HD-IC-006 · Outbreak Investigation & Control (UPDATED)

Outbreak Detection, Investigation, and Control in Hemodialysis

Policy HD-IC-006 · Hemodialysis Unit + Infection Control

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To define the process for rapid identification, investigation, reporting, and containment of outbreaks of infectious disease in the hemodialysis unit to prevent morbidity, mortality, and regulatory closure per MOH-Jordan Communicable Disease Law 2022 and CDC HICPAC guidelines.

2 Scope

Applies to all patients, staff, physicians, visitors, biomedical, and housekeeping personnel. Covers outbreaks of: Hepatitis B, Hepatitis C, HIV, bacterial BSIs including CRBSI, MDROs, C. difficile, influenza, Candida auris, and water-borne organisms.

3 Definitions

Outbreak ≥2 cases same infection above baseline in 3 months OR 1 HBV/HCV/HIV seroconversion OR 1 C. auris/CRE Seroconversion HBsAg-neg → positive OR HCV Ab-neg → positive Attack Rate # new cases ÷ # patients exposed × 100 MOH Notification Within 24h of suspected outbreak

4 Policy Statement UPDATED

Update 1.1 Zero delay & medical director authority

Any suspected outbreak triggers immediate action. Medical Director can halt admissions or close unit.

Enhanced: • Zero Delay: Any suspected outbreak triggers immediate action. No waiting for confirmation. • Medical Director Authority: Can halt admissions, close rows, or close unit to control outbreak. • Transparency: All outbreaks reported to MOH, patients, and staff. Cover-up = license revocation. • Root Cause: Investigation must identify source: water, machine, medication, staff, or patient-to-patient.

Rationale: MOH requires <24h detection-to-notification. Delays = unit closure. Cover-up is a licensing offense.

5 Procedure: 6 Phases of Outbreak Response UPDATED

Phase 1: Detection – Trigger Thresholds UPDATED

Trigger	Example	Action
1 HBV/HCV/HIV Seroconversion	HBsAg-neg patient turns positive	Immediate outbreak – Stop unit
2+ CRBSI same organism 30 days	2 CVC patients with S. aureus BSI	Suspected outbreak – Investigate
2+ C. diff cases 7 days	2 patients diarrhea + toxin+	Suspected outbreak – Isolate
1 C. auris or CRE case	Any positive culture	Immediate outbreak – MOH notify
Pyrogenic reactions ≥2 per week	3 patients chills/fever during HD	Water contamination suspected – Stop RO
CRBSI rate >3x baseline	Baseline 0.8, now 2.5/1000 days	Outbreak – Full investigation
2+ staff same infection	2 nurses with MRSA skin infection	Staff source suspected

Who Can Activate: Any RN, MD, or infection control officer. Call Medical Director + In-Charge RN immediately.

Phase 2: Initial Response – First 2 Hours

STOP: Halt all new treatments if HBV/HCV seroconversion, C. auris, or water contamination suspected.

ISOLATE: Place index case + suspected cases on Contact + Enhanced Precautions immediately.

NOTIFY:

Medical Director: _____ Time: _____
Infection Control: _____ Time: _____
Hospital Admin: _____ Time: _____
MOH Communicable Disease: 065-200-200 Time: _____

SECURE: Save all relevant items: med vials, dialysate samples, water samples, machine logs, staff assignments. Do NOT discard.

LIST: Generate line list of all exposed patients + staff last 2 weeks using HD-IC-006-F2.

Phase 3: Investigation – Hours 2-24 UPDATED

Update 2.1 Environmental testing & observational audit

Case definition, find cases, environmental testing, observational audit.

Enhanced: • Case Definition – explicit template. • Lab Review – pull all positive cultures, LFTs, serologies last 3 months. • Active Surveillance – test all exposed patients and staff. • Environmental Testing – table of suspected sources, tests, collectors, labs. • Observational Audit – 2-hour direct observation of hand hygiene, PPE, cleaning, medication prep, floating patterns.

Rationale: Environmental testing identifies the source. Observational audit identifies the breach. Both are MOH-required.

Suspected Source	Test	Who Collects	Lab
Water System	Bacterial count + Endotoxin pre-RO, post-RO, loop end	Biomedical	External lab 24h TAT
Dialysate	Bacterial + Endotoxin from 3 machines	RN	External lab
Machines	Culture blood tubing, ports, drain	Biomed	Micro lab
Medications	Culture all multidose vials: heparin, EPO	Pharmacy	Micro lab
Surfaces	ATP swabs: chair, machine, scale	Infection Control	ATP meter

Phase 4: Control Measures – Hour 2 Until Outbreak Over UPDATED

Measure

HBV/HCV

CRBSI

MDRO

Stop Admissions

Yes

If >3 cases

Cohort Patients

Positive in isolation room only

By organism

Dedicated Staff

Yes – cannot float

Yes for outbreak patients

Yes

Terminal Clean

Bleach entire room

Bleach + UV-C if available

Bleach 10min contact

Retrain All Staff

Within 24h

Within 72h

Within 1 week

Phase 5: Communication

Internal: Daily huddle with all staff. Update board: "Outbreak Status: [Organism] – [X] cases. Measures in place."

Patients: Notify all patients verbally + letter HD-IC-006-F3 within 48h. Include: what happened, risk to them, testing offered, contact number.

MOH: Daily report until outbreak declared over. Use HD-IC-006-F4 MOH Line List.

Media: Only hospital PR speaks. No staff social media posts.

Phase 6: Declare Outbreak Over

Criteria: No new cases for 2 incubation periods after last case + source controlled.

HBV: 6 months
HCV: 3 months
CRBSI: 1 month
C. diff: 2 weeks
Water: After 3 consecutive negative cultures

Medical Director + MOH sign HD-IC-006-F5 Outbreak Closure Form.

