Hepatitis Exposure Management

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Hepatitis Exposure Management

Tools to Help You Manage Exposures Hepatitis B and C.

Prompt assessment and management of potential hepatitis B and C exposures from needlesticks, splashes, sexual exposure, and human bites is paramount. While each exposure case is unique, there are standard strategies that help you determine who should receive hepatitis B prophylaxis and how to evaluate and monitor hepatitis C exposures. CCC clinicians have compiled and created tools to assist you in identifying what constitutes an exposure and how to test for and follow up on exposures confidently.

Up-to-date hepatitis exposure management guidelines

Current U.S. Public Health Service guidelines and select treatment protocols for managing exposures to HIV and hepatitis B and C. Guidelines on this page are updated in concordance with USPHS updates for each topic.

Hepatitis Exposure Management Guidelines

  • CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, 2013
    Open PDF Open PDF | From The CDC
  • CDC Recommended Testing and Follow-up for Healthcare Personnel Potentially Exposed to Hepatitis C Virus, 2016
    Open PDF 
    Open PDF | From The CDC
  • Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis, 2001
    Open PDF Open PDF | From The CDC MMWR
  • Recommendations for Prevention and Control of Hepatitis C Virus Infection and HCV-Related Chronic Disease
    Open Link Open Link | From The CDC MMWR


Hepatitis Exposure Quick Guide

The Quick Guide provides Guidelines-based hepatitis exposure recommendations from our clinicians to help you with urgent decision-making for needlestick and other occupational exposures to hepatitis B and C. Learn at a glance how to assess an exposure, how to best manage the exposure, and what initial and follow-up tests are required. 12/2016: Please note we are currently updating our Quick Guide. For the most up-to-date recommendations, please call our PEPline directly at (888) 448-4911.

Initial Evaluation: Assessing Exposures and Testing

What is considered to be a potential exposure to HIV, HBV or HCV?
For transmission of blood borne pathogens (HIV, HBV and HCV) to occur, an exposure must include both of the following:
• Infectious body fluid
o Blood, semen, vaginal fluids, amniotic fluids, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid and synovial flood can transmit HIV, HBV and HCV.
• Note that saliva, vomitus, urine, feces, sweat, tears and respiratory secretions do not transmit HIV (unless visibly bloody). The risk of HBV and HCV transmission from non-bloody saliva is negligible.
• A portal of entry
(percutaneous, mucous membrane, cutaneous with non-intact skin).
If both of these factors are not present, there is no risk of transmission and further evaluation is not required.

What baseline testing should be performed after an exposure?
(If no exposure occurred or SP tests negative, no testing is indicated.)
Source Person (SP):
• HIV Ab (rapid HIV Ab testing preferred if accessible)
• HCV Ab
• HBV surface Ag
*If SP’s rapid HIV Ab test is positive, assume this is a true positive and send confirmatory testing, usually with a Western Blot test.
Exposed Person (EP):
• HIV Ab
• HCV Ab
• HBV testing: Depends on immunization status.
Note that most healthcare and public safety personnel have been vaccinated against hepatitis B. If previously vaccinated and they know they responded to the vaccination series (a positive titer is >10mIU/mL, but most do not know their titer), they are considered to have lifelong immunity and require no further testing or treatment. Similarly, if employee health records indicate they responded to the vaccination series, they are considered to be immune. For all others, see the “Exposures to HBV and HCV” section of this guide.

Exposures to HBV and HCV

How are exposures to HBV managed?
We strongly encourage Source Patient testing for Hepatitis B surface antigen.
• If Source Patient is known to be hepatitis B uninfected, no hepatitis B testing or treatment of the Exposed Person is needed.
• If Exposed Person is known to be immune (e.g., they were told they had a positive response to the vaccine series, as measured by a follow-up HBsAb titer ≥10 mIU/mL), they are considered to have lifelong immunity and need no hepatitis B testing or treatment.


