Hep C Diagnosis --- Now What???!!!

[CNA_MISSY]

Last week, I was offered my dream job. I accepted and went through the whole process of having the physical done, including the TB test. I went back today and had the test read. When the nurse left the room, she left my chart open and obviously, I took a peek. I almost screamed when I saw that the lab results said I was Hep C positive. I have never used drugs so the only way I could have gotten it is back in 1979 when I had a blood transfusion after I started bleeding profusely during an emergency c-section situation with my first child.

When the nurse came back, I obviously had to act all cool and stuff when I was not but I managed to pull myself together. I asked her when I would get my clearance to attend orientation on Monday and she said, we don't have all of your labs back yet but someone will call you with the results.

OMG....I am so freaked because I am scared that I will not be able to work at this hospital in this position which I have dreamed about for the past year. I am also a nursing student and two more classes, will apply for my clinicals.

First, is it common for a hospital to turn away Hep C positive employees?

Second, do I need to seek a profession in something else as I will not be allowed to work in nursing because of this diagnosis.

Neither of the two hospitals I worked in previously tested me and I have never had a reason to be tested so this is all coming to light now. I don't know if this is making sense as I am a nervous wreck.

Thanks.

Missy:banghead:

[core0]

whoah, that would be freaky - but thankfully false positives do occur. OP said she called her previous doc and didn't have anything in her previous years records of elevated liver enyzmes. I would definitely go to PCP and investigate and redrawn. If Occupational health does call you with these results that are positive, then take that info to your PCP - if info is contradictory, then you can present that back to Occupational Health. Good luck.

Don't redraw the antibody get a HCV PCR quantitative. A Riba is an OK alternative but not as sensitive. The risk of conversion is around 3%. There are a lot of people that are HCV ab positive but don't have HCV. Here is a nice fact sheet on blood borne exposure with some good up to date recommendations:

http://www.traveldoc.com/download/needlestick.pdf

David Carpenter, PA-C

[CNA_MISSY]

Good morning.

Very weary today. I received a call from Employee Health and was advised that that two confirmatory tests were done.

The first was a RIBA which confirmed that the first test done was correct. It was positive!

The second test done was a PCR to test if the virus was active. The ANP in Employee Health said that the results determined the virus was "not detected". She acted like she did not know what that meant. These people are so cagey and it is very frustrating to me. Can someone please tell me WTH does "not detected" mean? Confused, confused, confused.:bugeyes:

I have to go in this PM to get some papers to take to my doctor so that the doctor can "conduct some preliminary test results to check my liver function". The ANP says the PCR will need to be retested on a follow up test with my PCP. At this point, my PCP needs to determine if "this is an old diseases that cleared itself from my body".

At this point, Employee Health is waiting for another "piece of information to clear me to start work in the ER". That information is general information regarding the job I will be doing. I was supposed to start today so IF I am cleared, the earliest I can start is sometime in September. Ugh!!!!!!!!!!!!!

THe ANP said my health information is not shared with HR or my manager but it seems to me that once this is done and over, everyone in ER will be looking at me like I have a third eyeball and I am not even sure that I want to even work there. I am, however, grateful for the test results so that I can follow up on my health.

((((Thanks)))))

[CNA_MISSY]

One more question, if this is an "old disease that cleared itself from my body", how can I be positive???? Thanks.

[CNA_MISSY]

UPDATE: I went to Employee Health and they gave me a paper to take to my PCP which has to be signed off on. The form says:

"Employee has applied for a CNA position in the ER. On pre-placement exam, labs for Hep C antibody and RIBA were positive. The HCV PCR Qualitative was negative and not detected. Please do any follow up evaluation as necessary for Hep C. Also, comment on restrictions of no exposure prone invasive procedures (EPIP). This will facilitate placement.

I have to see my doctor on 7-21 so I only have one more week to worry myself sick over this and I am ready to tell them to keep the *******' job!!

(((Thanks))))

[pattymac]

Now stop it. :wink2: This is bump in the road. If it truly is your dream job, then put up with it a little while longer. You would probably have to just go through all this again somewhere else. Might as well take care of it now. Hang in there....and keep us posted. We care.

[core0]

UPDATE: I went to Employee Health and they gave me a paper to take to my PCP which has to be signed off on. The form says:

"Employee has applied for a CNA position in the ER. On pre-placement exam, labs for Hep C antibody and RIBA were positive. The HCV PCR Qualitative was negative and not detected. Please do any follow up evaluation as necessary for Hep C. Also, comment on restrictions of no exposure prone invasive procedures (EPIP). This will facilitate placement.

