Garima Mittal

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Hepatitis-2015Orlando, USAJuly 20 - 22 2015

• Garima Mittal

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• Dr. Garima Mittal (MBBS, MD)
• Associate Professor, Microbiology

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• Himalayan Institute of Medical Sciences, SRHU,
  Dehradun, Uttarakhand, India

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Headings

• Introduction
• Our dialysis unit
• Aims and objectives
• Patients and methods
• Results
• Discussion
• Conclusion and suggestions
• References
• Acknowledgement

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Introduction
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• Our dialysis unit

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What we follow in our HD units
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Patients and methods
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Group 1

• Included 118 patients
• 19 were HCV positive at the start of study
• 99 were seronegative
• Not following strict isolation program for HCV
  seropositive patients
• Multidose heparin vials were used.

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Group 2

• Included 113 patients
• 14 were HCV positive at the start of study
• 99 were seronegative
• Following strict isolation program for HCV
  seropositive patients by using dedicated areas,
  machines and dedicated health care workers
• single dose heparin vials were used

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• Exclusion criteria
• Those who did not complete the period of study
  either due to death, leaving to other HD units or
  after kidney transplantation.

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Serological tests

• Blood samples were collected from all patients
  and sera separated.
• Tested for HCV antibodies using third generation
  ELISA kit (Hepanostika HCV ultra, Biomerieux,
  Netherlands, sensitivity100, specificity99.8).
  
• Screening for anti-HCV antibodies was done at
  every three months to look for seroconversion.

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Statistical analysis

• Data were analyzed using statistical package SPSS
  version 18
• Prevalence, odds ratios, P values and 95
  confidence intervals (CI) were calculated to
  assess differences between studied groups.
• Statistical significance was assessed at 0.05
  probability level in all analysis.

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Isolation of HCV and HCV- patients
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Dedicated area and machines for HCV patients
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Separate dialyzer re-processing units
HCV
HCV -
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Stored tubings and dialyzer for reuse
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Results
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Gender-wise distribution of patients
Group 1 N() Group 2 N()
Male 79 (66.9) 78 (69)
Female 39 (33.1) 35 (31)
Total 118 113
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Gender-wise distribution of patients
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Underlying causes for chronic renal failure in
both the groups

1. Chronic Glomerulonephritis (30.5)
2. Diabetic Nephropathy (26.3)
3. Hypertensive Nephropathy (19.5)
4. Chronic interstitial Nephritis (11.3)
5. Others (11.3)

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Causes for chronic renal failure in both the
groups
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HCV seroconversion in both groups
Group 1 Group 2 Odds ratio (95 CI) P value
Not seroconverted 82 (82.83) 96 (96.97) 6.63 (1.87-23.4) lt 0.05
Seroconverted 17 (17.17) 3 (3.03) 6.63 (1.87-23.4) lt 0.05
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Comparison of both groups
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Incidence of HCV with dialyzer reuse
Dialyzer Incidence of HCV (GROUP 1) P value Incidence of HCV (GROUP 2)
Reused 14 (82.4) lt 0.001 2 (66.7)
Not reused 3 (17.6) lt 0.001 1 (33.3.)
TOTAL 17 lt 0.001 3
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Discussion
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YEAR AUTHOR MAIN FINDING
2002 Harmankaya et al. 8 168 Turk patients HCV incidence 4.7 from 1992 to 2000
2003 Barril and Traver 9 multicentric study in Spain. ? incidence
2003 Yang et al 10 325 Taiwanese patients mean follow-up 4.8 years HCV incidence decreased from 9.1 to 2.9
2003 Saxena et al. 11 189 Middle East patients follow-up 73 months HCV incidence decreased from 6.8 to 1.01
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YEAR AUTHOR MAIN FINDING
2006 Gallego et al. 12 Spanish study HCV incidence decreased from 21.6 in 1995 to 6.8 in 2003
2006 Shebeb et al. 13 3 Egyptian dialysis units with two approaches 1. With isolation, HCV seroconversion decreased from 10 to 0 2. Without isolation, incidence increased from 10.5 to 16.7
2008 Alavian et al. 14 Iranian study, HCV prevalence decreased from 14.4 in 1999 to 4.5 in 2006
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YEAR AUTHOR MAIN FINDING
2009 Agarwal et al. 15 Indian study isolation decreased HCV incidence from 42 to 4 from 1998 to 2006
2009 Ross et al. 16 German multicentric study no new HCV infection in 1 year
2010 Mohamed 17 Middle East no HCV seroconversion in 36 patients followed for 5 years
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Comparison of different guidelines on HCV
isolation
YEAR ASSOCIATION/ BODIES RECOMMENDATION FOR ISOLATION
2001 CDC Not recommended
2002 European best practice guidelines Recommended in units with high HCV prevalence
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Contd..
YEAR ASSOCIATION/ BODIES RECOMMENDATION FOR ISOLATION
2008 KDIGO In case of continued nosocomial transmission, a local isolation policy may be deemed necessary
2009 Renal association UK Not recommended
KDIGO Kidney disease Improving global outcomes
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Suggestions

• Separate dialysis ward/room for HCV positive
  patients.
• Whether or not to reuse dialyzers???
• Separate area for storage and reprocessing of HCV
  infected dialyzers
• In new seroconversion Increase the frequency of
  anti-HCV screening to monthly

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• HCV RNA to be used as screening tool, if
  economically feasible.
• Regular training of all health care staff,
  patients on HD and their attendants on infection
  control practices.
• Long term follow up study on larger group of HD
  patients is required.

