Holiday haemodialysis and imported hepatitis C virus infection: A series of sixteen cases in two large haemodialysis units

EASL position paper on clinical follow-up after HCV cure

Following the advent of direct-acting antivirals (DAAs), hepatitis C virus (HCV) infection can be cured in almost all infected patients. This has led to a number of clinical questions regarding the optimal management of the millions of patients cured of HCV. This position statement provides specific guidance on the appropriate follow-up after a sustained virological response in patients without advanced fibrosis, those with compensated advanced chronic liver disease, and those with decompensated cirrhosis. Guidance on hepatocellular carcinoma risk assessment and the management of extrahepatic manifestations of HCV is also provided. Finally, guidance is provided on the monitoring and treatment of reinfection in at-risk patients. The recommendations are based on the best available evidence and are intended to help healthcare professionals involved in the management of patients after treatment for HCV.

South Asian Health: Inflammation, Infection, Exposure, and the Human Microbiome

This paper presents the results of the literature review conducted for the working group topic on inflammation, infection, exposure, and the human microbiome. Infection and chronic inflammation can elevate risk for cardiovascular disease and cancer. Environmental exposures common among South Asian (SA) subgroups, such as arsenic exposure among Bangladeshis and particulate matter air pollution among taxi drivers, also pose risks. This review explores the effects of exposure to arsenic and particulate matter, as well as other infections common among SAs, including human papillomavirus (HPV) and hepatitis B/C infection. Emerging research on the human microbiome, and the effect of microbiome changes on obesity and diabetes risk among SAs are also explored.

The prevention of hepatitis C virus transmission to hemodialysis patients and staff members

In this review article, we cover 4 topics very relevant to those involved in the care of hemodialysis (HD) patients and in the management of a HD unit. We start with an overview of the progress made over the last 25 years to reduce hepatitis C virus (HCV) transmission in HD. Next, we discuss the potential strategies to prevent the residual ongoing transmission of HCV to HD patients. Third, we discuss the actions to be taken if a seroconversion for HCV is nevertheless detected in a HD patient. Finally, we briefly discuss how best to protect HD staff members from occupationally acquired HCV infection.

The effect of holiday haemodialysis treatments on patient mood, adverse symptoms and subjective wellbeing using the Big Red Kidney Bus

BACKGROUND AND AIMS

People with end-stage kidney disease receiving haemodialysis are restricted to holidays where dialysis services are readily available. Holiday dialysis in regional, rural and remote areas is particularly challenging. The aims of this study were to evaluate the wellbeing of those who received dialysis in a holiday haemodialysis bus and to measure patient well-being with that of a comparable cohort of haemodialysis patients.

METHODS

A three machine haemodialysis bus, the Big Red Kidney Bus, was built to enable people, their families and carers to take holidays across a range of tourist destinations in Victoria, Australia. Measures included pre-post subjective well-being, dialysis symptoms and mood questionnaires complemented by post semi-structured telephone interviews.

RESULTS

Participating holidaymakers were positive about the haemodialysis bus service and the standard of care experienced. They reported decreased dialysis side effects of fatigue, muscle cramp and dry skin. The overall number of reported symptoms decreased, and the perceived level of bother associated with symptoms also decreased. No changes in subjective well-being and mood were detected. Mean Personal Wellbeing Index scores were significantly higher than in a comparative haemodialysis sample.

CONCLUSION

The Big Red Kidney Bus provided a safe and feasible holiday dialysis service. Holidaymakers' well-being was reflected by the decreased dialysis patient side effects.

Problems associated with hemodialysis and travel

BACKGROUND

While there is a recognized risk of hepatitis C acquisition associated with dialysis away from the "home" center, there is little documented data on the effect that dialysis while traveling has on the dialysis patient's health. This study was designed to examine the incidence of travel within a hemodialysis population and to ascertain whether travel was associated with morbidity for patients on hemodialysis.

METHODS

Travel data were collected prospectively over a 6-month period, from April 2009, for all patients receiving maintenance hemodialysis across our dialysis centers. Biochemical, microbiological, and hematological parameters as well as hepatitis serology and antibiotic starts were recorded for 12 weeks prior to and following dialysis away from center.

