- Email: [email protected]
Acute hepatitis C virus infection: hospital or community-acquired infection?
Letters to the Editor / Journal of Hospital Infection 79 (2011) 172–188
smoothly. Second, disconnection of a SEND on activation from a slip-lock syringe also occurred in a few cases. To address this concern we specified that needles must be attached using the push-and-twist method, or alternatively LuerLokÔ syringes were used. The results of this study clearly illustrate the need to carefully evaluate SENDs before full introduction. User satisfaction. It is important that HCWs are included in any decisions regarding the type of SEND introduced. In a study evaluating user satisfaction and acceptance of a new safety syringe by Mulherin et al., HCWs found that >40% of the syringes had not had the safety feature activated.8 The initial evaluation of any SEND prior to routine clinical use should therefore also include useracceptability. Such evaluations take a relatively short time to undertake and they provide valuable information regarding user preferences and product characteristics.3 Patient safety and comfort. SENDs must also take into account patient safety and comfort. The SEND should not cause any more discomfort than the standard device, or put the patient at any greater risk of possible infection. With the impending introduction of EU Directive 2010/32/EC into national legislation, healthcare organisations will be required to ensure that sharps safety becomes a priority.1 It is essential that any SEND chosen is fully evaluated for its suitability as no one device will fulfil all requirements and all HCW preferences.
Conflict of interest None declared. Funding None. References 1. European Agency for Safety and Health at Work. Council directive 2010/32/EU: implementing the framework agreement on prevention from sharps injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU. Off J Eur Union, 1 June 2010. 2. Federal Drug Administration. Guidance for industry and FDA staff. Medical devices with sharps injury prevention features. Rockville, MD: US Department of Health and Human Services; 2005. 3. Training for Development of Innovative Control Technology (TDICT) Project. Safety feature evaluation form. San Francisco: TDICT Project; 1998. 4. Adams D, Elliott TSJ. A comparative user evaluation of three needle protective devices. Br J Nurs 2003;12:470–474. 5. Sartori M, La Terra G, Aglietta M, Manzin A, Navino C, Verzetti G. Transmission of hepatitis C via blood splash into conjunctiva. Scand J Infect Dis 1993;25: 270–271. 6. Rosen HR. Acquisition of hepatitis C by a conjunctival splash. Am J Infect Control 1997;25:242–247. 7. Hosoglu S, Celen MK, Akalin S, Gevik MF, Soyoral Y, Kara IH. Transmission of hepatitis C by blood splash into conjunctiva in a nurse. Am J Infect Control 2003;31:502–504. 8. Mulherin S, Rickman LS, Jackson MM. Initial worker evaluation of a new safety syringe. Infect Control Hosp Epidemiol 1996;17:593–594.
D. Adamsa,* T.S.J. Elliottb a Mid Staffordshire NHS Foundation Trust, Stafford, UK b
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
* Corresponding author. Address: Mid Staffordshire NHS Foundation Trust, Infection Prevention and Control, Stafford Hospital, Stafford, UK. Tel.: þ44 (0)1785 257731x4718. E-mail address: [email protected] (D. Adams).
