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CDC recommendations for preventing transmission of infec- 5. Kamar N, Ribes D, Izopet J, Rostaing L. Treatment of hepatitis C virus
tions in hemodialysis units (2) were incorporated by reference, infection (HCV) after renal transplantation: implications for HCV-
positive dialysis patients awaiting a kidney transplant. Transplantation
with the exception of screening for hepatitis C. The referenced 2006;82:853–6.
recommendations have the authority of regulation. 6. CDC. Surveillance for acute viral hepatitis—United States, 2006.
This investigation documented four cases of patient-to- MMWR 2008;57(No. SS-2).
7. Sharara AI, Hunt CM, Hamilton JD. Hepatitis C. Ann Intern Med
patient transmission of HCV infection and identified five addi- 1996;125:658–68.
tional patients who might have acquired HCV infection while 8. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital
receiving treatment at the hemodialysis unit. Multiple possible health care–associated hepatitis B and C virus transmission: United
States, 1998–2008. Ann Intern Med 2009;150:33–9.
mechanisms of HCV transmission were identified, including 9. Gordon CE, Balk EM, Becker BN, et al. KDOQI US commentary on
contaminated health-care worker hands and treatment surfaces. the KDIGO clinical practice guideline for the prevention, diagnosis,
Contact transmission in the setting of extensive environmental evaluation, and treatment of hepatitis C in CKD. Am J Kidney Dis
contamination is a common mechanism for transmission of 2008;52:811–25.
10. Centers for Medicare and Medicaid Services, Center for Medicaid and
bloodborne pathogens in hemodialysis units (2). Because this State Operations/Survey and Certification Group. End Stage Renal
investigation was restricted to patients undergoing treatment Disease (ESRD) Program: interpretive guidance version 1.1. Baltimore,
as of July 31, 2008, the actual number of incident cases at the MD: Centers for Medicare and Medicaid Services; 2008. Available at
hemodialysis unit might have been larger.
This outbreak highlights the need for hemodialysis units to
adhere to recommendations for infection control and com-
prehensive HCV surveillance, including routine anti-HCV
screening, confirmatory testing of anti-HCV seroconversions, Methicillin-Resistant
assessment of the adequacy of infection control practices in Staphylococcus aureus Skin
the setting of documented HCV seroconversion, and prompt
Infections from an Elephant Calf —
reporting to the local health department as required by report-
able disease laws or regulations. Had the hemodialysis unit in San Diego, California, 2008
this report complied with these practices, HCV transmission Methicillin-resistant Staphylococcus aureus (MRSA) infections
might have been identified earlier, and control measures (e.g., are a major cause of human skin and soft tissue infections in the
reviewing infection control practices to identify potential United States (1). MRSA colonization and infection also have
mechanisms of transmission, ensuring adherence to unit infec- been observed in turtles, bats, seals, sheep, rabbits, rodents,
tion control policies, and retraining direct care staff members) cats, dogs, pigs, birds, horses, and cattle (2–8), and MRSA
could have been implemented to interrupt further HCV infections with an epidemiologic link to animal contact have
transmission. Because many patients with HCV infection are been reported in veterinary personnel, pet owners, and farm
asymptomatic, routine screening is essential to detect transmis- animal workers (5,7,8). On January 29, 2008, the County of
sion within hemodialysis facilities and ensure that appropriate San Diego Health and Human Services Agency was notified
precautions are being followed consistently. of skin pustules on an African elephant (Loxodonta africana)
calf and three of its caretakers at a zoo in San Diego County.
Acknowledgments After each of these infections (including the calf’s infection) was
This report is based, in part, on contributions by E Rocchio, MA, laboratory confirmed as MRSA, an outbreak investigation and
K Southwick, MD, N Sureshbabu, and T Kwechin, New York State response was initiated by the zoo and the agency. This report
Dept of Health; and K Bornschlegel, MPH, New York City Dept summarizes the results of that investigation, which identified
of Health and Mental Hygiene.