title: Hepatitis B Reverse Seroconversion and Transmission in a Hemodialysis Center: A Public Health Investigation and Case Report.
abstract: In March 2013, public health authorities were notified of a new hepatitis B virus (HBV) infection in a patient receiving hemodialysis. We investigated to identify the source and prevent additional infections. We reviewed medical records, interviewed the index patient regarding hepatitis B risk factors, performed HBV molecular analysis, and observed infection control practices at the outpatient hemodialysis facility where she received care. The index patient's only identified hepatitis B risk factor was hemodialysis treatment. The facility had no other patients with known active HBV infection. One patient had evidence of a resolved HBV infection. Investigation of this individual, who was identified as the source patient, indicated that HBV reverse seroconversion and reactivation had occurred in the setting of HIV (human immunodeficiency virus) infection and a failed kidney transplant. HBV whole genome sequences analysis from the index and source patients indicated 99.9% genetic homology. Facility observations revealed multiple infection control breaches. Inadequate dilution of the source patient's sample during HBV testing might have led to a false-negative result, delaying initiation of hemodialysis in isolation. In conclusion, HBV transmission occurred after an HIV-positive hemodialysis patient with transplant-related immunosuppression experienced HBV reverse seroconversion and reactivation. Providers should be aware of this possibility, especially among severely immunosuppressed patients, and maintain stringent infection control.
authors.affiliation: Epidemic Intelligence Service, CDC, Atlanta, GA; North Carolina Department of Health and Human Services, Raleigh, NC. Electronic address: srhea@cdc.gov.
authors.forename: Sarah
authors.initials: S
authors.lastname: Rhea
authors.affiliation: Division of Viral Hepatitis, CDC, Atlanta, GA.
authors.forename: Anne
authors.initials: A
authors.lastname: Moorman
authors.affiliation: North Carolina Department of Health and Human Services, Raleigh, NC.
authors.forename: Robert
authors.initials: R
authors.lastname: Pace
authors.affiliation: North Carolina Department of Health and Human Services, Raleigh, NC.
authors.forename: Victoria
authors.initials: V
authors.lastname: Mobley
authors.affiliation: North Carolina Department of Health and Human Services, Raleigh, NC; Office of Public Health Preparedness and Response, CDC, Atlanta, GA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: MacFarquhar
authors.affiliation: Guilford County Department of Public Health, Greensboro, NC.
authors.forename: Edward
authors.initials: E
authors.lastname: Robinson
authors.affiliation: Division of Viral Hepatitis, CDC, Atlanta, GA.
authors.forename: Tonya
authors.initials: T
authors.lastname: Hayden
authors.affiliation: Division of Viral Hepatitis, CDC, Atlanta, GA.
authors.forename: Hong
authors.initials: H
authors.lastname: Thai
authors.affiliation: Division of Viral Hepatitis, CDC, Atlanta, GA.
authors.forename: Jan
authors.initials: J
authors.lastname: Drobeniuc
authors.affiliation: Division of HIV/AIDS Prevention Surveillance and Epidemiology, CDC, Atlanta, GA.
authors.forename: John T
authors.initials: JT
authors.lastname: Brooks
authors.affiliation: North Carolina Department of Health and Human Services, Raleigh, NC.
authors.forename: Zack
authors.initials: Z
authors.lastname: Moore
authors.affiliation: Division of Healthcare Quality Promotion, CDC, Atlanta, GA.
authors.forename: Priti R
authors.initials: PR
authors.lastname: Patel
mesh_terms: D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D005260:Female; D006509:Hepatitis B / Q000097:blood* / Q000635:transmission*; D006510:Hepatitis B Antibodies / Q000097:blood*; D006801:Humans; D011634:Public Health; D006435:Renal Dialysis; D000069078:Seroconversion
chemical_list: D006510:Hepatitis B Antibodies
keywords: HIV infection; Hepatitis B virus (HBV); blood contamination; case report; environmental transmission; false-negative; hemodialysis; immunosuppression; infection control; reactivation; reverse seroconversion; viral testing; viral surveillance