Healthcare Notification and Testing Toolkit

Purpose

This toolkit provides a framework for use by state and local health departments for public notification as part of public health response to possible bloodborne pathogen exposures in a variety of healthcare settings.

Note: Bloodborne Pathogens Testing

In the event of a notification, recommendations for bloodborne pathogen screening are typically included. CDC staff are always available for consultation including discussion of testing algorithms for specific notification settings.

Please note that if potential exposures are less than six months earlier than the date of serologic screening, re-testing at a date greater than six months after last exposure may be warranted in order to identify recent infections that have not yet become serologically detectable. Alternatively, nucleic acid testing (NAT), which can detect infection much earlier than serologic testing, may be considered as an initial diagnostic test to detect infections after recent high-risk exposures.

Suggested tests may vary according to the recency and likelihood of exposure and typically include:

• serologic testing for hepatitis C antibody (anti-HCV) and if positive reflex to HCV RNA testing [PDF - 4 pages] (which may require an additional frozen serum specimen),
• serologic testing for hepatitis B surface antigen (HBsAg) [PDF - 28 pages] (may also consider total antibody to hepatitis B core antigen (total anti-HBc) and antibody to hepatitis B surface antigen (Anti-HBs) tests to determine past infection and immunity status), and
• HIV testing

Suggested Viral Hepatitis Tests, summary

	Initial baseline testing of potentially exposed person (s)*, **	Follow-up testing*, **,¶
HBV†	HBsAg test  Also consider antibody to hepatitis B core antigen (anti-HBc) antibody to hepatitis B surface antigen (anti-HBs) tests to determine past infection and immunity status.	HBsAg test at ≥ 12 weeks post exposure   Note: if immune at baseline or most recent exposure ≥ 12 weeks prior to baseline, no follow-up testing needed.
HCV	HCV antibody‡ and if positive reflex to HCV RNA Note: may need to draw two blood specimens for reflex testing. -OR- HCV RNA test	HCV antibody test at ≥ 6 months post exposure Note: If initial antibody test positive, test HCV RNA instead of HCV antibody. -OR- HCV RNA test at ≥ 3 weeks post exposure¶   Note: If most recent exposure ≥6 months prior to baseline anti-HCV test, or ≥3 weeks prior when HCV RNA tested at baseline, no follow-up testing is needed.

*Blood should be drawn immediately before treatment or vaccine is administered

**if HIV testing is considered, see HIV testing guidelines.  Note that the 4^th generation HIV test detects infection within three weeks after exposure in most individuals. If testing at least six weeks after exposure in persons with no known ongoing risk of exposure, no further follow-up is needed.

¶ A single negative NAT using currently available FDA-approved tests in the US is considered sufficient to rule out chronic infection when screening an antibody-positive individual with no known ongoing risk of exposure. HCV RNA becomes detectable after 2-3 weeks after exposure in most individuals even when the antibody is still undetectable.

†Note: Post-exposure prophylaxis (PEP) for HBV is recommended within 7 days of percutaneous exposure and should be administered as soon as possible, preferably within 24 hours.  The maximum interval after exposure during which postexposure prophylaxis is effective is unlikely to exceed 7 days for percutaneous exposures.  For prophylaxis, initiate HBV vaccine unless the exposed individual was known to have received and responded to HBV vaccine previously (defined as having an anti-HBs measured and documented as ≥10 mIU/mL following 3 or more documented vaccine doses). Hepatitis B immune globulin may be considered.  References:

Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part I: Immunization of Infants, Children, and Adolescents
Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: Immunization of Adults
CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management

‡ In one study of anti-HCV testing in a low (1%) prevalence nationally representative sample, approximately 30% of anti-HCV positive results were determined to be false positive (unpublished data, Division of Viral Hepatitis, manuscript in preparation Prevalence of false-positive hepatitis C antibody results, NHANES 2007-2012.)