الفهرس 
Infection control
Hepatitis C virus infectionOnly 14 pages are availabe for public view
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Abstract
Infection control refers to all policies, procedures and activities, which aim to prevent or minimize the risk of transmission of infectious diseases from patient to patient, staff member to patient and patient to staff member and staff member to staff member.(1) Standard infection control (IC) precautions are a set of tasks designed to protect the staff and patients, from contact (blood, body fluids, non intact skin, mucous membranes) with infectious agents, whenever health care is delivered, to be used all the time, whenever infection is known or not, in order to reduce infectious risks.(2) These precautions include hand hygiene, personal protective equipment, isolation precautions, aseptic techniques, cleaning and disinfection, sterilization, waste management, antibiotic use protocol, immunization and post exposure management.(3)
Dialysis is a procedure that replaces the normal functions of the kidney by removing metabolic waste products through diffusion and hydraulic pressure gradients. Dialysis treatment is accomplished by two primary mechanisms: Hemodialysis (HD) and peritoneal dialysis (PD). Hemodialysis utilizes an artificial dialyzer for removal of metabolic waste products while PD uses the patient’s peritoneal cavity and membranes.(7)
In renal dialysis, both patients and health care workers (HCWs) can be exposed to a wide variety of blood borne pathogens.(33) The most important of these pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Infection can also occur through contact with blood and respiratory secretions and contaminated equipment.(34-36) Proper IC procedures can prevent transmission of any infection to both patients and HCWs and can particularly reduce the risk of transmission of blood borne pathogens.(37-40)
Hepatitis B virus infection is one of the major health problems worldwide because out of 2,000 million people who have been infected with the virus, more than 400 million are chronic carriers of the virus. In Yemen, many surveys have been carried out and showed high carriage rates 26.3% of hepatitis B surface antigen.(69) Estimations done by WHO revealed that up to 3% of the world’s population (170 million individuals) have been infected with HCV. An estimated 8% to 10% of HD patients are infected with HCV.(62,95) HCV infection prevalence in HD patients is between 7% and 40% in some developed countries.(96,97) HCV infection and patient to patient transmission in kidney dialysis units has been demonstrated and has been associated with the length of time on dialysis, number of blood transfusions received and receiving dialysis next to a HCV infected patient.(98) Renal dialysis has been considered to be a low risk setting for transmission of HIV infection.(106)
The current study was carried out to study IC practices in the ministry of health and population (MOHP) hemodialysis center in Hodeidah Governorate, Yemen. The study aimed to:
1. Assess the IC practices at the MOHP hemodialysis center.
2. Assess knowledge and practice of the HCWs regarding IC.
3. Design, implement and evaluate an intervention program of IC for HCWs in the HD center.
4. Determine the incidence of HBV and HCV seroconversion in HD patients.
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The study was conducted using a cross sectional approach followed by an intervention approach (one group pre-test post test design) and a prospective follow up approach.
All HCWs at the MOPH hemodialysis center in Hodeidah Governorate were included in the study.
Observation of 450 IC practices in the HD center. Six IC practices were assessed: hand hygiene, use of personal protective equipment, aseptic techniques, waste management and environmental IC practices.
Personal interview with 303 patients.
Follow up of 392 HD patients for HBV and HCV seroconversion after 6 months using the immunochromatography test.(181)
The required data were collected using the following techniques:
1. Interview with HD center manager to collect information on the number of dialysis days/ week, number of shifts/ day, hours of dialysis stations, number of patients on hemodialysis, the physical layout of the HD center such as patient room, beds, hand washing facilities, laboratory services and information regarding IC as availability of IC guidelines, PPE, soap, safety boxes and final disposal of sharp and non sharp waste.
2. Self administered questionnaire with HCWs to inquire about personal data, pre or in-service training, knowledge and self reported practice regarding IC procedures as: timing of routine hand washing, timing of hand washing technique, timing of cleaning and disinfecting surfaces, rubbing hands with alcohol is a substitute to hand washing, using PPE, using aseptic techniques, diseases transmitted through kidney dialysis machines, vaccines that can be used in hemodialysis center, the risks of transmission of blood borne infections, procedures that must be followed in case of injury with used sharps, procedures that should be followed in case of a patient suffering from a blood borne disease, ways of protecting the fistula and CVC from infection and disposal of used sharps.
3. Observation checklists to collect information on IC practices: hand hygiene, PPE, aseptic techniques, waste management and environmental IC practices.
4. An interview checklist to collect information on personal characteristics of patients and the number of years of dialysis, duration of dialysis and the history of blood transfusion.
5. Hemodialysis patients were followed up for HBV and HCV seroconversion using by the immunochromatography test after 6 months..(181)
An intervention program was designed according to the results of program pre-test that were obtained and was tailored according to the needs of the HCWs in the hemodialysis center. Analysis of data was done using SPSS program.
The study revealed the following main results:
a. Assessment of the knowledge of the HCWs in the hemodialysis center:
More than 90% of HCWs had knowledge about importance of hand washing and using PPE.
