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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 672-678

Assessment of safety measures in hemodialysis units in Qalyubia Governorate


1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Nephrology, Benha Teaching Hospital, Benha, Qalyubia Governorate, Egypt

Date of Submission04-Jul-2016
Date of Acceptance09-Oct-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Sameh M Gharib
Damsheet, Tanta, Gharbia Governorate, 31741
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.218264

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  Abstract 

Objective
The objective of this study was to assess the infection-control measures that are considered one of the most important factors that threaten the safety of the patients and all workers in hemodialysis units.
Background
Patients undergoing hemodialysis are at risk for multiple infections, and preventing these infections in this high-risk population is a national priority.
Patients and methods
Nineteen hemodialysis units in Qalyubia Governorate were included in a descriptive study. A questionnaire was developed to assess infection-control measures in units.
Results
Most of the units studied were clean in general. Most dialysis units had enough basins, soap, and disinfectants to wash hands and an alternative disinfectant, but only 10.5% of the units studied showed commitment to wash hands or use an alternative disinfectant. Nonsterile gloves were available in 94.7% of the studied units, sterile gloves were available in 47.4% of units, and plastic gowns were available in 52.6% of the units, but none (0%) of the studied units showed full commitment to personal protection. All the units studied were keeping disinfectants and disinfection after repackaged bottles, skin disinfectant was available in 94.7% of the units, and sterile cotton enough for one patient was available in 78.9% of the studied units; 68.4% of the studied units showed that the be disposed of cotton unused after each patient, intravenous compressors reusable in 52.6% of the units, 52.6% of the studied units had no commitment to nontouch method. All employees had been vaccinated against hepatitis B virus in only 57.9% of the studied units. Finally, all units were ideal in terms of isolation of hepatitis C and B patients in separate halls, dealing with furniture and sheets, and data recording.
Conclusion
Hemodialysis units were ideal in terms of data recording, isolation, and dealing with furniture and sheets, but there was a clear error in hand hygiene, personal protection, methods to prevent pollution, environmental cleansing, dealing with waste products, and vaccination.

Keywords: hand hygiene, hemodialysis, infection control, personal protection, safety


How to cite this article:
Ahmed Khamis SS, El Aziz Kora MA, El Barbary HS, Gharib SM. Assessment of safety measures in hemodialysis units in Qalyubia Governorate. Menoufia Med J 2017;30:672-8

How to cite this URL:
Ahmed Khamis SS, El Aziz Kora MA, El Barbary HS, Gharib SM. Assessment of safety measures in hemodialysis units in Qalyubia Governorate. Menoufia Med J [serial online] 2017 [cited 2020 Apr 5];30:672-8. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/672/218264


  Introduction Top


End-stage renal disease (ESRD) represents a stage in which a patient's renal dysfunction has progressed to the point where homeostasis and survival can no longer be sustained with native kidney function and maximal medical management. At this point, renal replacement therapy (dialysis or renal transplantation) becomes necessary [1].

Patients with chronic kidney disease are more susceptible to some infections as the azotemic state alters innate immunity, with reports of reduced monocyte toll-like receptor 4 expression [2] reduced B-lymphocyte cell populations [3], and impaired polymorphonuclear chemotaxis and phagocytosis. It has also been proposed that changes in the gastrointestinal microbiota and increased intestinal permeability to endotoxin lead to a persistent activation of the innate immune system, resulting in the induction of immune-regulatory mediators that then suppress both innate and adaptive immunity [4]. In addition, immune responses may also be impaired by poor nutritional status, malnutrition, and vitamin D deficiency [5]. Patients undergoing hemodialysis (HD) are at risk for bloodstream infections, and preventing these infections in this high-risk population is a national priority [6].

In an environment where multiple patients receive dialysis concurrently, repeated opportunities exist for person-to-person transmission of infectious agents, directly or indirectly through contaminated devices, equipment and supplies, environmental surfaces, or the hands of personnel [7].

Infectious complications of HD include bacterial infections caused by contaminated water or equipment, other bacterial infections (including vascular access infections), and blood-borne viruses [primarily the hepatitis B and C viruses (HBC and HCV)] [8].

