POSSIBLE DIALYSIS-RELATED WEST NILE VIRUS TRANSMISSION--GEORGIA, 2003
Centers for Disease Control and Prevention
MMWR August 20, 2004 / 53(32);738-739
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5332a3.htm>
In October 2003, the Georgia Division of Public Health (DPH) was
notified of two patients from the same county with confirmed West Nile
virus (WNV) disease who had received hemodialysis on the same day and
on the same dialysis machine. The two dialysis patients (patients A and
C) had the only confirmed cases of human WNV disease reported in their
county in 2003. Review of the dialysis center's records indicated that
another patient (patient B) had received dialysis on the same machine
between these two patients on the same day. This report summarizes
results of the epidemiologic investigation, which suggested that WNV
might have been transmitted at the dialysis center. Hemodialysis
centers should adhere strictly to established infection-control
procedures to avoid WNV transmission through dialysis.
Patient A. The first patient, who received dialysis on the machine
(machine A) in late August, was a man aged 77 years with a history of
hypertension and end-stage renal disease (ESRD). Eight days after
dialysis, patient A was hospitalized with a 48-hour history of fever,
chills, confusion, and anorexia. Blood cultures were negative.
Serologic testing of serum revealed IgM and IgG antibodies to WNV by
enzyme-linked immunosorbent assay (ELISA) and a higher neutralizing
antibody titer to WNV (1:1,280) than to St. Louis encephalitis virus
(SLEV) (1:320). Patient A had not received a blood transfusion <30 days
before symptom onset. After a 9-day hospitalization, he was afebrile at
discharge.
Patient B. The second patient, who received dialysis on machine A
between patients A and C, was a woman aged 71 years with a history of
type 2 diabetes, ESRD, and hypertension. Dialysis center and hospital
records and patient interview revealed no symptoms of illness during
late August or early September, and patient B had not received a blood
transfusion in July, August, or September. In addition, she had never
received a flavivirus vaccination (which might elicit cross-reactive
antibody to serologic tests for WNV) or traveled outside the United
States. A serum sample obtained 42 days after dialysis was
uninterpretable for IgM antibody to WNV (i.e., because of high
background reactivity), negative for IgM to SLEV, and positive for IgG
to both WNV and SLEV by ELISA; the neutralizing antibody titers were
1:160 to WNV and 1:10 to SLEV. A second specimen taken from this
patient 84 days after dialysis was negative for IgM antibody to WNV and
SLEV by ELISA, positive for IgG to both WNV and SLEV by ELISA, and had
neutralizing antibody titers of 1:320 to WNV and 1:20 to SLEV.
Patient C. The third and last patient to receive dialysis on machine A
on the same day in late August was a man aged 60 years with a history
of type 2 diabetes, hypertension, alcoholism, recent onset of ESRD, and
prostate cancer. Nineteen days after his dialysis procedure, patient C
was admitted to a local hospital with fever, chills, altered mental
status, and cachexia. After admission, he had seizures and was
intubated and placed on a ventilator. Analysis of cerebrospinal fluid
(CSF) indicated a mild pleocytosis (67 white blood cells [62%
polynuclear cells, 38% mononuclear cells] and five red blood cells/mm3)
and an elevated protein level (122 mg/dL). Computerized tomography
scans of the patient's brain on the second and tenth days of
hospitalization revealed bilateral lacunar infarcts, white matter
changes, and cortical and subcortical atrophy. Serologic tests of serum
were positive for IgM and IgG antibodies to WNV by ELISA. The
neutralizing antibody titer was higher to WNV (1:1,280) than to SLEV
(1:20). Patient C had not received a blood transfusion <30 days before
symptom onset. Twenty days after admission, he had a high fever and
respiratory failure and died.
DPH and the local health department investigated practices and
procedures at the dialysis center. No breakdowns in disinfection
procedures for the dialysis machine or dialyzers and no breaches in
infection-control practices were revealed. All bloodline attachments to
the dialysis machine were disposable and discarded after each dialysis
session. Patient blood samples were withdrawn from the bloodline for
testing on a monthly basis, unless otherwise directed by the physician.
Medications were bottled in multiple-dose units but were drawn by using
a needle in a separate medication room and injected into the patients'
bloodlines with a syringe. Both the needle and syringe were then
discarded. No single medication was administered to all three patients
on the day of their dialyses. However, patients A and B had received a
common medication, and patients A and C also had received a common
medication, although most likely from separate vials. Blood samples
from three other patients who had received dialysis on machine A on the
previous day and on the following day were all negative for IgM and IgG
antibodies to WNV.
Patients A and C resided in the same neighborhood, 0.2 miles apart, and
patient B resided approximately 1 mile away from this neighborhood. An
environmental assessment around the homes of patients A and C and in
the neighborhood where they resided revealed a high potential for
mosquito exposure, including lack of window screens, barrels of
stagnant water, and wooded areas between homes. Mosquito surveillance
of the area in mid-October indicated that Culex quinquefasciatus
mosquitoes were the most abundant mosquito species; however, no
WNV-positive mosquitoes were identified, as would be expected from
mosquito collections obtained so late in the transmission season.
