Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Weekly March 6, 2009 / Vol. 58 / No. 8 Hepatitis C Virus Transmission National Kidney Month at an Outpatient Hemodialysis and World Kidney Day Unit — New York, 2001–2008 March is National Kidney Month in the United States, and March 12 is World Kidney Day. Both commemora- In July 2008, the New York State Department of Health tions are intended to raise awareness of kidney disease and (NYSDOH) received reports of three hemodialysis patients the importance of prevention and early detection. Kidney seroconverting from anti-hepatitis C virus (HCV) negative disease is the ninth leading cause of death in the United to anti-HCV positive in a New York City hemodialysis unit States (1), but persons with chronic kidney disease (CKD) during the preceding 6 months. NYSDOH conducted patient are more likely to die from cardiovascular disease than interviews and made multiple visits to the hemodialysis unit develop kidney failure (2). to observe hemodialysis treatments, assess infection control In 2000, approximately 26 million U.S. adults had practices, evaluate HCV surveillance activities, review medical CKD (3). However, in 1999–2004, only 42% of adults records, and conduct interviews with staff members. This report with severe kidney disease (stage 4) and fewer than 10% summarizes the results of that investigation, which found that of those with less severe disease (stages 1–3) were aware of six additional patients had HCV seroconversion during 2001– their conditions (4). CDC, in collaboration with partners, 2008 and that the hemodialysis unit had numerous deficiencies has developed the Chronic Kidney Disease Initiative, in infection control policies, procedures, and training. Of the including surveillance and screening projects and studies total of nine seroconversions, the sources for four HCV infec- of CKD costs. Additional information is available at http:// tions were identified phylogenetically and epidemiologically www.cdc.gov/diabetes/projects/kidney.htm. as four other patients in the unit. The unit’s policy for routine This year, World Kidney Day focuses on high blood patient testing for HCV infection was not in accordance with pressure, which, along with diabetes, is a leading cause of CDC recommendations, and the few recommendations fol- CKD (3). Information regarding kidney disease is available lowed were not implemented consistently. Hemodialysis units from the National Kidney Disease Education Program at http://www.nkdep.nih.gov. Information regarding should routinely assess compliance to ensure complete and World Kidney Day activities is available at http://www. timely adherence with CDC recommendations to reduce the worldkidneyday.org. risk for HCV transmission in this setting. References 1. Heron MP, Hoyert DL, Xu J, Scott C, Tejada-Vera B. Deaths: pre- liminary data for 2006. Natl Vital Stat Rep 2008;56(16):4–5. 2. Collins AJ, Li S, Gilbertson DT, Liu J, Chen SC, Herzog CA. INSIDE Chronic kidney disease and cardiovascular disease in the Medicare population. Kidney Int Suppl 2003;87:S24–31. 194 Methicillin-Resistant Staphylococcus aureus Skin Infections 3. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney from an Elephant Calf — San Diego, California, 2008 disease in the United States. JAMA 2007;298:2038–47. 198 Progress Toward Poliomyelitis Eradication — Afghanistan 4. Plantinga LC, Boulware LE, Coresh J, et al. Patient awareness of and Pakistan, 2008 chronic kidney disease: trends and predictors. Arch Intern Med 202 Notices to Readers 2008;168:2268–75. 205 QuickStats Department of Health and Human Services Centers for Disease Control and Prevention 190 MMWR March 6, 2009 The MMWR series of publications is published by the Coordinating The hemodialysis unit was a large, for-profit, outpatient Center for Health Information and Service, Centers for Disease facility treating 70–100 patients daily at 30 dialysis stations. Control and Prevention (CDC), U.S. Department of Health and On May 24, 2008, the New York City Department of Health Human Services, Atlanta, GA 30333. and Mental Hygiene informed NYSDOH of a confirmed Suggested Citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2009;58:[inclusive page numbers]. HCV seroconversion in one patient receiving chronic hemo- dialysis treatment at the unit. On July 1, the unit reported Centers for Disease Control and Prevention two additional HCV seroconversions directly to NYSDOH. Richard E. Besser, MD (Acting) Director Interviews conducted by NYSDOH with the three patients Tanja Popovic, MD, PhD who seroconverted revealed no other common health-care Chief Science Officer exposures or behavioral risk factors. In addition, none of the James W. Stephens, PhD three had been