In the Menoufia Governorate, there is a high prevalence of HCV among HD patients (49.6%), which may be attributed to the high prevalence of HCV in the general population (8%), the high rate of blood transfusion in dialysis units to treat anemia instead of iron therapy and erythropoietin, which is costly, and the lack of standard methods for infection control in dialysis units [9].

After cardiovascular causes, infectious diseases are the next most common cause of death among dialysis patients. The increased mortality rates in dialysis patients were the highest for sepsis, followed in descending order by peritonitis, influenza, tuberculosis, and pneumonia [10].

Quality control measures for HD have been developed to reduce the risk of transmission of blood-borne viruses in the ESRD population [11].

Standard precautions with additional measures recommended specifically for dialysis centers will prevent the transmission of bacteria and viruses from patient to patient [12].

These precautions include routine use of gloves, hand washing, and cleaning and disinfection of the external surface of the dialysis machine and other environmental surfaces. In addition, prevention of transmission of HBV infection requires vaccination of susceptible patients and staff, avoiding dialyzer reuse, and use of a dedicated room, dialysis machine, and staff members when treating patients chronically infected with this virus [13].

Hand hygiene is a key component of any effective patient safety and infection prevention program. Hand hygiene is generally accepted as the single most important measure in preventing the spread of infection [14].

Hand hygiene is the most important measure in preventing or reducing healthcare-associated infections. Healthcare workers must follow hand hygiene before touching a patient, before a procedure, after a procedure or body fluid exposure, after touching a patient, or after touching a patient's surroundings [15].

Personal-protective equipment (PPE) refers to a variety of barriers, used alone or in combination, to protect mucous membranes, airways, skin and clothing from contact with infectious agents. PPE used as part of standard precautions includes aprons, gowns, gloves, surgical masks, protective eyewear, and face shields. Selection of PPE is based on the type of patient interaction, known or possible infectious agents, and/or the likely mode(s) of transmission [16].

Hepatitis B vaccination is recommended for all susceptible chronic HD patients. Vaccination is recommended for pre-ESRD patients before they become dialysis dependent. Patients with uremia who were vaccinated before they required dialysis have been shown to have higher seroprotection rates and antibody titers. The response to hepatitis B vaccination may also be better in children [17].

Patients on HD should be screened for HBV and HCV infection before the initiation of HD and monitored every 3–6 months thereafter [18]. In this study, we attempted to assess infection-control parameters in HD units in the Qalyubia Governorate, Egypt, to reduce the infectious complications of HD, which include bacterial infections caused by contaminated equipment, other bacterial infections (including vascular access infections), and blood-borne viruses (primarily the HBV and HCV).


  Materials and Methods Top


This study was carried out on 19 units of HD in the Qalyubia Governorate.

Patients' inclusion criteria

All patients with ESRD under regular HD in these units were included.

Methods

A questionnaire was developed to assess infection-control measures in HD units, considered one of the most important areas of safety risk in dialysis facilities. The questionnaire was divided into sections: general information about the unit, cleanliness of the place, hand washing, personal protection, methods for preventing pollution, dealing with furniture and sheets, environment cleansing, dealing with waste products, and occupational health, isolation and records.

The process of HD in these units was monitored from the start of work to the end to assess all the infection-control aspects and the defects in these units. For example, I had to follow-up the entire medical team to determine the extent of their commitment to wear PPE, commitment to washing hands, etc., Also, I had to follow-up nurses while dealing with patients and HD machines to determine whether they follow infection-control policies. I examined the records files in every unit to determine whether the data, such as blood transfusion records, serological records, etc., were recorded or not. The patient/nurse ratio in the studied dialysis units was 6: 1.

Finally, the dialysis treatment surface area (m2) for each patient was not less than 8 m2 and space (distance) between dialysis beds/chairs was not less than 1.22 m in all studied units.

Statistical analysis

The data collected were tabulated and analyzed using the statistical package for the social science software, version 20 (IBM Corp., Armonk, New York, USA).


  Results Top


The highest percentage (57.9%) of the units studied showed that the place was clean in general [Table 1].
Table 1: Studied units in terms of cleanliness of the place and hand washing

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Soap was available all the studied units, whereas disinfectant was available in 89.7% of the units; basins were available in 68.4% of the units, hand drying was followed in 63.2% of the units, 47.4% of units had other hand disinfectants, and only 10.5% of the studied units showed commitment to wash hands or use an alternative disinfectant [Table 1].

