1172 Data analyses
Patients’ serum samples were tested for the presence of HCV antibody using the ARCHITECT Anti-HCV chemiluminescence immunoassay (Abbott Laboratories, Wiesbaden, Germany) in the Architect i2000SR system (Abbott Diagnostics, Abbott Park, IL) according to manufacturer’s instructions. HCV RNA measure- ments were performed using the Abbott realtime HCV assay (Abbott Molecular, Des Plaines, IL) using the mSample Pre- paration System reagents, m2000sp and m2000rt instruments (Abbott Molecular, Des Plaines, IL). The HCV genotypes were determined using the Abbott realtime HCV genotype II assay (Abbott Molecular, Des Plaines, IL). Phylogenetic analysis of the HCV strains were performed using partial E1–E2 sequences obtained by polymerase chain reaction (PCR) using the Super- Script III One-Step RT-PCR System (Invitrogen, Carlsbad, CA) and an ABI 3130xl Genetic Analyzer (Applied Biosystems, Foster City, CA). The sequences were checked manually and trimmed for the construction of phylogenetic tree using the neighbor- joining method with ClustalX version 2.0 software. Detailed laboratory tests are described in Supplementary File 1. SPSS version 23 software (SPSS, Chicago, IL) was used to perform the statistical analyses.
Results Epidemiological investigation
On December 5, 2017, a 53-year-old female (index case) who had received a post-deceased donor liver transplant 14 months pre- viously for polycystic liver and kidney disease was confirmed to have HCV genotype 6a infection with a viral load of >1×108IU/mL. Archived blood samples were persistently negative for anti-HCV antibodies, while the HCV RNA was retrospectively found to have been positive since September 22, 2017 (Fig. 1). No personal risk factors for HCV acquisition were present. The liver donor and all used blood products after the transplant were confirmed to be HCV negative.
Vincent C.C. Cheng et al Contact tracing was conducted according to the incubation
period of HCV (2 weeks to 6 months before the onset of liver function derangement), and the at-risk period of HCV acquisition for the index case was estimated to beMarch 22, 2017, to September 8, 2017. The index case had been hospitalized in the liver transplant center between August 6, 2017, and August 19, 2017. Also, 4 known HCV carriers stayed in the same ward during the index case’s hospitalization. Except for 1 patient with history of intravenous drug abuse who had HCV genotype 6a (potential source patient) and a viral load of 2.75×105 IU/mL, the other 3 HCV carriers had HCV genotype 1(1patient), 1b (1patient), and 3a (1 patient). Further contacttracing wasperformedforpatientshospitalizedinthe same ward as this potential source patient during his stay, which yielded another 100 potential contact cases for HCV testing (Fig. 2). No other secondary cases of HCV infection were found. Interviews with ward staff and observation of patient care
practice initially did not reveal any irregularities in practice or change in the staff-to-patient ratio. A review of the time log in the barcoding system in the computerized laboratory information system showed that 14 instances of phlebotomy from the source patient were followed by phlebotomy from the index patient on the same day, whereas the reverse only happened in 5 instances. Further investigation showed that the phlebotomy trolley and the reusable tube holders were the only shared items between the source and index patients with risk of cross infection. Because it was determined that reusable tube holders were not properly disinfected between patients, all reusable tube holders were seized and were replaced with single-use disposable devices. Despite the viral load of HCV RNA decreasing to 7.75×104IU/mL after 2 weeks of Harvoni (ledipasvir/sofosbuvir) and ribavirin therapy, the index case succumbed with multi-organ failure.
Environmental surveillance
A total of 34 environmental samples were collected, including the inner surface (14 samples) and the outside surface (14 samples) from 14 tube holders, a glucometer tray (1 sample), a tray used for
Fig. 1. Clinical history of index patient with nosocomial acquisition of hepatitis C virus. *Retrospective analysis of archived blood samples; # prospective analysis of blood samples. Note. LFT, liver function test; DDLT, deceased donor liver transplantation; UTI, urinary tract infection.
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