Prevalence of infected patients and understaffing have a role in hepatitis C virus transmission in dialysis

Are We on the Right Track for HCV Micro-Elimination? HCV Management Practices in Dialysis Centers in Poland-A National Cross-Sectional Survey

Chronic hepatitis C (CHC) is prevalent in the hemodialysis-dependent population. Currently, all patients with CHC should be considered for treatment; however, many hemodialysis-dependent patients are still left untreated. Following HCV cure, accurate surveillance is mandatory to reduce liver-related mortality and prevent reinfection. We aimed to establish HCV management practices and barriers to HCV elimination in dialysis centers in Poland. Polish dialysis centers were surveyed via email. The HCV management strategies were investigated. Representatives of 112 dialysis centers responded, representing 43.1% of all dialysis centers in Poland and 43.4% of hemodialysis-dependent patients' volume. Most respondents were Heads of hemodialysis centers and board-certified nephrologists. The study demonstrated that in the vast majority of hemodialysis centers (91.6%), subjects are considered for antiviral treatment (AVT); however, many obstacles preventing patients from being prescribed AVT were identified; patients' reluctance to undergo AVT was most reported (60%). The majority of dialysis units neither evaluate patients with CHC for liver fibrosis (60.4%) nor screen them for hepatocellular carcinoma (53.5%). In conclusion, the presented study demonstrates that HCV management practices across Polish dialysis centers vary substantially. There is a need to optimize and streamline the HCV management infrastructure in the hemodialysis population in Poland.

Performance of rapid test for antibodies to hepatitis C virus (anti-HCV) in hemodialysis patients and kidney transplant recipients

Rapid tests (RT) have been widely used for screening of hepatitis C virus (HCV) in general population, but its performance in hemodialysis (HD) patients and mainly in kidney-transplant recipients (RTx) is less known. The aim of this study was to evaluate the accuracy of RT for detection of anti-HCV in HD and RTx patients. Patients were prospectively included subdivided in four groups according to the positivity for anti-HCV detected by conventional serology: (1) HD patients anti-HCV +, (2) HD patients anti-HCV -, (3) RTx patients anti-HCV +, and (4) RTx patients anti-HCV -. All patients were retested for HCV using the commercial kit Alere HCV^® Bioeasy Rapid Test (Bioeasy Diagnóstica LTDA-Minas Gerais, Brazil) in capillary whole blood samples. During the period of study were included 46 HD patients anti-HCV+, 62 HD patients anti-HCV -, 53 RTx patients anti-HCV + and 56 RTx patients anti-HCV -. In patients on HD, the RT showed sensitivity (S), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and accuracy of 100%. In RTx patients, S of 96%, SP of 100%, PPV of 100% and NPV of 97% were found (accuracy of 98%). In conclusion, in patients on HD there was 100% agreement between RT and the conventional immunoassay. In the RTx group, although the agreement was not 100%, the RT performed very well when compared to conventional serology. This study demonstrates that the RT can be an alternative to conventional serology in HCV screening of patients on HD and RTx.

Mutations in AR or SRD5A2 Genes: Clinical Findings, Endocrine Pitfalls, and Genetic Features of Children with 46,XY DSD

OBJECTIVE

Androgen insensivity syndrome (AIS) and 5α-reductase deficiency (5α-RD) present with indistinguishable phenotypes among the 46,XY disorders of sexual development (DSD) that usually necessitate molecular analyses for the definitive diagnosis in the prepubertal period. The aim was to evaluate the clinical, hormonal and genetic findings of 46,XY DSD patients who were diagnosed as AIS or 5α-RD.

METHODS

Patients diagnosed as AIS or 5α-RD according to clinical and hormonal evaluations were investigated. Sequence variants of steroid 5-α-reductase type 2 were analyzed in cases with testosterone/dihydrotestosterone (T/DHT) ratio of ≥20, whereas the androgen receptor (AR) gene was screened when the ratio was <20. Stepwise analysis of other associated genes were screened in cases with no causative variant found in initial analysis. For statistical comparisons, the group was divided into three main groups and subgroups according to their genetic diagnosis and T/DHT ratios.

RESULTS

A total of 128 DSD patients from 125 non-related families were enrolled. Birth weight SDS and gestational weeks were significantly higher in 5α-RD group than in AIS and undiagnosed groups. Completely female phenotype was higher in all subgroups of both AIS and 5α-RD patients than in the undiagnosed subgroups. In those patients with stimulated T/DHT <20 in the prepubertal period, stimulated T/DHT ratio was significantly lower in AIS than in the undiagnosed group, and higher in 5α-RD. Phenotype associated variants were detected in 24% (n=18 AIS, n=14 5α-RD) of the patients, revealing four novel AR variants (c.94G>T, p.Glu32*, c.330G>C, p.Leu110=; c.2084C>T, p.Pro695Leu, c.2585_2592delAGCTCCTG, p.(Lys862Argfs*16), of these c.330G>C with silent status remained undefined in terms of its causative effects.

CONCLUSION

T/DHT ratio is an important hormonal criterion, but in some cases, T/DHT ratio may lead to diagnostic confusion. Molecular diagnosis is important for the robust diagnosis of 46,XY DSD patients. Four novel AR variants were identified in our study.

Updated Evidence on the Epidemiology of Hepatitis C Virus in Hemodialysis

Prevalence rates of HCV infection are decreasing in hemodialysis units of most developed countries; however, nosocomial transmission of HCV continues to occur in the hemodialysis setting, not only in the emerging world. According to the Dialysis Outcomes and Practice Patterns Study (DOPPS, 2012–2015), the prevalence of HCV among patients on regular hemodialysis was 9.9%; in incident patients, the frequency of HCV was approximately 5%. Outbreaks of HCV have been investigated by epidemiologic and phylogenetic data obtained by sequencing of the HCV genome; no single factor was retrieved as being associated with nosocomial transmission of HCV within hemodialysis units. Transmission of HCV within HD units can be prevented successfully by full compliance with infection control practices; also, antiviral treatment and serologic screening for anti-HCV can be useful in achieving this aim. Infection control practices in hemodialysis units include barrier precautions to prevent exposure to blood-borne pathogens and other procedures specific to the hemodialysis environment. Isolating HCV-infected hemodialysis patients or using dedicated dialysis machines for HCV-infected patients are not currently recommended; reuse of dialyzers of HCV-infected patients should be made, according to recent guidelines. Randomized controlled trials regarding the impact of isolation on the risk of transmission of HCV to hemodialysis patients have not been published to date. At least two studies showed complete elimination of de novo HCV within HD units by implementation of strict infection control practices without isolation practices. De novo HCV within hemodialysis units has been independently associated with facility HCV prevalence, dialysis vintage, and low staff-to-patient ratio. Antiviral treatment of HCV-infected patients on hemodialysis should not replace the implementation of barrier precautions and other routine hemodialysis unit procedures.

