Hepatitis C virus: An overview for dental health care providers R. Monina Klevens and Anne C.

Moorman JADA 2013;144(12):1340-1347 The following resources related to this article are available online at jada.ada.org ( this information is current as of November 27, 2013):
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Hepatitis C virus
An overview for dental health care providers
R. Monina Klevens, DDS, MPH; Anne C. Moorman, BSN, MPH

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IN G

ED

HEPATITIS C: AN OVERVIEW

Even before HCV was identified in the late 1980s, the observation that not all transfusion-associated hepatitis was associated with hepatitis A or B led to the label non-A, non-B hepatitis.4 Since then, our understanding of the virus and the devel-

Dr. Klevens is a medical epidemiologist, Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Mailstop G-37, 1600 Clifton Road, Atlanta, Ga. 30333, e-mail rmk2@cdc.gov. Address reprint requests to Dr. Klevens. Ms. Moorman is an epidemiologist, Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta.

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rompted by the transmission of hepatitis C virus (HCV) in a private dental practice in 2013,1 this review brings dental health care providers (DHCPs) up to date with the natural history and epidemiology of HCV; new screening guidelines from the Centers for Disease Control and Prevention2,3 (CDC); and new treatment, surveillance and health careassociated HCV transmission and prevention options. The article provides references and websites offering additional detail for those interested in learning more.