Pesticide spraying to kill adult mosquitoes in the neighborhood was
conducted two days after surveillance. Three neighbors of patients A
and C submitted blood samples for testing for WNV; all samples were
negative for IgM and IgG antibodies to WNV.
Reported by: CE Smith, MD, JM Jenkins, D Staib, PJ Newell, MD, KJ
Mertz, MD, S Lance-Parker, DVM, RM Kelly, PhD, KA Bryant, MPH, Georgia
Div of Public Health; EB Hayes, MD, GL Campbell, MD, Div of
Vector-Borne Infectious Diseases, National Center for Infectious
Diseases; A Srinivasan, MD, D Jernigan, MD, M Arduino, MD, Div of
Healthcare Quality Promotion; K Abe, PhD, EIS Officer, CDC.
Editorial Note:
This cluster of hemodialysis patients with WNV infections suggests
possible transmission of WNV in the dialysis center. However, the
epidemiologic investigation was inconclusive in determining a source of
infection. One or more of these dialysis patients might have acquired
WNV infection at the dialysis center through an undetected breach in
infection-control procedures, or outside the dialysis center from the
bite of an infected mosquito. Mosquito bites are the most common
transmission route for WNV; however, WNV transmissions through blood
transfusion, organ transplantation, in utero, and possibly through
breast milk have been described (1--4). Unlike patients A and C,
patient B was not confirmed with WNV disease, although laboratory
results for patient B were consistent with previous WNV infection (with
typical cross-reactivity to the closely related SLEV). The lack of
detectable IgM and stable neutralization titers precluded very recent
infection of patient B but was consistent with infection as recent as
early September.
In the United States, transmission of bloodborne pathogens such as
hepatitis B and hepatitis C viruses has occurred in health-care
settings. The majority of the outbreaks of hepatitis viruses among
hemodialysis patients were caused by cross-contamination of supplies,
equipment, or medication and lapses in infection-control practices (5).
Human immunodeficiency virus transmission to hemodialysis patients
outside of the United States has been associated with reuse of access
needles, dialyzers, and improper injection practices (6--8).
Patients on dialysis are highly susceptible to infections because they
often are immunocompromised and are exposed routinely to invasive
techniques and devices (9,10). The possibility that WNV might be
transmitted during dialysis underscores the necessity for dialysis
facilities to strictly adhere to proper infection-control procedures at
all times (9).
References
1. Pealer LN, Marfin AA, Petersen LR, et al. Transmission of West
Nile virus through blood transfusion in the United States, 2002. N Engl
J Med 2003;349:1236--45.
2. Iwamoto M, Jernigan DB, Guasch A, et al. Transmission of West
Nile virus from an organ donor to four transplant recipients. N Engl J
Med 2003;348:2196--203.
3. CDC. Possible West Nile virus transmission to an infant through
breast-feeding---Michigan, 2002. MMWR 2002;51:877--8.
4. CDC. Intrauterine West Nile virus infection---New York, 2002.
MMWR 2002;51:1135--6.
5. Alter MJ, Tokars JI, Arduino MJ, Favero MS. Control of infections
associated with hemodialysis. In: Mayhall CG, ed. Hospital Epidemiology
and Infection Control, 3rd edition, Philadelphia, Pennsylvania:
Lippincott Williams & Wilkins, 2004.
6. El Sayed NM, Gomatos PJ, Beck-Sague CM, et al. Epidemic
transmission of human immunodeficiency virus in renal dialysis centers
in Egypt. J Infect Dis 2000;181:91--7.
7. Velandia M, Fridkin SK, Cardenas V, et al. Transmission of HIV in
dialysis centre. Lancet 1995;345:1417--22.
8. Dyer E. Argentinian doctors accused of spreading AIDS. BMJ
1993;307:584.
9. CDC. Recommendations for preventing transmission of infections
among chronic hemodialysis patients. MMWR 2001;50(No. RR-5).
10. Horl WH. Neutrophil function and infections in uremia. Am J
Kidney Dis 1999;33:xlv--xlviii.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
WESTNILEVIRUS-L is an email discussion group for communication
and discussion about West Nile Virus, particularly regarding policy,
risk reduction and public education issues. It is moderated by
Dr. Lois Levitan, Program Leader of the Cornell University
Environmental Risk Analysis Program (ERAP).
To subscribe (or unsubscribe), send an email request with your name
and contact information to <envrisk@cornell.edu>.
To receive messages once a day in digest format, subscribers can
send an email to <listproc@cornell.edu> with message:
"set WESTNILEVIRUS-L mail digest-nomime".
Subscribers are encouraged to post to the group by sending
messages to <envrisk@cornell.edu>. Put "WNV Listserv" in
the subject line and send unformatted text, without attachments.
Received on Thu Aug 19 13:02:50 2004
This archive was generated by hypermail 2.1.8 : June 29 2005 EDT