The European Journal of Public Health Advance Access originally published online on July 21, 2005
The European Journal of Public Health 2005 15(5):467-469; doi:10.1093/eurpub/cki032
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Infectious Diseases |
An assessment of hepatitis C virus infection among health-care workers of the National Cancer Institute of Naples, Southern Italy
Maurizio Montella1,2, Anna Crispo1, Maria Grimaldi1, Pasquale Ruffolo3, Domenico Ronga4, Francesco Izzo5 and Angelo A. Mastro5
1 Epidemiology Unit, National Cancer Institute of Naples, ‘G. Pascale’ Foundation, Via M. Semmola Naples, Italy
2 Cancer Registry (R.T.P.), Campania Region, Italy
3 Thoracic Surgery Unit, National Cancer Institute of Naples, ‘G. Pascale’ Foundation, Via M. Semmola Naples, Italy
4 Transfusional Centre, National Cancer Institute of Naples, ‘G. Pascale’ Foundation, Via M. Semmola Naples, Italy
5 Surgery Unit ‘D’, National Cancer Institute of Naples, ‘G. Pascale’ Foundation, Via M. Semmola Naples, Italy
Correspondence: Maurizio Montella, MD, Epidemiology Unit, National Cancer Institute, Via Mariano Semmola, 80131 Naples, Italy, tel: +39 81 5903816, fax: +39 81 5462900, e-mail: epidemiologia.int{at}tin.it
Received February 10, 2004, accepted July 5, 2004
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Abstract |
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Background: As many people with chronic hepatitis C virus (HCV) infection are asymptomatic, HCV infection could spread easily among the health-care workers of the National Cancer Institute of Naples (especially before the identification of HCV and in the absence of good, effective preventative measures, e.g. sterile syringe use, gloves, protective glasses). Methods: In order to determine whether there is a transmission risk for HCV infection from patient to health-care worker, we carried out a cross-sectional study of a cohort of National Cancer Institute health-care workers in Naples, Southern Italy. Results: The
2-test was not significant; we did not find any significant risk for HCV in the ‘other untrained staff’ group [odds ratio (OR) 2.2; 95% confidence interval (CI) 0.4–10.9] or in the health-care workers group (OR 1.6; 95% CI 0.4–7.0). In the health-care worker subgroups, doctors were the reference category because of the low prevalence of HCV in this subgroup (3.3%). A non-significant association was found in the professional nurses group (OR 2.7; 95% CI 0.8–8.8), as well as in the categories of technicians and biologists. Conclusions: No excessive risk was found among the health-care workers as a whole or among the different categories of personnel, confirming that health-care employees have benefited sufficiently from preventative measures.
Keywords: HCV, health-care workers, prevention, public health, Southern Italy
Hepatitis C virus (HCV) is a recently identified virus, and its mechanism of transmission is not yet completely known. HCV infection is an emerging health problem.1 Many studies have shown that there are low-risk groups (blood donors), but of great significance are those groups with a high risk of contagion through contaminated needle-stick (intravenous drug users, veterans, hemodialysis patients, prisoners), especially as the high prevalence in drug users has confirmed that the main risk factor for the transmission of HCV is represented by the exchange of syringes.2–4 Health-care workers, a group seemingly at high risk for contagion, have demonstrated a low-risk for HCV infection.5
Owing to the several variants in the factors associated with prevalent HCV infection that may exist and the fact that indirect transmission of HCV may occur, as well as the fact that many people with chronic HCV infection are asymptomatic, the spread of HCV infection among the health-care workers of the National Cancer Institute of Naples is an understandable possibility. Even though there were effective preventive measures already in existence, only after the identification of HCV were these measures improved, with increased attention towards health-care workers. In Southern Italy, owing to the absence of good preventative measures in the past (e.g. extensive use of glass syringes, non-sterile syringe use, general poverty, poor education and promiscuity), a high prevalence for HCV was demonstrated in patients admitted to our Institute from 2000 to 2001, with the prevalence of HCV infection varying according to gender (9.0% for men and 7.0% for women) and diagnosis (up to 70% for liver cancer).6–8
In order to determine the transmission risk for HCV infection from patient to health-care worker, we carried out a cross-sectional study of a cohort of National Cancer Institute health-care workers. The National Cancer Institute is a scientific Institute with 300 beds. Its activities involve many different types of treatment and research activities in various research fields (e.g. clinical trials, genetic research, epidemiological studies).