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Background and Overview. Changes in the science of hepatitis C virus (HCV) infection and transmission in a private dental practice A 1 provide an opportunity to update dental health RT IC LE care providers about this pathogen. The authors aims in this review were to create awareness of health care associated transmission of hepatitis C and provide an update on the changes in testing and treatment. The authors include data from population-based epidemiologic surveys, clinical practice guidelines, surveillance reports and practice protocols. Results. In the United States, the elevated prevalence of chronic HCV infection among baby boomerspeople born during the period from 1945 through 1965led the Centers for Disease Control and Prevention to release new national screening guidelines. The authors summarize information about the natural history and epidemiology of hepatitis C and describe the new guidelines and novel treatment options. In addition, the authors provide an overview of how outbreaks of health careassociated HCV are detected and prevented. Practical Implications. Because dental health care professionals likely will treat people with current infection, education in the current science of HCV infection is useful. Key Words. Hepatitis C; Centers for Disease Control and Prevention; infections. JADA 2013;144(12):1340-1347.
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opment of treatments TABLE 1 for infected people have Resources regarding viral hepatitis and other evolved rapidly. HCV infections that can be transmitted during health is an RNA virus with great molecular hetcare services.* erogeneity within and RESOURCE WEBSITE DESCRIPTION across people, because www.cdc.gov/ Listing of investigations Healthcare-Associated mutations occur frehepatitis/Outbreaks/ of health careassociated Hepatitis B and C quently during replicaHealthcareHepOutbreakTable. transmission of hepatitis Outbreaks Reported to htm B or C, including links to the Centers for Disease tion. Viral diversity is references Control and Prevention one of the challenges to * (CDC) in 2008-2012 vaccine development; www.cdc.gov/injectionsafety Continuing education Injection Safety others include the lack documents, slides and campaign materials of a nonprimate animal www.cdc.gov/HAI/settings/ Integrates information Guide to Infection model and the unclear outpatient/outpatient-carefrom other sources to help Prevention for immune responses that guidelines.html health care workers prevent Outpatient Settings: infections in ambulatory Minimum Expectations lead to viral clearance.5 care settings for Safe Care (Outpatient There are six major Guide and Checklist) genotypes of HCV that www.cdc.gov/HAI/prevent/ Links to detailed documents Healthcare-Associated vary according to geoprevent_pubs.html about infection control, Infections: Guidelines including hand hygiene and and Recommendations graphical distribution; standard precautions most isolates (about 85 www.cdc.gov/ Step-by-step approach Viral Hepatitis percent) in the United hepatitis/Outbreaks/ to investigating possible Outbreaks: Healthcare States are genotype 1a HealthcareInvestigationGuide. transmission of infections Investigation Guide htm during health care, intended or 1b.4 for state and local health Transmission. departments HCV is transmitted * Source: Centers for Disease Control and Prevention. most efficiently by the Source: Centers for Disease Control and Prevention. Source: Centers for Disease Control and Prevention. parenteral route, and Source: Centers for Disease Control and Prevention. this transmission can Source: Centers for Disease Control and Prevention. occur at even low levels of viral contamination. From 2008 through 2012, CDC received for prevention of health careassociated hepanotice of 15 outbreaks of health careassociated titis infections, with new toolkits and resources transmission of HCV in nondental ambulatory available (Table 16,13-16). 6 care settings. In general, transmission of infecIn the United States, injection drug use is tious agents in health care settings can occur the risk behavior most frequently associated from patient to patient (for instance, because with HCV infection.17,18 Before 1992, and the of improper infection control practices), from availability of testing to screen blood and blood patient to provider (for instance, as a result of products, health care transmission in the form needle sticks) or from provider to patient (for of blood transfusions was associated with about instance, during surgery). The risk of transmis15 to 20 percent of HCV infections.19 Of more resion depends on factors related to the agent, the cent concern are clusters of HCV among young host and the environment. HCV can survive in nonurban adults injecting drugs, who often the environment for 16 hours on a dry surface7 started injecting cheaper heroin when they lost and in water at low temperatures for up to five access to prescription opioids.20,21 Sexual trans8 9 months, and it can be detected in saliva. Dismission is rare except with high-risk sexual infectants that inactivate hepatitis B virus also practices.22 Likewise, no documented infections will kill HCV on environmental surfaces,10 and have been associated with tattoos and piercing commercial hand antiseptics are effective in inperformed in commercial sites, but tattoo- and activating the virus on hands.8 The estimated risk of infection with HCV ABBREVIATION KEY. ALT: Alanine aminotransferase. from a percutaneous injury is about 2 perCDC: Centers for Disease Control and Prevention. 11 cent that is, greater than that with human CMS: Centers for Medicare and Medicaid Services. immunodeficiency virus (HIV), but less than DHCP: Dental health care provider. HCV: Hepatitis C that with hepatitis B virus. Standard Precauvirus. HIV: Human immunodeficiency virus. SHEA: tions for injection safety12 remain the foundation Society for Healthcare Epidemiology of America.
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piercing-associated transmissions have been documented in unregulated environments such as prisons.23 Burden of disease. DHCPs reasonably can expect to encounter patients with HCV infection, because about 1.6 percent of the U.S. population has been infected at one time or another.24 Although about 20 percent of infections resolve spontaneously,25 most infected people develop chronic infection (defined as an HCV-RNA positive test result from plasma or serum). CDC estimated in 2002 that 3.2 million people (1.3 percent of the total population) in the United States were HCV-RNA positive.24 The prevalence of chronic infection is higher among people born from 1945 through 1965 (3.25 percent of whom are infected).26 About 60 percent of dentists are in this cohort (baby boomers)27 and may have undetected past or current infection themselvesanother reason for DHCPs to be knowledgeable about hepatitis C. Acute infection is symptomatic in about 50 percent of cases in studies of people not infected via injection drug use, but in only 10 percent of people infected through injection drug use.28 When symptoms are present, they are nonspecific and can include jaundice, fever, abdominal pain, malaise and elevated liver function test results (alanine aminotransferase [ALT] or aspartate aminotransferase. Many (about 50 percent) are unaware of their infection status.29 Among people with chronic infection, about 15 to 30 percent may experience progression to liver cirrhosis,19 and of these patients, an estimated 1 to 3 percent will develop hepatocellular carcinoma.30 Currently, HCV is the leading indication for liver transplantation, costing a median of $120,500 per hospitalization.31 Deaths associated with HCV infection surpassed deaths associated with HIV infection in 2007.32 Screening, diagnosis and treatment. Until 2012, screening for HCV infection was recommended for people at highest risk of infection (that is, users of injection drugs, people with medical conditions that required dialysis or transfusions, and people who received organ transplants or transfusions before 1992) or with a known exposure to HCV (that is, children born to HCV-positive women and occupationally exposed people).33 CDC expanded the risk-based screening recommendations in 2012 to include an age-based recommendationspecifically, a one-time test for all people born between 1945 and 1965, with alcohol use screening and referral to care for infected people.26 Diagnosis in public health and primary care settings begins with the detection of antibody