Infection with hepatitis C virus in hemodialysis patients: An overview of the diagnosis and prevention rules within a hemodialysis center (Review)

Increase in the number of patients with chronic kidney disease (CKD) calls for improved management of these patients. In stage 5 CKD, when the initiation of renal replacement therapy (RRT) becomes necessary, there is an increase in the infection risk of the patients and immunological tests for hepatitis C virus (HCV) detection turn positive at an alarmingly higher rate compared to general population. With the introduction into clinical practice of diagnostic tests, the increased prevalence of HCV among CKD patients has been known since the 1990s. Also, the negative impacts of HCV infection on CKD evolution as well as the unfavorable evolution of grafts received by HCV infected patients are known. Chronic hemodialysis patients are a category of patients whose risk of HCV infection is substantial. Currently, in the hemodialysis centers, at the base of the transmission of HCV infection there are a multitude of factors. Infection with HCV has a different impact on patient with end-stage renal disease (ESRD). Comorbidities in this case have significant sources of mortality and morbidity. It was proven that the post transplantations problems were prevented and mortality was reduced for patients who were diagnosed with HCV and in whom the infection was treated before the kidney transplant (KT). Consequently, early detection of the infection and the application of specific treatment has a considerable impact on the outcome of the patients. Another important component of the management of HCV infection in the chronic hemodialysis patients is the prevention of the infection transmission by applying specific methods.

Clinical practice guideline management of blood borne viruses within the haemodialysis unit

Some people who are receiving dialysis treatment have virus infection such as hepatitis B, hepatitis C and/or HIV that is present in their blood. These infections can be transmitted to other patients if blood is contaminated by the blood of another with a viral infection. Haemodialysis is performed by passing blood from a patient through a dialysis machine, and multiple patients receive dialysis within a dialysis unit. Therefore, there is a risk that these viruses may be transmitted around the dialysis session. This documents sets out recommendations for minimising this risk.There are sections describing how machines and equipment should be cleaned between patients. There are also recommendations for dialysing patients with hepatitis B away from patients who do not have hepatitis B. Patients should be immunised against hepatitis B, ideally before starting dialysis if this is possible. There are guidelines on how and when to do this, for checking whether immunisation is effective, and for administering booster doses of vaccine. Finally there is a section on the measures that should be taken if a patient receiving dialysis is identified as having a new infection of hepatitis B, hepatitis C or HIV.

Sero Conversion of Viral Hepatitis among End Stage Renal Disease Patients on Hemodialysis in Kashmir: Results of a Prospective Study

BACKGROUND

The seroconversion is a significant health concern in patients with end-stage renal disease undergoing hemodialysis particularly in high endemic zones of HBV and HCV.

PATIENTS AND METHODS

This prospective study was conducted from January 2009 to April 2018 at Sheri Kashmir Institute of Medical Sciences, Srinagar, Kashmir. A cohort of 459 end-stage renal disease patients on hemodialysis was enrolled from four dialysis centres and followed in a longitudinal manner. Their seroconversion rates, risk factors were studied. Positive patients were treated and followed up.

RESULTS

This study demonstrated HBV seroconversion rate of 7.4 % (n = 34) and HCV seroconversion rate of 10% (n = 46) in a cohort of 459 patients on hemodialysis attending four dialysis centres of Kashmir. Patients with diabetes mellitus outnumbered in seroconversion rates of (43.75%) followed by patients with glomerulonephritis (23.75%). Of 15 patients who had undergone renal transplantation 10 (66.67%), patients had seroconversion on hemodialysis which was statistically significant (P < 0.001). Patients who were dialysed at multiple HD centres had significant seroconversion than those who followed up at a single center. Seroconversion was associated with longer duration of dialysis (80.30 ± 30.92 vs 61 ± 9.41months, P < 0.000). HBV vaccination of the ESRD patient on hemodialysis was significantly protective against seroconversion (P = 0.000).

CONCLUSIONS

Hepatitis B vaccination, stringent precautions in all dialysis centres could help to reduce the high seroconversion rates which have a high financial burden on ESRD patients. Intense health education to both patients and medical staff will be beneficial to lower the seroconversion rates.

Hemodialysis-Associated Infections

Hemodialysis patients are at increased risk of infections, which are common adverse events among this patient population. We review factors contributing to infections among hemodialysis patients and epidemiology of common infections and outbreaks, including bloodstream infections, vascular access infections, and infections caused by bloodborne pathogens. Recommendations for prevention are discussed with emphasis on essential infection control practices for hemodialysis settings.

Transmission of hepatitis C virus infection in hemodialysis: Current concepts

A variety of epidemiological data provides evidence for the occurrence of nosocomial transmission of hepatitis C virus (HCV) infection to hemodialysis (HD) patients. The most important factor implicated in HCV transmission between patients treated in the same dialysis unit is cross-contamination from supplies and surfaces as a result of failure of staff to follow infection control procedures. Parts of the HCV genome are highly variable and lend themselves to fingerprinting of each isolate using nucleic acid testing (NAT) and sequencing. This approach has permitted investigation of possible transmission routes within HD units. A systematic review of molecular virology papers revealed transmission of HCV via internal fluid pathways of the dialysis machines in a minority of reports only. Dialyzer reuse was not identified as a risk factor for HCV acquisition in multicenter databases. No randomized controlled trials exist on the impact of isolation on the risk of transmission of HCV to hemodialysis patients. A Belgian prospective multicenter study showed a reduction from 1.4% to 0% in the annual incidence of seroconversion for HCV without any isolation measures, by implementation of strict infection control procedures designed to prevent transmission of blood-borne pathogens, including HCV. However, an isolation policy for HCV-infected dialysis patients should be considered in dialysis units where nosocomial transmission of HCV persists despite reinforcement and audit of hygienic precautions for hemodialysis. Routine audit precautions (general and for dialysis machines) are recommended on a regular basis within HD units.

Hepatitis C virus infection: opportunities for an earlier detection in primary care

BACKGROUND/AIM

In the era of direct-acting antiviral medications, which can cure the hepatitis C virus (HCV) infection, the actual epidemiology of this condition in the general population is still unclear. We therefore aimed to estimate the prevalence rate of HCV and assess the determinants for incident cases of HCV in primary care in Italy.

METHODS

We identified outpatients aged at least 15 years registered in the Italian Health Search IMS Health Longitudinal Patient Database from 1 January 2002 to 30 June 2013. The annual trend of HCV prevalence was estimated. The candidate determinants for the risk of incident HCV infection included geographical area of residence, sex, age, infections by the HIV, hepatitis B virus (HBV), or other forms of hepatitis, and abuse of illicit substances or drugs.

RESULTS

The eligible cohort included 826 300 patients (53.5% women, mean age 48.1±19.1 years). The prevalence rate of HCV increased over the 11-year study period, ranging from 0.24 to 0.50%, with a small increase in men versus women. Patients aged more than 24 years had a higher risk than those aged 14-24 years, with up to a five-fold increase among patients aged 65-74 years. Being resident of Southern/Islands Italy, concurrent diagnosis HBV or HIV, and drug or illicit substance abuse were significant determinants for HCV infection.

CONCLUSION

Our study shows that the prevalence of HCV in Italy has doubled over the last decade. Patients with certain demographics and clinical characteristics are more prone to be infected by HCV. In this scenario, general practitioners may play a crucial role in screening, early identification, and therapy of high-risk patients.