6 Specific Outbreak Protocols UPDATED

A HBV Seroconversion – MOH Critical

Hour 0: Stop HD, test index. Hour 1-4: test all patients/staff. Observe procedures.

Enhanced: • Hour 0: Stop all HD. Test index patient HBsAg, Anti-HBc IgM, HBV DNA stat. • Hour 1-4: Test ALL patients HBsAg + ALT stat. Test ALL staff HBsAg + Anti-HBs. • Hour 4-24: Observe all CVC access, med prep, machine cleaning. Interview staff for breaches. • Source: Usually: multidose vial, contaminated machine, staff hands, or failure of HBV isolation room. • Post-Exposure: Give HBIG + vaccine to all non-immune patients within 7 days.

Rationale: MOH requires <24h notification for HBV seroconversion. This is a sentinel event.

B CRBSI Cluster

≥2 CRBSI same organism 30 days or rate >3/1000. Culture + PFGE typing. Audit CVC bundle.

Enhanced: • Definition: ≥2 CRBSI same organism 30 days OR rate >3/1000 CVC days. • Culture: Save blood cultures + catheter tips. Send for PFGE typing to prove clonal. • Common Sources: Poor CVC care, contaminated heparin vial, water bacteria, staff nares MRSA. • Intervention: Audit CVC bundle compliance. Switch to chlorhexidine/alcohol caps. Single-dose heparin only.

Rationale: PFGE typing is the gold standard to prove transmission. MOH requires clonal confirmation.

C Water Contamination

Trigger: Endotoxin >0.25 or bacteria >50 or pyrogenic reactions. Stop RO, disinfect, restart after 3 negative cultures.

Enhanced: • Trigger: Endotoxin >0.25 EU/mL OR bacteria >50 CFU/mL OR ≥2 pyrogenic reactions/week. • Hour 0: Stop using RO. Switch to bottled sterile fluid for emergency HD or transfer patients. • Disinfect: Superheat loop to 80°C 60min OR chemical disinfect per manufacturer. • Restart: Only after 3 consecutive negative cultures 48h apart + MOH approval.

Rationale: Water contamination can infect 12 patients in 48h. MOH requires immediate RO shutdown.

8 Staff Competency & Drills UPDATED

Update 3.1 Mock outbreak drills

Initial: all staff trained on triggers + Hour 0 actions. Annual: mock outbreak drill.

Enhanced: • Initial: All staff trained on outbreak triggers + Hour 0 actions. • Annual: Mock outbreak drill. Scenario: "HBsAg seroconversion at 10am." Time to notification + isolation. • Fail = Retrain: If staff cannot list 3 triggers or don't notify in drill, cannot work until pass.

Rationale: MOH inspectors may simulate an outbreak during survey to test staff response.

9 Quality Monitoring – QAPI UPDATED

Update 4.1 New & refined quality metrics

Outbreak rate 0, time to MOH notification <24h, CRBSI rate <1.0, seroconversion 0, days to contain <14.

Added: • % staff able to list 3 outbreak triggers – target 100% • % staff who notified MD/IC within 15min in drill – target 100% • Time from detection to environmental sampling – target <4h • MOH notification compliance – target 100% within 24h.

Rationale: Expanded KPIs address MOH audit red flags: staff knowledge, notification timeliness, and environmental sampling speed.

10 References UPDATED

Update 5.1 Updated reference list

CDC. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. MMWR 2016;65(3).
MOH Jordan. Communicable Disease Surveillance Guidelines, 2022. Outbreak reporting chapter.
APIC. Guide to the Elimination of Infections in Hemodialysis. 2018.
JCI. Accreditation Standards for Hospitals, 8th Ed. PCI: Prevention and Control of Infections.
WHO. Outbreak Communication Guidelines. 2008.
MOH-Jordan Outbreak Investigation Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Zero delay; Medical Director can close unit; cover-up = license revocation; root cause required	MOH requires <24h detection-to-notification. Cover-up is licensing offense.
5. Phase 1	Expanded trigger table: HBV/HCV seroconversion, C. auris, pyrogenic reactions, CRBSI rate >3x baseline	Clear triggers = faster activation. MOH audits trigger recognition.
5. Phase 3	Environmental testing table; 2-hour observational audit; staff screening	Environmental testing identifies source. Observational audit identifies breach.
5. Phase 4	Control measures grid: stop admissions, cohort, dedicated staff, terminal clean, retrain timelines	Clear accountability for each organism type. MOH expects documented control measures.
6. Specific Protocols	HBV seroconversion (HBIG + vaccine within 7 days), CRBSI cluster (PFGE typing), Water contamination (RO shutdown + 3 negative cultures)	MOH requires organism-specific protocols. PFGE proves transmission.
8. Competency	Mock outbreak drill annually; fail = retrain; staff must list 3 triggers	MOH may simulate outbreak during survey. Staff must know triggers.
9. QAPI	New KPIs: staff trigger knowledge (100%), drill notification <15min (100%), environmental sampling <4h, MOH notification <24h	Addresses MOH audit red flags: knowledge, timeliness, and speed.

Policy HD‑IC‑006 · Proposed updates June 26, 2026 All changes reviewed against CDC 2016, MOH‑Jordan 2022, APIC 2018, JCI 8th Edition.
⚠️ This policy is audit-proof for MOH 2022 + JCI PCI. One contaminated line can infect 12 patients in 48 hours – detect and stop in <24 hours or they'll shut you down.

Outbreak Investigation Policy · Version 2026-06-27 · Hemodialysis Unit

📋 Back to All Policies · 🖨️ Print This Page

Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.