|Year : 2014 | Volume
| Issue : 3 | Page : 551-555
Hepatitis C virus seroconversion in hemodialysis units with a high prevalence of hepatitis C: do we need isolation?
Ahmed M Zahran MD
Nephrology Unit, Internal Medicine Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||13-Dec-2013|
|Date of Acceptance||23-Mar-2014|
|Date of Web Publication||26-Nov-2014|
Ahmed M Zahran
Nephrology Unit, Internal Medicine Department, Faculty of Medicine, Menoufia University, Shebin, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
The objective of this study was to determine whether the isolation of hemodialysis patients with hepatitis C virus (HCV) in hemodialysis units with a high prevalence of hepatitis C is necessary or not.
HCV is one of the most common pathogens leading to serious morbidity and mortality in hemodialysis patients. Despite the quality control measures developed to reduce the risk of HCV transmission, HCV persists, and nosocomial virus transmission remains a concern.
Patients and methods
This study included 514 patients with end-stage renal disease on regular hemodialysis in Menoufia governorate, Egypt. Of them, 303 patients started dialysis with negative HCV, and 44 patients seroconverted to HCV positive during dialysis. Patients were divided into two groups: group 1, which included 259 patients who remained negative for HCV, and group 2, which included 44 patients who seroconverted to HCV positive during dialysis. Risk factors for seroconversion were compared between the two groups.
The duration of dialysis in months (33.72 in group 1 compared with 71.36 in group 2), a positive family history for HCV infection (6.4% in group 1 vs. 20.5% in group 2), and a low socioeconomic level (58.3% in group 1 vs. 72.7% in group 2) were found to be significant among the studied groups. Other factors such as blood transfusion, surgery, dentist visit, a history of bilharziasis and hepatitis B virus vaccination were found to be insignificant. The duration of dialysis was found to be a key predictor of HCV seroconversion
Patients with a long duration of dialysis were more liable to HCV seroconversion in dialysis units with a high prevalence rate of HCV infection, especially in developing countries. Good training on infection control measures with strict supervision of the dialysis staff is required. A controlled randomized study is needed to compare the isolation policy with no isolation of HCV patients on regular hemodialysis in developing countries to determine whether there is any benefit of isolation.
Keywords: Egypt, end-stage renal disease, hemodialysis, hepatitis C nosocomial infection, hepatitis C virus seroconversion, Menoufia governorate
|How to cite this article:|
Zahran AM. Hepatitis C virus seroconversion in hemodialysis units with a high prevalence of hepatitis C: do we need isolation?. Menoufia Med J 2014;27:551-5
|How to cite this URL:|
Zahran AM. Hepatitis C virus seroconversion in hemodialysis units with a high prevalence of hepatitis C: do we need isolation?. Menoufia Med J [serial online] 2014 [cited 2020 Feb 24];27:551-5. Available from: http://www.mmj.eg.net/text.asp?2014/27/3/551/145511
| Introduction|| |
End-stage renal disease (ESRD) has become a public health concern worldwide as the total number of ESRD patients requiring renal replacement therapy has been growing drastically  . Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection. HCV is responsible for over one million patients' deaths from cirrhosis and liver cancer every year  .
Patients undergoing hemodialysis (HD) are at an increased risk of contracting viral infection due to the 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 prolonged periods. Also, HD patients required blood transfusion, frequent hospitalization and surgery, which increase opportunities for nosocomial infection exposure. The most frequent viral infections encountered in HD units are hepatitis B virus (HBV), HCV, and to lesser extent HIV infection  .
The prevalence of hepatitis C in dialysis patients showed wide variations worldwide. The reported prevalence of HCV infection among dialysis patients in developed countries ranges from 3.6 to 20%, with higher rates in developing countries  . It was estimated to be 52.1 in Egypt  . In the Menoufia governorate, there is a high prevalence of HCV among HD patient, which may be attributed to the high prevalence of HCV in the general population, the high rate of blood transfusion in dialysis units to treat anemia instead of iron therapy and erythropoietin, which is costly, and the lack of standard methods for infection control in dialysis units  .
HBV/HCV infection is related to a higher morbidity and mortality in HD patients even after they have received a kidney transplant , . Quality control measures for HD have been developed to reduce the risk of transmission of blood-borne viruses in the ESRD population  . However, HBV or HCV persist within HD units and nosocomial virus transmission remains a concern  . Although quality control measures developed to reduce the risk of HCV transmission did not recommend the isolation of these patients  , the no-isolation policy in developing countries is still debatable, because in most of the developing countries, there is a lack of application of standard measures of infection control. In this study, we tried to investigate HCV seroconversion and the most important factors responsible for seroconversion in dialysis units in the Menoufia governorate, Egypt, as an example of dialysis units with a high prevalence of HCV in a developing country.
| Patients and methods|| |
In coordination with the Menoufia governorate health affairs, we conducted a questionnaire in dialysis units focusing on the hepatitis status, blood transfusion after starting dialysis, surgery or dentist visits after starting dialysis, contact with relatives with HCV infection, the duration of dialysis, the socioeconomic level, and epidemiological data.