informed by the hemodialysis unit of their Associate Director for Science Steven L. Solomon, MD HCV infections. Initial site visit findings by NYSDOH docu- Director, Coordinating Center for Health Information and Service mented poor infection control practices and oversight. Specific Jay M. Bernhardt, PhD, MPH recommendations addressing deficiencies were provided to the Director, National Center for Health Marketing unit’s administrative staff members at the initial site visit and Katherine L. Daniel, PhD throughout the investigation. An epidemiologic investigation Deputy Director, National Center for Health Marketing subsequently was undertaken to identify additional patients Editorial and Production Staff with HCV infection, assess infection control practices, and Frederic E. Shaw, MD, JD Editor, MMWR Series make recommendations to prevent ongoing transmission. Susan F. Davis, MD (Acting) Assistant Editor, MMWR Series Epidemiologic Investigation Robert A. Gunn, MD, MPH Associate Editor, MMWR Series The epidemiologic study population consisted of all 162 Teresa F. Rutledge patients who were receiving hemodialysis at the unit as of July Managing Editor, MMWR Series 1, 2008. For all patients, HCV-related test results reported Douglas W. Weatherwax through the unit’s central electronic laboratory system and the Lead Technical Writer-Editor NYSDOH Electronic Clinical Laboratory Reporting System Donald G. Meadows, MA Jude C. Rutledge were reviewed, and patients were matched against New York Writers-Editors state and New York City hepatitis surveillance registries. All Martha F. Boyd current patients were offered anti-HCV testing. Because hemo- Lead Visual Information Specialist dialysis unit staff members were not considered likely sources Malbea A. LaPete Stephen R. Spriggs of HCV transmission in this investigation, staff members were Visual Information Specialists not tested. Kim L. Bright, MBA Patients were considered HCV positive if their serum was Quang M. Doan, MBA 1) determined positive by enzyme immunoassay (EIA) testing Phyllis H. King Information Technology Specialists with a signal-to-cutoff ratio consistent with CDC recommen- dations for a confirmed anti-HCV positive test or 2) deter- Editorial Board mined positive by EIA followed by recombinant immunoblot William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN assay or nucleic acid testing for HCV RNA (1). A chronic case David W. Fleming, MD, Seattle, WA of HCV was defined as a case in a patient who was HCV William E. Halperin, MD, DrPH, MPH, Newark, NJ Margaret A. Hamburg, MD, Washington, DC positive before or upon admission to the hemodialysis unit. King K. Holmes, MD, PhD, Seattle, WA An incident case was defined as a case in a patient who was Deborah Holtzman, PhD, Atlanta, GA HCV negative upon admission to the hemodialysis unit but John K. Iglehart, Bethesda, MD Dennis G. Maki, MD, Madison, WI who subsequently was confirmed HCV positive. Unit medi- Sue Mallonee, MPH, Oklahoma City, OK cal records for all HCV-positive patients were reviewed, and Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Remington, MD, MPH, Madison, WI serum from available patients was submitted to NYSDOH’s Barbara K. Rimer, DrPH, Chapel Hill, NC Wadsworth Center laboratory for HCV sequencing and phy- John V. Rullan, MD, MPH, San Juan, PR William Schaffner, MD, Nashville, TN logenetic analysis. Anne Schuchat, MD, Atlanta, GA Of the 162 patients, HCV infection status at hemodialysis Dixie E. Snider, MD, MPH, Atlanta, GA John W. Ward, MD, Atlanta, GA unit admission could be documented through medical records Vol. 58 / No. 8 MMWR 191 and previous test results for 110 (68%). Twenty (18%) of the The joint phylogenetic-epidemiologic analysis identified four 110 had chronic HCV infection at admission. Ninety (82%) different patients as the sources of HCV infection in four were anti-HCV negative at admission, of whom nine (10%) were patients who seroconverted during 2005–2008 (all sequence determined to have acquired incident HCV infection, serocon- identity matches between source and incident patients were verting to anti-HCV positive during 2001–2008 (Figure). >98%). Of the four source patients, one was among the nine Among the 162 patients, a total of 45 (28%) had at least with incident infection, two were among those with chronic one anti-HCV positive EIA test result, either at admission HCV infection at admission, and one had unknown HCV or during their hemodialysis treatment period. Serum was infection status at admission. All four patients with incident collected and tested from 35 of these patients, of whom 26 infection and their respective source patients had dozens of had sufficient virus for sequencing and subtyping of NS5b treatment