| Issue Number
27, March 18, 2005 |
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| Contents of this Issue |
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ABBREVIATIONS: ACIP, Advisory Committee on Immunization Practices; CDC, Centers
for Disease Control and Prevention; DVH, Division of Viral Hepatitis; HAV,
hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; IAC,
Immunization Action Coalition; IDU, injection drug user; MMWR, Morbidity and
Mortality Weekly Report; MSM, men who have sex with men; STD, sexually
transmitted disease; VIS, Vaccine Information Statement; WHO, World Health
Organization.
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March 18, 2005
CDC REPORTS ON TRANSMISSION OF HEPATITIS B VIRUS AMONG PERSONS UNDERGOING BLOOD
GLUCOSE MONITORING
[The following is cross posted from the Immunization Action Coalition's "IAC
EXPRESS" electronic newsletter, 03/14/05.]
CDC published "Transmission of Hepatitis B Virus Among Persons Undergoing Blood
Glucose Monitoring in Long-Term–Care Facilities--Mississippi, North Carolina,
and Los Angeles County, California, 2003-2004" in the March 11 issue of MMWR.
The article is reprinted below in its entirety with the exception of references.
***********************
Regular monitoring of blood glucose levels is an important component of routine
diabetes care. Capillary blood is typically sampled with the use of a
fingerstick device and tested with a portable glucometer. Because of outbreaks
of hepatitis B virus (HBV) infections associated with glucose monitoring, CDC
and the Food and Drug Administration (FDA) have recommended since 1990 that
fingerstick devices be restricted to individual use. This report describes three
recent outbreaks of HBV infection among residents in long-term–care (LTC)
facilities that were attributed to shared devices and other breaks in
infection-control practices related to blood glucose monitoring. Findings from
these investigations and previous reports suggest that recommendations
concerning standard precautions and the reuse of fingerstick devices have not
been adhered to or enforced consistently in LTC settings. The findings
underscore the need for education, training, adherence to standard precautions,
and specific infection-control recommendations targeting diabetes-care
procedures in LTC settings.
The three outbreaks described in this report were all reported by state or local
health departments to CDC, which provided epidemiologic and laboratory
assistance. In each of the three LTC settings, residents were tested for
serologic markers for HBV infection. Under the case definitions used in these
investigations, residents who tested positive for IgM antibody to hepatitis B
core antigen (anti-HBc) were defined as having acute HBV infection. Residents
who tested positive for hepatitis B surface antigen (HBsAg) and total anti-HBc,
but who tested negative for IgM anti-HBc, were considered to have chronic HBV
infection. Residents who tested positive for total anti-HBc, but who tested
negative for HBsAg, or those who had antibody to HBsAg (anti-HBs) >=10 milli-International
Units (mIU) per milliliter were considered immune to HBV infection. Residents
were considered susceptible to HBV if they had no HBV markers. A retrospective
cohort study was performed as part of each investigation; the study was
restricted to acutely infected and susceptible residents to identify risk
factors. In all three investigations, staff members were evaluated; none were
identified as sources of infection. Medical records were reviewed and
infection-control procedures were assessed through direct observation and by
interviews with nursing staff members.
Nursing Home A, Mississippi
During November–December 2003, the Mississippi Department of Health received
reports of two fatal cases of acute HBV infection among residents of nursing
home A. The first patient with recognized symptoms of HBV infection had received
serologic testing for viral hepatitis infection in June 2003 as part of a
hospital emergency department evaluation for abdominal pain. Although this
patient was found to have a positive test for IgM anti-HBc, indicating acute HBV
infection, and the finding was noted in the patient's chart in September 2003,
nursing home A did not contact the state health department or initiate an
internal investigation. Subsequently, the patient died.
In December 2003, after a second patient with acute HBV infection had died, and
after a third with acute HBV infection was reported, serologic testing was
performed on specimens from all 158 residents. Test results were available for
160 residents, including the two decedents; 15 (9%) had acute HBV infection, one
was chronically infected, 15 (9%) were immune, and 129 (81%) were susceptible.
Percutaneous and other possible exposures among residents were evaluated. Among
38 residents who routinely received fingersticks for glucose monitoring, 14 had
acute HBV infection, compared with one of 106 residents who did not receive
fingersticks (relative risk [RR] = 39.0; 95% confidence interval [CI] =
5.3–290.0).