Seroprevalence of hepatitis B and C virus in patients who undergo hemodialysis in Antalya province, Turkey

Background

Chronic hepatitis B (HBV) and C virus (HCV) infections are important causes of morbidity and mortality in patients who undergo hemodialysis (HD).

Objectives

To define seroprevalence of HBV and HCV in patients who underwent HD in Antalya province, Turkey.

Methods

We included 1347 patients with end-stage renal failure who underwent HD at one of the 23 centers in Antalya province from January 01 to March 31, 2014 in this retrospective cross-sectional study. Hepatitis B surface antigen (HBsAg) and anti-HCV seropositivity were assessed clinically using a third-generation enzyme-linked immunosorbent assay. HBV DNA and HCV RNA were determined in HBsAg positive and anti- HCV positive HD patients respectively.

Results

Of the patients included, 805 (59.8%) were male. Mean age (± standard deviation) of the patients was 53.9 ± 17.0 (range 17–89) years. The sera of 2.4% patients was positive for HBsAg, and the sera of 5.5% of the patients was positive for anti-HCV. The sera of 56% of patients positive for HBsAg was also positive for HBV DNA, and the sera of 43% of patients positive for anti-HCV was also positive for HCV RNA. Coexistence of HBsAg and anti-HCV was 1.02%.

Conclusions

The present study showed that the prevalence of chronic HBV and HCV infection in patients who underwent HD in Antalya province was moderate-to-low for Turkey. Compliance of HD centers with infection control rules, isolation of HBsAg positive patients, isolation of the equipment used for HBV susceptible patients, and active surveillance of the HD patients may have resulted in lower prevalence rates.

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

Universal Sustained Viral Response to the Combination of Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir with/without Ribavirin in Patients on Hemodialysis Infected with Hepatitis C Virus Genotypes 1 and 4

BACKGROUND

Hepatitis C virus (HCV) infection is highly prevalent among patients on hemodialysis (HD) and is associated with poor prognosis. Treatment with interferon and ribavirin is poorly tolerated, and few data are available on the impact of new direct-acting antivirals (DAAs). This study was intended to analyze the efficacy and safety of treatment with a combination of ombitasvir/paritaprevir/ritonavir and dasabuvir with/without ribavirin in HCV-infected patients on HD from 3 hospitals.

METHODS

This is a multicentric study. We analyze the clinical course of all patients on HD with HCV infection who had been treated with the combination of ombitasvir/paritaprevir/ritonavir and dasabuvir in 3 hospitals in Madrid, Spain. All patients under treatment had undergone Transient elastography (FibroScan®) and HCV RNA (PCR) and HCV genotype were determined simultaneously.

RESULTS

Thirty-five patients aged 53.3 ± 8.9 years (68.6% males) and with genotypes 1 and 4 were treated with the DAA regimen, and 17 were also given ribavirin. The most common etiology was glomerular disease. Sustained viral response was achieved in 100% of patients. Adverse effects were negligible, and no patient had to discontinue treatment. The most significant side effect was anemia, which led to a significant increase in the dose of erythropoiesis-stimulating agents. Anemia was more marked in patients receiving ribavirin. No patients required transfusions.

CONCLUSION

A combination of ombitasvir/paritaprevir/ritonavir and dasabuvir with/without ribavirin for the treatment of HCV in patients on HD is highly effective and causes minimal side effects. This regimen represents a major advance in disease management. A considerable improvement in prognosis seems likely.

Effectiveness of direct-acting antivirals in Hepatitis C virus infection in haemodialysis patients

Hepatitis C virus (HCV) infection is highly prevalent among patients on haemodialysis and leads to a poorer prognosis compared to patients who do not have said infection. Treatment with interferon and ribavirin is poorly tolerated and there are limited data on the experience with new direct-acting antivirals (DAAs). The aim of this study is to retrospectively analyse the current prevalence of HCV infection and efficacy and safety results with different DAA regimens in the haemodialysis population of 2hospital areas. This is a multicentre, retrospective and observational study in which HCV antibodies were analysed in 465 patients, with positive antibody findings in 54 of them (11.6%). Among these, 29 cases (53.7%) with genotypes 1 and 4 were treated with different DAA regimens, including combinations of paritaprevir/ritonavir, ombitasvir, dasabuvir, sofosbuvir, simeprevir, daclatasvir and ledipasvir, with/without ribavirin. Mean age was 53.3±7.9 years, 72.4% of patients were male and the most important aetiology of chronic kidney disease involved glomerular abnormalities. In 100% of cases, a sustained viral response was achieved after 24 weeks, regardless of DAA regimen received. Adverse effects were not relevant and no case required stopping treatment. In 15 cases, ribavirin was combined with the DAA. In these cases, the most significant adverse effect was anaemic tendency, which was reflected in the increase of the dose of erythropoietin stimulating agents, although none required transfusions. In summary, we conclude that new DAAs for the treatment of HCV in haemodialysis patients are highly effective with minimal adverse effects; it is a very important advance in HCV management. These patients are therefore expected to have a much better prognosis than they have had until very recently.

Prevalence of hepatitis C virus infection among patients undergoing haemodialysis in Latin America

Hepatitis C infection is a worldwide problem. The global prevalence of the hepatitis C virus (HCV) averages 3%. Moreover, its prevalence among patients undergoing haemodialysis (HD) varies worldwide, ranging from as low as 1% to up to 70%. There are few data on its prevalence in developing countries, and even less information is available on HD patients. A literature review revealed that the prevalence of HCV infection among patients undergoing HD in Latin America ranges from 4.2 to 83.9%, with most data stemming from Argentina, Brazil, Mexico, Peru, Chile, Venezuela and Cuba. The most common genotype was genotype 1, and subtype 1b was the most frequent. The risk factors associated with this condition were the duration of the HD treatment and blood transfusion before hepatitis C screening. In addition, HCV RNA detection by polymerase chain reaction is crucial for the diagnosis of HCV infection in HD patients. Trials using combinations of new oral antiviral drugs, such as sofosbuvir and combo (ombitasvir, paritaprevir, ritonavir and dasabuvir), should be the next step in the improvement of care among HD patients with HCV, because these therapeutic agents apparently do not require dose adjustment according to renal function. Finally, information on this subgroup of patients remains unavailable in some countries; therefore, additional studies are needed to determine the prevalence trend of HCV infection in these populations.

A Large Nosocomial Outbreak of Hepatitis C Virus Infections at a Hemodialysis Center

Objective:

To identify modes of HCV transmission during an outbreak of HCV infection in a hemodialysis unit.

Design:

An epidemiologic study, virologie analysis, assessment of infection control practices and procedures, and technical examination of products and dialysis machines.

Setting:

A private hemodialysis unit treating approximately 70 patients.

Patients:

Detection of HCV RNA by PCR was performed among patients receiving dialysis in 2001. Case-patients were patients who had a first positive result for HCV RNA between January 2001 and January 2002 and either acute hepatitis, a seroconversion for HCV antibodies, or a previous negative result. Three control-patients were randomly selected per case-patient.

