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HCV transmission at hemodialysis clinic suggests poor infection control
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Recent data confirmed that hepatitis C virus was transmitted to several patients at a dialysis clinic during a 6-year duration, underscoring the importance of aggressive infection control measures.
“Hepatitis C virus (HCV) infection is several times more prevalent among hemodialysis patients than the general U.S. population,” CDC researchers wrote. “Outbreaks of new HCV infections have been reported in U.S. dialysis centers, typically associated with lapses in infection control (IC), including improper parenteral medication handling and preparation, inadequate cleaning and disinfection of environmental surfaces between patient treatments and poor hand hygiene and glove use.”
During an epidemiologic investigation, the researchers evaluated HCV test results of all patients treated at an outpatient hemodialysis clinic in Philadelphia from January 2008 through April 2013. HCV tests were performed at admission and then annually for patients deemed susceptible to infection. All patients also underwent monthly screening for serum alanine aminotransferase (ALT); those with elevated ALT were tested for HCV antibodies.
The researchers tested the hypervariable region 1 of HCV in infected patients to determine viral genetic-relatedness. They also observed the clinic’s patient flow and IC practices, including hand hygiene and glove use, vascular access care, parenteral medication protocols, and cleaning and disinfection practices.
HCV infection was found in 26 of 66 patients, with 18 patients seroconverting since 2008. Based on the first positive HCV test, seven patients seroconverted in 2012; the other seroconverted in 2013. Because 48 patients were considered at-risk during this period, the attack rate for 2012-2013 was calculated at 16.7%. In two cases, no elevated ALT was seen, and neither patient showed symptoms consistent with acute hepatitis.
Of the 23 patients available for further testing, 11 case patients and two previously infected patients were classified into four transmission clusters. A quasispecies analysis revealed high homology and close clustering between one case patient and one formerly infected patient, indicating HCV transmission. While other links were observed between patients in each cluster, the directionality of transmission was unclear.
Various breaches of IC protocol were identified in the clinic, including staff moving between machines without changing gloves, using ungloved hands without hand hygiene and failure to label clean and dirty sinks. The investigators conducted environmental testing and detected visible and invisible blood on several surfaces. The clinic’s layout also did not comply with facility guidelines that recommend dialysis machines be at least 80 square feet apart and that dialysis chairs be at least 4 feet apart. Finally, since the clinic operated 3 days per week, the researchers suspected that a compressed schedule and facility crowding may have increased workload and thus reduced time for staff to practice appropriate cleaning protocols.
“This was one of the largest outbreaks of HCV infection among dialysis patients that we have encountered in the past decade,” the researchers wrote. “Although it remains critically important for dialysis clinic staff to continue adherence to current recommended IC practices to prevent spread of HCV and other infections, more aggressive strategies may be needed to stop HCV outbreaks from occurring in outpatient hemodialysis centers.” – by Jen Byrne
Disclosure: The researchers report no relevant financial disclosures.
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