175
Accepted by J.A. Child Available online 23 July 2011 Ó 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2011.05.020
Acute hepatitis C virus infection: hospital or community-acquired infection? Madam, In France, 3000–4000 new hepatitis C virus (HCV) infections are diagnosed each year.1 The role played by nosocomial contamination is difficult to quantify.2 Several cases of HCV contamination have resulted from shared medical devices.3,4 Some cases of healthcare worker (HCW)-to-patient transmission have been reported during invasive surgical procedures or home care.5–8 In September 2008, an acute HCV infection was diagnosed during the pulmonary pre-transplant examination of a 29-year-old female patient with cystic fibrosis at the Nantes University Hospital. An internal investigation was performed by multidisciplinary team to identify the risk factors for contamination. Local investigations were also conducted in collaboration with the West Nosocomial Infections Control Regional Coordinating Centre and the LoireAtlantique Local Health Authority. The exposure period was estimated by retrospective analysis of the laboratory database. In April 2008, the results of the first routine pre-transplant HCV testing of the patient were negative (anti-HCV antibodies and HCV RNA). The tests for anti-HCV antibodies and HCV RNA (6.4 log10 IU/mL) were found to be positive in September 2008 during the second pre-transplant examination. The period of exposure was thus established to be between April and September 2008. The infection control practitioner interviewed the patient to assess personal risk factors for HCV infection. During the exposure period, the patient declared no risk factors, such as intravenous drug use, tattooing, body piercing or acupuncture. During this period, the patient had been hospitalised twice: in April and May 2008 for respiratory insufficiency secondary to cystic fibrosis. To determine a potential hospital-acquired transmission, all care involving blood contact (surgery, blood transfusion, dialysis, endoscopy or injection of radiographic contrast material) was reviewed by studying the patient’s medical records. The only invasive blood procedure was implantation of a venous port in the surgical unit. Infection control practices and all procedures performed in the operating room were in accordance with standard hygiene precautions. No use of multi-dose vials during anaesthesia was noted. Four patients underwent surgery on the same day as the case patient: two patients were tested negative for HCV after consent and two patients were dead at the time of investigation (no postmortem samples available for testing anti-HCV antibodies). All hospital HCWs (operating room and medical unit) who provided care to the case patient were encouraged to be voluntarily HCV tested. None of the 22 HCWs identified was infected with HCV. At home, the patient received nursing care, including rinsing of the implantable venous port and intravenous antibiotic injections. One of the three home HCWs tested positive for anti-HCV antibodies and HCV RNA (7.4 log10 UI/mL) in July 2009. The HCW had previously been unaware of being infected with HCV.
176
Letters to the Editor / Journal of Hospital Infection 79 (2011) 172–188
6a_AY85952 4a_Y11604 5a_AF06449 3a_AF04686 2b_AB04763 1b_AF13959 1a_AB07907 1a_AY69543 1a_AY88523 1a_DQ24960 1a_AF34492 1a_AF29097 1a_M67463 1a_AF01175 1a_AB07909 1a_AF34519 1a_AJ55744 1a_AF11861 1a_079078 1a_AF34500 1a_M74804 1a_M62321 1a_AF27163 1a_AF26856 1a_AF51195 1a_DQ83873 1a_AB07908 1a_AF34507 1a_AF11859 1a_AF11857 1a_AF34504 1a_AF34488 1a_AF34519 1a_AF11860 1a_AF34518 1a_AF11858 1a_B079085 1a_AY95646 Patient 63 Healthcare worker 56 1a_L12353 1a_AF11861 1a_AY61579 1a_AF34514 1a_AY95804 1a_AJ27883 1a_AF34518 1a_DQ06130
0.05
1a_AF52929 1a_AF34503 1a_AF11860 1a_AF11857 1a_AF11861 1a_AF34494 1a_AF11862 1a_AF34512 1a_AF11860 1a_AF34497 1a_AF11859 1a_AB07908
Figure 1. Neighbour-joining phylogenic tree analysis comparing E1 nucleotide sequences from healthcare worker and patient isolates. Analysis performed by DNADist (PHYLIP v3.65 package), Kimura 2-parameter, Ts/Tv 2.0. The numbers at the nodes of the tree represent the bootstrap values (expressed as percentage of all tree) obtained from 1000 replicates.
Letters to the Editor / Journal of Hospital Infection 79 (2011) 172–188
After consent, molecular analysis was performed at the National Reference Center for Viral Hepatitis B, C and delta to investigate a possible epidemiological link between the patient and the HCW strains. Genotyping was determined from the nonstructural coding region 5B (NS5B). A phylogenic analysis of nucleotide sequences was performed on a 286 base-pair (bp) fragment within the NS5B region, on a 551 bp fragment within the E1 region and on an 81 bp fragment within the HVR1 region. Sequences were aligned with the Clustal W program and the phylogenic tree analysis was done by the neighbour-joining method, DNADistNeighbor, as implemented in the PHYLIP v3.5 package. The patient and the HCW were both infected with HCV genotype 1a. Phylogenic analysis of the NS5b, E1 and HVR1 regions revealed that the sequences from the patient and the HCW were closely related, with a homology of 50% (Figure 1). We documented a case of HCV transmission to a patient, using epidemiologic and molecular approaches. Genetic and phylogenic analysis of the patient and the home HCW strains suggest a possible HCV transmission during home care. The HCW HCV status was not known before the present investigation, consequently we are unable to confirm patient-to-HCW or HCW-to-patient transmission. Transmissions of bloodborne viruses have been reported in the literature from infected HCW to patients.5,6 Breaches of infection control and a high plasma level of HCV RNA are often associated with a high risk of transmission. In conclusion, this investigation reports a possible case of HCW-to-patient HCV transmission during home care. The infection could be the result of a blood exposure during care of the implantable venous port but the circumstances remain uncertain. Prevention of blood exposure and implementation of standard hygiene precautions, in particular wearing gloves during procedures involving exposure to blood, is the primary way to prevent HCV contamination.
