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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 2  |  Page : 183-188
Prevention of Viral Transmission in HD Units: The Value of Isolation


Kanoo Kidney Center, Dammam Central Hospital, Dammam, Saudi Arabia

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   Abstract 

We have investigated the influence of isolation of patients with different viral serology status on the transmission of viral hepatitis among patients on hemodialysis (HD). Our kidney center was designed to facilitate isolation of infected patients and implement infection control pre-cautions. These included separate rooms, separate entrances and exit sites, and designated HD machines for patients with hepatitis B, hepatitis C, and sero-negative patients. In addition, universal infection control polices and procedures were implemented. These included proper chemical and heat disinfection of all HD machines following each HD session. These measures were complemented with education and training of the nursing staff detailing strict adherence to all infection control policies and procedures. All of our patients and staff were vaccinated against hepatitis B. Our results showed that after four years of follow-up, there was a decrease in the annual incidence of hepatitis C seroconversion from an average of 2.4% to 0.2%. The current prevalence of hepatitis C is 29% compared to 57% at the start of the study. In addition, there have been no reported sero-conversion cases of hepatitis B. Furthermore, our data also confirmed that the prevalence of hepatitis C (as well as hepatitis B) is more frequent in HD (29%) than peritoneal dialysis (5%) units. Surgical procedures, blood transfusion, and frequent visits to different dialysis units remain the major risk factors for contracting viral hepatitis. In conclusion, these results clearly show that isolation of patients and machines, together with strict adherence to infection control policies and procedures, result in a significant decline in the incidence and prevalence and better control of viral hepatitis transmission among HD patients.

Keywords: Infection control, Hepatitis B &C, Prevention, Isolation, HD.

How to cite this article:
Karkar A, Abdelrahman M, Ghacha R, Malik TQ. Prevention of Viral Transmission in HD Units: The Value of Isolation. Saudi J Kidney Dis Transpl 2006;17:183-8

How to cite this URL:
Karkar A, Abdelrahman M, Ghacha R, Malik TQ. Prevention of Viral Transmission in HD Units: The Value of Isolation. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2019 Nov 22];17:183-8. Available from: http://www.sjkdt.org/text.asp?2006/17/2/183/35788

   Introduction Top


It is well known that patients undergoing dialysis treatment, and in particular hemodialysis (HD), are at increased risk for contracting viral infections. This is due to their underlying impaired cellular immunity, which increases their susceptibility to infection. In addition, the process of HD requires blood exposure to infectious materials through the extra­corporeal circulation for a prolonged period. Moreover, HD patients may require blood transfusion, frequent hospitalizations, and surgery, which increase opportunities for nosocomial infection exposure.

The most frequent viral infections encountered in HD units are hepatitis B (HBV), hepatitis C (HCV) and, to a lesser extent, human immunodeficiency virus infection (HIV). The incidence of HBV infection has declined dramatically following the application of standard precautions, isolation, blood product screening, but most importantly the avail­ability and implementation of an effective vaccination scheme.

In contrast, the incidence of HCV is increasing in the general population; it is affecting 200 million people worldwide and, therefore, poses a significant and growing public health problem. [1] Additionally, the prevalence of HCV in HD units has been progressively increasing; ranging from 5% in some western countries to 95% in some developing countries. [2] This increase is largely due to the lack of an effective vaccine. However, it is also due to inadequate infection control policies and procedures, and/or a breakdown in infection control procedures. [3] These include inadequate isolation of infected patients, contamination of dialysis machines and/or improper sterili­zation, occasional need of invasive procedures and blood transfusion, and inadequately trained practicing staff on the value of hand washing, wearing sterile gowns, masks and gloves, and proper disposal of contaminated linens and used disposables. [4]

It is well known that both hepatitis B and C can lead to chronic active hepatitis, liver cirrhosis, and hepatocellular carcinoma. Despite the availability of some effective anti­-viral treatments, prevention of contamination and avoiding nosocomial transmission of viral hepatitis remain the corner stone, not only in controlling the disease, but also in reducing the financial burden. Therefore, it is essential and crucial that health care personnel take the necessary steps and measures to prevent and control the transmission of viral infection among patients and other staff in the dialysis units.