Nonsterile gloves were available in 94.7% of the studied units and sterile gloves were available in 47.4% of units, plastic gowns were available in 52.6% of the units, 63.2% of the units did not change gloves after each use, and none (0%) of the studied units showed commitment to personal protection [Table 2].
Table 2: Studied units in terms of personal protection

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All the studied units were keeping disinfectants and disinfection after repackaged bottles, cleansing of dialysis treatment area (dialysis chair/bed+dialysis machine+table or chest drawers), skin disinfectant was available in 94.7% of the units. In 89.5% of the studied units, the solution used for the patient was the only commentator solutions holder and sterile cotton enough for one patient in 78.9% of the studied units; in 68.4% of the studied units, the be disposed of cotton unused after each patient, reusable intravenous compressors were used in 52.6% of the units, none of the units had an uncontaminated plastic roller, and 52.6% of the studied units had no commitment to nontouch method [Table 3].
Table 3: Studied units in terms of methods for preventing pollution

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All units were ideal in all aspects of dealing with furniture and sheets. The sheets were changed after each patient and were sent in impermeable bags to the laundry. Clean sheets and furnishings were stored in a clean place in all the studied units [Table 4].
Table 4: Studied units in terms of dealing with furniture and sheets and environmental cleansing

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In all the studied units, there were containers of concentrated solutions (with a tight lid). Also, in all the studied units, there was adequate space between dialysis patients, machines were cleaned in 89.5% of the studied units, and beds were cleaned in 84.2% of the units, but in 52.6% of the units, there was a lack of sufficient complete separation between storage areas and the patient treatment area. Overall, 73.3% of studied units showed false dealing with blood stains. At the minimum, the dialysis treatment surface area for each patient was not less than 8 m2 and the space (distance) between dialysis beds/chairs was not less than 1.22 m [Table 4].

Only 63.2% of units separated medical waste from regular waste and staff were committed to the separation of waste; collection of waste was performed correctly in 78.9% of the units, there were not enough safety boxes in 68.4% of units, and syringes in the safety box were not covered in all the studied units [Table 5].
Table 5: Studied units in terms of dealing with waste products

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All employees had been vaccinated against HBV in only 57.9% of the studied units. The infected hepatitis C patients were treated in a separate room in all (100%) studied units and the three units that treated hepatitis B positive patients followed 100% isolation of these patients in own halls [Table 6].
Table 6: Studied units in terms of occupational health and isolation

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All units were ideal in all items used in the evaluation of records; all of these records were prepared in all studied units [Table 7].
Table 7: Studied units in terms of records

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  Discussion Top


After cardiovascular causes, infectious diseases are the next most common cause of death in dialysis patients. The increased mortality rates for dialysis patients were the highest for sepsis, followed in descending order by peritonitis, influenza, tuberculosis, and pneumonia [10].

Standard precautions with additional measures recommended specifically for dialysis centers will prevent transmission of bacteria and viruses from patient to patient [12].

The questionnaire in our study was developed for the assessment of infection-control measures in HD units, which is considered one of the most important areas of safety risk in dialysis facilities.

Most dialysis units were in a large percent clean in general.

In terms of hand hygiene factors, which are generally considered the single most important measure in preventing the spread of infection, most dialysis units had enough basins, soap, and disinfectants to wash hands and an alternative disinfectant. Despite the availability of soap, disinfectants, and alternatives in dialysis units, there was significant noncommitment from all medical staff to wash hands or use an alternative disinfectant.

PPE refers to a variety of barriers, used alone or in combination, to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. PPE used as part of standard precautions includes the use of aprons, gowns, gloves, surgical masks, protective eyewear, and face shields. Selection of PPE is based on the type of patient interaction, known or possible infectious agents, and/or the likely mode(s) of transmission [16].

Sterile gloves are used before central venous catheter insertion, whereas nonsterile gloves are used before invasive procedures on the patient such as needle insertion, before noninvasive procedures such as blood pressure measurement, and before cleaning and disinfection of the dialysis machine and the surrounding environment. Sterile gloves were available in about half of the dialysis units, whereas nonsterile gloves were available in all units. This is because the central venous catheter inserting maneuver, which needs sterile gloves, was not followed in all dialysis units.