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Conclusions

• In Haemodialysis units with a high prevalence of
  HCV seropositivity, strict isolation of HCV
  patients in combination with implementation of
  universal work precaution measures can limit the
  spread of HCV infection in HD patients.

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References

• 1. Agarwal SK. Hemodialysis of Patients with
  HCV Infection Isolation Has a Definite Role.
  Nephron Clin Pract 2011117c328c332
• 2. Pol S, Vallet-Pichard A, Fontaine H, Lebray
  P. HCV infection and hemodialysis. Semin Nephrol
  2002 22 331339.
• 3. Castell J, Gutiérrez G Outbreak of 18 cases
  of hepatitis C in a hemodialysis unit (in
  Spanish). Gac Sanit 2005 19 214220.
• 4. Spada E, Abbate I, Sicurezza E, Mariano A,
  Parla V, Rinnone S, Cuccia M, Capobianchi MR,
  Mele A Molecular epidemiology of a hepatitis C
  virus outbreak in a hemodialysis unit in Italy. J
  Med Virol 2008 80 261267.
• 5. Carneiro MA, Teles SA, Lampe E, Espírito,
  Santo MP, Gouveia-Oliveira R, Reis NR, Yoshida
  CF, Martins RM Molecular and epidemiological
  study on nosocomial transmission of HCV in
  hemodialysis patients in Brazil. J Med Virol
  2007 79 13251333.
• 6. Valtuille R, Fernández JL, Berridi J,
  Moretto H, del Pino N, Rendo P, Lef L Evidence
  of hepatitis C virus passage across dialysis

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• 7. Sartor C, Brunet P, Simon S, Tamalet C,
  Berland Y, Drancourt M Transmission of hepatitis
  C virus between hemodialysis patients sharing the
  same machine. Infect Control Hosp Epidemiol 2004
  25 609611.
• 8. Harmankaya O, Cetin B, Obek A, Seber E Low
  prevalence of hepatitis C virus infection in
  hemodialysis units effect of isolation? Ren Fail
  2002 24 639644.
• 9. Barril G, Traver JA Decrease in the
  hepatitis C virus (HCV) prevalence in
  hemodialysis patients in Spain effect of time,
  initiating HCV prevalence studies and adoption of
  isolation measures. Antiviral Res 2003 60 129
  134.
• 10. Yang CS, Chang HH, Chou CC, Peng SJ
  Isolation effectively prevents the transmission
  of hepatitis C virus in the hemodialysis unit. J
  Formos Med Assoc 2003 102 7985.

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1. Saxena AK, Panhotra BR, Sundaram DS, Naguib M,
   Venkateshappa CK, Uzzaman W, Mulhim KA Impact of
   dedicated space, dialysis equipment, and nursing
   staff on the transmission of hepatitis C virus in
   a hemodialysis unit of the Middle East. Am J
   Infect Control 2003 31 2633.
2. Gallego E, López A, Pérez J, Llamas F, Lorenzo
   I, López E, Illescas ML, Andrés E, Olivas E,
   Gómez-Roldan C Effect of isolation measures on
   the incidence and prevalence of hepatitis C virus
   infection in hemodialysis. Nephron Clin Pract
   2006 104c1c6.
3. Shebeb AM, Kotkat AM, Abd El Reheim SM, Farghaly
   AG, Fetohy EM An intervention study for
   prevention of HCV infection in some hemodialysis
   units in Alexandria. J Egypt Public Health Assoc
   2006 81 119141.

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• 14. Alavian SM, Bagheri-Lankarani K, Mahdavi-
  Mazdeh M, Nourozi S Hepatitis B and C in
  dialysis units in Iran changing the
  epidemiology. Hemodial Int 2008 12 378382.
• 15. Agarwal SK, Dash SC, Gupta S, Pandey RM
  Hepatitis C virus infection in haemodialysis the
  no-isolation policy should not be generalized.
  Nephron Clin Pract 2009 111c133-c140.
• 16. Ross RS, Viazov S, Clauberg R, Wolters B,
  Fengler I, Eveld K, Scheidhauer R, Hüsing J,
  Philipp T, Kribben A, Roggendorf M Lack of de
  novo hepatitis C virus infections and absence of
  nosocomial transmissions of GB virus C in a large
  cohort of German haemodialysis patients. J Viral
  Hepat 200916230238.
• 17. Mohamed WZ Prevention of hepatitis C virus
  in hemodialysis patients five years experience
  from a single center. Saudi J Kidney Dis Transpl
  2010 21 548554.

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Acknowledgement

• Dr Pratima Gupta Professor Head, AIIMS,
  Rishikesh
• Dr R K Agarwal Professor Head, HIMS
• Research committee, HIMS
• Dr Shahbaz Ahmad Nephrologist, HIMS
• Dialysis staff and patients
• Serology technicians

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Thank you
Dr. Garima Mittal (MBBS, MD) Associate Professor,
Microbiology HIMS, SRHU, India
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Meet the eminent gathering once again
atHepatitis-2016Dubai, UAEOctober 17 - 19,
2016

• Hepatitis 2016 Website
• hepatitis.omicsgroup.com