathias RG. Public health and hepatitis C. Canadian Jurnal f Public Health 2000; 91:S18-S21. (28) Public Health Agency f Canada (PHAC). Infectin cntrl guidelines: Handwashing, cleaning, disinfectin, and sterilizatin in health care. CCDR 1998; 24(S8): Gvernment f Alberta 12 f 12