New Call for Infection Control in Wake of HCV Transmissions

Lara C. Pullen, PhD

February 27, 2015

The Centers for Disease Control and Prevention report two separate cases of transmission of hepatitis C virus (HCV) via breaches of infection prevention practices during surgery. The source of transmission was confirmed via molecular analyses of HCV strains.

Andria Apostolou, PhD, from the Centers for Disease Control and Prevention, Epidemic Intelligence Service, Rockville, Maryland, and colleagues discuss the cases in an article published in the February 27 issue of the Morbidity and Mortality Weekly Report.

The cases point to the importance of hepatitis C surveillance and underscore the possibility of healthcare transmission. The authors suggest healthcare and public health professionals consider the possibility of healthcare-associated transmission of HCV when evaluating acute infections.

Case 1

In the first case (New Jersey, 2010), HCV was transmitted when two patients received injectable propofol from the same medication cart.

Patient A contracted HCV when she underwent a uterine dilation and curettage procedure. Patient B had an HCV (genotype 1a) infection and had previously undergone a procedure by the same anesthesiologist. Patients A and B had different procedures, different surgeons, different operating rooms, and different surgical equipment.

A follow-up of 80 patients who had received treatment by the same anesthesiologist resulted in no further cases of known HCV infection. The New Jersey facility has since revised its procedures for assigning, stocking, and cleaning carts used for anesthesia.

Case 2

In the second case (Wisconsin, 2011), two patients had received kidneys that been perfused on the same machine. Patient 1 had undergone hemodialysis for 1 year before he received a kidney transplant.

Two years after his transplant, he tested positive for HCV genotype 4 (HCV-4) via enzyme immunoassay antibody test. An investigation confirmed that the donor was negative for HCV at the time of organ procurement.

However, patient 2 had liver failure from chronic HCV-4 infection as well as chronic kidney disease that required hemodialysis. He received a kidney transplant at the same time as patient 1.

The two patients were in nonadjoining areas of the hospital at the same time for approximately 1 week. Separate healthcare teams worked with each patient during this time. Only one surgeon was common to both transplant operations.

Donated organs for both patients were shipped separately, but both kidneys were perfused on the same machine. Investigators conclude that transmission occurred when the perfusion machine was moved from patient 2's operating room to patient 1's operating room.


Approximately 3.2 million United States residents have chronic HCV infections. This article adds to a body of literature that describes healthcare-associated HCV transmission.

The authors emphasize that an important aspect of infection control is ensuring that equipment and supplies are adequately cleaned and disinfected. Healthcare professionals must strictly adhere to standard precautions to prevent the spread of blood-borne pathogens. All operating room staff members should work together as a team to ensure the safest surgical patient care possible.

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2015;64:165-170. Full text


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