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BACKGROUND: Infection control lapses in hemodialysis facilities put patients at risk for acquiring hepatitis B and C virus (HBV and HCV, respectively). Dialysis-associated HBV and HCV outbreaks have occurred across the US, including in New York City (NYC), and the Centers for Disease Control and Prevention recommends that dialysis facilities routinely screen patients for these viruses. The NYC Department of Health and Mental Hygiene (DOHMH) and the New York State Department of Health (NYSDOH) require reporting of all new infections (seroconversions) detected in dialysis facilities. To identify any unreported seroconversions, DOHMH established enhanced surveillance of dialysis centers in 2012. We evaluated this surveillance system from October 2012-May 2014, a period when three seroconversions were reported by dialysis facilities, and one seroconversion was identified during a NYSDOH investigation.
METHODS: Clinical laboratories must electronically report positive HBV/HCV tests among NYC residents to DOHMH. DOHMH identified new HBV/HCV reports in which the ordering facility address matched a NYC dialysis center. Investigators interviewed facility directors regarding these reports using a standardized questionnaire. Seroconversions were defined as a new serologic marker of infection within one year after a negative test. Patient and provider interviews were conducted for all seroconversions; however, investigations were not conducted for seroconversions that were anti-HCV positive but HCV RNA-negative. We assessed the system’s positive predictive value (PPV), acceptability, stability, and simplicity through descriptive analysis of investigations and outcomes and by semi-structured investigator interviews.
RESULTS: During the 21-month evaluation period, 194 new reports of HBV (n=72) or HCV (n=122) matched a dialysis facility address. Of these, 105 (54.1%) corresponded to dialysis patients. No HBV seroconversions were identified. Twelve HCV seroconversions were identified. Six were HCV RNA-negative, five were HCV RNA-positive and one had no RNA test performed; only one had been reported. The PPV was 3.1% (6/194). To date, no additional dialysis-associated transmission has been identified from these investigations. Investigators reported that investigations and system maintenance were labor-intensive, requiring multiple phone calls and ongoing adjustment of computer code used to match disease reports with facility addresses. Investigator turnover threatened system stability. Components contributing to system complexity included data entry into several systems and multiple patient, provider, and facility interviews. Benefits included increased awareness among dialysis facility staff of testing recommendations and reporting requirements.
CONCLUSIONS: Substantial effort was required to detect five previously unknown HCV seroconversions through the enhanced dialysis surveillance system. The system strengthened relationships between DOHMH and dialysis facilities.