2025年北部某地區醫院血液透析室急性病毒性C型肝炎群聚事件

Acute Hepatitis C Outbreak in a Hemodialysis Unit, Northern Taiwan, 2025

2025年1月國內北部某地區醫院血液透析室通報2名急性病毒性C型肝炎確診病例，經衛生福利部疾病管制署檢驗及疫苗研製中心進行病毒核酸基因序列比對，顯示2名病例的C型肝炎病毒株基因型相同，研判為一起C型肝炎群聚感染事件。經由感染管制專家現場訪查，發現血液透析室有B、C肝床位配置與非肝炎床位區域交集風險、工作人員跨區照護，以及執行抽藥及採血皆在同一台工作車等感染管制措施未落實的情形，高度懷疑是由醫護工作人員照護下傳播所致。後續透過衛生單位及專家介入，與落實改善院所感染管制措施，持續監測至2025年7月止，未再新增個案。本群聚事件凸顯血液透析室人員應落實感染管制措施、透析環境清潔消毒及透析患者定期監測C型肝炎的重要性。

In January 2025, a hemodialysis unit of a hospital in northern Taiwan reported two confirmed cases of acute hepatitis C. Viral nucleic acid sequencing conducted by the Taiwan Centers for Disease Control’s Center for Diagnostics and Vaccine Development showed that both isolates were of the same genotype, indicating a hepatitis C cluster. On-site investigation by infection control experts identified several gaps in infection control practices, including the absence of a physical barrier separating zones for patients with hepatitis B or C from those without hepatitis, which created cross-zone exposure risks; staff providing care across different zones; and the use of the same mobile cart for both medication preparation and blood collection. These factors raised strong suspicion of transmission occurring during healthcare worker–mediated care. Following intervention by local health authorities and experts, and the implementation of strengthened infection control measures, no additional cases were detected through July 2025. This outbreak highlights the importance of strict adherence to infection control measures in hemodialysis units, proper cleaning and disinfection of the dialysis unit environment, and routine hepatitis C surveillance of hemodialysis patients.