177
M. Coste-Burelc S. Chevaliezd,e D. Villersf H. Abbeyg A. Halounh J-M. Pawlotskyd,e H. Sénéchali J-M. Thioletj D. Lepelletiera,k a Unité de Gestion du Risque Infectieux et Prévention des Infections Associées aux Soins – Service de Bactériologie-Hygiène, Centre Hospitalier Universitaire, Nantes, France b
Service de Santé au Travail, Centre Hospitalier Universitaire, Nantes, France c
Service de Virologie, Centre Hospitalier Universitaire, Nantes, France
d
Laboratoire de Virologie et INSERM U955, Hôpital Henri Mondor, Créteil, France e
Centre National de Référence des Hépatites Virales B, C et delta, Créteil, France f Comité de Lutte contre les Infections Nosocomiales, Réanimation Médicale, Centre Hospitalier Universitaire, Nantes, France
g
Unité Qualité Risques Evaluation, Service d’Evaluation Médicale et d’Education Thérapeutique, Centre Hospitalier Universitaire, Nantes, France h
Unité de Transplantation Thoracique, Centre Hospitalier Universitaire, Nantes, France
i
Centre de Coordination de la Lutte contre les Infections Nosocomiales Ouest, Rennes, France j
Conflict of interest statement None declared.
Institut de Veille Sanitaire, Saint Maurice, France
k
EA 3826 «Thérapeutiques cliniques et expérimentales des infections» – Université de Nantes – UFR Médecine, France *
Corresponding author. Address: Unité de Gestion du Risque Infectieux, Bâtiment le Tourville, 5 rue du Pr Boquien, 44093 Nantes Cedex 01, France. Tel.: þ33 2 40 08 34 47. E-mail address: [email protected] (C. Bourigault).
Funding sources None.
References 1. Delarocque-Astagneau E, Pioche C, Desenclos JC, pour le comité de pilotage. Surveillance nationale de l’hépatite C à partir des pôles de référence volontaires: année 2001–2004. Bull Epidemiol Hebd 2006;51–52:415–418. 2. Roudot-Thoraval F, Pawlotsky JM. Transmission nosocomiale du virus de l’hépatite C. Virologie 2001;4:405–411. 3. Krause G, Trepka MJ, Whisenhunt RS, et al. Nosocomial transmission of hepatitis C virus associated with the use of multidose saline vials. Infect Control Hosp Epidemiol 2003;24:122–127. 4. Delarocque-Astagneau E, Baffoy N, Thiers V, et al. Outbreak of hepatitis C virus infection in a hemodialysis unit: potential transmission by the hemodialysis machine? Infect Control Hosp Epidemiol 2002;23:328–334. 5. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;334:555–560. 6. Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendrof M. Transmission of hepatitis C virus from a patient to anaesthesiology assistant to five patients. N Engl J Med 2000;343:1851–1854. 7. Lot F, Delarocque-Astagneau E, Thiers V, et al. Hepatitis C virus transmission from a healthcare worker to a patient. Infect Control Hosp Epidemiol 2007;28: 227–229. 8. Beltrami E, Kozak A, Williams IT, et al. Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker. Am J Infect Control 2003;31: 168–175.