Protective clothing (apron or gown) must be worn by all healthcare workers if there is close contact with the patient, materials, or equipment that may lead to contamination of skin, uniforms, or other clothing with infectious agents and if there is a risk of contamination with blood, body substances, secretions, or excretions (except sweat). In terms of the availability of plastic gowns, only 10.5% of the dialysis units did not have plastic gowns available and in the rest of the units, plastic gowns were available, but were not enough in 36.8% of the units. Despite the availability of PPE by a large percent, there was a noticeable lack of commitment to personal protection and only 36.8% of the medical staff reported partial (not enough) commitment to personal protection; also, the majority (63.2%) did not change gloves after each use.

Our research showed that all the studied units were keeping disinfectants and disinfection after repackaged bottles, cleaned the dialysis treatment area (dialysis chair/bed+dialysis machine+table or chest drawers), and disinfected the patient's skin. Skin disinfectant was available in 94.7% of the units.

In 89.5% of the studied units, The solution used for the patient was the only commentator solutions holder, because presence of another solution may transmit a lot of infections between patients each other.

Aseptic nontouch technique (ANTT) is a technique used to prevent contamination of key parts and key sites by microorganisms that could cause infection. In ANTT, asepsis is ensured by identifying and then protecting key parts and key sites by hand hygiene, the nontouch technique, using new sterilized equipment, and/or cleaning existing key parts to a standard that renders them aseptic before use [19]. In terms of the commitment to the ANTT, about 52.6% of the units showed no commitment to this technique whereas the rest of units showed incomplete (not enough) commitment to this technique.

All the adhesive rollers in the HD units were contaminated and considered a source of infection between persons inside units. Also, reusable intravenous compressors were available in 52.6% of units and caused transmission of infection from one patient to another.

Sterile cotton enough for one patient was available in 78.9% of the studied units; in 68.4% of the units, the cotton was disposed after use on each patient.

The study also showed that all units were ideal in all aspects of dealing with furniture and sheets. The sheets were changed after each patient and were sent in impermeable bags to the laundry. Clean sheets and furnishings were stored in a clean place in all the studied units.

The study showed that in all the studied units, there were containers of concentrated solutions (tight lid); machines were cleaned in 89.5% of the studied units and beds were cleaned in 84.2% of the units, whereas in 52.6% of the units, there was not enough separation between storage areas and the patient treatment area.

The study showed that 73.3% of the studied units showed false dealing with blood stains.

It is recommended that the dialysis treatment surface area for each dialysis patient should not be less than 8–9 m2, allowing an adequate distance of not less than 1.22 m between dialysis beds/chairs to prevent the risk of cross infection and to allow a degree of privacy for patients [20]. In all studied units, the dialysis treatment surface area for each patient was more than 8 m2 and there were adequate spaces exceeding 1.22 m between dialysis beds/chairs. These excellent results in this aspect were very important because lack of adequate spaces (congested dialysis units) can be a potential risk factor for infection transmission in dialysis units.

The study showed that only 63.2% of units separated medical waste from regular waste and staff were committed to the separation of waste; correct procedures for collection of waste were followed in 78.9% of units. There were not enough safety boxes in 68.4% of units and syringes in the safety box were not covered in any of the studied units.

Patients on HD should be screened for HBV and HCV infection before the initiation of HD and monitored every 3–6 months thereafter [18].

The study showed that all employees had been vaccinated against HBV in only 57.9% of the studied units. The infected hepatitis C patients were treated in a separate room in all (100%) studied units and the three units that treated hepatitis B positive patients showed 100% isolation of these patients in own halls.

In the dialysis units studied, there was an isolation policy for HCV-infected and HBV-infected patients. In one study carried out to determine the effect of isolation of HCV patients, Karkar et al. [21] reported a significant reduction in HCV and HBV seroconversion in isolated patients with strict application of infection-control measures. Yuan et al. [22] also reported the same effect of isolation of HBV and HCV patients with the application of infection-control measures in reducing the incidence of HBV and HCV seroconversion. Another study from Saudi Arabia also concluded that isolation of HCV patients, minimizing blood transfusion, and strict enforcement of infection-control guidelines help in the prevention of HCV transmission among HD units [23]. Agarwal et al. [24] concluded that the isolation of HCV-infected patients during HD significantly decreases the HCV seroconversion rate and recommended that the 'no-isolation' policy should not be generalized. In contrast to this concept, an old study from Belgium concluded that the strict enforcement of universal precautions fully prevents HCV transmission to HD patients and concluded that the isolation of anti-HCV-positive patients is not necessary [25].

