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Transmission and postexposure management of bloodborne virus infections in the health care setting: Where are we now?
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[Read eLetter] The relationship between nurse-to-patient ratio transmission of HCV in a hemodialysis unit
ANIL K. SAXENA, MD; MRCP (Dublin), B.R. Panhotra, MD; PhD, MNAMS ; Ali M. Al-Arabi Al-Ghamdi, ABFM, SBFM, FFCM   (29 May 2003)

The relationship between nurse-to-patient ratio transmission of HCV in a hemodialysis unit 29 May 2003
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ANIL K. SAXENA, MD; MRCP (Dublin),
Consultant Nephrologist & Deputy Chief
Division of Nephrology, King Fahad Hospital & Tertiary Care Center, Hofuf, 31982, Saudi Arabia,
B.R. Panhotra, MD; PhD, MNAMS ; Ali M. Al-Arabi Al-Ghamdi, ABFM, SBFM, FFCM

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Re: The relationship between nurse-to-patient ratio transmission of HCV in a hemodialysis unit

dranil_31982{at}yahoo.com ANIL K. SAXENA, MD; MRCP (Dublin), et al.

Hemodialysis (HD) is not feasible without access to the vascular system to endow with adequate and dependable source of blood flow through the dialyzer. This exclusive prerequisite for vascular access site along with the extracorporeal circulation to perform HD increases the risk of parenteral exposure of end stage renal disease (ESRD) patients to hepatitis C virus (HCV) infection within the unit [1]. Cross infection through blood contaminated gloves and hands of staff, dialysis equipment, dialyzer and blood line surfaces, may occur in a high-risk HD environment from the patients already infected [2-7].The nurse understaffing in the HD units may imperil the environmental safety and hygiene further and facilitate the dissemination of the HCV during HD.

We retrospectively reviewed the records of 198 patients with end stage renal disease (ESRD) enrolled on long term HD at King Fahad Hospital and Tertiary Care Center, Hofuf, Saudi Arabia, from October 1995- September 2000, to determine the HCV prevalence and seroconversion rates among patient groups, in relation to being dialyzed with different nurse- to-patient ratios (1:2 to 1:4). The difference in the staffing ratios reflected essentially the constant turnover of the nursing staff during the study period. The majority of the nurses were expatriates, on contract appointments for variable periods ranging from six months to several years. In addition, the N/P ratios were also subject to the patient’s comorbidities such as ischemic heart disease, diabetes mellitus and congestive heart failure, involving higher levels of nursing care during HD.

The mean age of the patients was 47.0 ± 17.5 years (range 15-84 years).There were 107 (54.0%) males and 91 (46.0%) females. All ESRD patients had been on HD for a mean dialytic age of 39.5 ±7.25 months (range 4-102 months). These ESRD patients were dialyzed two or three times per week with each dialysis session lasting for 4 hours, through disposable single use high- flux dialyzer membranes (polysulphone, Bellco, Mirandola, Italy, polyacrylonitrile Filtrat 10 AN 69, Hospal, Meyzieu, France) and blood lines, in a common space without any separation between HCV positive and HCV negative patients. However, male and female patients were dialyzed in separate rooms and the patients with HBV infection were strictly isolated as per well known Centers for Disease Control (CDC) guidelines, practiced worldwide.

The over all HCV prevalence of 43.4% (86/198) and seroconversion rate of 8.6% per year, were recorded. The lowest HCV prevalence of 26.8% (15/56) and seroconversion rate of 5.35% per year were observed in the patients group with nurse/patient ratio (N/P ratio) of 1:2. The group of patients with N/P ratio 1:3 recorded HCV prevalence of 43.6% (48/110) and seroconversion rate of 8.7% per year [Odds ratio (OR) 2.11, 95% Confidence Interval (CI) 0.99-4.5]. The group dialyzed with N/P ratio of 1:4 documented the peak HCV prevalence [71.8% (23/32)] and annual seroconversion rate of 14.4% [OR-6.98, 95% CI (2.39-20.93)].

Significantly higher annual HCV seroconversion rates in group with N/P ratio 1:3 and 1:4 suggest that the patients dialyzed with leaner N/P ratios, carried much higher risk of acquisition of HCV infection, compared to those with richer N/P ratio of 1:2.