against HCV (anti-HCV).3 Rapid tests now are available that have high sensitivity and specificity; these use blood from either a fingerstick capillary or whole blood from venipuncture and provide results in less than 40 minutes.34 However, there are no tests approved in the United States to detect antibodies in oral fluid. Most anti-HCV tests are immunoassays. Immunoassays can indicate whether or not a person has ever been infected with HCV, but only a nucleic acid test to detect HCV-RNA can indicate whether a person has current infection.3 HCVRNA tests can be qualitative (positive or negative) or quantitative (viral copies per milliliter). The genotype test is another type of nucleic acid test that can be performed to support decisions about clinical management.35 Not all infected people receive diagnosis and treatment. Researchers combined data from a CDC cohort with data from a nationally representative survey to determine the number of infected people who have been diagnosed and are receiving appropriate care.36 Of the estimated 3.2 million U.S. residents currently infected, only about 50 percent have been diagnosed. Of these, about 32 to 38 percent have been referred to care, 7 to 11 percent have been treated and 5 to 6 percent have been cured.36 Until 2011, the routine treatment protocol consisted of pegylated interferon plus ribavirin.35 This regimen required weekly injections, had only about a 50 percent success rate for genotype 1 and was associated with frequent adverse effects. Since then, the protease inhibitors telaprevir and boceprevir have been introduced; they still are used in conjunction with interferon and ribavirin but have greater success rates.37,38 In 2013, sofosbuvir, used in the first interferonfree treatment regimens, was submitted for U.S. Food and Drug Administration approval.39 These and other therapies currently undergoing clinical trials already are revolutionizing the treatment of chronic HCV infection.40
SURVEILLANCE

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Surveillance for HCV in the United States. National surveillance is conducted for two discrete HCV events: acute disease and past or present hepatitis C infection (that is, people with current chronic infection and people with a history of infection). The surveillance case definition for acute disease requires a combination of symptoms and laboratory findings, but for past or present disease, only laboratory findings are required. In 2012, CDC,41 working with the Council of State and Territorial Epidemiologists, defined acute HCV infection as

