IN PRACTICE Epidemiology, Surveillance, and Prevention of Hepatitis C Virus Infections in Hemodialysis Patients Priti R. Patel, MD, MPH, 1 Nicola D. Thompson, PhD, 2 Alexander J. Kallen, MD, MPH, 1 and Matthew J. Arduino, DrPH 1 Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States; the prevalence in maintenance hemodialysis patients substantially exceeds that in the general population. In hemodialysis patients, HCV infection has been associated with increased occurrence of cirrhosis and hepatocellular carcinoma and increased mortality. Injection drug use and receipt of blood transfusions before 1992 has accounted for most prevalent HCV infections in the United States. However, HCV transmission among patients undergoing hemodialysis has been documented frequently. Outbreak investigations have implicated lapses in infection control practices as the cause of HCV infections. Preventing these infections is an emerging priority for renal care providers, public health agencies, and regulators. Adherence to recommended infection control practices is effective in preventing HCV transmission in hemodialysis facilities. In addition, adoption of routine screening to facilitate the detection of incident HCV infections and hemodialysis-related transmission is an essential component of patient safety and infection prevention efforts. This article describes the current epidemiology of HCV infection in US maintenance hemodialysis patients and prevention practices to decrease its incidence and transmission. Am J Kidney Dis 56:371-378. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is a US Government Work. There are no restrictions on its use. INDEX WORDS: Hepatitis C; dialysis; epidemiology; transmission; infection control. T his is the first of 2 articles discussing infec- tion control in hemodialysis units; the sec- ond article focuses on the epidemiology, surveil- lance, and prevention of bloodstream infections. 1 CASE PRESENTATION A 53-year-old man who had been treated in a freestanding dialysis unit for 2 years was noted to be jaundiced when he presented for a routine hemodialysis treatment. He reported malaise, but no other symptoms. The patient was sent to an urgent care center for evaluation and subsequently dis- charged with plans for close follow-up. Laboratory studies, including hepatitis serologic tests that were sent, confirmed a diagnosis of acute HCV infection. A review of the patient’s laboratory records from the hemodialysis facility showed that he had had negative test results for antibody to HCV (anti-HCV) during routine screening performed 5 months before the diagnosis. The patient’s serum alanine aminotrans- ferase (ALT) level 1 month before diagnosis was 192 U/L, which was increased in comparison to his serum ALT level (21 U/L) in prior months. The patient did not report recent behavioral risk factors for HCV infection, including injec- tion drug use or high risk sexual practices. During the following 2 months, a second and third patient treated at the same dialysis unit were found to be newly anti-HCV positive. Neither patient experienced jaundice nor other signs or symptoms of acute hepatitis. A review of monthly serumALT results found they were newly increased (ALT, 758 and 149 U/L in the 2 patients). These patients had been treated at the hemodialysis unit for longer than 1 year and had had negative test results for anti-HCV on admission to the facility. Although serum ALT levels were obtained monthly for patients at the facility, results of these tests were not actively monitored. Staff at the facility initiated a review of medical records for all patients in the unit and implemented additional case-finding activities by performing monthly anti-HCV screening for all patients not previously anti-HCV positive. The 3 patients with a new diagnosis of HCV infection had received hemodialysis treatment on the same schedule and shift as other patients at the facility with existing HCV infection. No other common epide- miologic links or exposure opportunities were identified among them. The facility consulted with their local and state health departments, who recommended a thorough review of their infection control practices. Facility staff and public health officials examined infec- tion control practices at the facility on different days and shifts. They identified a number of practices that were suboptimal, including use of a mobile medication cart to deliver medications to dialysis treatment stations, prepara- From the 1 National Center for Preparedness, Detection, and Control of Infectious Diseases and 2 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Cen- ters for Disease Control and Prevention, Atlanta, GA. Received September 10, 2009. Accepted in revised form January 29, 2010. Originally published online as doi:10.1053/ j.ajkd.2010.01.025 on June 16, 2010. Address correspondence to Priti R. Patel, MD, MPH, 1600 Clifton Rd, MS A-31, Atlanta, GA 30333. E-mail: ppatel@cdc.gov Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is a US Government Work. There are no restrictions on its use. 0272-6386/10/5602-0017$0.00/0 doi:10.1053/j.ajkd.2010.01.025 American Journal of Kidney Diseases, Vol 56, No 2 (August), 2010: pp 371-378 371