Recent figures from an investigation by Centers for Disease Control (CDC), Atlanta, suggest that nurse understaffing may be a risk factor for nosocomial infections and thus considered to be a surrogate marker of sub- optimal quality of health care [8-9]. A multicenter prospective study from Italy concluded that the combination of understaffing and a high level of infected patients (high HCV prevalence) in the dialysis setting increased the risk of nosocomial transmission of HCV [10].The presence of hepatitis C virus ribonucleic acid (HCV-RNA) in the hand washings from nurses dialyzing HCV positive as well as HCV negative patients, has been demonstrated in a recent clinicovirological study from the Middle East [7]. Even though, the breakdown in the infection control procedures and contamination of the vascular access sites with HCV, is the most likely mechanism essentially attributable to the relative increase in the HCV annual seroconversion rates in all the patient groups; such breakdowns are more liable to occur among patient groups with lower staffing levels (N/P ratios-1:3, 1:4) placing the HD environmental and therefore patients’ safety, at enormous risk.

Improved nurse staffing and keeping the turnover of trained and experienced nursing personnel to minimum, is essential to the appropriately implement the universal infection control measures that would further improve the personal and environmental hygiene in the HD setting. The nurse’s education regarding proper handling of the vascular accesses and possibly the strict isolation policy for the HCV positive patients as well, might assist in reducing the incidence of HCV infection in high HCV prevalence HD units [11, 12].

Nevertheless, further investigations are required to define the most beneficial (optimal) N/P ratios for the HD units particularly with high HCV prevalence to plan the more appropriate strategies for the prevention of HCV transmission among patients on long-term HD. In addition, during healthcare reforms, the effect of nurse staffing reductions on nosocomial HCV transmission needs to be sincerely evaluated in outsized high HCV prevalence HD units affiliated with the hospitals where there is continuous turnover of the nursing workforce.

References

1.Saxena AK, Panhotra BR, Sundaram DS. The role, the vascular access plays in the transmission of hepatitis C virus in a high prevalence hemodialysis unit. J Vasc Access 2002; 3: 158-63

2.MC Laughlin KJ, Cameron SO, Good T, Mc Cruden E. et al. Nosocomial transmission of hepatitis C within a British dialysis center. Nephrol Dial Transplant 1997; 12:304-9.

3.Stuyver L, Claeys H, Wyseur A. et al. Hepatitis C virus in hemodialysis unit: Molecular evidence for nosocomial transmission. Kidney Int1996; 49:889-95.

4.Jadoul M. Transmission routes of HCV infection in dialysis. Nephrol Dial Transplant 1996; 11:36-38.

5.Okuda K, Hayashi H, Kobayashi S, Irie Y: Mode of hepatitis C infection transmission not associated with blood transfusion among hemodialysis patients. J Hepatol 1995; 23:28-31.

6.Valtuille R, Fernandez JL, Berridi Jet al. Evidence of hepatitis C virus passage across dialysis membrane. Nephron 1998; 80:194-95.

7.Alfurayah O, Sabeel A, Al Ahdal MN et al. Hand contamination with hepatitis C virus in staff looking after hepatitis C positive hemodialysis patients. Am J Nephrol 2000; 20:103-6

8.Fridkin SK, Pear SM, Williamson T H, Galgiani JN, Jarvis WR: The role of understaffing in central venous catheter associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-58.

9.Robert J, Fridkin SK, Blumberg HM et al. The influence of composition of the nursing staff on primary blood stream infection rates in surgical intensive care unit. Infect Control Hosp Epidemiol 2000; 21:12 -17.

10.Petrosillo N, Gilli P, Serraino D et al Prevalence of infected patients and understaffing have a role in hepatitis C transmission in dialysis. Am J Kidney Dis 2001; 37:1004-10.

11.Saxena AK, Panhotra BR. Nosocomial transmission of hepatitis C virus: impact of strict isolation on annual seroconversion rate in hemodialysis unit. Saudi J Kidney Dis Transplant 2002; 13: 186-87.

12.Saxena AK, Panhotra BR, Naguib M et al. The impact of dedicated space, dialysis equipment and nursing staff on the transmission of hepatitis C in haemodialysis unit of the Middle East. Am J Infect Control 2003; 31: 26-33.