The seroconversion rate of hepatitis C in our studied units was 4%.

A cohort study by Abdelaali et al. [26] showed that the incidence of seroconversion was 0.9 per 100 patients/year in Moroccan HD units. These excellent results are because of continuous application of universal rules of hygiene.

Increasingly more serious attempts should be made to follow the infection-control policies mentioned in our study in all studied units by all healthcare workers for testing all the patients for HCV, HBV, and HIV before admission to dialysis service, introduction of HBV vaccination, isolation of HBV-positive patients, use of dedicated dialysis machines, treatment of HCV-positive patients in a separate room/area designated only for HCV-positive patients, regular screening for HCV, HBV, and HIV every 3–6 months thereafter and ongoing commitment to hand washing, use of appropriate PPE, use of the aseptic technique to reduce patient exposure to microorganisms, management of sharps, blood spills, linen, and waste to maintain a safe environment, and Routine environmental cleaning. All these precautions should be taken by healthcare workers attempting to reduce the prevalence of infections and the seroconversion rate of hepatitis C.

Finally, our study showed that all units were ideal in all items used in the evaluation of records; all of these records were maintained in all the studied units.

There were some difficulties in the proper implementation of infection-control practices, for example, lack of full commitment to wash hands by all medical staff, unavailability of PPE in some units, no use of the nontouch method, improper dealing of central venous catheters by nurses, presence of reusable intravenous compressors in most dialysis units, and lack of continuing education for all employees on infection-control practices. Therefore, some suggestions that may help overcome these difficulties include continuous education to all healthcare workers and patients and showing nurses how to perform all the skills needed, a proper vaccination program for all persons in the units, and full supervision of the dialysis process from the start to the end to determine defects then correction.


  Conclusion Top


The HD units studied in Qalyubia Governorate were ideal in data recording, isolation of hepatitis B patients from other patients, and dealing with furniture and sheets, but there were clear errors in hand hygiene, personal protection, methods for preventing pollution, environmental cleansing, dealing with waste products, and vaccination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kliegman RM, Behrman RE, Jenson HB. Renal failure. In: Elk Grove Village, editor. Nelson textbook of pediatrics. 18th ed. Philadelphia, PA: Elsevier; 2007. 2210–2214.  Back to cited text no. 1
    
2.
Koc M, Toprak A, Arikan H, Odabasi Z, Elbir Y, Tulunay A, et al. Toll-like receptor expression in monocytes in patients with chronic kidney disease and haemodialysis: relation with inflammation. Nephrol Dial Transplant 2011; 26:955–963.  Back to cited text no. 2
    
3.
Pahl MV, Gollapudi S, Sepassi L, Gollapudi P, Elahimehr R, Vaziri ND. Effect of end-stage renal disease on B-lymphocyte subpopulations, IL-7, BAFF and BAFF receptor expression. Nephrol Dial Transplant 2010; 25:205–221.  Back to cited text no. 3
    
4.
Anders HJ, Andersen K, Stecher B. The intestinal microbiota, a leaky gut and abnormal immunity in kidney disease. Kidney Int 2013; 83:1010–1016.  Back to cited text no. 4
    
5.
Stubbs JR, Idiculla A, Slusser J, Menard R, Quarles LD. Cholecalciferol supplementation alters calcitriol-responsive monocyte proteins and decreases inflammatory cytokines in ESRD. J Am Soc Nephrol 2010; 21:353–361.  Back to cited text no. 5
    
6.
Patel PR, Thompson ND, Kallen AJ. Epidemiology, surveillance, and prevention of hepatitis C virus infections in hemodialysis patients. Am J Kidney Dis 2010; 56:371–378.  Back to cited text no. 6
    
