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, 1998
    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. 02/2017: Please note we are currently updating our Quick Guides. 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 fluid, amniotic fluid, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid and synovial fluid 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?
Source Person (SP):
• HIV Ag/Ab or HIV Ab (rapid HIV testing preferred if accessible)*
• HCV Ab (CDC prefers HCV RNA)
• HBV surface Ag
*If SP’s rapid HIV test is positive, assume this is a true positive and send confirmatory/supplemental testing. See below*.
Exposed Person (EP):
(If no exposure occurred or SP is confirmed negative on baseline testing, no baseline testing is clinically indicated for the EP. Testing may be considered for other purposes including medicolegal concerns or as per institutional protocols. For bites, see “How should a human bite be managed?”)
• HIV Ag/Ab or 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), 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 can be considered immune. For all others, see the “Exposures to HBV” section of this guide. For additional details on HIV testing, see the PEP Quick Guide for Occupational Exposures

Exposures to HBV

How are exposures to HBV managed?
We strongly encourage source person testing for Hepatitis B surface antigen.
• If source person is known to be hepatitis B uninfected, no hepatitis B testing or post-exposure 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 a complete HBV vaccine series, indicated by post-vaccination HBsAb titer ≥10 mIU/mL), they are considered to have lifelong immunity and need no hepatitis B testing or post-exposure treatment.

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

Recommendations for Post-Exposure Prophylaxis After HBV Exposure

EXPOSED PERSON VACCINATION STATUS TEST RECOMMENDED FOR EXPOSED PERSON TREATMENT
Previously Vaccinated (see below *)
Responder after complete series (HBsAb ≥10 mIU/mL) None No action needed
Response unknown after 3 doses HBsAb If ≥10 mIU/mL: No action needed
HBsAb If <10 mIU/mL: check HBcAb, administer HBIG x 1** and revaccinate
HBsAb <10 mIU/mL after one series of 3 doses HBcAb (total) HBIG x 1** and revaccinate
Non-responder
(HBsAb <10 mIU/mL after two series of 3 doses)
 HBcAb (total) HBIG** x 2 (one month apart)
Unvaccinated or Incompletely Vaccinated
Unvaccinated or incompletely vaccinated HBcAb (total)
Follow-up at 6 months: HBcAb (total) and HBsAg
HBIG** x 1 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, a 4th vaccine dose (booster) can be followed with a HBsAb at 4-6 weeks; if this is positive (≥10 mIU/mL) the person is considered immune and no further treatment is needed.
** HBIG: 0.06mL/kg ASAP (max dose: 5mL). HBIG is considered effective up to a week after occupational exposures. Per CDC Guidelines, healthcare personnel (HCP) with anti-HBs <10mIU/mL after complete vaccination series (or who are unvaccinated/incompletely vaccinated), and sustain an exposure to a source person who is HBsAg-positive or has unknown HBsAg status, should undergo baseline testing for HBV infection as soon as possible after exposure, and follow-up testing approximately 6 months later. Initial baseline tests consist of total anti-HBc; follow-up testing consists of HBsAg and total anti-HBc.
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.

Exposures to HCV

How are exposures to HCV managed?
• The risk of HCV transmission after percutaneous exposure is about 1 in 56 (1.8%) when the source person is HCV-infected. There is no post-exposure prophylaxis currently available/approved for HCV prevention.
• After review of available studies, guidelines and summary documents, the CCC PEPline recommends the following approach:

Testing Recommendations for the Exposed Person

Recommendations Baseline testing Initial follow-up Final follow-up
PEPline 2017 HCV+ SP [1]
or
SP has potential HCV risk factors
HCV Ab [2] 6 weeks [3]
HCV RNA
6 months
(24 weeks)
HCV Ab [2][4][5]
SP HCV status unknown
or
SP is known and has no known HCV risk factors
Optional:
6 week HCV RNA
CDC 2016 [6] HCV Ab [2] ≥3 weeks HCV RNA Optional: ≥6 month HCV Ab [2]
CDC 2001 [7] HCV Ab and ALT If earlier diagnosis desired: HCV RNA at 4-6 weeks 4-6 months
HCV Ab and ALT
Abbreviations: HCV+ = hepatitis C positive; SP = source person; Ab = antibody; ALT = alanine aminotransferase
[1] For purposes of initial post-exposure management, a source person can be considered HCV+ if either HCV antibody or HCV RNA is positive (RNA is the more accurate indicator, as some people may have positive HCV antibody but are subsequently found to be HCV RNA negative).
[2] If HCV antibody is positive at any point, follow-up HCV RNA testing is required. Persons with confirmed positive HCV RNA results should be referred for further evaluation and care.
[3] The PEPline recommends initial HCV follow-up test at 6 weeks, to coincide with the first HIV follow-up test. There are no data that establish a clinical advantage to testing at 3 weeks vs. 6 weeks [Glynn, et al, Busch, et al, Hajarizadeh, et al]. HCV RNA becomes detectable beginning at 3 weeks. Testing earlier than 6 weeks can be performed at the discretion of the managing clinician, especially if preliminary assessment is needed. Positive HCV RNA indicates likely infection. However, approximately 25% of new infections will clear spontaneously [Naggie, et al]. Refer to an experienced provider for additional counseling, testing, and follow-up if positive.
[4] In HCV infection, HCV RNA can be transiently undetectable [Mosley, et al]. Additionally, HCV antibodies develop slowly. Therefore, even though an early initial negative HCV RNA can be preliminarily reassuring, the PEPline recommends further HCV antibody testing at 6 months (24 weeks) post-exposure to confirm transmission did not occur.
[5] An interval (i.e. 12-16 week) HCV antibody test may provide some reassurance for exposed persons in many instances (and align with HIV surveillance). However: (a) testing at this time point may not impact overall exposure management significantly, and (b) it is not sufficiently sensitive to completely exclude HCV transmission. Even at 15 weeks, only about 80% of HCV-infected persons will have positive HCV Ab [MMWR rr5005a1]. Therefore, the 6 month (24-week) HCV antibody test is considered to be conclusive in excluding HCV acquisition: ≥97% will be positive at 6 months post exposure [MMWR rr5005a1].
[6] Updated Information for Healthcare Personnel Potentially Exposed to Hepatitis C Virus (HCV): Recommended Testing and Follow-up (CDC). Nov 2016. Available at http://www.cdc.gov/hepatitis/pdfs/testing-followup-exposed-hc-personnel-3d.pdf.
[7] Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR 2001; 50 (RR11): 1-42.
Note regarding exposed persons with symptoms: Symptoms of a viral illness compatible with acute HCV at any point up to 6 months post-exposure should prompt immediate evaluation.
Note regarding availability and feasibility of HCV RNA testing: HCV RNA testing might not be available or feasible at all institutions.  If it is not possible to obtain the recommended HCV RNA testing, surveillance using antibody testing is essential in assessing HCV transmission.
Note regarding hepatic enzyme testing: The PEPline does not recommend routine liver enzyme testing for follow-up because of the possibility of abnormal results from causes other than HCV.
References cited:
Busch MP, Shafer KAP. Acute-phase hepatitis C virus infection: implications for research, diagnosis, and treatment. Clin Infect Dis. (2005) 40 (7):959-961.
Glynn SA, Wright DJ, Kleinman SH, et al. Dynamics of viremia in early hepatitis C virus infection. Transfusion. 2005 June; 45(6):994–1002.
Hajarizadeh B, Grebely J, Applegate T, et al. Dynamics of HCV RNA levels during acute hepatitis C virus infection. J Med Virol. 2014 Oct; 86(10): 1722–1729.
Mosley JW, Operskalski EA, Tobler LH, et al. The course of hepatitis C viraemia in transfusion recipients prior to availability of antiviral therapy. J Viral Hepat. 2008 Feb;15(2):120-8.
Naggie S, Holland DP, Sulkowski MS, et al. Hepatitis C virus postexposure prophylaxis in the healthcare worker: why direct-acting antivirals don’t change a thing. Clin Infect Dis. 2017 Jan 1;64(1):92-99. Epub 2016 Sep 28.
Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR. April 27, 2001;50(RR05):1-43. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm.

Follow-Up Testing of the Exposed Person

HBV (See Exposures to HBV)
• Follow-up testing is only necessary for persons who do not have baseline (or history of) positive HBV surface Ab after complete vaccine series.
• If SP is HBsAg positive, check HBsAg and HBcAb at 6 months.
• If SP cannot be tested for HBV or SP is unknown, testing should be as above.
• If SP is HBsAg negative, no follow-up testing is clinically indicated to determine whether transmission occurred, although follow-up testing to confirm post-vaccination serologic status is recommended.
• Symptoms of acute hepatitis should prompt immediate evaluation.

HCV (See Exposures to HCV)
• If SP is HCV positive (or HCV status is unknown but there is a concern for risk), obtain follow-up HCV RNA at 6 weeks and HCV Ab at 6 months (24 weeks). If SP HCV status is unknown or there are no known HCV risk factors, HCV RNA at 6 weeks can be considered; however, final follow-up testing should be performed with HCV Ab at 6 months (24 weeks).
• If SP is HCV negative, no follow-up testing is clinically indicated for the EP.
• Symptoms of acute hepatitis should prompt immediate evaluation.

For HIV testing of the Exposed Person, see the PEP Quick Guide for Occupational Exposures.

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.

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