Numerous measures have been taken to reduce the incidence and prevalence of viral hepatitis in HD units. However, isolation of dialysis patients and machines in separate rooms/halls, in order to prevent or reduce nosocomial transmission and sero-conversion of viral hepatitis in HD units, remains a controversial issue.

In this study, we investigated the effectiveness of HD patient isolation on the incidence and prevalence rates of hepatitis B and C.


   Materials and Methods Top


The design of our new center at Dammam Central Hospital, Dammam, Saudi Arabia, included separate dialysis sections on each floor for the HBV positive, the HCV positive, and sero-negative patients. All dialysis sections had their own entrance and exit sites to avoid the possibility of cross infection among the nursing staff and patients. Furthermore, separate routes, including chutes, were structured on each site for the disposal of all dirty bed sheets, linens, and other used disposables in designated bags. Additionally, HD machines were not moved between these sections. Heat and chemical disinfection protocols were enforced after each dialysis session. All new hemodialysis patients with unknown serology status were treated on designated machines until serology results became available.

Universal infection precautions included disinfecting instruments used during HD session (e.g. machine surfaces, HD tables and sphygmomanometers). Each patient had a disposable set of materials for each dialysis session. All other infection control precautions applied in the old unit were reinforced. The nursing staff was repeatedly instructed about infection control polices and procedures. In addition, the nursing staff was restricted to their respective sections. They were also strictly instructed on hand washing, the systematic use of sterile gowns, masks, and gloves, avoiding the practice of sharing multi-dose heparin or erythropoietin vials, and maintaining proper disposal of contaminated linens and used disposables. All patients' conditions and infection control regulations were revised in regular staff meetings.

We studied four years of incidence and prevalence of hepatitis B and C in 265 patients (147 males and 118 females) with a mean age of 47.5 years (range 15-85 years) and dialysis duration varying between 4 and 21 years. We compared the results with those in our old unit over a similar period.

Compiled data also included the number of blood transfusions, number and type of surgical procedures, history of kidney transplantation, and number of visits to different HD centers.

All the patients had viral serologies checked at the time of initiation of hemo- or peritoneal dialysis and routinely every three months thereafter. The assays were repeated upon arrival for patients who had HD treatment in other centers during their travel. The anti­HCV antibodies were assayed by ELISA-III using Murex version III kits (Murex diagnostics, France) and the positive results were confirmed by detecting the HCV-RNA by polymerase chain reaction (PCR) technique. The hepatitis B surface antigen (HbsAg) was assayed by ELISA method using Abbott diagnostic kits.


   Statistical Analysis Top


Student's "t" test was used for quantitative comparison. Chi-square was used to analyze group differences in the categorical variables. All tests were two tailed and a P value of <0.05 was considered significant.


   Results Top


[Figure - 1] shows the annual incidence of HCV in the old and new centers. The annual incidence of hepatitis C seroconversion decreased significantly from an average of 2.4% to 0.2% (P<0.001), with no new sero­conversion cases in the last two years. 12 HBV antigen positive patients were found positive at the time of dialysis initiation.

[Figure - 2] shows the prevalence of hepatitis C in our new and old centers. The prevalence decreased from 57% in the old center to 29% in the new one (P<0.001). However, the prevalence is still relatively high since many newly admitted HCV positive patients are transferred from other HD units.

The majority of HCV positive patients (75%) has been previously exposed to different surgical procedures and received multiple blood transfusions. Among the new 16 hepatitis C sero-converted patients in years 2002 and 2003, 10 patients contracted their infection following repeated visits to other HD centers, where they received blood trans­fusions and were exposed to different surgical procedures,including creation of new vascular access and dental interventions. Two of the other four sero-converted patients were diagnosed following failed kidney trans­plantation abroad from hepatitis C positive donors. One case required multiple blood transfusions due to very low hemoglobin (3gm/dl) following the surgical removal of a necrotic rejected transplanted kidney. One patient had repeated chest infections and required lung aspirations, in addition to different surgical procedures, including cholecystectomy. The other cases showed no obvious cause except that one patient was diagnosed with a psychiatric illness and required repeated admission to other hospitals. The other patient had a sister with post kidney transplant hepatitis C.

Furthermore, our data also showed that the prevalence of hepatitis C was more frequent in HD (29%) than peritoneal dialysis (5%) sections. All HCV positive patients on peritoneal dialysis were originally positive before they started peritoneal dialysis.