I have to see my doctor on 7-21 so I only have one more week to worry myself sick over this and I am ready to tell them to keep the *******' job!!

(((Thanks))))

The HCV antibody will be positive for anyone exposed to the virus. This is similar to any other virus. If you had chickenpox you would have a positive varicella virus. The thought used to be that we kept this antibody forever. Now the thinking is that the antibody and immunity may fade over time. This is one of the reasons that older people are recommended to have varicella titers checked for example.

The RIBA test looks for several specific antibodies to the viral coat and and core. Unlike the Elisa ab it is more specific to HCV exposure. It looks for the core antibody and three domain specific antibodies. It does not tell if you have active infection.

The HCV qual tells if they detect virus in the blood. It essentially tells if there is active viral replication. Normally we use an HCV quantitative assay as it is more sensitive than the qualitative assay.

Not giving medical advice but with patients in this case if they have another HCV quant that is negative six months apart they are negative. Essentially this is someone that was exposed but their immune system fought off the virus. Similar to those who were exposed to HCB but did not get active disease. The chance of developing disesase if there is one negative qual is less than 3%. The antibody will be positive for an indeterminate amount of time. In a patient such as this I would suggest that they see a hepatologist if one is available locally. Depending on the RIBA pattern they may be able to tell the patient more about the infection.

David Carpenter, PA-C

[CNA_MISSY]

The HCV antibody will be positive for anyone exposed to the virus. This is similar to any other virus. If you had chickenpox you would have a positive varicella virus. The thought used to be that we kept this antibody forever. Now the thinking is that the antibody and immunity may fade over time. This is one of the reasons that older people are recommended to have varicella titers checked for example.

The RIBA test looks for several specific antibodies to the viral coat and and core. Unlike the Elisa ab it is more specific to HCV exposure. It looks for the core antibody and three domain specific antibodies. It does not tell if you have active infection.

The HCV qual tells if they detect virus in the blood. It essentially tells if there is active viral replication. Normally we use an HCV quantitative assay as it is more sensitive than the qualitative assay.

Not giving medical advice but with patients in this case if they have another HCV quant that is negative six months apart they are negative. Essentially this is someone that was exposed but their immune system fought off the virus. Similar to those who were exposed to HCB but did not get active disease. The chance of developing disesase if there is one negative qual is less than 3%. The antibody will be positive for an indeterminate amount of time. In a patient such as this I would suggest that they see a hepatologist if one is available locally. Depending on the RIBA pattern they may be able to tell the patient more about the infection.

David Carpenter, PA-C

coreO,

Thank you so much, your posts are so informative. I have the results here at home and I went back and reviewed them after reading your post response.

anti-HCV=reactive

HCV ab Riva was positive

Hep C Riba Band Pattern was reference range=netative, reactive

C33c reference range=nonreactive, reactive

Hep C Antibody was reactive

Hep C Riba C22P was reference range=nonreactive, reactive

HCV PCR Qualitative=not detected (test performed using the COBAS AMPLICOR, version 2.0).

All other results were normal, nonreactive, or within normal range.

What is your take on these results, opinion not diagnosis of course!

[EmBeMap]

Viruses are evil little creatures that lay dormant or sometimes disappear. What I meant was you can test positive for an anti-body (you were exposed and body mounted a response) or actually have a reproducing actively damaging antigen. you need to find out what you tested positive for (antibody or antigen) and see if you will need to seek treatment. Example...testing positive for hep b treated with tenofovir (now lab work only shows immunity, no virus) something to think about. PS there are HIV and HEP B poz nurses and techs everywhere. thats why we treat everyone as infected because you never know their status as nurse or patient. That's why I say fight for it...

[EmBeMap]

also in texas we have to sign for hep b and hiv test consents... did you authorize this hep c test... it seems discriminatory in my opinion. that they wouldn't hire you makes me wonder if they would fire you after a needle stick you became infected by... just my 2 cents

[core0]

coreo,

thank you so much, your posts are so informative. i have the results here at home and i went back and reviewed them after reading your post response.

anti-hcv=reactive

hcv ab riva was positive

hep c riba band pattern was reference range=netative, reactive

c33c reference range=nonreactive, reactive

hep c antibody was reactive

hep c riba c22p was reference range=nonreactive, reactive

hcv pcr qualitative=not detected (test performed using the cobas amplicor, version 2.0).

all other results were normal, nonreactive, or within normal range.

what is your take on these results, opinion not diagnosis of course!

