[NATAP] Transmission of HCV by Discarded Needle

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Transmission of Hepatitis C Virus by Discarded-Needle Injury

Clinical Infectious Diseases

July 1 2005

Letter to the Editor

Agnès Libois, Emilio Fumero, Pedro Castro, Meritxell Nomdedeu, Cruceta, José Gatell, and Felipe

Infectious Diseases Unit, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, School of Medicine, University of Barcelona, Spain

SIR-The transmission of virus infection by percutaneous injuries from needles discarded in public settings is assumed to be biologically possible but has remained unproven. To date, no reports have been published of cases in which this route of virus transmission may have occurred [1]. We report clearly documented hepatitis C virus (HCV) seroconversion that occurred after an injury that involved a discarded needle.

A 64-year-old woman pricked herself accidentally in the hand with a discarded needle in a cemetery while she was cleaning up a mausoleum. Five hours later, she was admitted to the emergency department, where antiretroviral prophylaxis was proposed (zidovudine, lamivudine, and nelfinavir) at the patient's insistent request; the patient also received a first dose of hepatitis B vaccine, and a blood analysis was performed. The hematological examination findings, renal function, and liver enzyme levels were normal. A serum sample tested negative for hepatitis B virus antigen, HIV-1, HIV-2, and HCV antibodies, and plasma HIV and HCV loads were undetectable. In a scheduled visit that the patient had to perform with her doctor 1 month later, the patient remained asymptomatic, but blood analysis revealed a slight increase in liver enzyme levels (aspartate aminotransferase [AST] level, 50 IU/L [normal range, 5-40 IU/L; alanine aminotransferase [ALT] level, 63 IU/L [normal range, 5-40 IU/L]); the sample remained negative for HCV antibodies.

At the scheduled visit 3 months after the exposure, the patient complained of severe weakness and persistent asthenia during the previous 4 weeks. The findings of a physical examination were normal. She tested positive for HCV antibodies, and the liver enzyme levels had increased (AST level, 108 IU/L; ALT level, 109 IU/L). Control analysis was performed 15 days later and confirmed the diagnosis. The HCV RNA level was 4,100,000 IU/mL, and the liver enzyme levels had continued to increase (AST level, 300 IU/L; ALT level, 364 IU/L). The patient received treatment with pegylated IFN. A posttreatment response (negative results of tests for serum HCV RNA levels and normal liver enzyme levels at the end of treatment) was obtained, and HCV RNA remained undetectable 24 weeks after the end of treatment.

The injured woman had been married for 35 years. Her husband consistently tested negative for HCV antibodies and HCV RNA. The patient claimed never to have injected drugs and had no history of blood transfusions, surgical operations, or invasive procedures in recent months (including dental and medical procedures, tattooing, or body piercing). There have continued to be no serological markers of hepatitis B and HIV infection.

Parenteral modes of transmission are the main risk factors for HCV infection [2-6]. However, in a large proportion of patients, the source of infection remains unknown. Percutaneous injuries associated with needles discarded in public settings result in requests for evaluation for potential nonoccupational viral exposure with a certain frequency. These injuries typically involve small-bore needles that contain only limited amounts of blood, and the viability of any virus present is limited [7, 8]. In a Spanish study of 84 accidental injuries associated with discarded needles, no cases of HCV transmission were reported [9]. Usually, it is considered a low-risk exposure, and no antiretroviral treatment is proposed [1]. When the individual knows that this exposure is low risk, it is likely that he or she might assume that follow-up control visits are not necessary. This case outlines the necessity of strict follow-up for individuals with injuries due to discarded needles.