Glucose monitoring of 14 residents with acute HBV infection and the resident
with chronic HBV infection was performed by staff members based at the same
nursing station. Reviews of infection-control practices and site inspections
indicated that each of the four nursing stations in nursing home A was equipped
with one glucometer and one spring-loaded, pen-like fingerstick device. Staff
members reported that a new end cap and lancet assembly was used for each
fingerstick procedure; however, the spring-loaded barrel and glucometer were not
routinely cleaned between patients. Investigators also observed that insulin and
other multidose medication vials were not labeled with patient names or the
dates the vials were opened. In an anonymous survey, several staff members
reported observing other workers reuse a needle or lancet or fail to change
gloves between patients. No other percutaneous exposures were associated with
illness.
Assisted Living Center B, Los Angeles County, California
During January–February 2004, the Los Angeles County Department of Health
Services received reports of four residents with diabetes in assisted living
center B who had acute HBV infection during November 2003–January 2004. Because
these initial reports were among residents with diabetes, serologic testing was
performed in January 2004 on residents who had received fingersticks for blood
glucose monitoring during May–December 2003. Of 22 residents tested (three
declined), eight (36%) had acute HBV infection, including the four residents
previously identified; six (27%) were immune (and excluded from the analysis),
and none had chronic infection. Reviews of patient records indicated that one of
the acutely infected residents had been repeatedly tested at a separate
hemodialysis center and had seroconverted to HBsAg-positive in July 2003. Of the
nine patients who had daily exposure to fingerstick procedures performed by
nursing staff, eight had acute HBV infection, compared with none among the seven
residents who performed their own fingersticks (RR = undefined; CI =
2.8–undefined). Although receipt of insulin was also significantly associated
with infection, two residents with acute HBV infection had not received insulin.
Other percutaneous exposures (e.g., podiatric or dental care) were not
associated with HBV infection. Fingerstick procedures were often performed by
nursing staff members in a central living area, with diabetes patients seated at
a common table. Although residents had their own fingerstick devices, nurses
reported occasionally using a pen-like fingerstick device barrel from their own
kits to collect consecutive blood samples; a single glucometer was typically
used for all residents. Nurses reported that they were discouraged from wearing
gloves to decrease the sense of a clinical environment, and hand hygiene was not
performed between procedures.
Nursing Home C, North Carolina
In May 2003, a case of HBV infection in a resident of nursing home C was
reported to the North Carolina Department of Health. During June–July 2003,
serologic testing was performed on specimens from all 192 residents; 11 (6%) had
acute HBV infection, 16 (8%) were immune, and 165 (86%) were susceptible. No
resident had chronic HBV infection. Of 45 residents who received fingersticks
for glucose monitoring, eight (18%) had acute HBV infection, compared with three
(3%) of 117 residents without this exposure (RR = 6.9; CI = 1.9–25.0). After
data were controlled for fingerstick exposures, acute HBV infection was not
associated with other percutaneous exposures (e.g., insulin injections, podiatry
procedures, or phlebotomy). Two diabetes patients at nursing home C who were
potential sources of the outbreak were identified retrospectively; one had
clinical symptoms of hepatitis B and serologic markers of acute infection during
2002, whereas the other had chronic HBV infection and died in February 2002.
Interviews with staff and direct observation of glucose-monitoring practices
revealed that only single-use lancets were used, and insulin vials were not
shared among patients. However, on each wing of the facility, a single
glucometer was used for all patients receiving fingersticks; glucometers were
not routinely cleaned between patients. On some days, a single healthcare worker
performed approximately 20 fingerstick procedures during a single work shift. In
an anonymous survey, nursing staff members indicated that some healthcare
workers did not always change gloves between patients when performing
fingerstick procedures.
Editorial Note:
Lack of adherence to standard precautions and failure to implement long-standing
recommendations against sharing fingerstick devices place LTC residents at risk
for acquiring infections from bloodborne pathogens such as HBV. In nursing home
A, the spring-loaded barrel of a fingerstick device was used for multiple
patients. Previous outbreaks have been linked to such devices when the platform
or barrel supporting the disposable lancet was reused for multiple patients,
when used lancets were stored with unused lancets, or when lancet caps were
reused. In assisted living center B, nursing staff members routinely
administered fingersticks without wearing gloves or performing hand hygiene
between patients, and spring-loaded fingerstick devices were also occasionally
shared.