Results:

Of the 61 patients treated in the unit in 2001 and not infected with HCV, 22 (36.1%) became case-patients with onset from May 2001 to January 2002 for an incidence density rate of 70 per 100 patient-years. Phylogenic analysis identified four distinct HCV groups and an index case-patient for each with a similar virus among patients already known to be infected. No multidose medication vials or material was shared between patients. Connection to a dialysis machine by a nurse who had connected an HCV-infected patient “just before” or “one patient before” increased the risk of HCV infection, whereas using the same dialysis machine after a patient infected with HCV did not. Understating, lack of training, and breaches in infection control were documented. Direct observation of practices revealed frequent flooding of blood into the double filter on the arterial pressure tubing set.

Conclusions:

During this outbreak, HCV transmission was mainly patient to patient via healthcare workers' hands. However, transmission via dialysis machines because of possible contamination of internal components could not be excluded.

Standard precautions: a KAP study among nurses in the dialysis unit in a University Hospital in Alexandria, Egypt

BACKGROUND

Compliance with standard precautions measures is essential to prevent and control health-care-associated infections.

OBJECTIVES

This study was conducted to determine the degree to which standard precautions were applied by nurses in a dialysis unit in terms of hand hygiene and use of personal protective equipments. It also aimed to assess nurses' knowledge and attitudes toward standard precautions.

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted in the dialysis unit of the Student University Hospital in Alexandria governorate. The study population included all nurses (17 nurses). An observational checklist was used to record practical activities performed by the nurses and a self-administered questionnaire was used to assess their knowledge and attitude toward standard precautions. A minimum required sample size was estimated to be 323 observations per shift. Each nurse was observed 19 times on different work shifts.

RESULTS

During the study period, 1082 opportunities for applying standard precautions were recorded. None of the nurses (0%) washed hands before and after the different activities that required hand washing or used plastic aprons or face protection. In contrast, all of them (100%) wore nonsterile gloves before or after the different activities that required wearing of gloves. Less than half of nurses (47.1%) correctly knew that they had to wash their hands before and after caring for a patient. None of the nurses received training in infection control. Among the reported barriers for not applying standard precautions, inaccessibility of sinks, high workload or lack of appropriate staffing, and interference with the practice of care, were cited as the most important barriers.

CONCLUSION AND RECOMMENDATIONS

The dialysis unit should revise staff compliance with dialysis unit precautions, and wherever necessary improve the precautions to be applied in the care of all patients and provide performance feedback to nurses. Training of health-care workers (preservice and inservice) about blood-borne infections and universal blood precautions should be regularly carried out.

Investigation of a Case of Genotype 5a Hepatitis C Virus Transmission in a French Hemodialysis Unit Using Epidemiologic Data and Deep Sequencing

BACKGROUND Hepatitis C virus (HCV) is a major cause of chronic liver disease worldwide. A patient was recently found to be HCV seropositive during hemodialysis follow-up. OBJECTIVE To determine whether nosocomial transmission had occurred and which viral populations were transmitted. DESIGN HCV transmission case. SETTING A dialysis unit in a French hospital. METHODS Molecular and epidemiologic investigations were conducted to determine whether 2 cases were related. Risk analysis and auditing procedures were performed to determine the transmission pathway(s). RESULTS Sequence analyses of the NS5b region revealed a 5a genotype in the newly infected patient. Epidemiologic investigations suggested that a highly viremic genotype 5a HCV-infected patient who underwent dialysis in the same unit was the source of the infection. Phylogenetic analysis of NS5b and hypervariable region-1 sequences revealed a genetically related virus (>99.9% nucleotide identity). Deep sequencing of hypervariable region-1 indicated that HCV quasispecies were found in the source whereas a single hypervariable region-1 HCV variant was found in the newly infected patient, and that this was identical to the major variant identified in the source patient. Risk analysis and auditing procedures were performed to determine the transmission pathway(s). Nosocomial patient-to-patient transmission via healthcare workers' hands was the most likely explanation. In our dialysis unit, this unique incident led to the adjustment of infection control policy. CONCLUSIONS The data support transmission of a unique variant from a source with a high viral load and genetic diversity. This investigation also underlines the need to periodically evaluate prevention and control practices.

Transmission of hepatitis C virus in dialysis units: a systematic review of reports on outbreaks

BACKGROUND

Hepatitis C virus (HCV) outbreaks among patients on hemodialysis are still an important health concern all over the world.

AIMS

We performed a systematic review of reports on HCV outbreaks within dialysis units of developed and less-developed countries (between 1992 and 2015) to evaluate risk factors and practices associated with patient-to-patient transmission of HCV in this setting.

METHODS

The research was performed using the PubMed Database and the Outbreak Database; studies were selected according to the PRISMA algorithm. Inclusion criteria were established before the papers were retrieved in order to avoid selection biases.

RESULTS

36 papers reported on 45 outbreaks that involved 335 unique patients on maintenance hemodialysis; no fatal cases were detected. Nosocomial transmission of HCV was confirmed by phylogenetic analysis in most (n=31; 69%) reports. Sharing contaminated hemodialysis machines and multidose vials (heparin or saline solution) was suggested responsible for HCV transmission in 8 (18%) and 6 (13%) outbreaks, respectively. Breaches in environmental cleaning and disinfection practices, and failures in medication preparation and administration practices was considered in 29 (65%) outbreaks; however, the exact mechanism of transmission of HCV could not be ascertained in each facility where an outbreak occurred.

CONCLUSIONS

Our systematic review of reports on hepatitis C virus outbreaks shows that, although the full extent of HCV transmission in dialysis units is unknown, outbreaks continue to occur. Full compliance to standard/specific infection control procedures and routine serologic screening for HCV antibody play a pivotal role for preventing the transmission of HCV within hemodialysis units.

Viral hepatitis in hemodialysis: An update

Hepatitis outbreaks in hemodialysis (HD) patients and staff were reported in the late 1960s, and a number of hepatotropic viruses transmitted by blood and other body fluids have been identified. Hepatitis B virus (HBV) was the first significant hepatotropic virus to be identified in HD centers. HBV infection has been effectively controlled by active vaccination, screening of blood donors, the use of erythropoietin and segregation of HBV carriers. Hepatitis delta virus is a defective virus that can only infect HBV-positive individuals. Hepatitis C virus (HCV) is the most significant cause of non-A, non-B hepatitis and is mainly transmitted by blood transfusion. The introduction in 1990 of routine screening of blood donors for HCV contributed significantly to the control of HCV transmission. An effective HCV vaccine remains an unsolved challenge; however, pegylation of interferon-alfa has made it possible to treat HCV-positive dialysis patients. Unexplained sporadic outbreaks of hepatitis by the mid-1990s prompted the discovery of hepatitis G virus, hepatitis GB virus C and the TT virus. The vigilant observation of guidelines on universal precaution and regular virologic testing are the cornerstones of the effective control of chronic hepatitis in the setting of HD. Major recent advances in the viral diagnosis technology and the development of new oral, direct-acting antiviral agents allow early diagnosis and better therapeutic response. The current update will review the recent developments, controversies and new treatment of viral hepatitis in HD patients.

