2020年南部地區某醫院血液透析室急性C型肝炎院內感染事件

Hepatitis C Virus Transmission in a Hemodialysis Unit, Southern Taiwan, 2020

2020年南部地區某醫院血液透析室通報1例急性C型肝炎病例，與同透析室另1名慢性C型肝炎病人病毒株基因型別相同，續送衛生福利部疾病管制署檢驗進行病毒株基因親緣性比對，結果具高度關聯性，研判為C型肝炎院內透析室感染事件。經感控查核委員訪查，發現血液透析室B、C肝床配置區域及出入口在工作動線上有交集風險、配藥地點未設專區亦未分乾淨區及汙染區，以及多劑型藥物稀釋液未採獨立包裝重複抽藥。後續透過衛生單位及專家介入，與院所感控措施之改善與落實，監測至2021年6月止，無新增個案。本事件顯示醫療機構血液透析落實感染管制措施的重要性。

In June 2020, a case of acute hepatitis C was diagnosed at a hemodialysis unit in Southern Taiwan. Nucleic acid sequencing and phylogenetic analysis demonstrated genetic similarity between the viral strains from the case-patient and a patient with chronic hepatitis C who received dialysis at the same unit, suggesting a healthcare-associated infection. An infection control team conducted a field inspection and revealed lapses in infection prevention and control, including use of inappropriate dialysis beds layout with cross-contamination potential, lack of dedicated area for drug dispensing, lack of separation between clean and contaminated working areas, and use of single-package drug diluent for multidose use. After correcting these lapses, no incident acute hepatitis C cases were noted as of July 2021. This event highlighted the importance of compliance with infection control measures in hemodialysis units.