In nursing home C, as with other recent outbreaks, transmission of HBV among
residents with diabetes occurred despite use of single-use fingerstick devices
or insulin medication vials that were dedicated for individual patient use. In
these settings, glucose monitors, insulin vials, or other surfaces contaminated
with blood from an HBV-infected person might have resulted in transfer of
infectious virus to a healthcare worker's gloves and to the fingerstick wound or
subcutaneous injection site of a susceptible resident. Similar indirect
transmission of HBV in healthcare settings through contaminated environmental
surfaces or inadequately disinfected equipment has been reported with other
healthcare procedures, such as dialysis. HBV is stable at ambient temperatures;
infected patients, who often lack clinical symptoms of hepatitis, can have high
concentrations of HBV in their blood or body fluids. To prevent
patient-to-patient transmission of infections through cross-contamination,
healthcare providers should avoid carrying supplies from resident to resident
and avoid sharing devices, including glucometers, among residents.
The risk for patient-to-patient transmission of HBV infection can be reduced by
implementing specific prevention measures. LTC staff often perform numerous
percutaneous procedures; frequent blood glucose monitoring increases
opportunities for bloodborne pathogen transmission. The outbreak investigations
reported here identified residents with diabetes who received fingersticks from
nursing staff members as often as four times per day, according to their
physician's routine orders, despite having consistently normal glucose levels.
Expert panels have concluded that approximately 8 years are needed before the
benefits of glycemic control result in reductions in microvascular
complications. In LTC settings, schedules for fingerstick blood sampling of
individual patients should be reviewed regularly to reduce the number of
percutaneous procedures to the minimum necessary for their appropriate medical
management. In each of the investigations described in this report,
implementation of infection-control measures was recommended, along with
follow-up serologic testing for markers of HBV.
An estimated 70,000–80,000 HBV infections occur each year in the United States.
Most of these infections occur among young adults with behavioral risk factors
(i.e., sexual contact and injection-drug use); these adults should receive
hepatitis B vaccine. Preventing transmission of HBV among patients in
long-term–care settings requires adherence to recommended infection-control
practices and prompt response to identified instances of transmission. Routine
hepatitis B vaccination or screening of LTC residents is not recommended. In the
outbreaks described in this report, initial cases were not identified or
investigated in a timely fashion, resulting in missed opportunities to correct
deficient practices and interrupt transmission. Evidence of acute viral
hepatitis in any LTC resident should prompt a thorough investigation. For a case
involving a resident with diabetes, fingerstick blood sampling procedures and
insulin administration should receive particular scrutiny. Health departments
should encourage reporting of such cases and offer assistance in identifying the
source of infection. CDC continues to support investigations in LTC and other
healthcare settings and is working toward improved implementation of the
infection-control recommendations described in this report.
********************
BOX 1. Recommended practices for preventing patient-to-patient transmission of
hepatitis viruses from diabetes-care procedures in long-term–care settings
Diabetes-care procedures and techniques
- Prepare medications such as insulin in a
centralized medication area; multidose insulin vials should be assigned to
individual patients and labeled appropriately.
- Never reuse needles, syringes, or lancets.
- Restrict use of fingerstick capillary blood
sampling devices to individual patients.
- Consider using single-use lancets that
permanently retract upon puncture.
- Dispose of used fingerstick devices and
lancets at the point of use in approved sharps containers.
- Assign separate glucometers to individual
patients. If a glucometer used for one patient must be reused for another
patient, the device must be cleaned and disinfected. Glucometers and other
environmental surfaces should be cleaned regularly and whenever contamination
with blood or body fluids occurs or is suspected.
- Store individual patient supplies and
equipment, such as fingerstick devices and glucometers, within patient rooms
when possible.
- Keep trays or carts used to deliver
medications or supplies to individual patients outside patient rooms. Do not
carry supplies and medications in pockets.
- Because of possible inadvertent contamination,
unused supplies and medications taken to a patient's bedside during
fingerstick monitoring or insulin administration should not be used for
another patient.
Hand hygiene and gloves
- Wear gloves during fingerstick blood glucose
monitoring, administration of insulin, and any other procedure involving
potential exposure to blood or body fluids.
- Change gloves between patient contacts and
after every procedure that involves potential exposure to blood or body
fluids, including fingerstick blood sampling. Discard gloves in appropriate
receptacles.
- Perform hand hygiene (i.e., hand washing with
soap and water or use of an alcohol-based hand rub) immediately after removal
of gloves and before touching other medical supplies intended for use on other
patients.
********************
BOX 2. Recommended medical management, training, and oversight measures to
prevent patient-to-patient transmission of hepatitis viruses from diabetes-care
procedures in long-term–care settings
- Regularly review patient schedules for
fingerstick blood glucose sampling and insulin administration and reduce the
number of percutaneous procedures to the minimum necessary for appropriate
medical management of diabetes and its complications.
