The Nurse with a Needlestick from an HCV-Positive Patient
A 28-year-old emergency department nurse sustains a hollow-bore needlestick to the left index finger while recapping a needle after drawing blood from a patient known to be hepatitis C positive (HCV RNA positive, genotype 1a). The injury occurred 2 hours ago. She is not vaccinated against hepatitis B (she declined at hire), and her hepatitis B surface antibody status is unknown. She has no known HIV risk factors. She is anxious and asks what her risk is and what she should do. The hospital has a post-exposure protocol but the charge nurse is unsure whether HCV prophylaxis is available.
1. What is her risk of acquiring HCV from this exposure, and is there post-exposure prophylaxis for HCV?
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Risk: The average risk of HCV transmission from a single hollow-bore needlestick with HCV-positive blood is approximately 1.8% (range 0–7%). Risk is higher with hollow-bore needles, larger inoculum, and visible blood on the device. Her risk is therefore low but real.
HCV prophylaxis: There is no approved post-exposure prophylaxis for HCV and no vaccine. The standard of care is serial monitoring: baseline HCV RNA and antibody testing at the time of exposure, then HCV RNA at 4–6 weeks and 3–6 months (some protocols add 12 weeks). If she seroconverts, she can be treated with direct-acting antivirals (DAAs) - modern DAAs achieve cure rates >95%, so early detection and treatment is highly effective.
Important: Do not tell her "there is nothing we can do" - the correct message is that there is no prophylaxis, but there is excellent treatment if infection occurs, and monitoring is essential.
2. What else must be addressed at this visit, and what follow-up do you recommend?
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Other exposures to address:
- Hepatitis B: She is unvaccinated and her immune status is unknown. Check HBsAb, HBsAg, and HBcAb. If susceptible, give hepatitis B vaccine (and consider HBIG if the source were HBsAg-positive - here the source is HCV, so HBIG is not indicated, but vaccination should be started).
- HIV: The source is not known to be HIV-positive, but standard practice is to offer HIV testing of the source (with consent) and baseline HIV testing of the nurse; if the source were HIV-positive, PEP would be indicated. Here, HIV risk is low but baseline testing is reasonable.
- Tetanus: Confirm tetanus vaccination status.
Follow-up:
- Baseline HCV RNA and antibody now.
- HCV RNA at 4–6 weeks and 3–6 months.
- Repeat HIV and HBV testing as per protocol.
- Counsel on symptoms of acute hepatitis (jaundice, fatigue, RUQ pain) and to report them.
- Document the exposure, the source status, and the counseling.
- Report the incident through the hospital's exposure reporting system and review the root cause (recapping needles is prohibited under sharps safety standards - use safety-engineered devices and never recap).