RENETA TODOROVA STOYANOVA

Gender: Female

Nationality: Bulgarian

Date of birth: Jul 30, 1957

1978: Diploma in general nursing. 1978-2003: worked as an R/N for several
Bulgarian hospitals.

Presently, in her last year of part-time English Studies (distant
education). Estimated time of her BA graduation: summer 2004.

Lives in Varna, the third big BG town. Married, two sons.

2003-on: works as a translator for Softis: http://softisbg.com/.

Her translations of English fiction into BG language are published on-line
at: http://softisbg.com/library/library.htm

Author of two books: My Virtual Badwulf (2000, in English, about 200 p.) and
Chronicle of a Leave Foretold (ISBN 054-760-050-8, published 2003, in
Bulgarian, ab. 300 p.).

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To whom it may concern

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

This morning , May 22, 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, 31and
June 3, 2003; and a group from Israel will also be dialyzed here on May 27,
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:

O 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 world.[1] 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];

O 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]

O 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;

O 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.

O 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.

O 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 March, 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 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.

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