C. Bourigaulta,* V. Naelb E. Garnierc
Accepted by J.A. Child Available online 16 July 2011 Ó 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2011.06.004
H1N1 pandemic influenza impact on hand hygiene and specific precautions compliance among healthcare workers Madam, Hand hygiene (HH) and specific precautions (SPs) are important tools in the prevention of healthcare-associated infections (HCIs).1 However, even though these procedures have been shown
smoothly. Second, disconnection of a SEND on activation from a slip-lock syringe also occurred in a few cases. To address this concern we specified that needles must be attached using the push-and-twist method, or alternatively LuerLokÔ syringes were used. The results of this study clearly illustrate the need to carefully evaluate SENDs before full introduction. User satisfaction. It is important that HCWs are included in any decisions regarding the type of SEND introduced. In a study evaluating user satisfaction and acceptance of a new safety syringe by Mulherin et al., HCWs found that >40% of the syringes had not had the safety feature activated.8 The initial evaluation of any SEND prior to routine clinical use should therefore also include useracceptability. Such evaluations take a relatively short time to undertake and they provide valuable information regarding user preferences and product characteristics.3 Patient safety and comfort. SENDs must also take into account patient safety and comfort. The SEND should not cause any more discomfort than the standard device, or put the patient at any greater risk of possible infection. With the impending introduction of EU Directive 2010/32/EC into national legislation, healthcare organisations will be required to ensure that sharps safety becomes a priority.1 It is essential that any SEND chosen is fully evaluated for its suitability as no one device will fulfil all requirements and all HCW preferences.
Conflict of interest None declared. Funding None. References 1. European Agency for Safety and Health at Work. Council directive 2010/32/EU: implementing the framework agreement on prevention from sharps injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU. Off J Eur Union, 1 June 2010. 2. Federal Drug Administration. Guidance for industry and FDA staff. Medical devices with sharps injury prevention features. Rockville, MD: US Department of Health and Human Services; 2005. 3. Training for Development of Innovative Control Technology (TDICT) Project. Safety feature evaluation form. San Francisco: TDICT Project; 1998. 4. Adams D, Elliott TSJ. A comparative user evaluation of three needle protective devices. Br J Nurs 2003;12:470–474. 5. Sartori M, La Terra G, Aglietta M, Manzin A, Navino C, Verzetti G. Transmission of hepatitis C via blood splash into conjunctiva. Scand J Infect Dis 1993;25: 270–271. 6. Rosen HR. Acquisition of hepatitis C by a conjunctival splash. Am J Infect Control 1997;25:242–247. 7. Hosoglu S, Celen MK, Akalin S, Gevik MF, Soyoral Y, Kara IH. Transmission of hepatitis C by blood splash into conjunctiva in a nurse. Am J Infect Control 2003;31:502–504. 8. Mulherin S, Rickman LS, Jackson MM. Initial worker evaluation of a new safety syringe. Infect Control Hosp Epidemiol 1996;17:593–594.
D. Adamsa,* T.S.J. Elliottb a Mid Staffordshire NHS Foundation Trust, Stafford, UK b
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
* Corresponding author. Address: Mid Staffordshire NHS Foundation Trust, Infection Prevention and Control, Stafford Hospital, Stafford, UK. Tel.: þ44 (0)1785 257731x4718. E-mail address: [email protected] (D. Adams).
