Knowledge and Practices of Hepatitis Screening and Infection Control in County Outpatient Hemodialysis Facilities

Background: In 2010, the Dallas County Department of Health and Human Services (DCHHS) received reports of two hemodialysis patients from the same outpatient center seroconverting from anti-hepatitis C virus (HCV) negative to anti-HCV positive.  Each case was virologically linked to source patients with known chronic HCV infection being serviced at the same dialysis facility, through viral sequencing and genotyping. Challenges encountered during this outbreak investigation prompted an interest in assessing the general knowledge of hemodialysis facilities in this area regarding awareness and implementation of the CDC guidelines for screening and prevention of hepatitis transmission. 

Objective: To assess knowledge of the 2001 CDC guidelines for hepatitis screening, extent of implementation, and infection control practices at outpatient hemodialysis facilities in Dallas County, Texas.

Methods: Of 40 area outpatient hemodialysis facilities identified, a total of 18 facilities agreed to voluntarily participate in health department interviews.  A survey instrument was created to assess knowledge and implementation of CDC recommendations for hepatitis B virus (HBV) and HCV screening, and infection control practices.  Phone interviews were conducted with the designated respective Directors of Nursing for each facility over a three-week period. 

Results: The facilities reported servicing a combined patient base of 1,748 hemodialysis patients, including 257 (15%) with known chronic HCV infection and 20 (1%) with chronic HBV infection.  All facilities reported conducting infection control training and audits of staff on a regular basis, however there was substantial variability in frequency of such sessions. All centers denied using mobile carts for preparation of medications.  Although all facilities reported screening all patients for both HBV and HCV on admission, only 4 (22%) practiced subsequent routine screening of susceptible patients every 6 months for HCV in accordance with CDC recommendations.  The remaining 14 (78%) of facilities screened such patients once a year.  Only one facility cited reimbursement issues as affecting the frequency of hepatitis screening.  Two (11%) facilities reported ever identifying cases of HBV or HCV seroconversion in their patient populations. Although all centers reported the existence of a written response plan in the event of detection of a HBV or HCV seroconversion, seven (39%) facilities reported that they unaware of the requirement to report such new cases to the health department.

Conclusions: Greater awareness and implementation of CDC recommendations for screening and prevention of hepatitis transmission needs to be promoted in outpatient dialysis centers, so that potentially health-care associated instances of transmission can be detected and investigated in a timely manner, and appropriate interventions conducted.