RESULTS

A total of 172 individuals traveled on 200 occasions. The blood stream infection rate for travelers with a central venous catheter was 0.25 versus 0.83/1,000 access days (p = 0.038) in the 12 weeks pre-travel versus post-travel. Parenteral and oral antibiotic starts were both significantly elevated post-travel and were mainly instituted for either chest or urinary sepsis. There was evidence of raised inflammatory markers and anemia on return to center but no evidence of hepatitis B or hepatitis C seroconversion.

CONCLUSIONS

Travel and dialysis away from a patient's usual hemodialysis unit is a common occurrence but is associated with an increased risk of bacterial infection, anemia, and inflammatory response. This study provides evidence for the concern that hemodialysis away from center is associated with increased morbidity.

Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL). Part I: Status Report of HCV Infection in India

Globally, around 150 million people are infected with hepatitis C virus (HCV). India contributes a large proportion of this HCV burden. The prevalence of HCV infection in India is estimated at between 0.5% and 1.5%. It is higher in the northeastern part, tribal populations and Punjab, areas which may represent HCV hotspots, and is lower in western and eastern parts of the country. The predominant modes of HCV transmission in India are blood transfusion and unsafe therapeutic injections. There is a need for large field studies to better understand HCV epidemiology and identify high-prevalence areas, and to identify and spread awareness about the modes of transmission of this infection in an attempt to prevent disease transmission.

Hepatitis B and C infection in international travelers

BACKGROUND

Hepatitis B and C virus (HBV and HCV) cause significant morbidity and mortality worldwide. With the rise in international travel over the last three decades, many travelers are at risk of HBV and HCV infection.

METHODS

This review focuses on the epidemiology of HBV and HCV in international travelers, the modes of transmission, and the prevention of infection in travelers.

RESULTS

The risk of HBV and HCV infection varies widely and depends on the prevalence of the destination country, the duration of travel, and the activities undertaken while abroad. Travelers commonly undertake high-risk activities that place them at risk of both HBV and HCV infection. Poor uptake of preventative health measures and poor adherence to health recommendations are also common. The monthly incidence of HBV infection for long-term travelers to endemic countries ranges from 25 to 420 per 100,000 travelers. HBV infection can be prevented through timely vaccination of travelers. HBV vaccination is safe and efficacious with protective levels of antibodies achieved in >90% of recipients. Information regarding the risk of HCV acquisition is scarce and until recently was limited to case reports following medical interventions.

CONCLUSIONS

This review demonstrates international travelers are at risk of HBV and HCV infection and provides evidence-based information enabling health practitioners to provide more appropriate pre-travel advice. HBV vaccination should be considered in all travelers to countries with a moderate to high HBV prevalence (HBsAg ≥ 2%) and the risk and benefits discussed with the individuals in consultation with the health practitioner. There is no duration of travel without risk of HBV infection. However, it is apparent that those travelers with a longer duration of travel are at greatest risk of HBV infection (ie, expatriates). Travelers should also receive advice regarding the modes of transmission and the activities that place them at risk of both HBV and HCV infection.

Epidemiology and molecular investigation of hepatitis C infection following holiday haemodialysis

BACKGROUND

Hepatitis C virus infection (HCV) is not infrequent among haemodialysis patients. Most published reports suggest that patient-to-patient spread, either directly or indirectly, is the most common mode of transmission in renal units.

AIM

To investigate the source of an outbreak, and the route of transmission, of acute HCV infection in two Scottish patients occurring within eight weeks of receiving haemodialysis in the same unit while on holiday in Majorca.

METHODS

This was an international epidemiological and molecular investigation of HCV infection among a cohort of haemodialysis patients from nine countries.

FINDINGS

No further HCV-positive infections were observed among residents and holidaymakers receiving haemodialysis at the unit in Majorca. Molecular investigations confirmed that a Spanish healthcare worker (HCW) was the source of infection for the two Scottish patients. The investigators were unable to determine the route of transmission.

CONCLUSIONS

This outbreak is the first reported case of HCW-to-patient transmission of HCV in a renal unit, and the third reported case of transmission involving a HCW who had not performed invasive procedures. The issue of whether renal units are an exceptional case with regards to the risk of transmission associated with non-invasive procedures should be considered, in conjunction with the need to improve surveillance of blood-borne virus transmissions in renal units in the UK and abroad.