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illness with discrete onset of symptoms (such as nausea, Hospital and Commercial anorexia, fever, malaise or Health Care Providers Clinical Laboratories abdominal pain) and jaundice or elevated serum ALT levels (> 400 international units per liter). They also set Maintain database Local Health Departments forth an option of identifyInvestigate new cases Classify ing a new seroconversion as Analyze an acute case; this requires only one positive test result State Health Departments with a previous negative result within the previous six months.18 With advances Centers for Disease Control in information technology, and Prevention most health departments have developed electronic, laboratory-initiated reporting to conduct routine surveillance for viral hepatitis Figure. Flow of information in hepatitis C surveillance. cases more efficiently.42 Flow of surveillance information. HCV frequently begins with a telephone call from an infection is a reportable condition in most astute clinician who diagnoses HCV infection in states.17 Providers, facilities and laboratories a person with no behavioral risk factors or sees usually are required to report potential cases, an unexpectedly high number of infections in a but in practice, most cases are identified first short period (such as two to three cases in two from laboratory-initiated reporting. Local and weeks compared with no cases for months). At state health departments receive the reports the health department, follow-up of potential and check to determine whether the case was health careassociated transmission of HCV reported previously or represents a new case.43 typically begins by confirming whether infection Health departments conduct investigations of indeed occurred. Then surveillance investigareports, depending on available resources, and tors assess all potential exposures within the submit these reports to CDC each week (Figure). incubation period, including, if appropriate, a When a person with HCV infection is deterrelative measure of the risk of potential transmined to represent a new, acute case, health mission of HCV during health care delivery. departments pursue supplemental clinical and Once the report is received, health department demographic data for him or her; however, in officials face many barriers to conducting inpractice, resources frequently limit the number vestigations.44 If the investigators identify risky of cases investigated. Investigators also assess infection control practices, patients potentially risk factors for infection by identifying expoexposed during the at-risk period are notified sures during the incubation period (two weeks of the need to seek testing. More than 90,000 to six months before symptom onset). Among at-risk people have been notified of the need the potential exposures, health departments to seek HCV testing because of their possible collect history of accidental needlesticks, outpaassociation with the 16 outbreaks reported to tient injections, employment in the medical or CDC from 2008 through 2012.6 CDC16 developed dental field, hospitalization, surgery, and dental a Healthcare Investigation Guide to support treatment or oral surgery. health departments in their efforts to quickly Data from HCV surveillance are used in identify transmission of infection and to control public health to describe burden of disease and any unsafe clinical practices (Table 16,13-16). characteristics of infected populations. CDC and Health department personnel often work in health departments disseminate reports online collaboration with CDC during HCV investigaand in scientific venues to guide prevention and tions, especially in the area of laboratory support. Genetic sequencing is used to assign virus help health care policymakers plan for health isolated from different individuals into related care resource needs at the state and national clusters according to their degree of relatedlevels.17 Health careassociated outbreak deness.44 For example, in an investigation of HCV tection and investigation. An investigation transmission in an endoscopy clinic, molecular
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characterization confirmed a high degree of similarity between two source patients with chronic HCV infection and seven patients infected at the clinic.45 Laboratory analyses are, and must be, conducted and the results interpreted as a component of a larger epidemiologic investigation. Reported health careassociated HCV outbreaks. From 2008 through 2012, CDC received notice of 16 outbreaks of health careassociated transmission of HCV; 15 of these were in ambulatory care settings.6 Combined, these outbreaks involved 160 confirmed outbreak-associated infections. Five of these outbreaks likely were associated with syringe reuse, three were associated with drug diversion (that is, when a prescription medication is used by an infected health care worker with subsequent contamination of the medication vial or syringe) and six occurred in hemodialysis settings; in one outbreak, no identified lapses in infection control were observed during the investigation. The Oklahoma Health Department is collaborating with CDC in investigating the first transmission of HCV in a dental setting, specifically in an oral surgery practice. Further detail is available online.1 CDC maintains an updated list of viral hepatitis outbreaks associated with health care, as well as links to toolkits for investigation of health careassociated infections, on a website.46 Because of the long incubation period (up to six months) and typically asymptomatic course of acute HCV infection, many cases are missed by routine surveillance. Therefore, it is likely that only a fraction of such outbreaks have been detected. Asymptomatic infections frequently go undetected for many years, leading to underreporting of cases to the health department and difficulty in identifying a health care encounter during which transmission may have taken place. Furthermore, even people with HCV-related symptoms might not recognize them and seek medical attention, or the clinician might not suspect HCV infection. Even if diagnosed, HCV infections might not be reported to the health department because clinicians might not understand when, how or what to report. Personnel, resource and legal barriers may prevent state and local health departments from investigating clusters thoroughly and reporting them to CDC.44 There also is underrecognition of the potential for health care as a risk factor for viral hepatitis transmission, so the numbers reported to CDC likely lead to underestimation of the number of outbreak-associated cases and the number

of at-risk people notified of the need for screening. CDC has developed numerous tools and questionnaires to support health departments in investigating potential outbreaks of health careassociated infections.46,47
PREVENTION