175
Accepted by J.A. Child Available online 23 July 2011 Ó 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2011.05.020
Acute hepatitis C virus infection: hospital or community-acquired infection? Madam, In France, 3000–4000 new hepatitis C virus (HCV) infections are diagnosed each year.1 The role played by nosocomial contamination is difficult to quantify.2 Several cases of HCV contamination have resulted from shared medical devices.3,4 Some cases of healthcare worker (HCW)-to-patient transmission have been reported during invasive surgical procedures or home care.5–8 In September 2008, an acute HCV infection was diagnosed during the pulmonary pre-transplant examination of a 29-year-old female patient with cystic fibrosis at the Nantes University Hospital. An internal investigation was performed by multidisciplinary team to identify the risk factors for contamination. Local investigations were also conducted in collaboration with the West Nosocomial Infections Control Regional Coordinating Centre and the LoireAtlantique Local Health Authority. The exposure period was estimated by retrospective analysis of the laboratory database. In April 2008, the results of the first routine pre-transplant HCV testing of the patient were negative (anti-HCV antibodies and HCV RNA). The tests for anti-HCV antibodies and HCV RNA (6.4 log10 IU/mL) were found to be positive in September 2008 during the second pre-transplant examination. The period of exposure was thus established to be between April and September 2008. The infection control practitioner interviewed the patient to assess personal risk factors for HCV infection. During the exposure period, the patient declared no risk factors, such as intravenous drug use, tattooing, body piercing or acupuncture. During this period, the patient had been hospitalised twice: in April and May 2008 for respiratory insufficiency secondary to cystic fibrosis. To determine a potential hospital-acquired transmission, all care involving blood contact (surgery, blood transfusion, dialysis, endoscopy or injection of radiographic contrast material) was reviewed by studying the patient’s medical records. The only invasive blood procedure was implantation of a venous port in the surgical unit. Infection control practices and all procedures performed in the operating room were in accordance with standard hygiene precautions. No use of multi-dose vials during anaesthesia was noted. Four patients underwent surgery on the same day as the case patient: two patients were tested negative for HCV after consent and two patients were dead at the time of investigation (no postmortem samples available for testing anti-HCV antibodies). All hospital HCWs (operating room and medical unit) who provided care to the case patient were encouraged to be voluntarily HCV tested. None of the 22 HCWs identified was infected with HCV. At home, the patient received nursing care, including rinsing of the implantable venous port and intravenous antibiotic injections. One of the three home HCWs tested positive for anti-HCV antibodies and HCV RNA (7.4 log10 UI/mL) in July 2009. The HCW had previously been unaware of being infected with HCV.
176
Letters to the Editor / Journal of Hospital Infection 79 (2011) 172–188
6a_AY85952 4a_Y11604 5a_AF06449 3a_AF04686 2b_AB04763 1b_AF13959 1a_AB07907 1a_AY69543 1a_AY88523 1a_DQ24960 1a_AF34492 1a_AF29097 1a_M67463 1a_AF01175 1a_AB07909 1a_AF34519 1a_AJ55744 1a_AF11861 1a_079078 1a_AF34500 1a_M74804 1a_M62321 1a_AF27163 1a_AF26856 1a_AF51195 1a_DQ83873 1a_AB07908 1a_AF34507 1a_AF11859 1a_AF11857 1a_AF34504 1a_AF34488 1a_AF34519 1a_AF11860 1a_AF34518 1a_AF11858 1a_B079085 1a_AY95646 Patient 63 Healthcare worker 56 1a_L12353 1a_AF11861 1a_AY61579 1a_AF34514 1a_AY95804 1a_AJ27883 1a_AF34518 1a_DQ06130
0.05
1a_AF52929 1a_AF34503 1a_AF11860 1a_AF11857 1a_AF11861 1a_AF34494 1a_AF11862 1a_AF34512 1a_AF11860 1a_AF34497 1a_AF11859 1a_AB07908
Figure 1. Neighbour-joining phylogenic tree analysis comparing E1 nucleotide sequences from healthcare worker and patient isolates. Analysis performed by DNADist (PHYLIP v3.65 package), Kimura 2-parameter, Ts/Tv 2.0. The numbers at the nodes of the tree represent the bootstrap values (expressed as percentage of all tree) obtained from 1000 replicates.
Letters to the Editor / Journal of Hospital Infection 79 (2011) 172–188
After consent, molecular analysis was performed at the National Reference Center for Viral Hepatitis B, C and delta to investigate a possible epidemiological link between the patient and the HCW strains. Genotyping was determined from the nonstructural coding region 5B (NS5B). A phylogenic analysis of nucleotide sequences was performed on a 286 base-pair (bp) fragment within the NS5B region, on a 551 bp fragment within the E1 region and on an 81 bp fragment within the HVR1 region. Sequences were aligned with the Clustal W program and the phylogenic tree analysis was done by the neighbour-joining method, DNADistNeighbor, as implemented in the PHYLIP v3.5 package. The patient and the HCW were both infected with HCV genotype 1a. Phylogenic analysis of the NS5b, E1 and HVR1 regions revealed that the sequences from the patient and the HCW were closely related, with a homology of 50% (Figure 1). We documented a case of HCV transmission to a patient, using epidemiologic and molecular approaches. Genetic and phylogenic analysis of the patient and the home HCW strains suggest a possible HCV transmission during home care. The HCW HCV status was not known before the present investigation, consequently we are unable to confirm patient-to-HCW or HCW-to-patient transmission. Transmissions of bloodborne viruses have been reported in the literature from infected HCW to patients.5,6 Breaches of infection control and a high plasma level of HCV RNA are often associated with a high risk of transmission. In conclusion, this investigation reports a possible case of HCW-to-patient HCV transmission during home care. The infection could be the result of a blood exposure during care of the implantable venous port but the circumstances remain uncertain. Prevention of blood exposure and implementation of standard hygiene precautions, in particular wearing gloves during procedures involving exposure to blood, is the primary way to prevent HCV contamination.