HIV transmission at a Saudi Arabia hemodialysis unit

This study confirms the occurrence of hemodialysis-associated HIV infection. The occurrence of such transmission is linked to the suboptimal compliance with prevention and control of infection measures.

Background. Hemodialysis is associated with increased risk of healthcare-associated infections but considered a low-risk setting for human immunodeficiency virus (HIV) transmission. We investigated 3 hemodialysis unit (HDU) patients with new HIV infections to determine whether transmission was hemodialysis-associated and to correct factors that contributed to transmission.

Methods. Each patient was evaluated for HIV risk factors. Blood samples were tested to determine relatedness of HIV strains. Clinical data (gathered over 18 months) was reviewed to identify seroconversions at 12 HDUs. Infection prevention and control practices were evaluated at 14 HDUs.

Findings. No other HIV seroconversions were identified during the study. HIV gag, pol, and env gene sequences were consistent with a clonal relationship. HIV and hepatitis C virus prevalence rates at one HDU 1 (5.7% and 6.5%, respectively) were higher than for 11 other HDUs (0% and 0.15%, respectively).

Conclusions. Sequencing supports either patient-to-patient or common-source transmission. Infections occurred despite Saudi Arabia's low HIV prevalence and national dialysis policies that emphasize stringent infection prevention and control practices.

Hepatitis C virus screening and management of seroconversions in hemodialysis facilities

Over the past two decades, healthcare-associated exposure has increasingly been proved to be a means of hepatitis C virus (HCV) transmission, especially in hemodialysis facilities. The prevalence of HCV among hemodialysis patients is known to be several times greater than that of the general population of the United States, and chronic HCV infection is associated with significant morbidity and mortality among these patients. During 2008-2011, HCV infection outbreaks were identified in multiple US hemodialysis facilities, resulting in at least 46 new HCV infections among hemodialysis patients. These outbreaks, linked to infection control breaches, also highlight the failure of some facilities to follow established guidelines for routine HCV antibody (anti-HCV) screening and response to new HCV infection among hemodialysis patients. Current national guidelines recommend screening of hemodialysis patients for anti-HCV on facility admission and, for susceptible patients, on a semiannual basis. Here, we seek to underscore the importance of compliance with national recommendations for anti-HCV screening of hemodialysis patients and actions to be taken in the event of possible HCV transmission within a hemodialysis facility. These include general steps to ensure that: hemodialysis patients are routinely screened for anti-HCV to facilitate early detection of new infections; newly infected patients are informed of the change in their HCV status and undergo clinical evaluation; and public health officials are notified of new HCV infections in a timely manner. We then focus on the need to assess infection control practices at the facility, with particular attention given to safe handling of injectable medications, hand hygiene and disinfection practices. In the absence of a vaccine, routine screening and adherence to standard infection control practices will remain the key strategies for preventing HCV transmission in hemodialysis units.

Interferon treatment for patients with chronic hepatitis C complicated with chronic renal failure receiving hemodialysis

BACKGROUND AND AIMS

The Japan Society for Dialysis Therapy established "Guidelines for the Treatment of Hepatitis C Virus Infection in Dialysis Patients." We evaluated the status of HCV infection and the treatment of hemodialysis patients in Gunma prefecture.

METHODS

Questionnaires concerning the infection rate, recognition of the guidelines, and treatment status were sent to all 64 hospitals/clinics that had hemodialysis systems in Gunma prefecture. The hepatitis C virus-infected hemodialysis patients who received pegylated interferon (peg-IFN) were analyzed at Gunma University Hospital.

RESULTS

The positive rate for hepatitis C virus antibody was 256/2582 hemodialysis patients (9.9%). The positive rate varied between institutions (range 0-40.0%; median 9.0%). All institutes recognized the establishment of the guidelines. Conventional or peg-IFN treatment was being given at 37.5% of the institutions. The other 62.5% institutions answered that they intended to provide the treatment in the future if collaboration with a hepatologist could be arranged. The most common answers regarding the indication for IFN treatment were as follows: few complications, under 60 years of age, more than 10 years of survival expected on hemodialysis. Eighteen patients received peg-IFN treatment. The sustained virological response rate of all patients was 33.3%, 0% in 1b/high viral titer, 50% in genotype 2, and 100% in genotype 2/low viral titer. The sustained virological response rate was worse in the patients with 1b/high viral load and diabetic nephropathy (P < 0.05).

CONCLUSIONS

Recognition of the publication of the guidelines was high. However, the number of patients treated with peg-IFN was still low. Further enlightenment and cooperation between hemodialysis teams and hepatologists are therefore needed.

Healthcare workers and prevention of hepatitis C virus transmission: exploring knowledge, attitudes and evidence-based practices in hemodialysis units in Italy

BACKGROUND

Evidence exists regarding the full prevention of HCV transmission to hemodialysis patients by implementing universal precaution. However, little information is available regarding the frequency with which hospitals have adopted evidence-based practices for preventing HCV infection among hemodialysis patients. A cross-sectional survey has been conducted among nurses in Calabria region (Italy) in order to acquire information about the level of knowledge, the attitudes and the frequencies of evidence-based practices that prevent hospital transmission of HCV.

METHODS

All 37 hemodialysis units (HDU) of Calabria were included in the study and all nurses were invited to participate in the study and to fill in a self-administered questionnaire.

RESULTS

90% of the nurses working in HDU participated in the study. Correct answers about HCV pattern of transmission ranged from 73.7% to 99.3% and were significantly higher in respondents who knew that isolation of HCV-infected patients is not recommended and among those who knew that previous bloodstream infections should be included in medical record and among nurses with fewer years of practice. Most correctly thought that evidence-based infection control measures provide adequate protection against transmission of bloodborne pathogens among healthcare workers. Positive attitude was significantly higher among more knowledgeable nurses. Self-reporting of appropriate handwashing procedures were significantly more likely in nurses who were aware that transmission of bloodborne pathogens among healthcare workers may be prevented through adoption of evidence-based practices and with a correct knowledge about HCV transmission patterns.

CONCLUSIONS

Behavior changes should be aimed at abandoning outdated practices and adopting and maintaining evidence-based practices. Initiatives focused at enabling and reinforcing adherence to effective prevention practices among nurses in HDU are strongly needed.

Hepatitis C virus infection and dialysis: 2012 update

Hepatitis C virus infection is still common among dialysis patients, but the natural history of HCV in this group is not completely understood. Recent evidence has been accumulated showing that anti-HCV positive serologic status is significantly associated with lower survival in dialysis population; an increased risk of liver and cardiovascular disease-related mortality compared with anti-HCV negative subjects has been found. According to a novel meta-analysis (fourteen studies including 145,608 unique patients), the adjusted RR for liver disease-related death and cardiovascular mortality was 3.82 (95% CI, 1.92; 7.61) and 1.26 (95% CI, 1.10; 1.45), respectively. It has been suggested that the decision to treat HCV in patients with chronic kidney disease be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and co-morbidities. According to recent guidelines, the antiviral treatment of choice in HCV-infected patients on dialysis is mono-therapy but fresh data suggest the use of modern antiviral approaches (i.e., pegylated interferon plus ribavirin). The summary estimate for sustained viral response and drop-out rate was 56% (95% CI, 28-84) and 25% (95% CI, 10-40) in a pooled analysis including 151 dialysis patients on combination antiviral therapy (conventional or pegylated interferon plus ribavirin).

