New York: Hepatitis C Infections Found in Clinic Patients

Four patient-to-patient hepatitis C virus transmissions at a now-closed Manhattan hemodialysis clinic that occurred during 2005-2008 were likely due to improper infection controls, according to a New York State Department of Health (NYSDOH) investigation. Five additional patients might also have acquired HCV while receiving treatment at the unit, the Life Care Dialysis Center at 221 West 61st St., CDC reported Friday.

A patient complaint in January 2008 that the clinic was dirty prompted the NYSDOH investigation, said Dr. Jenifer Jaeger, a CDC officer assigned to the state and the report's chief investigator. In July 2008, NYSDOH received reports of three dialysis patients acquiring HCV during the preceding six months, and subsequent investigations uncovered six additional HCV seroconversions during 2001-2008.

More patients may have been infected, but the investigation focused on just the 162 patients who were receiving dialysis at the clinic as of July 1, 2008.

Of the nine seroconversions identified, four were genetically linked to four different patients at the clinic. All four patients and their respective HCV source patients had dozens of treatment days in common, and two of the four had been hooked up to the same machine as their HCV source patient. Source patients could not be identified for the five other cases, but none of the five had known HCV risk factors, and only two had health care exposures outside of hemodialysis. The clinic tested patients for HCV erratically, and it did not inform those who seroconverted, the report said.

Health investigators described the center as filthy; they said employees did not wash their hands and failed to consistently wear gloves when treating patients. Dried blood was observed on dialysis machines, treatment surfaces and the surrounding floor, and bleach solution for cleaning was improperly stored, prepared, and used, the report said. Many staff members were unaware of written cleaning and disinfection policies at the large, for-profit unit, which treated 70-100 patients at 30 stations.

The full report, "Hepatitis C Virus Transmission at an Outpatient Hemodialysis Unit -- New York, 2001-2008," was published in CDC's Morbidity and Mortality Weekly Report (2009;58(08):189-194).

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