An Outbreak of Hospital-Acquired Hepatitis B Virus Infection Among Patients Receiving Chronic Hemodialysis

Objective:To investigate a cluster of hepatitis B virus (HBV) infections between December 1995 and May 1996 among chronic hemodialysis patients in one county.Setting:Two dialysis centers (A and B) and a hospital (C) in one county.Patients:Six case-patients who were dialyzed in one of two centers, A and B, and had all been hospitalized between January and February 1996 at hospital C.Methods:Patient 1, usually dialyzed in center A sero-converted to hepatitis B surface antigen (HBsAg) in December 1995 and could have been the source of infection for the others, who seroconverted between March and April 1996. Two cohort studies were conducted: one among patients dialyzed in center A to determine where transmission had occurred, and one among patients dialyzed at hospital C at the time patient 1 was hospitalized, to identify factors associated with infection.Results:Four (15%) of the 26 susceptible patients dialyzed at center A became infected with HBV. Hospitalization at hospital C when patient 1 was hospitalized was associated with infection (P=.002). A cohort study of the 10 susceptible patients dialyzed at hospital C during the time patient 1 was hospitalized did not identify specific risk factors for infection. However, supplies and multidose vials were shared routinely among patients, providing opportunities for transmission.Conclusion:When chronic hemodialysis patients require dialysis while hospitalized, their HBsAg status should be reviewed, and no instrument, supplies, or medications should be shared among them.