Incidence of hepatitis C virus infection in patients on hemodialysis: a systematic review and meta-analysis

Hepatitis C virus infection is a perennial concern for hemodialysis units because the prevalence of hepatitis C is significantly higher there than in the general population. Through a systematic review and meta-analysis, we aim to assess the incidence rate of hepatitis C virus infection in hemodialysis units and explore its potential risk factors. Five electronic databases were used to search articles from 1990 to 2012, including PubMed, Embase, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang. A random-effects analysis was used to estimate the overall incidence rate of hepatitis C virus infection. A subgroup analysis and meta-regression analysis were conducted to explore factors associated with heterogeneity between studies. Twenty-two eligible articles were found, including 23 incidence rate estimates. The overall incidence rate of hepatitis C virus infection was 1.47 per 100 patient-years (95% confidence interval [CI] 1.14 to 1.80). In the subgroup analysis, the pooled incidence rate was 4.44 (CI 2.65, 6.23) per 100 patient-years in the developing world and 0.99 (CI 0.66, 1.29) per 100 patient-years in the developed world. [Correction added on 2 November 2012, after first online publication: Pooled incidence rate in the developed world has been changed.] In addition, in hemodialysis units with higher prevalence, the incidence rate of hepatitis C virus infection also tended to be higher. Meta-regression analysis showed that the country's development level and initial HCV prevalence combined could explain 67.91% of the observed heterogeneity. The incidence rate of hepatitis C virus infection among patients on hemodialysis was significantly high. Efforts should be taken to control hepatitis C virus infection in hemodialysis units, especially in developing countries.

Seropositivity for anti-HCV core antigen is independently associated with increased all-cause, cardiovascular, and liver disease-related mortality in hemodialysis patients

Background

It is not known whether chronic or past hepatitis C virus (HCV) infection contributes to the high mortality rate in hemodialysis patients.

Methods

This prospective study of 1077 adult hemodialysis patients without hepatitis B virus infection used Poisson regression analysis to estimate crude and sex- and age-adjusted rates (per 1000 patient-years) of all-cause, cardiovascular, infectious disease-related and liver disease-related mortality in patients negative for HCV antibody (group A), patients positive for HCV antibody and negative for anti-HCV core antigen (group B), and patients positive for anti-HCV core antigen (group C). The relative risks (RRs) for each cause of death in group B vs group C as compared with those in group A were also estimated by Poisson regression analysis after multivariate adjustment.

Results

A total of 407 patients died during the 5-year observation period. The sex- and age-adjusted mortality rate was 71.9 in group A, 80.4 in group B, and 156 in group C. The RRs (95% CI) for death in group B vs group C were 1.23 (0.72 to 2.12) vs 1.60 (1.13 to 2.28) for all-cause death, 0.75 (0.28 to 2.02) vs 1.64 (0.98 to 2.73) for cardiovascular death, 1.64 (0.65 to 4.15) vs 1.58 (0.81 to 3.07) for infectious disease-related death, and 15.3 (1.26 to 186) vs 28.8 (3.75 to 221) for liver disease-related death, respectively.

Conclusions

Anti-HCV core antigen seropositivity independently contributes to elevated risks of all-cause and cause-specific death. Chronic HCV infection, but not past HCV infection, is a risk for death among hemodialysis patients.

Adequacy of dialysis clinic staffing and quality of care: a review of evidence and areas of needed research

Improving the quality of care delivered to patients receiving in-center dialysis treatment remains a perpetual concern with stakeholders. Quality indicators traditionally have focused on such items as adequacy of dialysis, anemia management, patient survival, and, most recently, the percentage using arteriovenous fistulas. Largely overlooked in the quest for improvement has been adequate consideration of dialysis clinic staffing levels. Staffing is important because it has been identified as a structural measure of quality. With 326,671 (93.1%) of all dialysis patients receiving in-center treatments, this is a potentially critical issue. This article reviews evidence related to inadequacies in clinic staffing and how they may be contributing to suboptimal care and outcomes. Focusing on nephrologists, nurses, patient care technicians, dietitians, and social workers, this article suggests areas of needed research.

Patient-care practices associated with an increased prevalence of hepatitis C virus infection among chronic hemodialysis patients

OBJECTIVE

To identify patient-care practices related to an increased prevalence of hepatitis C virus (HCV) infection among chronic hemodialysis patients.

DESIGN

Survey.

SETTING

Chronic hemodialysis facilities in the United States.

PARTICIPANTS

Equal-probability 2-stage cluster sampling was used to select 87 facilities from all Medicare-approved providers treating 30-150 patients; 53 facilities and 2,933 of 3,680 eligible patients agreed to participate.

METHODS

Patients were tested for HCV antibody and HCV RNA. Data on patient-care practices were collected using direct observation.

RESULTS

The overall prevalence of HCV infection was 9.9% (95% confidence interval [CI], 8.2%-11.6%); only 2 of 294 HCV-positive patients were detected solely by HCV RNA testing. After adjusting for non-dialysis-related HCV risk factors, patient-care practices independently associated with a higher prevalence of HCV infection included reusing priming receptacles without disinfection (odds ratio [OR], 2.3 [95% CI, 1.4-3.9]), handling blood specimens adjacent to medications and clean supplies (OR, 2.2 [95% CI, 1.3-3.6]), and using mobile carts to deliver injectable medications (OR, 1.7 [95% CI, 1.0-2.8]). Independently related facility covariates were at least 10% patient HCV infection prevalence (OR, 3.0 [95% CI, 1.8-5.2]), patient-to-staff ratio of at least 7 : 1 (OR, 2.4 [95% CI, 1.4-4.1]), and treatment duration of at least 2 years (OR, 2.4 [95% CI, 1.3-4.4]).

CONCLUSIONS

This study provides the first epidemiologic evidence of associations between specific patient-care practices and higher HCV infection prevalence among hemodialysis patients. Staff should review practices to ensure that hemodialysis-specific infection control practices are being implemented, especially handling clean and contaminated items in separate areas, reusing items only if disinfected, and prohibiting mobile medication and clean supply carts within treatment areas.