- Ensure that adequate staffing levels are
maintained to perform all scheduled diabetes-care procedures, including
fingerstick blood glucose monitoring.
- Consider diagnosis of acute viral hepatitis
infection in patients with illness that includes hepatic dysfunction or
elevated liver transaminases (serum alanine aminotransferase and aspartate
aminotransferase).
- Provide a full hepatitis B vaccination series
to all previously unvaccinated staff members with exposure to blood or body
fluids. Check and document postvaccination titers 1-2 months after completion
of the vaccination series.
- Establish responsibility for oversight of
infection-control activities. Investigate and report any suspected case of
newly acquired bloodborne infection.
- Require staff members to know standard
precautions and demonstrate proficiency in taking these precautions with
procedures involving potential blood or body fluid exposures.
- Provide staff members who perform percutaneous
procedures with infection-control training that includes practical
demonstration of aseptic techniques and instruction regarding reporting
exposures or breaches. Conduct annual retraining of all staff members who
perform procedures with exposure to blood or body fluids.
- Assess compliance with infection-control
recommendations (e.g., hand hygiene or glove changes) by periodic observation
of staff and tracking use of supplies.
***********************
To access a web-text (HTML) version of this article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5409.pdf
To receive a FREE electronic subscription to MMWR (which includes new ACIP
statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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March 18, 2005
NATIONAL VIRAL HEPATITIS ROUNDTABLE MEETING SET FOR APRIL 10-12
The National Viral Hepatitis Roundtable (NVHR) has planned its national meeting
for April 10-12, in Washington, D.C.
NVHR is a coalition of public, private, and voluntary organizations dedicated to
reducing the incidence of infection, morbidity, and mortality from viral
hepatitis in the United States through strategic planning, leadership,
coordination, advocacy, and research.
If your organization is interested in becoming a part of NVHR, and/or attending
the meeting in Washington D.C., please contact Richard T. Conlon, by phone (404)
325-0900, fax (404) 325-0032, or email at
rconlon@nvhr.org Information about NVHR and the conference is also
available at www.nvhr.org
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March 18, 2005
CDC OFFERS VIRAL HEPATITIS INTEGRATION INFORMATION TO HIV COMMUNITY PLANNERS
A brochure titled "Viral Hepatitis Integration for HIV Prevention Community
Planners" can now be ordered or downloaded from CDC's website.
The brochure was developed to inform and motivate HIV Prevention Community
Planners to include viral hepatitis messages and interventions into their
comprehensive HIV plans. The material stresses the importance of integrating
viral hepatitis counseling, testing, and immunization services into existing
programs. The brochure identifies specific populations of clients at increased
risk for viral hepatitis and other STDs, recommends comprehensive interventions
to prevent and control transmission of these infections, and provides examples
of successful public health programs that provide integrated viral hepatitis
services.
Up to 50 copies of "Viral Hepatitis Integration for HIV Prevention Community
Planners" (item number H13) can be ordered by clicking
here.
The brochure can also be downloaded as a PDF (ready-to-print) document by
clicking
here.
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March 18, 2005
NATIONAL VIRAL HEPATITIS PREVENTION CONFERENCE WEBSITE NOW LIVE
The link for the National Viral Hepatitis Prevention Conference website is now
live at http://www.nvhpc.com
The conference is scheduled for December 5-9, in Washington, D.C. As a result of
attending this conference, participants will be able to
- Outline strategies for hepatitis prevention
for infants, children, adolescents, and adults.
- Identify specific intervention strategies that
address the needs of individuals in high-risk groups including, but not
limited to, infants born to HBsAg-positive mothers, clients engaged in
injection drug use/substance abuse, clients in STD/HIV clinics, men who have
sex with men, homeless populations, and inmates in correctional settings.
- Identify specific intervention strategies that
address the viral hepatitis prevention needs of individuals in groups with
health disparities including, but not limited to, Asian Americans and Pacific
Islanders, American Indians/Alaska Natives, and African-Americans.
- Describe methods for integrating and
evaluating viral hepatitis prevention services into existing programs.
- Identify and access communication, education,
and training needs and available resources for viral hepatitis prevention and
control; evaluate the effectiveness of education and training methods.
Visit the conference website for
additional information. Abstracts are being solicited and must be submitted by
May 27.
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March 18, 2005
MEDLINE OFFERS ONLINE HEPATITIS B TUTORIAL
An interactive tutorial about hepatitis B has been added to MedlinePLUS, an
informational website sponsored by the National Library of Medicine. The
tutorial, developed by the Hepatitis B Foundation, is an interesting, simple way
to learn the basics of hepatitis B, and is offered in English and Spanish.