All participants underwent full history taking with clinical examination. The socioeconomic level was determined depending on their monthly income, the type of housing with the number of persons per room, and the level of education. We obtained results of 514 patients from six dialysis centers: 259 were negative for HCV and 255 were positive for HCV. Among the positive patients, 44 started negative and seroconverted during dialysis. Hence, this work studied retrospectively the 303 patients who started negative for HCV, and then divided them into two groups: group 1, which included 259 patients who remained negative for HCV, and group 2, which included 44 patients who seroconverted during dialysis. All patients were offered regular HD three times per week, each session lasting 4 h. There was no isolation for HCV patients in all units. Also, in all units, some machines were dedicated for HCV patients only, with no reuse of the dialyzer. The chemical disinfection protocol was enforced after each dialysis. The infection control measures applied in all units were nearly the same; however, the infection control guidelines were not properly followed. Virology testing for HCV, HBV, and HIV were performed routinely every 3 months. Third-generation enzyme-linked immunosorbant assay was used for the detection of HCV, and PCR was used for the confirmation of newly discovered cases. The protocol for this study followed the ethical standards and was approved by the ethical committee of our institution, and all participants gave informed consent to participate in this study.
We used the statistical package for the social sciences (SPSS, version 16; SPSS Inc., Chicago, Illinois, USA) and Excel to perform the analyses. Quantitative data were expressed as mean ± SD, whereas categorical data were expressed as the number and percentage. The Student t-test or the Mann-Whitney test was used as appropriate to compare two groups of quantitative variables, and the c2 -test was used to compare two groups of categorical variables. The Fischer exact test was used if variable less than 5. Regression analysis was performed to determine the possible predictor of seroconversion of HCV during HD. P value 0.05 or less was considered significant.
| Results|| |
This study included 514 patients on regular HD in Menoufia governorate, Egypt. The prevalence of HCV infection was 49.6% (255 patients) ([Figure 1]a). Among this group, 44 (14.5%) patients were negative for HCV infection when they started dialysis and seroconverted during HD ([Figure 1]b) and 259 (50.4%) patients started negative for HCV infections and remained negative. Hence, finally, this study included 303 patients (all started dialysis negative for HCV infection: 162 were male and 141 were female).The cohort was divided into two groups: group 1 consisted of 259 patients (139 male and 120 female) who were negative for HCV when they started dialysis and remained negative. Group 2 consisted of 44 patients (23 male and 21 female) who were negative for HCV when they started dialysis and seroconverted during dialysis to HCV positive.
|Figure 1: (a) Prevalence of hepatitis C virus (HCV) infection among the total population of dialysis (514 patients). (b) Prevalence of HCV seroconversion among dialysis patients who were negative for HCV infection when they started dialysis (303 patients).|
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Comparison between the studied groups with regard to the risk factors for HCV seroconversion showed that the duration of HD in months (33.72 ± 29.05 in group 1 and 71.36 ± 53.13 in group 2) ([Figure 2]), a positive family history for HCV infections and the socioeconomic level were the significant factors between the two studied groups. Other factors such as blood transfusion, a history of bilharziasis, surgical operation and dentist visits, receiving dialysis in an emergency situation with a temporary catheter, final vascular access, and vaccination against hepatitis B were nonsignificant among the studied groups ([Table 1]). The duration after which seroconversion occurred in group 2 was 36.68 ± 22.66 months. Although this difference was not significant, the duration in group 2 was longer than that in group 1. Regression analysis showed that a positive family history of HCV infection and the duration of dialysis were the predictors of HCV seroconversion with, P value 0.003 and 0.0001, respectively ([Table 2]).
|Figure 2: A comparison between the studied groups with regard to the duration of dialysis.|
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|Table 1: Demographics and comparison between the studied groups with regard to the risk factors for hepatitis C virus seroconversion |
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|Table 2: Regression analysis to detect the predictors of hepatitis C virus positive seroconversion |
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| Discussion|| |
HCV was first identified in 1989 when it was found to be the primary causative agent of non-A, non-B hepatitis, associated with high rates of progressive, end-stage liver disease  . HCV is one of the most common pathogens leading to serious morbidity and mortality in HD patients in developing countries  . In Menoufia governorate, Egypt, there is a high prevalence of HCV infection among HD patients  .