   Discussion Top


There have been conflicting reports in the literature regarding the value and practical aspect of isolating HCV positive patients on HD. Huraib [2] reviewed most of these studies and the problems faced with isolation; he concluded that isolation was favorable.

Currently, the isolation of HCV patients may be more advisable. The early diagnosis of hepatitis C (as well as B) has become widely available and more achievable by ELISA III and PCR techniques, making detection and isolation of HCV infected patients easier in the early phase of the disease. In addition to the application of universal precautions, the progressive increase in the incidence and prevalence of HCV worldwide, in particular in dialysis patients, may warrant patient isolation; despite the existence of many HCV genotypes that may result in cross infection among the isolated HCV positive patients.

It must be stressed, however, that proper isolation of seropositive patients requires extra nursing staff and additional areas to segregate dialysis patients and machines, according to virology status. However, the value of reducing the incidence and pre­valence of viral hepatitis transmission should also be taken in consideration, at least in major dialysis centers.

Despite the fact that enforcement of the infection control policies and procedures has largely contributed to decreases in HCV incidence and prevalence, [4],[5] we believe that there is a considerable effect of patient and HD machine isolation on our results.

However, there are other major risk factors in the transmission of viral hepatitis among patients on HD treatment. These include blood transfusion, surgical and dental interventions, transplanted organs from positive donors, and the multiple HD centers' visits. Emphasis on the sterilization of surgical theaters and instruments, screening of kidney donors, and avoidance of transfusions, together with the use of widely available disposable materials have reduced the risk of viral transmission in our centers.

It is accepted that the frequent travel of some dialysis patients to different HD centers, which do not adhere to the infection control measures, may be hardly modifiable. [6] In fact, the HCV sero-conversion of the majority (62.5%) of our newly reported cases was due to the multi-center visit effect. In order to control the possible deleterious consequences of multi-center visits and the possibility of contracting HCV or HBV, certain measures and precautions have been devised and implemented by our center. These include such as allocation of special HD space and machines to treat temporarily visiting patients to our center and those who return after visits to other centers during the window period. Hemofiltration using disposable equipment and solutions could be another alternative but expensive choice. Furthermore, we advocate checking viral serologies on these patients monthly to detect seroconverted cases early.

In conclusion, our results suggest that the enforcement of universal precautions and patient isolation in the HD centers can reduce the incidence and prevalence of viral hepatitis. Traveling of patients with multiple dialysis center visits and requirement of blood transfusion, and exposure to different surgical procedures remain major risk factors for contracting viral hepatitis. These issues require special attention and clear practical guidelines to overcome.

 
   References Top

1.Delahooke TE. Hepatitis C: what is the nature of the problem? J Viral Hepat 2004;11 (suppl 1):5-11.  Back to cited text no. 1  [PUBMED]  
2.Huraib SO. Hepatitis C in dialysis patients. Saudi J Kidney Dis Transplant 2003;14 (4):442-50.  Back to cited text no. 2    
3.Al-Jiffri AM, Fadeg RB, Ghabrah TM, Ibrahim A. Hepatitis C virus infection among patients on HD in Jeddah: a single center experience. Saudi J Kidney Dis Transplant 2003;14(1):84-9.  Back to cited text no. 3    
4.Goldberg D, Anderson E. Hepatitis C: who is at risk and how do we identify them? J Viral Hepat 2004;11(suppl 1):12-8.  Back to cited text no. 4  [PUBMED]  
5.Al-Ghamdi SM. Nurses'knowledge and practice in HD units: comparison between nurses in units with high and low prevalence of hepatitis C virus infection. Saudi J Kidney Dis Transplant 2004;15 (1):34-40.  Back to cited text no. 5    
6.Kashem A, Nusairat I, Mohamad M, et al. Hepatitis C virus among HD patients in Najran: prevalence is more among multi­center visitors. Saudi J Kidney Dis Transplant 2003;14(2):206-11.  Back to cited text no. 6    

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Correspondence Address:
Ayman Karkar
Kanoo Kidney Center, Dammam Central Hospital, PO Box 11825, Dammam 31463
Saudi Arabia
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PMID: 16903625

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