The tutorial is available as an interactive video or as a print document at
http://www.nlm.nih.gov/medlineplus/tutorials/hepatitisb/htm/index.htm
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March 18, 2005
IAC UPDATES SIX VIRAL HEPATITIS EDUCATION PIECES
[The following is cross posted from the Immunization Action Coalition's "IAC
EXPRESS" electronic newsletter, 03/14/05.]
IAC recently updated six of its print pieces related to viral hepatitis.
Following is a list of the revised pieces.
(1) "Labor & Delivery and Nursery Unit Guidelines to Prevent Hepatitis B Virus
Transmission" was revised to acknowledge the licensure of two combination
vaccines for possible use in completing the hepatitis B series.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2130per.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2130.htm
(2) "Give the birth dose . . . Hepatitis B vaccine at birth saves lives!" was
revised to include information on the use of combination vaccines and to update
some web references.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2125.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2125.htm
(3) "Hepatitis A, B, and C: Learn the Differences" now includes current
information on all licensed treatment options and updated statistics.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p4075abc.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p4075abc.htm
(4) "Should You Be Vaccinated Against Hepatitis B?" is a screening questionnaire
for adults. This piece has been shortened to include only the risk groups for
whom the vaccine is currently recommended by CDC. However, it also offers anyone
the option of requesting vaccination, and also has been redesigned so the
respondent doesn't have to identify a risk group.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/2191hepb.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/2191hepb.htm
(5) "Should You Be Vaccinated Against Hepatitis A?" is a screening questionnaire
for adults. This piece has been shortened to include only the risk groups for
whom the vaccine is currently recommended by CDC. However, it also offers anyone
the option of requesting vaccination, and also has been redesigned so the
respondent doesn't have to identify a risk group.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/2190hepa.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/2190hepa.htm
(6) "If you have hepatitis C, what vaccinations do you need?" has been updated
and given a cleaner, more adult look.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/4042hepc.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/4042hepc.htm
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March 18, 2005
NEW BILINGUAL HEPATITIS B POSTERS AVAILABLE
The Washington State Asian and Pacific Islander Hepatitis B Task Force, a
program of Healthy Mothers, Healthy Babies Coalition of Washington State,
supported by the Washington State Department of Health, has developed five new
posters about hepatitis B. These culturally appropriate, bilingual posters
promote screening, vaccination, and treatment of hepatitis B among the Asian
Pacific Islander American population.
The posters measure 8.5" by 14" and are available in Cambodian, Chinese,
Laotian, Korean, and Vietnamese. Persons in Washington state can order the
posters for no charge by emailing
debbien@hmhbwa.org Persons outside Washington state who are interested
in obtaining samples of these posters should send a request to Toni C. Ho at
ToniH@hmhbwa.org
To view an online example, go to:
http://www.hmhbwa.org/forprof/materials/hepb_posters.htm
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March 18, 2005
"CHANGING THE LEGACY" PROGRAM SCHEDULED FOR APRIL 28 IN SAN GABRIEL VALLEY
The Los Angeles County Hepatitis B Task Force, Focus on Asian & Pacific
Islanders, is sponsoring an evening meeting on April 28, 2005. "Changing the
Legacy: Hepatitis B and Asian & Pacific Islander Communities" will feature seven
expert speakers discussing clinical aspects of chronic hepatitis B, serology and
virology of HBV infection, the psychosocial aspects of hepatitis B and liver
cancer, and more.
The meeting will take place at the San Gabriel Valley Medical Center from
6:00-9:30 p.m. Registration is required, but there is no fee to attend. For more
information, call Wendy at (213) 351-2780 or email
wberger@ladhs.org
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March 18, 2005
NEW ISSUE OF "VIRAL HEPATITIS" AVAILABLE ON VHPB WEBSITE
The Viral Hepatitis Prevention Board (VHPB) website has been updated to include
a new issue of the publication "Viral Hepatitis."
"Viral Hepatitis," Volume 13, Number 2, provides an update of the
epidemiological situation of viral hepatitis in France, gives an overview of the
surveillance systems for infectious diseases and adverse events following
vaccination, and offers an evaluation of the current French prevention and
control measures. The issue is titled "Prevention and Control of Viral Hepatitis
in France: Lessons Learnt and the Way Forward."
To access the ready-to-copy (PDF) version of this issue, go to:
http://www.vhpb.org/Default.asp?navItem=newsletters
To access the home page of the VHPB website, go to:
http://www.vhpb.org
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