Hepatitis C virus transmission at an outpatient hemodialysis unit--New York, 2001-2008.

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.