There is no vaccine for primary prevention of hepatitis C. Standard Precautions remain the foundation of protection against transmission of HCV and other infectious agents during patient care in the dental setting. Original CDC infection control guidelines for dental offices were published in 2003,48 and these are the same basic principles and evidence base for infection control in all outpatient settings. In 2011, CDC14 developed a tool outlining the minimum expectations for safe care in outpatient settings. The tool contains basic information as a general reference from which more detailed documents can be accessed quickly and easily.14 Table 212 summarizes the Standard Precautions for dental and other outpatient settings. These include hand hygiene, proper use of personal protective equipment (that is, gloves, masks and gowns), safe handling of sharps and safe injection practices, environmental cleaning, proper use of medical equipment and drug delivery systems (such as reusable versus single-use), and respiratory hygiene and cough etiquette (that is, use of measures to contain respiratory secretions of symptomatic people and education of health care workers to prevent spread of respiratory secretions). CDC provides many resources for DHCPs in these areas (Table 16,13-16), including continuing education for health care providers and materials to use in educating staff members in infection control. Injection safety. Safe injection practices are a part of the Standard Precautions. Most HCV transmissions in outpatient health care settings have been attributed to syringe reuse or other practices that led to contamination of the solution or medication intended to be injected49 (such as fentanyl or propofol). Medications never should be administered to more than one patient by means of the same syringe, even if the needle is changed. In other words, medication vials should not be entered with a used syringe or needle. Single-use vials should never be used for more than one patient.49 Postexposure care of health care workers. If, despite prevention efforts, a needlestick or other exposure to HCV occurs, it is important to have a protocol to follow in responding. Briefly, CDCs recommended follow-up for exposed health care workers consists of baseline HCV

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TABLE 2

Summary of Standard Precautions to prevent transmission of infectious agents during patient care in outpatient settings.*
COMPONENT Hand Hygiene Personal Protective Equipment Gloves Mask, eye protection, face shield Gown Proper Use of Equipment and Drug Delivery Systems Soiled patient-care equipment RECOMMENDATIONS FOR USE Perform after touching blood, body uids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts Wear when touching blood, body uids, secretions, excretions, contaminated items; wear when touching mucous membranes and nonintact skin Wear during procedures and patient-care activities likely to generate splashes or sprays of blood, body uids, secretions Wear during procedures and patient-care activities when contact of clothing or exposed skin with blood or body uids, secretions and excretions is anticipated

Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene after handling Develop procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas Handle in a manner that prevents transfer of microorganisms to others and to the environment Do not recap, bend, break or hand-manipulate used needles; use safety features when available; place used sharps in a puncture-resistant container Never administer medications from the same syringe to more than one patient; do not enter a medication vial with a used needle or syringe; never use singledose vials for more than one patient; follow proper infection control practices during administration of injected medications Instruct a symptomatic person to cover his or her mouth and nose when sneezing or coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation from other people, more than three feet if possible

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Environmental infection control Textiles (linen and laundry) Needles and other sharps Injection safety

Respiratory Hygiene and Cough Etiquette

* Adapted from Siegel and colleagues.12

antibody testing of both the exposed health care worker and the source patient.11 In addition, the health care worker should receive a baseline assessment of ALT activity. Follow-up testing of the exposed health care worker should be performed at, for example, four to six months after exposure. Testing for HCV-RNA also may be done at four to six weeks postexposure if earlier diagnosis is desired. Administration of immunoglobulin is not recommended for postexposure protection.11 CDCs50 2012 recommendations for the management of the care of health care workers infected with hepatitis B did not address the issue of HCV-infected health care workers. However, The Society for Healthcare Epidemiology of America (SHEA) recommends that HCVinfected health care workers with high circulating viral burden ( 104 genome equivalents/ mL) follow certain precautions and abstain from performing certain invasive procedures. According to SHEA guidelines, HCV-infected health care workers with less than 104 genome equivalents/mL of circulating virus should undergo

