Preventing iatrogenic HCV infection: A quantitative risk assessment based on observational data in an Egyptian hospital

BackgroundWhen compliance with infection control recommendations is non-optimal, hospitals may play an important role in hepatitis C (HCV) transmission. However, few studies have analysed HCV acquisition risk based on detailed empirical data in order to identify high-risk patient profiles or transmission hotspots. MethodsWe used data from a prospective cohort study conducted on 500 patients in the internal medicine and surgery departments of Ain Shams hospital (Cairo, Egypt). We first performed a sequence analysis to describe patient trajectory profiles. Second, we estimated each patients individual risk of HCV acquisition based on ward-specific prevalence and procedures undergone. We then identified within-hospital risk hotspots by computing ward-level risks. A beta regression model was used to highlight upon-admission factors linked to HCV acquisition risk. Finally, ward-focused and patient-focused strategies were assessed for their ability to reduce HCV infection risk. FindingsSequence analysis identified 4 distinct patient profiles. The estimated HCV acquisition risk varied widely between patients and patient profiles. The risk was found to be higher in the internal medicine hospital compared to the surgery hospital (median: 0{middle dot}188% IQR [0{middle dot}142%-0{middle dot}235%] vs. 0{middle dot}043%, CI 95%: [0{middle dot}036%-0{middle dot}050%]). Upon-admission risk predictors included source of admission, age, reason for hospitalization, and history of anti-schistosomiasis treatment, injection and endoscopy. Patient-focused interventions were found to be most effective to reduce HCV infection risk. InterpretationOur results might help reduce the risk of HCV acquisition during hospitalisation in Egypt by targeting enhanced control measures to ward-level transmission hotspots and to at-risk patients identified upon admission. FundingINSERM-ANRS (France Recherche Nord and Sud Sida-HIV Hepatites) O_TEXTBOXResearch in context Evidence before this studyWe searched PubMed for articles published between Jan 1, 1990 and Jul 05, 2022, and focused on risk assessment of iatrogenic HCV transmission. We used "Hepatitis C", "risk assessment", "model", "transmission", "hospital" and "patients" as keywords. We found five risk assessment articles, the oldest published in 1999 and the most recent in 2012. All of these studies were conducted in countries with low HCV prevalence and were only focusing on HCV transmission from patients to healthcare workers. In addition, the risks estimated within these studies were based on limited observations and did not take into account the procedure-specific transmission risk. Added value of this studyOur study presents a probabilistic risk assessment of HCV transmission to patients within an Egyptian hospital using detailed empirical data. Based on these results, at-risk patient profiles and transmission hotspots were identified. In addition, we simulated ward-focused and patient-focused interventions in order to estimate the efficacy of a better equipment handling on the overall risk of HCV infection. Patient-focused interventions, for instance dedicating sterilized single-use material, were often found to be more efficient than ward-focused ones. However, targeting wards might be financially, logistically and ethically more acceptable. Implications of all the available evidenceConsidering the promising though insufficient results and high costs of the Egyptian HCV elimination program, our results may help reduce HCV transmission at an hospital level. The score we built may be used upon admission to detect high risk patients. In addition, enhanced control measures in transmission hotspots may lead to an important risk reduction for hospitalized patients. Finally, this work could be extended to other bloodborne pathogens such as Hepatitis B or HIV. C_TEXTBOX