MMWR Morb Mortal Wkly Rep. 2009 Mar 6;58(8):189-94.
In July 2008, the New York State Department of Health (NYSDOH) received reports of three hemodialysis patients seroconverting from anti-hepatitis C virus (HCV) negative to anti-HCV positive in a New York City hemodialysis unit during the preceding 6 months. NYSDOH conducted patient interviews and made multiple visits to the hemodialysis unit to observe hemodialysis treatments, assess infection control practices, evaluate HCV surveillance activities, review medical records, and conduct interviews with staff members. This report summarizes the results of that investigation, which found that six additional patients had HCV seroconversion during 2001--2008 and that the hemodialysis unit had numerous deficiencies in infection control policies, procedures, and training. Of the total of nine seroconversions, the sources for four HCV infections were identified phylogenetically and epidemiologically as four other patients in the unit. The unit's policy for routine patient testing for HCV infection was not in accordance with CDC recommendations, and the few recommendations followed were not implemented consistently. Hemodialysis units should routinely assess compliance to ensure complete and timely adherence with CDC recommendations to reduce the risk for HCV transmission in this setting.
2008年7月，纽约州卫生部（NYSDOH）收到报告称，在纽约市的一家血液透析单位中，有3名血液透析患者在过去6个月内抗丙型肝炎病毒（HCV）检测结果从阴性转为阳性。NYSDOH对患者进行了访谈，并多次前往该血液透析单位观察血液透析治疗过程、评估感染控制措施、评价HCV监测活动、查阅病历，并与工作人员进行访谈。本报告总结了该调查结果，调查发现，在2001年至2008年期间还有另外6名患者发生了HCV血清转化，且该血液透析单位在感染控制政策、程序和培训方面存在诸多不足。在总共9次血清转化事件中，通过系统发育和流行病学方法确定，4例HCV感染的传染源为该单位的其他4名患者。该单位对HCV感染患者进行常规检测的政策不符合美国疾病控制与预防中心（CDC）的建议，且少数遵循的建议也未得到一贯执行。血液透析单位应定期评估合规情况，以确保完全并及时遵守CDC的建议，从而降低在此环境下HCV传播的风险。