first let me give you my opinion on why employee health should not be doing these tests. if they knew what they were doing they should have explained the tests to you. the moral of this story is don't do a test if you don't know how to explain it. this is a personal issue i have with employee health doing tests and then punting things back to the pcp. morally its simply not defensible.

ok now i can step down off of my soapbox.

here is a nice flowchart adapted from the cdc. its apparently the similar to the algorithm that many employee health systems use:uhoh3:.

http://www.ptpg.com/pubdocs/featured_procedures/hcv%20testing.pdf

if you open this in another window you can follow along. we will use the tests done above as an "example". i'm going to arrange them so they make more sense:

anti-hcv=reactive

hep c antibody was reactive

these are the same test. if you look on the flowchart you go to positive ab. which goes to do riba.

hcv ab riva was positive

hep c riba band pattern was reference range=netative, reactive

c33c reference range=nonreactive, reactive

hep c riba c22p was reference range=nonreactive, reactive

this shows that the occupational health department or the hospital is cheap by using a first generation test (or doing a second generation test incorrectly). the c22p and c33c are protiens within hcv virus. this shows antibodies to the specific protiens. depending on the test 2 out of three is considered positive. if you follow the algorithm you are on the left side. with positive riba you go to hcv quant do genotype.

hcv pcr qualitative=not detected (test performed using the cobas amplicor, version 2.0).

once again showing their cheapness they do an older test. the qual is negative if you look at the algorithm you come to this:

"the presence of antibodies indicates past or present infection.

a single negative pcr result does not rule out active infection.

recommend second pcr (qualitative) in a month."

so the interpretation of this "example" is no evidence of active hcv infection but a follow up pcr is needed to confirm this.

the reason for this is that there are very rare reports (mostly from organ transplant) of patients with negative antibodies and pcr where the recipient later develops hcv. there is a window where the patient has not developed the antibody but there is no virus present in the blood. this has to do with the sensitivity of the test. the cobra amplicor has a sensitivity of 50iu/ml. for explanation purposes it can detect 50 or more viral particles in a cc of blood. in comparison active infection can be 10,000 to more than 1 billion. in early infection there may be a brief period that is less than this. this is why in transplant we use a more sensitive test that goes to 1/10th of a particle per ml (ie 500x more sensitive).

there is an even rarer case right after an active infection where the body has produced antibody but the infection is progressing. in this case the the antibody has developed so the body is killing virus in the blood stream but the active infection is in the liver and will eventually progress. to actually catch this on a single test is kind of getting hit by lightning while winning the lottery rare.

so in this example i would tell the patient that in all likelihood this is a past infection that was naturally cleared by the body. to make absolutely sure i would recommend a hcv pcr with good sensitivity (2 or 10 iu/ml) in one month. to be double extra sure i would repeat this at 3 and six months but the chance of hcv becoming positive after 2 pcrs 1 month apart is on the order of 1:150,000. i would then belittle employee health for a while and call them bad names:rolleyes:.

david carpenter, pa-c

[core0]

also in texas we have to sign for hep b and hiv test consents... did you authorize this hep c test... it seems discriminatory in my opinion. that they wouldn't hire you makes me wonder if they would fire you after a needle stick you became infected by... just my 2 cents

In Georgia we have to get consent for HIV but not HBV. I haven't heard of getting HBV consents but I guess anything is possible. Given that most schools require proof of HBV vaccination I don't see how this is possible. Personally I feel that neither should require special permission. We have too many people out there that have HIV and don't know it. The way that you take away the stigma of the disease is to take away stigma around testing. We have good treatment for HIV if we can get them to the patients. Here is a couple of articles on this:

http://www.washingtonpost.com/wp-dyn/content/article/2006/06/04/AR2006060400325.html

http://uk.reuters.com/article/healthNews/idUKCOL06945620071030

HCV should be the same way. It should be part of routine screening. There is treatment for HCV which works better if its caught early. Many patients will not require treatment but do require careful monitoring.

In the case used as an "example" I would actually support this. HCW is a known risk for HCV. Its important to know the workers status for their own protection. If the worker is negative at the start of work and becomes positive at any time during work it opens the possibility for workmens comp to pay for it. It simply protects both the employer and employee.

just my thoughts

David Carpenter, PA-C

[EmBeMap]

I undertand your rationality but workmens comp only covers treatment. What do you do with the rest of your life? Stop being a PA RN or MD ? You gave your life to help others, so now because of standardized testing no one wants to hire you. Sounds bad but it happens still. Nobody wants the POZ ER nurse... might be a pt risk or cost too much to insure them. I have seen people eased out of their positions after having to be treated at their on hospitals.