177
M. Coste-Burelc S. Chevaliezd,e D. Villersf H. Abbeyg A. Halounh J-M. Pawlotskyd,e H. Sénéchali J-M. Thioletj D. Lepelletiera,k a Unité de Gestion du Risque Infectieux et Prévention des Infections Associées aux Soins – Service de Bactériologie-Hygiène, Centre Hospitalier Universitaire, Nantes, France b
Service de Santé au Travail, Centre Hospitalier Universitaire, Nantes, France c
Service de Virologie, Centre Hospitalier Universitaire, Nantes, France
d
Laboratoire de Virologie et INSERM U955, Hôpital Henri Mondor, Créteil, France e
Centre National de Référence des Hépatites Virales B, C et delta, Créteil, France f Comité de Lutte contre les Infections Nosocomiales, Réanimation Médicale, Centre Hospitalier Universitaire, Nantes, France
g
Unité Qualité Risques Evaluation, Service d’Evaluation Médicale et d’Education Thérapeutique, Centre Hospitalier Universitaire, Nantes, France h
Unité de Transplantation Thoracique, Centre Hospitalier Universitaire, Nantes, France
i
Centre de Coordination de la Lutte contre les Infections Nosocomiales Ouest, Rennes, France j
Conflict of interest statement None declared.
Institut de Veille Sanitaire, Saint Maurice, France
k
EA 3826 «Thérapeutiques cliniques et expérimentales des infections» – Université de Nantes – UFR Médecine, France *
Corresponding author. Address: Unité de Gestion du Risque Infectieux, Bâtiment le Tourville, 5 rue du Pr Boquien, 44093 Nantes Cedex 01, France. Tel.: þ33 2 40 08 34 47. E-mail address: [email protected] (C. Bourigault).
Funding sources None.
References 1. Delarocque-Astagneau E, Pioche C, Desenclos JC, pour le comité de pilotage. Surveillance nationale de l’hépatite C à partir des pôles de référence volontaires: année 2001–2004. Bull Epidemiol Hebd 2006;51–52:415–418. 2. Roudot-Thoraval F, Pawlotsky JM. Transmission nosocomiale du virus de l’hépatite C. Virologie 2001;4:405–411. 3. Krause G, Trepka MJ, Whisenhunt RS, et al. Nosocomial transmission of hepatitis C virus associated with the use of multidose saline vials. Infect Control Hosp Epidemiol 2003;24:122–127. 4. Delarocque-Astagneau E, Baffoy N, Thiers V, et al. Outbreak of hepatitis C virus infection in a hemodialysis unit: potential transmission by the hemodialysis machine? Infect Control Hosp Epidemiol 2002;23:328–334. 5. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;334:555–560. 6. Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendrof M. Transmission of hepatitis C virus from a patient to anaesthesiology assistant to five patients. N Engl J Med 2000;343:1851–1854. 7. Lot F, Delarocque-Astagneau E, Thiers V, et al. Hepatitis C virus transmission from a healthcare worker to a patient. Infect Control Hosp Epidemiol 2007;28: 227–229. 8. Beltrami E, Kozak A, Williams IT, et al. Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker. Am J Infect Control 2003;31: 168–175.
C. Bourigaulta,* V. Naelb E. Garnierc
Accepted by J.A. Child Available online 16 July 2011 Ó 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2011.06.004
H1N1 pandemic influenza impact on hand hygiene and specific precautions compliance among healthcare workers Madam, Hand hygiene (HH) and specific precautions (SPs) are important tools in the prevention of healthcare-associated infections (HCIs).1 However, even though these procedures have been shown