routine follow-up with a personal physician and maintain consultation with an infection control expert to ensure that they continue to use appropriate infection control practices.51 Oversight of infection control practices. The Centers for Medicare and Medicaid Services (CMS) requires periodic reports of quality measures from many facilities that receive reimbursement for services (such as ambulatory surgical centers and hemodialysis facilities). CMS routinely conducts audits and surveys of facilities through regional offices. CDC collaborates with CMS because both agencies are concerned with patient safety and preventing health careassociated infections (such as vaccination coverage for hepatitis B among patients receiving hemodialysis and among health care workers). For example, CDC developed an infection control audit tool to help ambulatory surgical centers prepare for CMS audits. Facilities that demonstrate adherence to CDC infection control guidelines receive CMS financial incentives. No such oversight exists for monitoring infection control practices in dental settings.
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isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(10 suppl 2): S65-S164. 13. Centers for Disease Control and Prevention. Injection safety. www.cdc.gov/injectionsafety. Accessed Nov. 4, 2013. 14. Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care, May 2011. www.cdc.gov/HAI/settings/outpatient/outpatientcare-guidelines.html. Accessed Nov. 6, 2013. 15. Centers for Disease Control and Prevention. Healthcareassociated infections: guidelines and recommendations. www.cdc.gov/ HAI/prevent/prevent_pubs.html. Accessed Nov. 4, 2013. 16. Centers for Disease Control and Prevention. Viral hepatitis outbreaks: healthcare investigation guide. www.cdc.gov/hepatitis/ Outbreaks/HealthcareInvestigationGuide.htm. Accessed Nov. 4, 2013. 17. Centers for Disease Control and Prevention. Surveillance for viral hepatitis: United States, 2011. www.cdc.gov/hepatitis/ Statistics/2011Surveillance/index.htm. Accessed Oct. 1, 2013. 18. Klevens RM, Hu DJ, Jiles R, Holmberg SD. Evolving epidemiology of hepatitis C virus in the United States. Clin Infect Dis 2012;55(suppl 1):S3-S9. 19. Alter MJ, Mast EE, Moyer LA, Margolis HS. Hepatitis C. Infect Dis Clin North Am 1998;12(1):13-26. 20. Centers for Disease Control and Prevention. Use of enhanced surveillance for hepatitis C virus infection to detect a cluster among young injection-drug users: New York, November 2004-April 2007. MMWR Morb Mortal Wkly Rep 2008;57(19):517-521. 21. Centers for Disease Control and Prevention. Notes from the field: risk factors for hepatitis C virus infections among young adultsMassachusetts, 2010. MMWR Morb Mortal Wkly Rep 2011;60(42):1457-1458. 22. Tohme RA, Holmberg SD. Is sexual contact a major mode of hepatitis C virus transmission? Hepatology 2010;52(4):1497-1505. 23. Tohme RA, Holmberg SD. Transmission of hepatitis C virus infection through tattooing and piercing: a critical review. Clin Infect Dis 2012;54(8):1167-1178. 24. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144(10):705-714. 25. Page K, Hahn JA, Evans J, et al. Acute hepatitis C virus infection in young adult injection drug users: a prospective study of incident infection, resolution, and reinfection. J Infect Dis 2009;200(8):1216-1226. 26. Smith BD, Morgan RL, Beckett GA, et al; Centers for Disease Control and Prevention. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965 (published correction appears in MMWR Recomm Rep 2012;61[43]:886). MMWR Recomm Rep 2012;61(RR-4):1-32. 27. American Dental Association. 2010 Survey of Dental Practice. Chicago: American Dental Association; 2011. 28. Klevens RM, Liu S, Roberts H, Jiles R, Holmberg S. Estimating acute viral hepatitis infections from reported cases. Am J Public Health. In press. 29. Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical followup among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology 2012;55(6):1652-1661. 30. Rosen HR. Clinical practice: chronic hepatitis C infection. N Engl J Med 2011;364(25):2429-2438. 31. Kim WR, Gross JB Jr, Poterucha JJ, Locke GR 3rd, Dickson ER. Outcome of hospital care of liver disease associated with hepatitis C in the United States. Hepatology 2001;33(1):201-206. 32. Ly KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007 (published correction appears in Ann Intern Med 2012;156[11]:840). Ann Intern Med 2012;156(4):271-278. 33. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease: Centers for Disease Control and Prevention. MMWR Recomm Rep 1998;47(RR19):1-39. 34. Smith BD, Drobeniuc J, Jewett A, et al. Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus. J Infect Dis 2011;204(6):825-831. 35. Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study of Liver Diseases. Diagnosis, management, and