Treatment of hepatitis C virus infection in patients with end-stage renal disease

Hepatitis C virus (HCV) infection is a major health problem in patients with end-stage renal disease (ESRD). The incidence of acute HCV infection during maintenance dialysis is much higher than that in the general population because of the risk of nosocomial transmission. Following acute HCV infection, most patients develop chronic HCV infection, and a significant proportion develop chronic hepatitis, cirrhosis, and even hepatocellular carcinoma. Overall, chronic hepatitis C patients on hemodialysis bear an increased risk of liver-related morbidity and mortality, either during dialysis or after renal transplantation. Interferon (IFN) therapy is modestly effective for the treatment of HCV infection in ESRD patients. Conventional or pegylated IFN monotherapy has been used to treat acute hepatitis C in ESRD patients with excellent safety and efficacy. Regarding chronic hepatitis C, approximately one-third of patients can achieve a sustained virological response (SVR) after conventional or pegylated IFN monotherapy. The combination of low-dose ribavirin and conventional or pegylated IFN has further improved the SVR rate in treatment-naïve or retreated ESRD patients in clinical trials. Similar to the treatment of patients with normal renal function, baseline and on-treatment HCV virokinetics are useful to guide optimized therapy in ESRD patients. Of particular note, IFN-based therapy is not recommended at the post-renal transplantation stage because of the low SVR rate and risk of acute graft rejection. In conclusion, ESRD patients with HCV infection should be encouraged to receive antiviral therapy, and those who achieve an SVR usually have long-term, durable, virological, biochemical, and histological responses.

Molecular epidemiology of a hepatitis C virus epidemic in a haemodialysis unit: outbreak investigation and infection outcome

Background

HCV is a leading cause of liver chronic diseases all over the world. In developed countries the highest prevalence of infection is reported among intravenous drug users and haemodialysis (HD) patients. The present report is to identify the pathway of HCV transmission during an outbreak of HCV infection in a privately run haemodialysis (HD) unit in Italy in 2005.

Methods

Dynamics of the outbreak and infection clinical outcomes were defined through an ambi-directional cohort study. Molecular epidemiology techniques were used to define the relationships between the viral variants infecting the patients and confirm the outbreak. Risk analysis and auditing procedures were carried out to define the transmission pathway(s).

Results

Of the 50 patients treated in the HD unit 5 were already anti-HCV positive and 13 became positive during the study period (AR = 28.9%). Phylogenic analysis identified that, all the molecularly characterized incident cases (10 out of 13), were infected with the same viral variant of one of the prevalent cases. The multivariate analysis and the auditing procedure disclosed a single event of multi-dose vials heparin contamination as the cause of transmission of the infection in 11 out of the 13 incident cases; 2 additional incident cases occurred possibly as a result of inappropriate risk management.

Discussion

More than 30% of all HCV infections in developed countries results from poor application of standard precautions during percutaneous procedures. Comprehensive strategy which included: educational programmes, periodical auditing on standard precaution, use of single-dose vials whenever possible, prospective surveillance for blood-borne infections (including a system of prompt notification) and risk assessment/management dedicated staff are the cornerstone to contain and prevent outbreaks in HD

Conclusions

The outbreak described should serve as a reminder to HD providers that patients undergoing dialysis are at risk for HCV infection and that HCV may be easily transmitted whenever standard precautions are not strictly applied.

Epidemiology, surveillance, and prevention of hepatitis C virus infections in hemodialysis patients

Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States; the prevalence in maintenance hemodialysis patients substantially exceeds that in the general population. In hemodialysis patients, HCV infection has been associated with increased occurrence of cirrhosis and hepatocellular carcinoma and increased mortality. Injection drug use and receipt of blood transfusions before 1992 has accounted for most prevalent HCV infections in the United States. However, HCV transmission among patients undergoing hemodialysis has been documented frequently. Outbreak investigations have implicated lapses in infection control practices as the cause of HCV infections. Preventing these infections is an emerging priority for renal care providers, public health agencies, and regulators. Adherence to recommended infection control practices is effective in preventing HCV transmission in hemodialysis facilities. In addition, adoption of routine screening to facilitate the detection of incident HCV infections and hemodialysis-related transmission is an essential component of patient safety and infection prevention efforts. This article describes the current epidemiology of HCV infection in US maintenance hemodialysis patients and prevention practices to decrease its incidence and transmission.

Effects of oral levamisole as an adjuvant to hepatitis B vaccine in adults with end-stage renal disease: a meta-analysis of controlled clinical trials

BACKGROUND

Many patients receiving long-term dialysis do not produce protective antibodies to hepatitis B virus (HBV) surface antigen (HBsAg) after HBV vaccination. The results from several studies have suggested benefit of oral levamisole as an adjuvant to HBV vaccination in patients with end-stage renal disease (ESRD). However, reliable information is still lacking.

OBJECTIVE

This meta-analysis assessed the efficacy and safety profile of oral levamisole as an adjuvant to HBV vaccine in patients with ESRD.

METHODS

This meta-analysis included prospective controlled clinical trials identified using literature searches of MEDLINE, SCOPUS, Institute for Scientific Information bibliographic database, and Cochrane Collaboration's Central Register of Controlled Clinical Trials for controlled clinical trials that weighted the seroprotection rate in patients with ESRD who received oral levamisole + HBV vaccine versus those who received the HBV vaccine alone (control). The fixed-effects Mantel-Haenszel model was applied with the heterogeneity and sensitivity analyses. The response rate, defined as the proportion of patients with seroprotective concentrations of antibodies to HBsAg (>10 mIU/mL) at completion and 6 to 10 months after completion of the HBV vaccine schedule, was the end point of interest and was also analyzed separately. For the tolerability assessment, studies that reported dose reduction, levamisole discontinuation, and their adverse effects including laboratory abnormalities were included.

RESULTS

The literature search identified 4 studies that fulfilled the inclusion criteria (328 patients). The mean ages of the patients in these studies ranged from 41 to 53 years, and sex distribution ranged from 52.6% to 68.0% male. Twenty-two patients received oral levamisole 100 mg/d for 12 days (from 6 days before to 6 days after each vaccination). A total of 106 patients received oral levamisole 80 to 120 mg for 4 to 6 months. Aggregation of study results suggested a significant increase in response rate in the group that received levamisole + HBV vaccine compared with the control group (pooled odds ratio [OR] = 2.77 [95% CI, 1.56-4.94]) after completion and 6 to 10 months after the vaccination period (pooled OR = 3.96 [95% CI, 1.71-9.18]). The test of heterogeneity was not statistically significant in either group. Five patients underwent dose reduction due to mild adverse events. In one trial, 3 patients died, 1 of whom was receiving levamisole; however, the authors did not provide the causes of death. No other serious adverse events were reported with levamisole administration.

CONCLUSION

The results from this meta-analysis suggest significant benefit in the administration of levamisole as an adjuvant to HBV vaccine to increase seroprotection in patients with ESRD.

Hepatic and extra-hepatic sequelae, and prevalence of viral hepatitis C infection estimated from routine data in at-risk groups

Background

Concerns about the hepatitis C virus (HCV) are due to the high risk of chronic liver disease and poor treatment efficacy. Synthesizing evidence from multiple data sources is becoming widely used to estimate HCV-infection prevalence. This paper aims to estimate the prevalence of HCV infection, and the hepatic and extrahepatic sequelae in at-risk groups, using routinely collected data in the Lazio region, Italy.

Methods

HCV laboratory surveillance and dialysis, hospital discharge, and drug-user registers were used as information sources to identify at-risk groups and to estimate HCV prevalence and sequelae.