7.
Savey A, Simon F, Izopet J, Lepoutre A, Fabry J, Desenclos JC. A large nosocomial outbreak of hepatitis C virus infections at a hemodialysis center. Infect Control Hosp Epidemiol 2005; 26:752–760.  Back to cited text no. 7
    
8.
O'Grady NP, Alexander M, Burns LM, Dellinger EP, Garland J, Heard SO, et al. Guideline for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52:e162–e193.  Back to cited text no. 8
    
9.
Zahran A. Epidemiology of hemodialysis patients in Menoufia governorate, Egypt. MNF Med J 2011; 24:59–70.  Back to cited text no. 9
    
10.
Wakasugi M, Kawamura K, Yamamoto S, Kazama JJ, Narita I. High mortality rate of infectious diseases in dialysis patients: a comparison with the general population in Japan. Ther Apher Dial 2012; 16:226–231  Back to cited text no. 10
    
11.
Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO clinical practice guidelines for the prevention, diagnosis, evaluation, and treatment of hepatitis C in chronic kidney disease. Kidney Int 2008; 109:S1-S99.  Back to cited text no. 11
    
12.
Holley JL. A descriptive report of errors and adverse events in chronic hemodialysis units. Nephrol News Issues. 2006; 29:57–58. 60–61, 63  Back to cited text no. 12
    
13.
Grabsch EA, Burrell LJ, Padiglione A, O'Keeffe JM, Ballard S, Grayson ML. Risk of environmental and healthcare worker contamination with vancomycin-resistant enterococci during outpatient procedures and hemodialysis. Infect Control Hosp Epidemiol 2006; 27:287–293.  Back to cited text no. 13
    
14.
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, et al. National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007; 65 (Suppl 1):S1–S64.  Back to cited text no. 14
    
15.
Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health Care Settings. Recommendations of the Health care Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002; 51:1–45.  Back to cited text no. 15
    
16.
Clark L, Smith W, Young L. Protective clothing: principles and guidance. London, UK: Infection Control Nurses Association; 2002.  Back to cited text no. 16
    
17.
Mast EE, Weinbaum CM, Fiore AE. A comprehensive immunization strategy to eliminate transmission of hepatitis b virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006; 55:1–33.  Back to cited text no. 17
    
18.
Alashek WA, McIntyre CW, Taal MW. Provision and quality of dialysis services in Libya. Hemodial Int 2011; 15:444–452.  Back to cited text no. 18
    
19.
Rowley S, Clare S, Macqueen S, Molyneux R. ANTTv2: an updated practice framework for aseptic technique. Br J Nursing2010; 19:S5-S11.  Back to cited text no. 19
    
20.
Saudi Ministry of Health. Standers for the construction, equipping and operation of dialysis units; 2013.  Back to cited text no. 20
    
21.
Karkar A, Abdelrahman M, Ghacha R, Malik TQ. Prevention of viral transmission in HD units: the value of isolation. Saudi J Kidney Dis Transpl 2006; 17:183–188.  Back to cited text no. 21
    
22.
Yuan J, Yang Y, Han F, Zhang P, Du XY, Jiang H, et al. Quality control measures for lowering the seroconversion rate of hemodialysis patients with hepatitis B or C virus. Hepatobiliary Pancreat Dis Int 2012; 11:302–306.  Back to cited text no. 22
    
23.
Mohamed WZ. Prevention of hepatitis C virus in hemodialysis patients: five years experience from a single center. Saudi J Kidney Dis Transpl 2010; 21:548–554.  Back to cited text no. 23
    
24.
Agarwal SK, Dash SC, Gupta S, Pandey RM. Hepatitis C virus infection in haemodialysis: the 'no-isolation' policy should not be generalized. Nephron Clin Pract 2009; 111:c133–c140.  Back to cited text no. 24
    
25.
Jadoul M, Cornu C, van Ypersele de Strihou C. Universal precautions prevent hepatitis C virus transmission: a 54 month follow-up of the Belgian multicenter study. The Universitaires Cliniques St-Luc (UCL) Collaborative Group. Kidney Int 1998; 53:1022–1025.  Back to cited text no. 25
    
26.
Abdelaali B, Omar M, Taoufik D, Samir A, Saad M. Hepatitis C viral prevalence and seroconversion in Moroccan hemodialysis units: eight year follow up. J Med Diagn Meth 2013; 2:141.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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