If Source Patient is known to have had hepatitis B or the Source Patient’s hepatitis B status is unknown, manage blood exposures as follows:

Recommendations for Post Exposure Prophylaxis After Exposure to HBV

EXPOSED PERSON VACCINATION STATUS TEST RECOMMENDED TREATMENT
Previously Vaccinated (see below *)
Responder
(HBsAb ≥10 mIU/mL)
None No action needed
Response unknown HBsAb If ≥10 mIU/mL: No action needed
HBsAb If
Non-responder
(HBsAB ≤10 mIU/mL after one series of 3 doses)
HBcAb (total) HBIG** and revaccinate
Non-responder
(HBsAb ≤10 mIU/mL after two series of 3 doses)
HBIG** x 2 (one month apart)
Unvaccinated or Incompletely Vaccinated
Unknown HBcAb (total)
Follow-up at 6 months: HBcAb (total) and HBsAg
HBIG** and vaccinate/revaccinate
* HBV (vaccine): The series is usually given at baseline, 1 month, and 6 months, followed by HBsAb to confirm immunity (HBsAb ≥10 mIU/mL). For persons previously immunized with the series of 3 immunizations but have negative HBsAb titer when tested at the time of exposure and source patient is negative for HBsAg, the first injection in the series can be followed with a HBsAb at 4-6 weeks; if positive (≥10 mIU/mL) the person is considered immune and no further treatment is needed.** HBIG: 0.06mL/kg ASAP. All persons receiving HBIG should have HBsAg and HBsAb drawn before HBIG administration. HBIG is considered effective up until a week in the occupational setting. Note: Testing the exposed HCP for prior HBV infection is not required before vaccinating unless the exposed is at independent risk of HBV infection (e.g., from HBV endemic area). Adapted from: CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR: December 20, 2013

How soon do hepatitis B vaccine and HBIG need to be given?
In general, if hepatitis B vaccine and/or HBIG are required, the sooner they are administered the better. The effectiveness of HBIG when given after 7 days for occupational exposures is unknown.

How are exposures to HCV managed?
• The risk of transmission of HCV attributed to needlestick exposure is about 1 in 56 (1.8%) exposures when the source patient is HCV-infected. There is no post-exposure prophylaxis for HCV.
• Direct viral testing with HCV RNA PCR viral load at 6 weeks, before HCV Ab seroconversion has occurred, allows for early identification of transmission and subsequent referral for early evaluation and potential HCV treatment. The rate of spontaneous clearance of HCV infection is about 25% in healthy persons. However, early diagnosis and treatment may increase HCV clearance to 90% or greater.
• HCV antibody testing should be performed at 4-6 months to rule out HCV infection.

How should a human bite be managed?
• Human bite exposures can result in exposure to both the biter and the bitten person. The bitten sustains a cutaneous exposure to HIV if blood was present in the mouth of the biter before the bite. The biter sustains a mucous membrane exposure to HIV if blood from the bitten person enters the oral cavity of the biter.
• If the saliva is non-bloody, there is no risk to the exposed for HIV. The risk of HBV and HCV transmission from non-bloody saliva is negligible.

Follow-Up Testing

What follow-up testing should be performed?
Source Person:
The SP does not need follow-up testing.

Exposed Person:
Standard follow-up for an EP should include the following:

HBV
• Serologic follow-up testing for HBV exposures is only required for persons who do not have baseline positive HBV surface Ab. Testing at 6 months consists of HBsAg and HBcAb (total).
(See also Exposures to HBV and HCV)

HCV
• If SP is HCV positive or has risk factors for HCV but unknown HCV status, obtain HCV RNA PCR viral load at 6 weeks and HCVAb at 4-6 mo. We generally recommend at 6 months to match with HIV testing.
• Symptoms of acute hepatitis should prompt immediate evaluation.
• If SP is HCV negative, no follow-up testing is recommended for EP.

HIV
• If SP is HIV positive, check HIV Ab at 6 weeks, and a 4th generation Ag/Ab test or HIV RNA test at 3-4 months. If these tests are not available, standard antibody testing should be performed at 3 and 6 months. Extended testing to 12 months is only indicated for HCP who actually became infected with HCV after exposure to an HCV-HIV co-infected source. Symptoms of acute HIV should prompt immediate evaluation.
• If SP cannot be tested for HIV or SP is unknown, testing should be as above.
• If SP tests negative for HIV, no follow-up HIV testing is recommended for the EP.

Guidance for Exposed Persons

What do I do if I am the exposed individual?
Exposure to HIV, HBV, and HCV requires immediate evaluation by a medical professional (e.g., emergency room, urgent care, Occupational/Employee Health service, personal physician). Report your exposure to your supervisor immediately.



Additional hepatitis exposure management resources

The CCC has compiled or created the following tools to aid you in your practice when managing exposures to hepatitis B and C.

  • Recommended Testing Sequence for Identifying Current Hepatitis C Infection
    Open PDF Open PDF
  • Interpretation of Hepatitis C Test Results
    Open PDF Open PDF