More than three quarters of HCWs had knowledge about rubbing hands with alcohol as a substitute to hand washing,
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More than half of HCWs indicated that a dialysis machine may transmit diseases.
More than 86% of HCWs had knowledge about importance of hepatitis B vaccine.
Regarding the procedures that must be followed in case of injury with used sharps, the majority of HCWs knew that testing the blood for infectious diseases should be done, while less than two thirds of HCWs mentioned the following: pressing on the site of injury to let blood get out and washing using running water and cleaning the site of injury using alcohol and only 18.4% of them mentioned that NSIs should be reported to the IC team. About procedures that should be followed in case of patients suffering from blood borne diseases, a high percent of HCWs mentioned that it is necessary to wear double gloves and IC procedures should be accurately followed, while half of HCWs mentioned that they should pay special attention to the patient and less than half of them mentioned that sterilization of instruments and regular testing of the patient should be performed.
Almost all HCWs mentioned that these patients must use a special dialysis machine.
The majority of HCWs indicated that disposal of used cannula and used needles must be done as it is and less than one quarter of them mentioned that recapping used cannula and needles should be done with both hands.
b. Assessment of self reported practices of HCWs about IC:
A high percent of HCWs stated that they wear white coat and gloves and wash their hands before performing any procedure, while more than three quarters of HCWs do not apply hand washing technique and more than a half indicated that they clean and disinfect equipment in the dialysis station.
The majority of HCWs reported disposal of used cannula in plastic containers as it is, while only 5.3% recap needle of cannula and dispose it in plastic refuse bags.
More than three quarters of HCWs stated that they dispose the used needle in plastic containers as it is, while 13.2% bend the needle and dispose it in plastic refuse bags and only 10.5% dispose the syringe in plastic refuse bags as it is.
All HCWs in the HD center reported that safety boxes were not available.
In the HD center in Hodeidah governorate/Yemen, the correct ways of protecting the fistula and central venous catheter (CVC) from infection were reported by less than half of HCWs during all the performed procedures. About 58% of HCWs said that they do not reuse unsterilized sharps, while 42.1% mentioned that they were obliged to reuse unsterilized sharps. The most common causes mentioned for the use of unsterilized sharps were shortage of supplies (68.8%), being more rapid (43.75%) and for saving money (18.75%).
c. Assessment of IC practices:
In about two thirds of the observations, hand washing was done when hands were soiled or visibly dirty, while hands were cleaned before connecting the patient to the dialysis machine through the fistula and before wearing gloves in more than one third and more than one quarter of the observations respectively, and about 68% of the observations, hands were washed with soap and water.
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In less than one quarter of the observations, hand washing technique was applied before wearing gloves.
In 73.8% of the observations, gloves were used during caring for patients’ vascular accesses or catheters and in almost the same percent during administrating intravenous medications. Gloves were used during cleaning of blood spills in 66.5%, and during cleaning and disinfecting dialysis machine in 48% of the observations. Latex gloves were used by 88% of HCWs, while only 12% used sterile gloves. White coat was used in 72.7% of the observations and in 29.1% of the observations, hands were cleaned before wearing PPE. Protective eyewear, masks and plastic aprons were not used by HCWs at required times. Regarding changing gloves: in 18.1% of observations, gloves were removed immediately after use, in 10.3%, 5.4%, 3.7% and 2.8% of the observations respectively, gloves were changed during going from a dirty area or task to a clean area or task, when soiled with blood, dialysate or other body fluids, between patients and during moving from a contaminated body site to a clean body site of the same patient.
Heparin was prepared just prior to use for each patient and multiple dose vials were not carried from station to station in the majority of the observations, while in 64.1% of the observations, multiple dose vials were prepared in clean area away from dialysis station and a sterile set of equipment was used for each patient in less than half of the observations (45.7%).
Care of the fistula site: the blood pressure was not measured from the hand containing the fistula, injection at fistula site was not done, the site of fistula was not cleaned after removal of the cannula, secure sterile dressing was applied over the fistula site and there was no drawing of blood from fistula site in a high percent of the observations. Examination before the start of dialysis and observation of bleeding at fistula site and cleaning the fistula site before the start of dialysis were done in more than two thirds of the observations and signs of infection were observed in more than half of the observations (58.8%).
Care of the CVC: there was no application of gel or cream at site of CVC and CVC was changed in case of occurrence of infection in 87.4%, while dressing was replaced if damp, loosened or soiled and aseptic technique was used during dressing changes in more than two thirds of the observations. The skin was cleaned, gauze or a bandage was used to cover the site of the CVC and dressing was changed in 29.5%, 28.4% and 20% of the observations respectively.
Safety boxes were not available at the hemodialysis center. The majority of the observations revealed that the sharp waste was disposed in plastic containers, non sharps were disposed in plastic refuse bags and dialyzer tubing was discarded in plastic refuse bags. In all observations, final disposal of sharp and non sharp medical waste was by burning with public waste.
