Infection Control & Hospital Epidemiology (2018), 39, 1170–1177 doi:10.1017/ice.2018.175


Original Article


Nosocomial transmission of hepatitis C virus in a liver transplant center in Hong Kong: implication of reusable blood collection tube holder as the vehicle for transmission


Vincent C.C. Cheng MD1,2, Shuk-Ching Wong MNurs2, Sally C.Y. Wong FRCPath1, Siddharth Sridhar FRCPath3, Cyril C.Y. Yip PhD1, Jonathan H.K. Chen PhD1, James Fung MD4,KelvinH.Y.ChiuMRCP1,Pak-Leung Ho MD3,


Sirong Chen PhD5, Ben W.C. Cheng MHKCRRT(CNMR)5,Chi-LaiHo MD5, Chung-Mau Lo MS6 and Kwok-Yung Yuen MD3 1Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China, 2Infection Control Team, Queen Mary Hospital, Hong Kong West Cluster, Hong Kong Special Administrative Region, China, 3Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong


Kong, Hong Kong Special Administrative Region, China, 4Department of Medicine, Queen Mary Hospital, Hong Kong Special Administrative Region, China, 5Department of Nuclear Medicine & Positron Emission Tomography, Hong Kong Sanatorium and Hospital, Hong Kong Special Administrative Region, China and 6Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China


Abstract


Background: A liver transplant recipient developed hospital-acquired symptomatic hepatitis C virus (HCV) genotype 6a infection 14 months post transplant. Objective: Standard outbreak investigation. Methods: Patient chart review, interviews of patients and staff, observational study of patient care practices, environmental surveillance, blood collection simulation experiments, and phylogenetic study of HCV strains using partial envelope gene sequences (E1–E2) of HCV genotype 6a strains from the suspected source patient, the environment, and the index patient were performed. Results: Investigations and data review revealed no further cases of HCV genotype 6a infection in the transplant unit. However, a suspected source with a high HCV load was identified. HCV genotype 6a was found in a contaminated reusable blood-collection tube holder with barely visible blood and was identified as the only shared item posing risk of transmission to the index case patient. Also, 14 episodes of sequential blood collection from the source patient and the index case patient were noted on the computerized time log of the laboratory barcoding system during their 13 days of cohospitalization in the liver transplant ward. Disinfection of the tube holders was not performed after use between patients. Blood collection simulation experiments showed that HCV and technetium isotope contaminating the tip of the sleeve capping the sleeved-needle can reflux back from the vacuum-specimen tube side to the patient side. Conclusions: A reusable blood-collection tube holder without disinfection between patients can cause a nosocomial HCV infection. Single- use disposable tube holders should be used according to the recommendations by Occupational Safety and Health Administration and World Health Organization.


(Received 30 April 2018; accepted 3 July 2018; electronically published August 29, 2018)


Hepatitis C virus (HCV) is an important global cause of bloodborne infection. Infection is asymptomatic in 80% of infected persons, and 75% of the infected will progress to chronic HCV infection, with a 15%–30% risk of progression to hepatic cirrhosis and hepatocellular carcinoma within 20-30 years.1 Since nucleic acid amplification screening for HCV in blood donors became routine in 2002, nosocomial HCV transmissions have been largely confined to hemodialysis units due to environmental contamination with HCV-positive blood, suboptimal compliance with standard pre- cautions, unsafe handling of multidose heparin and anesthetic vials,


Author for correspondence: Kwok-Yung Yuen, Carol Yu Centre for Infection,


Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China. E-mail: kyyuen@hku.hk Cite this article: Cheng VCC, et al. (2018). Nosocomial transmission of hepatitis C


virus in a liver transplant center in Hong Kong: implication of reusable blood collection tube holder as the vehicle for transmission. Infection Control & Hospital Epidemiology 2018, 39, 1170–1177. doi: 10.1017/ice.2018.175


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved


and possible reuse of contaminated needles.2–9 In a case-control study conducted in a skilled nursing facility with an outbreak of acute HCV infections, podiatry and international normalized (prothrombin time) ratio monitoring by phlebotomy were also noted to be significantly associated with case status10; however, the exact procedure of phlebotomy and the mechanism of HCV transmission were not identified in this study. Percutaneous expo- sure from a known HCV-positive patient carries a transmission risk of 1%–3%.11 The introduction of vacuum extraction tube system as a closed system for phlebotomy markedly reduced the risk of nee- dlestick injury among healthcare workers. The vacuum extraction tube system contains a double-end needle with a patient end (ie, skin-needle) and non–patient end covered by a rubber sleeve (ie, sleeved-needle) that is screwed onto a blood collection tube holder. The tube holder facilitates the fitting of the sleeved-needle with the vacuum-specimen tube in place and protects healthcare workers from direct contact with the collected blood. Moreover, the system


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