CONCLUSIONS

The first documented HCV transmission in a dental setting serves as a reminder of the need to educate DHCPs about hepatitis C. An estimated 3.2 million people in the United States have chronic HCV infection; most are asymptomatic. HCV transmission in health care settings is preventable through the use of Standard Precautions, including injection safety measures. New tools are available to support health departments in conducting investigations and to give health care providers easy access to information about infection control. Because DHCPs likely will treat people with current or past infection, education in the evolving science of HCV infection could be of substantial value. n
Disclosure. Dr. Klevens and Ms. Moorman did not report any disclosures. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, Atlanta. The authors thank Drs. Jennifer Cleveland and Fujie Xu of the Centers for Disease Control and Prevention, Atlanta, for their thoughtful comments, which improved the manuscript of this article. 1. Tulsa Health Department. Public health response: situation update 22. www.tulsa-health.org/news/public-health-responsesituation-update-22. Accessed Nov. 4, 2013. 2. Moyer VA; U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2013;159(5): 349-357. 3. Centers for Disease Control and Prevention (CDC). Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep 2013;62(18):362-365. 4. Ray SC, Thomas DL. Hepatitis C: Non-A, non-B viral hepatitis and hepatitis C. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennetts Principles and Practice of Infectious Diseases. 7th ed. Philadelphia: Churchill Livingstone; 2009:2157. 5. Feinstone SM, Hu DJ, Major ME. Prospects for prophylactic and therapeutic vaccines against hepatitis C virus. Clin Infect Dis 2012;55(suppl 1):S25-S32. 6. Centers for Disease Control and Prevention. Healthcareassociated hepatitis B and C outbreaks reported to the Centers for Disease Control and Prevention (CDC) in 2008-2012. www.cdc.gov/ hepatitis/Outbreaks/HealthcareHepOutbreakTable.htm. Accessed July 17, 2013. 7. Kamili S, Krawczynski K, McCaustland K, Li X, Alter MJ. Infectivity of hepatitis C virus in plasma after drying and storing at room temperature. Infect Control Hosp Epidemiol 2007;28(5):519-524. 8. Ciesek S, Friesland M, Steinmann J, et al. How stable is the hepatitis C virus (HCV)? Environmental stability of HCV and its susceptibility to chemical biocides. J Infect Dis 2010;201(12): 1859-1866. 9. Hermida M, Ferreiro MC, Barral S, Laredo R, Castro A, Diz Dios P. Detection of HCV RNA in saliva of patients with hepatitis C virus infection by using a highly sensitive test. J Virol Methods 2002;101(1-2):29-35. 10. U.S. Environmental Protection Agency Office of Pesticide Programs. List D: EPAs registered antimicrobial products effective against human HIV-1 and hepatitis B virus, January 9, 2009. www.epa.gov/oppad001/list_d_hepatitisbhiv.pdf. Accessed Oct. 21, 2013. 11. U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001;50(RR-11):1-52. 12. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee. 2007 guideline for

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treatment of hepatitis C: an update. Hepatology 2009;49(4): 1335-1374. 36. Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl J Med 2013;368(20): 1859-1861. 37. Ghany MG, Nelson DR, Strader DB, Thomas DL, Seeff LB; American Association for Study of Liver Diseases. An update on treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases. Hepatology 2011;54(4):1433-1444. 38. Fox AN, Jacobson IM. Recent successes and noteworthy future prospects in the treatment of chronic hepatitis C. Clin Infect Dis 2012;55(suppl 1):S16-S24. 39. Clarke T. FDA panel backs Gilead hepatitis C drug sofosbuvir. www.reuters.com/article/2013/10/25/us-gilead-hepatitis-cidUSBRE99O0XK20131025. Accessed Nov. 4, 2013. 40. Barreiro P, Vispo E, Poveda E, Fernndez-Montero JV, Soriano V. Hepatitis C therapy: highlights from the 2012 annual meeting of the European Association for the Study of the Liver. Clin Infect Dis 2013;56(4):560-566. 41. Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System: hepatitis C, acute2012 case definition. wwwn.cdc.gov/nndss/script/casedef.aspx?CondYrID=723& DatePub=1/1/2012 12:00:00 AM. Accessed Nov. 6, 2013. 42. Centers for Disease Control and Prevention. Progress in increasing electronic reporting of laboratory results to public health agencies: United States, 2013. MMWR Morb Mortal Wkly Rep 2013;62(38):797-799. 43. Klevens RM, Miller J, Vonderwahl C, et al. Population-based surveillance for hepatitis C virus, United States, 2006-2007. Emerg

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