Alert to Health Authorities Concerning the Risk of infection with hepatitis for foreign citizens on treatment in the hemodialysis unit of St Marina Hospital, Varna Translation from Bulgarian:

Original in Bulgarian

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		FROM:		Reneta T. Stoyanova [address] Varna Date: 22-May- 2003
To whom it may concern

TO:		St. Marina Hospital Varna
Cc:		Regional Health Center Varna
Cc:		Parliament Commission of Health Sofia
Cc:		Ministry of Foreign Affairs Sofia
Cc:		bTV News email: news@btv.bg email: btv_reporterite@btv.bg

Re: Risk of infection with hepatitis for foreign citizens on treatment in the hemodialysis unit of St Marina Hospital, Varna

This morning, 22-May-2003, eight Belgian citizens began their first hemodialysis session in our HD unit. Another eight will have been served by the end of the day. Thus 16 Belgian citizens will undergo six HD sessions each while on holiday at the seaside, as follows: on May 24, 27, 29, 31 and 3-Jun-2003; and a group from Israel will also be dialyzed here on 27-May-2003. There is nothing unusual in this. Combining the pleasures of a holiday with medical treatment, or medical tourism, is widely practiced in many countries around the world.

International medical tourism, however, poses high requirements on the conditions offered by host countries. A possible risk of infection for the visiting patients is one of its most sensitive matters. I think that our HD unit is quite vulnerable in this regard.

These are our weak points:

• A high percentage of virus carriers among our patients (out of about 80 patients served here, 23 are hepatitis C positive and 6 – hepatitis B positive which makes almost 40% virus carriers by current data, and by data from two or three years ago – about 80%) compared with about 20% on average in the HD units all over the world¹. In Europe, in particular, quote: “Among member nations in the European Dialysis and Transplant Association, for example, the prevalence of anti-HCV declined from 21 percent in 1992 to 17.7 percent in 1993 [40]. Nonetheless, the 0.4 to 15 percent incidence of anti-HCV positivity in hemodialysis units continues to be a cause for concern”².
  
• Dializing of both non-infected and infected with hepatitis C patients in a common room: a 13-station HD room. Since the question whether virus carriers of hepatitis C should be isolated in a separate room or not is still controversial among medical professionals, and perhaps because of a lack of funds for repair and reconstruction in our unit, it has been decided that isolation of hepatitis C infected is not needed and only the hepatitis B infected are isolated in a separate room with two stations. There is a contrary opinion in the American Journal of Infection Control, February 2003, volume 31, No. 1: “Conclusions: Evidently, the sharing of facilities in a high-risk HD environment for a prolonged dialytic age facilitates the nosocomial transmission of HCV infection. A significant decline of annual seroconversion rate from 6.8% to 1.01% (odds ratio [OR], 7.535; 95% CI, 1.598-48.89; P < .005) suggests that a comprehensive, strictly enforced isolation policy for HCV-positive patients may play a significant role in limiting HCV transmission in HD units, just as it has in drastically reducing HBV transmission in these settings. (Am J Infect Control 2003;31:26-33.)”³.
  
• Lack of regular serologic tests for hepatitis B, C (HBV, HCV), HIV and CMV. While several years ago, both our patients and staff were tested for these viruses every three months, now the tests are done irregularly – perhaps the more precise term is chaotically – whenever a patient manages to obtain a referral from his/her GP. That is why we have regular patients who have not been tested for over a year and new patients who have been on HD treatment for months and are still untested; moreover, the procedure of testing, is complicated and unreliable even for the staff; for instance, several nurses, among whom I, have been awaiting our hepatitis C test results already for over two months, the senior nurse Demireva has made numerous phone calls but the results still have not been established.
  
• Lack of “clean” room for non-infected foreign patients. A clean room is a room with HD machines on which only regularly tested non-infected patients or new patients are served after they have presented negative results from their preliminary tests. In our HD unit, the new patients start dialysis not having been tested in advance and they are accommodated on the presumably “clean” machines in the big 13-station room until their first results are received. A most recent illustration of how dangerous this practice might be is a patient who, being new, started dialysis on one of these “clean” machines and after receiving his positive result for hepatitis B was moved to the special 2-station room for virus carriers of hepatitis B. At this very moment, one of the Belgian citizens is being dialyzed on this same machine, and for the rest of the foreign patients the guarantees are only verbal.
  
• Availability of deviations from the strict observation of the standards for duration of HD machines disinfection. Regarding a particular case of such non observance, I personally submitted a letter alerting the head of our HD unit, Dr Kiril Nenov, Asst.-Prof. The staff member reported to have neglected his duties was Nikolay Nenov, Eng., who works as a technician in our HD unit. Our unit head paid no attention to this case.
  
• Availability of deviations from the standards for using the machines devoted to hepatitis C carriers only by hepatitis C carriers. A particular case of non-observance of these standards, namely using a machine devoted to hepatitis C positives by a hepatitis C negative patient, was reported in writing in the physician’s report on 25-Mar-2003. It says that it happened without the knowledge of the physician on duty in the large room where hepatitis C positive and negative patients are dialyzed together– and this is another example of how wrong the practice of not isolating hepatitis C carriers in another room might be. The staff member reported as bearing responsibility for this case, was once again Nikolay Nenov. Our unit head likewise chose to overlook this case as well.

The Belgian and Israeli patients who have arrived for medical tourism are “clean”, i.e. not infected with hepatitis B or C, and their treatment in our HD unit has been arranged by Prof. Dimitar Nenov. We were informed about this by the senior nurse Demireva on 20-May-2003 , that is one day before the first group of foreign citizens started dialysis. We were promised additional ‘direct’ payment. It is not the first time we have treated foreign patients, but never before have so many patients arrived at one time. My attempts to raise the question of the risk of infection for the guests were in vain: I was informed that others made the decisions and we had to do what we were told.

Hemodialysis procedures are one of the most expensive medical services. In theory, our HD unit might treat foreign patients who pay for the service, something from which the whole hospital would benefit. Suffice it to invest in constructing a new room with new HD machines specially set up for non-infected foreign patients. In practice, however, the endless excuses based on a supposed ‘lack of funds,’ the attempts at silencing the voices of staff members who tell unpleasant truths, and the typical reliance upon the vagaries of good luck--and perhaps the pursuit of easy profit--sooner or later will precipitate an international scandal similar to that with the Bulgarian health workers in Libya.

[name, signature]

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¹ see here [in the original, the English text was given as footnote whenever there was a reference link]. Back
² see here. Back
³ see. here. Back