In 24.4% of the observations, the areas designated for preparation, handling and storage of medications and unused supplies and equipment were cleaned. The surfaces in the dialysis station were cleaned and disinfected in more than one third of the observations, while the dialysis bed surfaces were cleaned and disinfected between patients. The external surfaces of the dialysis machines were cleaned and disinfected between patients. Linens were changed between the patients in less than one quarter of the observations. Blood spills were cleaned up immediately and soiled and potentially infectious waste as dressing and gauzes were removed in 46.2% and 85.2% of the observations respectively. A separate dialysis machine was used for patients with
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known blood borne infections in only 3.2% of the observations. In more than half of the observations (56.2%), there was no smoking or eating in the dialysis station.
Multivariate analysis of variance (MANOVA) revealed a significant multivariate main effect for experience period on the general knowledge, practice and observational scores. A significant univariate main effect for the experience period on the general observation score and the score of observational aseptic technique was also observed.
d. Results of intervention program:
HCWs post intervention in HD center were 5 times more likely to have good level of knowledge compared to HCWs pre intervention. There was a highly significant difference between both the pre and post intervention knowledge scores. Also HCWs post intervention were 15 times more likely to have good level of practice compared to HCWs pre intervention. There was a highly significant difference between both pre and post the intervention practice scores. Concerning IC practices, HCWs post intervention were about 4.5 times more likely to have good level of observations compared to HCWs pre intervention. There were significant differences between both pre and post intervention observation scores.
e. Results of personal interview with hemodialysis patients:
1. The male patients in the HD center constituted 67.3% and the females constituted 32.7%.
2. More than 31% of patients live in urban areas and 68.3% in rural areas.
3. More than half 56.4% of patients were illiterate, only 4.3% had university education and a high percentage of patients (80.1%) were unemployed.
4. The majority of the families (47.9%) consisted of less than 4 members.
5. About 14% of patients had family history of chronic renal failure.
6. More than one quarter of family members of patients were suffering from renal troubles.
7. The majority of the patients were diagnosed since less than two years.
8. The majority of the patients perform dialysis twice weekly. More than three quarters of the patients had previous diseases such as urinary tract infection and urinary tract stones. More than one third (33.7%) of patients had performed surgery.
9. The majority of the patients took blood transfusion in the previous years and 84.5% of those received calcium supplements.
f. Results of laboratory tests:
In the studied HD center, out of the 392 HD patients free of blood borne diseases at the beginning of the study, 18.8% had HCV, 3.6% had HBV, 1.7% had both HCV and HBV and 0.7% had HIV after six months of the study. The risk of occurrence of hepatitis C per 1000 dialysis session was estimated to be 4.54 while the risk of occurrence of hepatitis B per 1000 dialysis session was estimated to be 1.1 and the risk of occurrence of HIV was estimated to be 0.7 per 1000 dialysis session.
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The main recommendations of the study are:
a. For HCWs: Education and training of HCWs on IC policies, raising their awareness about the importance of vaccination against HBV, using gloves for each patient, routine serologic testing for HBV, HCV and HIV infections and regular assessment of IC policies and practices in the HD center. Health care workers must follow the proper steps for care of fistula: examination and cleaning the fistula site before the start of dialysis, cleaning the site of fistula after removal of cannula, observation for signs of infection and bleeding at fistula site, absence of injection, withdraw of blood and measurement of blood pressure from the hand containing the fistula and application of sterile dressing over the fistula site. Health care workers must follow the proper steps to care CVC: clean the skin, use gauze or a bandage to cover the site of CVC, replace dressing if damp, loosened or soiled, change dressing, do not use any gel or cream at site of CVC, change CVC in case of infection and use aseptic techniques while changing dressing. There should be no eating or smoking in the dialysis station. There should be proper management of sharp injuries: wash the wound with soap and water, identify the source patient, who should be tested for HIV, HB, and HC infections, report to IC team, emergency department, or other designated treatment facility, immediate testing for HIV, HB, and HC infections, getting post exposure prophylaxis in accordance with CDC guidelines.
b. For hemodialysis patients: separate machines should be used for patients infected with blood borne pathogens, and adequate space should be provided between patients. Health care workers should use a sterile set of equipment for each patient and avoid sharing of instruments, medications or supplies between patients, regular routine serologic testing for HBV, HCV and HIV infections, cleaning and disinfection of the dialysis station (e.g. chairs, beds, tables, machines) between patients, training and education of patients regarding personal hygiene, hand washing and ways of caring for vascular access and vaccinations of chronic hemodialysis patients.
c. For MOHP hemodialysis center:
1. Providing sufficient with separate machines for patients infected with blood borne pathogens.
2. Providing adequate sterile set of equipment for each patient.
3. Providing sufficient supply of gloves, masks and eye protective.
4. Providing sufficient supply of safety boxes and disposable syringes, needles.
5. Providing clean and safe places for the preparation and storage of medicines.
6. Education and training of HCWs on IC policies.
7. Giving attention to following IC policies.
d. For the researchers: Investigation of IC practices in other HD centers in Yemen to know the exact magnitude of the problem in Yemen.