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Materials and methods |
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The study recruited all staff of the National Cancer Institute over 30 years of age and employed since 1970. The HCV test results referenced the first laboratory screenings carried out in 1991, when the test became mandatory for health-care workers in Italy (since that year, it has become mandatory annually). The serological diagnosis of HCV infection was carried out on residual serum samples using a first-generation enzyme-linked immunosorbent assay (ELISA) test (Ortho Diagnostic Systems, Raritan, NJ, USA). In following years, the samples were re-tested with the new generation ELISA test. We considered as positive for anti-HCV only those positive for both tests, as we found only a slight difference between the two tests.
We enrolled 781 National Cancer Institute employees. They comprised: 91 administrative personnel (personnel management employees, accounting employees, etc., who normally have no contact with patients), 112 ‘other untrained staff’ (OUS) (cleaning and maintenance employees) and 578 health-care workers. This latter group consisted of 349 professional nurses (administrative therapies and everything concerning direct assistance to patients), 149 doctors (physicians and surgeons), 45 biologists (serological and biochemical investigation in laboratories) and 35 technicians (provide support with serological and biochemical investigation, radiation therapy, etc.). A 2-test was used to compare HCV infection in the three categories of National Cancer Institute staff. The administrative personnel screened for HCV antibodies were considered to have a reduced risk for HCV exposure, and thus were used as the reference category to compare the other groups with. For the subgroup analysis of health-care workers, we considered medical doctors as the reference category. Odds ratios (OR) and 95% confidence intervals (CI) for anti-HCV seropositivity were calculated by logistic regression analysis, adjusted for age and time of professional exposure. Because of the small number of women and the none positive for HCV that existed in some of the professional categories, we considered only the men in the multiple logistic analysis.
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Results |
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The prevalence in the administrative personnel group was 5.6% (three of 54) among males and 8.1% (three of 37) among females. The OUS category reported a prevalence of 12.5% (12 of 96) among males, which proved to be the greatest percentage when compared with the other professional categories, while there were no positives reported among the females. The HCV prevalence rate for health-care workers was 6.9% for males and 3.3% for females. Among the professional subgroups, the professional nurses had the highest prevalence (8.9%) amongst the men and a prevalence of 4.4% amongst the females; for the categories of doctors, technicians and biologists, among the men, the prevalence rates were 3.3% (four of 121), 6.7% (two of 30) and 9.5% (two of 21), respectively, while no positives were recorded amongst the females (see table 1). The
2-test was not significant; we did not find any significant risk in the multivariate logistic regression analysis and no significant association in terms of risk for HCV in the OUS male group (OR 2.2; 95% CI 0.4–10.9) or in the health-care workers group (OR 1.6; 95% CI 0.4–7.0). In the health-care worker subgroups (males), doctors were the reference category owing to the low prevalence of HCV in this subgroup (3.3%). A non-significant association was found in the professional nurses group (OR 2.7; 95% CI 0.8–8.8), as well as in the categories of technicians and biologists (see table 2). We also computed the OR among women, comparing the administrative personal (reference category) with the other employees of the National Cancer Institute, adjusting for age and time of professional exposure: OR 0.4; 95% CI 0.08–1.62.
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Discussion |
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HCV infection has been shown to demonstrate two distinct transmission patterns. In the first, where the majority of infections were found among young persons (indicating that the risk for HCV infection has been greatest during the relatively recent past), injection drug use was the predominant risk factor (e.g. USA, Australia). In the second, where the majority of HCV infections were found among adults, unsafe injection and contaminated equipment used in health-care-related procedures appears to have played the predominant role in HCV transmission.6,9 Studies conducted in Southern Italy, where the health system is less efficient than in Northern Italy, examined two variables associated with HCV infection: age and previous hospitalization. The findings from these studies indicate that HCV infection is common in the elderly, perhaps as a result of past iatrogenic transmission. The prevalence in general population was 10.4% (higher than the prevalence that we found in the health-care workers) and increases from 0.4% in subjects 10–29 years of age to 34.0% in those <60 years of age. These findings again indicate that HCV infection is common in the elderly, perhaps as a result of past iatrogenic transmission such as surgical intervention. Lack of modern hygiene standards in medical practice may have caused many HCV infections in the past.7
However, our results are similar to other studies on the seroprevalence of HBV and HCV among health-care workers, and show that prevalence is quite similar to that of the control group.10 No substantial risk of HCV transmission from infected patients to the various professional groups (whether male or female) emerged, even in an environment hyperendemic for HCV. Although two positive HCVs were found among the surgeons and two positive HCVs were found among the laboratory physicians, no excessive risk was found among the health-care workers as a whole, or among the different categories of personnel, confirming that health-care employees have benefited sufficiently from the preventative measures in place.
Key points
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Acknowledgments |
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We acknowledge the invaluable contribution of Jenà Wynn-Bellezza for her editorial assistance. This work was supported by a grant from ‘Compagnia di San Paolo’.
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References |
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