Infectious complications in dialysis--epidemiology and outcomes

This Review focuses on the changing epidemiology of infections among patients with end-stage renal disease who are undergoing dialysis. In particular, bloodstream infections related to vascular access in patients undergoing hemodialysis, and peritonitis in patients undergoing peritoneal dialysis, are highlighted. Gram-positive (staphylococcal and enterococcal) bloodstream infections and Gram-negative peritonitis (especially extended-spectrum β-lactamase-producing organisms) contribute substantially to excess health-care use owing to infection caused by dialysis access. Although the management of peritoneal-dialysis-related peritonitis has been hampered by a dearth of randomized, controlled studies, epidemiological data have provided useful information. To overcome the problem of differing methods used to monitor infections within various dialysis centers, uniform reporting systems for vascular-access-related infection and peritoneal-dialysis-related peritonitis, as recommended by the Centers for Disease Control and Prevention and the International Society for Peritoneal Dialysis, respectively, are discussed. Infections unrelated to the port of entry for dialysis are also examined, namely hepatitis and respiratory infection. To address the disease burden, we examine the infection-related mortality as well as the implications for subsequent cardiovascular mortality.

Decreased prevalence and incidence of HCV markers in haemodialysis units: a multicentric French survey

BACKGROUND

A variety of epidemiological data provide evidence for the nosocomial transmission of hepatitis C virus (HCV) infections to haemodialysis patients. We conducted a multicentric study to determine the prevalence and incidence of HCV infection in French haemodialysis units.

METHODS

Patients undergoing chronic haemodialysis in 56 French units (4718 patients) were systematically screened for anti-HCV antibodies using third-generation tests. The incidence was estimated by detecting HCV RNA in seronegative patients using a standardized real-time PCR assay on pooled samples.

RESULTS

Testing for HCV antibodies identified 361 patients with anti-HCV antibodies, giving a prevalence of 7.7%. Multivariate analysis demonstrated that anti-HCV status was linked to the time on haemodialysis, previous kidney transplantation and the presence of anti-HBc antibodies, whereas erythropoietin therapy and carrying out dialysis in dedicated spaces seem to protect against HCV infection. Only two of the 4357 patients without anti-HCV antibodies tested positive for HCV RNA, giving an estimated incidence of 0.05% new HCV infections/year. Molecular analyses indicated that the two patients probably acquired HCV outside the haemodialysis unit.

CONCLUSION

This decreased prevalence and incidence emphasizes the importance of adhering to the recommended universal infection-control precautions. Virological follow-up based on detecting anti-HCV antibodies with sensitive, specific new-generation serological tests could be adequate for dialysis units with few HCV infections. However, new infections in haemodialysis units should be identified by determining the HCV RNA status of seronegative patients. Standardized real-time PCR assays, plus pooling serum samples, make this a promising method for large-scale epidemiological studies.

Epidemiology, surveillance, and prevention of hepatitis C virus infections in hemodialysis patients

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.

Analytical evaluation of HCV core antigen and interest for HCV screening in haemodialysis patients

BACKGROUND

It is important to diagnose a hepatitis C virus infection in the acute phase in order to reduce the incidence of this infection in high-risk populations like haemodialysis patients. But detection systems for serum HCV antibodies are insensitive in the acute phase because of the long serological window. Previous studies showed that the HCV core antigen (HCV Ag) may be an alternative to HCV RNA in this context.

OBJECTIVES

To evaluate the performances of the new Abbott ARCHITECT((R)) HCV Ag test and its usefulness in screening for HCV infections in haemodialysis patients.

STUDY DESIGN

The serum HCV Ag titre was compared to the HCV RNA viral load in 98 samples from HCV-infected patients to determine the correlation between the two markers and the influence of genotype. We screened 2752 patients from 37 French haemodialysis units who tested negative for HCV antibodies using the HCV Ag and RNA assays.

RESULTS

The HCV Ag titre was correlated with the HCV RNA (Spearman test coefficient 0.9041, p<0.0001) and all genotypes and subtypes were detected. The HCV Ag and HCV RNA results agreed well for haemodialysis patients. Diagnostic specificity of HCV Ag was high (99.2%) considering HCV RNA as the reference. The two seronegative patients (of 2752) who were HCV RNA positive were also HCV Ag positive.

CONCLUSIONS

The ARCHITECT HCV Ag test is a reliable, highly specific assay for screening acute HCV infections in haemodialysis units. It is a robust alternative to HCV RNA testing.