Full name and birth date were used as linkage keys for the various health registries. Prevalence was estimated as the percentage of cases within the general population and the at-risk groups, with 95% confidence intervals (95% CI) from 1997 to 2001. The risk of sequelae was estimated through a follow-up of hospital discharges up to December 31, 2004 and calculated as the prevalence ratio in HCV-positive and HCV-negative people, within each at-risk group, with 95% CI.

Results

There were 65,127 HCV-infected people in the study period; the prevalence was 1.24% (95%CI = 1.23%-1.25%) in the whole population, higher in males and older adults. Drug users (35.1%; 95%CI = 34.6-35.7) and dialysis patients (21.1%; 95%CI = 20.2%-22.0%) showed the highest values. Medical procedures with little exposure to blood resulted in higher estimates, ranging between 1.3% and 3.4%, which was not conclusively attributable to the surgical procedures. Cirrhosis, hepatocellular carcinoma and encephalopathy were the most frequent hepatic sequelae; cryoglobulinaemia and non-Hodgkin's lymphoma were the most frequent extrahepatic sequelae.

Conclusions

Synthesising data from multiple routine sources improved estimates of HCV prevalence and sequelae in dialysis patients and drug users, although prevalence validity should be assessed in survey and sequelae need a well-defined longitudinal approach.

Infecção pelo vírus da hepatite c em pacientes em hemodiálise: prevalência e fatores de risco

CONTEXTO: Doentes com doença renal crônica em tratamento hemodialítico apresentam risco aumentado de aquisição do vírus da hepatite C (VHC). Elevadas taxas de prevalência têm sido detectadas em unidades de diálise do mundo inteiro. Estudos recentes têm demonstrado que a infecção pelo VHC interfere de forma negativa na sobrevida dos pacientes em hemodiálise e naqueles submetidos ao transplante renal. OBJETIVOS: Determinar a prevalência e os fatores de risco da infecção pelo VHC em pacientes submetidos a hemodiálise. MÉTODOS: Realizou-se estudo transversal entre janeiro e dezembro de 2007. Neste período, 236 pacientes em hemodiálise foram testados pelo ELISA de terceira geração. Os casos positivos foram submetidos a pesquisa qualitativa do HCV-RNA pelo método de PCR. Consideraram-se como portadores de infecção pelo VHC aqueles pacientes com anti-VHC e HCV-RNA positivos. Dosagens mensais de ALT e a média do valor de 12 meses foram obtidas em 195 pacientes. Do total de pacientes, 208 (88,1%) responderam ao questionário padronizado visando a identificação de fatores de risco associados à infecção pelo VHC. RESULTADOS: A prevalência de pacientes anti-VHC positivos encontrada entre os 236 testados foi de 14,8% (35/236); destes, a pesquisa do HCV-RNA foi positiva em 71,6% (25/35). Portanto, a prevalência da infecção crônica pelo VHC foi de 10,6% (25/236) dos pacientes. Pela análise bivariada, os principais fatores de risco associados à infecção pelo VHC foram o tempo de hemodiálise, o número de transfusões de sangue, a realização prévia de diálise peritonial e história de doença sexualmente transmissível. Contudo, após análise multivariada, somente o tempo de hemodiálise e história de doença sexualmente transmissível foram significativamente associados à infecção pelo VHC. Pacientes com mais de 10 anos de hemodiálise apresentaram risco de aquisição do VHC 73,9 (IC de 17,5 a 311,8) vezes maior quando comparados a pacientes com até 5 anos de tratamento. Indivíduos com doença sexualmente transmissível prévia apresentaram risco 4,8 (IC de 1,1 a 19,9) vezes superior de contaminação pelo VHC quando comparados àqueles sem doença sexualmente transmissível. O valor médio da ALT foi significantemente maior nos pacientes infectados pelo VHC (44,0 ± 13,5 U/L versus 33,5 ± 8,0 U/L, P<0,001). CONCLUSÃO: A infecção pelo VHC apresentou elevada prevalência na unidade de diálise analisada. O tempo de tratamento dialítico e história prévia de doença sexualmente transmissível foram os principais fatores de risco associados à infecção pelo VHC. Indivíduos em hemodiálise com infecção crônica pelo VHC apresentaram maior atividade de ALT que pacientes sem hepatite C crônica.

Clinical significance of alanine aminotransferase levels and the effect of ursodeoxycholic acid in hemodialysis patients with chronic hepatitis C

BACKGROUND

The natural history of hepatitis C virus (HCV) carriers and the effect of ursodeoxycholic acid (UDCA) have not been fully elucidated among hemodialysis (HD) patients.

METHODS

Eighty-four anti-HCV antibody- and HCV RNA-positive and 154 anti-HCV antibody-negative HD patients who were retrospectively observed for at least 3 years were analyzed. We investigated the factors associated with thrombocytopenia (< 1.3 x 10(5)/microL) and decreased platelet count (PLT) (more than 20% decrease during the follow-up period), which were considered to be indicators of hepatic fibrosis. In addition, another 16 HD patients with HCV who received 300 mg/day UDCA orally for at least 6 months were investigated. Changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT) and PLT were assessed.

RESULTS

After the 60.3-months mean follow-up period, HCV infection was independently associated with both thrombocytopenia [odds ratio (OR) 2.589] and decreased PLT (OR 2.339) in 238 HD patients. In 84 HD patients with HCV, the average ALT levels (> or = 15 IU/L) during the follow-up period was associated with thrombocytopenia (OR 3.882) and decreased PLT (OR 4.470). In addition, ALT, AST and GGT significantly decreased at 6 months after starting UDCA, but PLT did not change in 16 HD patients with HCV.

CONCLUSIONS

These results indicate that HCV infection is a risk for thrombocytopenia which should be associated with hepatic fibrosis in HD patients. In addition, the clinical course of ALT levels predicts the progression of thrombocytopenia, and UDCA may effectively lower ALT levels in HD patients with HCV.

Infection control guidelines for prevention of health care-associated transmission of hepatitis B and C viruses

Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patient's circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.

Health care-associated transmission of hepatitis B and C viruses in hemodialysis units

Liver disease is a significant cause of morbidity and mortality in patients receiving long-term dialysis. This article summarizes the most recent information on epidemiology, clinical significance, and management of infection by hepatitis B and C viruses in this population.

Hospital safety climate, psychosocial risk factors and needlestick injuries in Japan

To investigate the interactions between safety climate, psychosocial issues and Needlestick and Sharps Injuries (NSI), a cross-sectional study was undertaken among nurses at a university teaching hospital in Japan (89% response rate). NSI were correlated with various aspects of hospital safety climate including supporting one another at work, the protection of staff against blood-borne diseases being a high management priority, managers doing their part to protect staff from blood-borne disease, having unsafe work practices corrected by supervisors, having the opportunity to use safety equipment to protect against blood-borne disease exposures, having an uncluttered work area, and having minimal conflict within their department. In conclusion, this study has demonstrated the importance of hospital safety climate in Japanese health care practice, particularly its relationship with NSI. Although the provision of safer devices remains critical in preventing injuries, ensuring a positive safety climate will also be essential in meeting these important challenges for nurses' occupational health.