CDC Releases Report on Hep C Outbreak at NY Clinic

3/5/2009 8:52:33 PM

 
Poor infection control techniques lead to an outbreak of Hepatitis C at a New York dialysis clinic last summer, according to a report released today by the Centers for Disease Control and Prevention. Even when staff became aware of the positive cases, the agency said, patients initially weren't informed of the results.

The outbreak, which ultimately involved nine patients, forced the closing of the Life Care Dialysis Center in Manhattan on Sept. 16. In addition to surrendering its operating certificate, the center paid a civil penalty of $300,000 to the state.

In its report, the CDC said the state Department of Health had received reports from dialysis staff as early as May of a patient who had contracted Hepatitis C who was receiving treatment at the clinic. On July 1, the dialysis clinic reported two more patients who had tested positive for Hepatitis C. The six additional patients contracted the disease between 2001--2008 at the clinic. "The unit's policy for routine patient testing for HCV infection was not in accordance with CDC recommendations, and the few recommendations followed were not implemented consistently," the CDC wrote.

During the site investigation, state health officials documented inadequate HCV infection surveillance and patient follow-up. Numerous deficiencies in standard infection control practices also were identified, the CDC report said.

The hemodialysis unit did not obtain confirmatory testing for anti-HCV positive results, inform patients of their change in HCV infection status, report HCV seroconversions to the local health department, or provide patients with medical evaluation related to HCV infection. Contrary to CDC recommendations, monthly alanine aminotransferase (ALT) levels were not obtained from >90% of HCV-susceptible patients, and anti-HCV testing, although conducted on most patients, was performed at intervals ranging from once per month to once per two years rather than semiannually.

"Inadequate cleaning and disinfection practices were observed during site visits in July and August 2008. In one instance, a single bleach-soaked gauze pad was used to clean a patient's entire dialysis station, including dialysis machine surfaces and ancillary patient equipment (e.g., blood pressure cuff and shared computer monitor and keyboard)," the CDC report said.

The bleach solution was prepared and stored improperly, and staff members did not allow sufficient contact time between surfaces and bleach. Visible blood remained on dialysis chairs, dialysis machine surfaces, and the surrounding floor between patient treatments. Moreover, direct care staff members failed to use gloves with every patient encounter, change gloves between patients, or perform hand hygiene after contact with patients and soiled surfaces.

Supervisory staff members failed to address these breaches. Many of the direct care staff members were unaware of the hemodialysis unit's written infection control policies, including those pertaining to cleaning and disinfection. Investigators also noted the lack of a separate clean area for medication
storage and preparation and short turnover periods between patient treatments, the report said.

The CDC says an estimated 3.2 million persons have chronic HCV infection, the most common chronic bloodborne infection in the United States. The prevalence of anti-HCV is estimated at 8% among chronic hemodialysis patients, compared with 1.6% in the U.S. population overall.