Today we have two stories about massage therapists exposed to the blood of clients with hepatitis C. Are they at risk for exposure to this common and serious infection? It depends.
What do you think it depends on? Spoiler alert: It has a lot to do with hygienic precautions.
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0:00:01.2 Ruth Werner: Hey, "I Have a Client Who... " listeners, did you know I have a growing library of NCB-approved, one-hour online self-paced continuing education courses that you can do any time anywhere? Well, now you know, current classes include what's next, COVID-19 updates from massage therapists, and a massage therapist's introduction to pharmacology Part One, and brand new, a massage therapist's introduction to pharmacology Part Two. Classes are $20 each and they confer one hour of continuing education credit. Wanna know more? Visit my website at ruthwerner.com and check it out. Be sure to sign up for my mailing list so you'll never miss a new class.
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0:01:33.5 RW: Hi, and welcome to "I Have a Client Who... " Pathology Conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes, as we have all learned, that is harder than it looks. Today's episode comes from a couple of different sources, but they take us to the same place, so I'm going to use both stories together. The first one comes from a Facebook thread that I stumbled on today while I was ignoring some other imminent deadlines. The massage therapist who gave me permission to share this as long as no names are mentioned, said something like, Help, my client told me they have hepatitis C, and they had a pimple rupture during our session, do I need to get tested? Later in that thread, the massage therapist shared that the client had not disclosed their hepatitis C infection until the conversation had wandered into a discussion of meridians and referred pain patterns for the liver and the gall bladder.
0:03:03.7 RW: The second story is one of my own from many years ago, I had written the column on hepatitis for a trade journal, and a massage therapist saw it and sent me a note that went something like this. I have a client who I see regularly, he is a fisherman, and he always has lots of little scabs and cuts on his hands, they're small and they're not bleeding or anything, so I don't pay much attention. Today, while I was massaging his hands, he told me he had just tested positive for hepatitis C. Well, I went to my health department and I got a test and guess what? I tested positive for hepatitis C too. Did I catch it from my client? Right, so there's a fair amount of appropriate attention being paid to hepatitis C communicability, and it seems like this is a good time to talk about that. Firstly, let's talk about this virus and its fellow liver-loving viruses. There's this group of viruses and they love hepatocytes. The first one we found was named hepatitis A virus, HAV, and that's the one that can make you feel really sick for a few weeks, but it's not usually dangerous, and one infection imparts life-long immunity.
0:04:13.6 RW: There's also a really effective one and done vaccine, Hep A is spread mostly through oral fecal contamination, which is why we see those hand-washing signs in restaurants, but in some cases, it can be spread by sexual activity. Then we discovered hepatitis B. This one is a lot longer lasting than Hep A, and it has the potential to set up some serious problems in the liver with chronic inflammation, about 5% of exposed people, are long-term carriers of hepatitis B, and they don't respond well to treatment. A small percentage of people with Hep B go on to develop cirrhosis, or liver failure, or liver cancer as consequences of this virus. It's spread mainly through sexual activity or direct blood exposure, this could be by way of direct contact, like with shared needles or piercing equipment, but it could also be through things like contaminated toothbrushes, touching other toothbrushes, because indirect contact works too, that's how communicable HEPB is. It's also sturdy outside of a host and it can stay together and infectious for a long time, waiting for new opportunities and new hosts. We have an effective vaccine series for hepatitis B that requires three doses over the course of 18 months. And then a new liver-loving virus showed up for years, it was called hepatitis non-A non-B.
0:05:46.5 RW: Finally, it was named hepatitis C virus or HCV. And we'll get back to that in just a second, because I do wanna mention that we now have a few more hepatitis viruses, I believe we're up to G. Most of these are not super virulent or they're only active when another virus is present, and one of them, F, I think, is actually just a theorized pathogen, also none of these viruses are specifically related to the others, that means they all just happen to love liver cells, but exposure to one offers no protection from any of the others, and in fact, it is perfectly possible to be co-infected with multiple liver viruses all at the same time, and this is very bad news.
0:06:33.0 RW: So let's return to the star of the show, hepatitis non-A, non-B, that is to say hep C. Hep C is the most common bloodborne infection in the United States. About 4 million Americans have it, and we see about 30,000 new diagnoses each year.
0:06:54.9 RW: Unlike A and B, the prognosis for untreated hepatitis C patients is really not great. Only about 25% of infected people spontaneously get better. 75% of people with hepatitis C who don't get treatment go on to develop serious complications, like liver failure and liver cancer. This risk is much higher if hep C is present at the same time as hepatitis B, HIV, or alcoholism.
