Travel-associated acquisition of hepatitis C virus infection in patients receiving haemodialysis

Background. It has been proposed that hepatitis C virus ( HCV)- infected patients with end- stage renal disease undergoing maintenance haemodialysis may lack HCV antibody ( anti- HCV) despite chronic HCV viraemia. This carries important implications for the design of surveillance policies. Methods. To characterize the prevalence of antibody-negative/ RNA- positive HCV infection, patients attending seven haemodialysis units underwent anti-HCV testing using a third- generation assay and HCV RNA testing using real- time PCR. Results. At screening, anti- HCV prevalence was 12/ 360 ( 3.3%; 95% CI 1.7 - 5.8%); 7/ 12 ( 58.3%) anti- HCV positive samples were HCV RNA positive. Among anti- HCV- negative samples, 2/ 348 (0.6%; 95% CI 0.2-2.1%) tested HCV RNA positive ( genotype 1a). Retrospective testing of stored sera dated the infections to a period of holiday in the Indian subcontinent. The two infections were unrelated by HCV- NS5B sequencing. Only one of the two newly infected persons showed raised transaminases. Both developed anti-HCV within 8 - 13 weeks of follow- up. Prospective surveillance of travellers to resource- limited countries returning to the units showed a HCV incidence of 4/ 153 travel episodes ( 2.6%; 95% CI 0.7 - 6.6%) among 131 persons ( 3.1%; 95% CI 0.8 - 7.6%). Conclusions. Among haemodialysis patients in the United Kingdom, antibody- negative/ RNA- positive HCV status is associated with newly acquired infection, rather than lack of antibody responses in chronic HCV infection. There is a significant risk of HCV infection associated with travel to resource- limited countries. Given that transaminase levels may be normal, HCV RNA testing is recommended in patients re- entering a dialysis unit following haemodialysis in settings where suboptimal infection control policies pose a risk of exposure to blood- borne viruses.