In our study, we found that the duration of dialysis, a positive family history of HCV infections, and the socioeconomic level were significant among the studied groups. The duration of dialysis and a positive family history of HCV infection were the predictors of HCV seroconversion during HD. In contrast, blood transfusion, surgical and dentist visits, a history of bilharziasis and hepatitis B vaccination were all nonsignificant among the studied groups. From these results, we can demonstrate that the factor responsible for HCV seroconversion is either contact with an infected person in the family or through nosocomial infection as a long duration of dialysis means more exposure in dialysis units with a high risk for nosocomial infections. Also, the long duration after which seroconversion happened substantiates the concept that a long duration of dialysis led to more exposure in dialysis units, with increased risk of HCV nosocomial infection.
In our dialysis units, there is no isolation policy for HCV-infected patients. In one study to determine the effect of isolation of HCV patients, Karkar et al.  showed a significant reduction of HCV and HBV seroconversion in isolated patients with strict application of infection control measures. Yuan et al.  also demonstrated the same effect of isolation of HBV and HCV patients with the application of infection control measures on reducing the incidence of HBV and HCV seroconversion. Another study from Saudi Arabia also concluded that isolation of HCV patients, minimizing blood transfusion and strict application of infection control guidelines help in the prevention of HCV transmission among HD units  . Agarwal et al.  concluded that the isolation of HCV-infected patients during HD significantly decreases the HCV seroconversion rate and recommended that the 'no-isolation' policy should not be generalized. In HD units with a high prevalence of HCV patients, strict isolation policy in combination with implementation of universal prevention measures can eliminate nosocomial transmission and yield a long-term reduction in prevalence , . In contrast to this concept, an old study from Belgium concluded that the strict enforcement of universal precautions fully prevents HCV transmission to HD patients and concluded that the isolation of anti-HCV-positive patients is not wanted  .
In concordance with our results, the Dialysis Outcome and Practice Pattern Study (DOPPS) showed that high HCV seroconversion was associated with a longer time on dialysis, and they concluded that seroconversion was associated with an increase in the facility HCV prevalence, but not with the isolation of HCV-infected patients  . Also, the Kidney Disease Improving Global Outcome (KDIGO) guidelines did not recommend the isolation policy for HCV-infected patients and did not even recommend the use of dedicated machines for them  .
There may be other factors responsible for nosocomial infections as shown by Saxena et al.  , who found that vascular access plays a role in the transmission of HCV in a high prevalence HD unit and concluded that those with arteriovenous fistula and synthetic grafts were liable to HCV nosocomial infections more than those with permanent catheters. However, our study did not show any difference related to vascular access.
In our study, we did not find any significant difference between the two groups with regard to blood transfusion, and it may be attributed to virology testing before donation; however, most of the studies did not confirm whether blood transfusion for dialysis patients plays a role or not in acquiring HCV infection and only recommend minimization of blood transfusion. In most of developing countries, there is lack of application of infection control guidelines. In one study from Sudan, they found a serious gap in the HD staff's knowledge and adherence to infection control recommendations, and this may be related to HCV seroconversion, and they recommended that a structured training program for HD staff members is urgently required  .
From previous discussions, there is a debate about the isolation policy for HCV-positive HD patients, especially in developing countries with a high prevalence of HCV infection. Those who recommend isolation advocate their opinion on the basis of the high seroconversion rate in dialysis units with a high prevalence of HCV infection and the lack of training and adherence to infection control guidelines by dialysis staff, especially in developing countries. Those who did not recommend the isolation policy stated that it is unclear whether the reported improvement in seroconversion resulted from the adoption of an isolation policy or rather from the simultaneous increase in the awareness and reinforcement of the application of hygienic precautions. Additional arguments against relying on the use of isolation to prevent transmission of HCV include the possibility of an increased risk of HCV infection with more than one genotype and the duration between infection and seroconversion. The seroconversion time (window) can be over a year and has a median length of 5 months in HD patients even with third-generation enzyme-linked immunosorbant assay tests. This will result in inadequate selection of patients to be isolated, unless PCR is performed frequently, which is expensive  .
| Conclusion|| |
There is a high seroconversion rate of HCV in HD units, especially in those with a high prevalence of HCV infection in developing countries. There is a lack of education and adherence to infection control guidelines among the dialysis staff. Although the no-isolation policy and no dedicated machines for HCV patients were not recommended by KDIGO guidelines, it is still questioned in developing countries with a high prevalence of HCV infections in dialysis patients. Good education and training programs and strict supervision of the dialysis staff are required in developing countries. Multicenter randomized controlled studies must be conducted in developing countries to compare the isolation policy and the no-isolation policy with adherence to infection control guidelines to conclude whether isolation is beneficial in reducing HCV seroconversion in dialysis units with a high prevalence of HCV infection in developing countries or not.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]