0:07:26.6 RW: However, this is a slow-acting virus, and lots of people go for many months, or years, or even decades, just gradually accruing liver damage, because the liver likes to accommodate for this, and hep C just doesn't cause a lot of symptoms until it has progressed pretty far.
0:07:49.4 RW: And here's another kicker. The communicability path of hepatitis C is not always clear. It moves most efficiently through direct exposure to intimate fluids. That's blood, semen, vaginal secretions, and breast milk. However, there are cases of indirect communicability, like via shared razors or toothbrushes, and in some cases, the root of communicability is never really clear. And there's no vaccine.
0:08:18.9 RW: The good news of that hepatitis C is that we now have some treatment options that are incredibly effective and the outlook for someone who can get these treatments is very positive. Remember, 75% of infected people are at risk for chronic liver disease. The bad news about hepatitis C is that the treatment protocols cost between $40,000 to $100,000, and that is a lot less than it used to be, but it still locks a lot of people out of access to treatment.
0:08:52.9 RW: So the question of the hour for us is, are we at risk for hepatitis C infection in the massage session room? The short answer is yes. The longer answer is, say it with me, "It depends, it depends on the viral load carried by the sick person," who might be the massage therapist or the client, by the way. Untreated hepatitis B and C tend to have a pretty high viral load. It doesn't take much blood exposure to transfer infectious amounts of the virus. It also depends on whether there was exposure to an open wound with both parties, we're gonna work on the assumption that exposure to other intimate fluids is not happening in the massage setting. And of course, it depends on what hygienic practices are being used in this setting. And this is why we treat every single person who walks into our session room as though they might have a blood-borne infection. This is the fundamental principle behind universal precautions and hygienic practices.
0:10:02.6 RW: We make sure that nothing one person has touched is touched by another person until it has been cleaned, covered or replaced. Because of course, we often have tiny lesions around our cuticles or elsewhere, and our clients might as well. Remember, that fishermen had lots of cuts and scabs on his hands, and the other client had a popped pimple that presumably bled during a massage. And in that case, the massage therapist also identified a small but visible wound on their own hand, which is what prompted them to ask this question in the first place.
0:10:35.6 RW: In that situation, the general suggestion offered on the thread was to call their doctor to get advice on whether they should get tested. And I concur, this would be a good place to start. I discovered that OSHA has some guidelines for healthcare providers who might be exposed to hep C, but they might only apply in certain locations. They really are focused on direct exposure to hepatitis C, like with needle sticks. But there are a couple of other lessons to be taken from this interaction.
0:11:05.5 RW: For instance, it only came up by accident in a conversation about liver and gall bladder meridians and referred pain patterns that the client disclosed that they had hepatitis C. That makes me wince a little. This is the kind of thing it would be good to know ahead of time, especially since the medications can create some major side effects. If this client was one of the lucky folks who got that great treatment and recovered completely, then their communicability risk is probably close to zero. That's awesome, but we don't know the answer to that question until we ask. Also, the massage therapist had a visible and uncovered lesion on their hand, and this situation is a great example of why we cover these lesions when we work with clients.
0:11:54.6 RW: I will assume that the massage therapist didn't get really closely involved with the ruptured pimple. In most cases, we can just clean up the exudate with a tissue and move on, but I'm really glad that this person put together the risk of exposure from this leaky lesion with the hepatitis C disclosure, because that is appropriate self-care. In reference to the other story with the fisherman, it is of course impossible to know if the massage therapist picked up their hepatitis C infection from the client. I have to imagine that it's unlikely if the massage therapist washed their hands directly after the session.
0:12:31.5 RW: And it turns out that the massage therapist had engaged in some high-risk behaviors in their youth. It might be hard for some listeners to believe, but there was a time when the scariest thing that could happen if you had unprotected sex was an unintended pregnancy. It's likely that this person was exposed during those years. So, that's a little airing out of the hepatitis C communicability question.
0:13:01.5 RW: To recap, it is the most common bloodborne infection in the United States. We have no effective vaccine. There are effective, but extremely costly treatment options. And although it might have no symptoms, it can be spread through direct, or indirect contact with the blood, which is why we assume that every person who walks into our treatment room could have it or some other invisible bloodborne infection.
0:13:31.0 RW: Hey everybody, thanks for listening to "I Have a Client Who... " Pathology Conversations with Ruth Werner. Remember, you can send me your I Have a Client Who stories to firstname.lastname@example.org. That's Ihaveaclientwho all one word, all lower case @abmp.com. I can't wait to see what you send me and I'll see you next time.