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Hep Express Issue 9

(1 of 7)
October 3, 2003
CDC REPORTS ON TRANSMISSION OF HEPATITIS B AND C VIRUSES IN U.S. OUTPATIENT SETTINGS DURING 2000-02

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 9/29/03.]

The Centers for Disease Control and Prevention (CDC) published "Transmission of Hepatitis B and C Viruses in Outpatient Settings--New York, Oklahoma, and Nebraska, 2000-2002" in the September 26 issue of "Morbidity and Mortality Weekly Report" (MMWR). Portions of the article and the complete contents of a box of information about infection-control and safe injection practices are reprinted below.

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[The article's first paragraph]
Transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) can occur in health-care settings from percutaneous or mucosal exposures to blood or other body fluids from an infected patient or health-care worker. This report summarizes the investigation of four outbreaks of HBV and HCV infections that occurred in outpatient health-care settings. The investigation of each outbreak suggested that unsafe injection practices, primarily reuse of syringes and needles or contamination of multiple-dose medication vials, led to patient-to-patient transmission. To prevent transmission of bloodborne pathogens, all health-care workers should adhere to recommended standard precautions and fundamental infection-control principles, including safe injection practices and appropriate aseptic techniques.

[The article's Editorial Note in its entirety, excluding references]
These four outbreaks are among the largest health-care-related viral hepatitis outbreaks reported in the United States and share several common characteristics. All occurred in outpatient settings and were reported to public health authorities by clinicians who suspected these infections might have been health-care-related. The investigations were resource-intensive and involved notification, testing, and counseling of hundreds of patients. Transmission probably occurred indirectly from patient to patient after exposure to injection equipment that was contaminated with the blood of one or more source patients. All of these outbreaks could have been prevented by adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications.

Health-care-related exposures are a well-recognized but uncommon source of viral hepatitis transmission in the United States. The majority of outbreaks identified previously have been associated with unsafe injection practices, primarily reuse of syringes and needles or contamination of multiple-dose medication vials. However, because the majority of patients with acute HBV or HCV infection are asymptomatic, clusters of patients infected in the health-care setting might be unrecognized. Health-care-related transmission should be suspected when cases are detected among persons without traditional risk factors for infection. State and local health authorities should consider strategies to improve case identification, such as targeting intensive follow-up for persons who typically are at low risk for infection (e.g., persons aged over 60 years).

In the outbreaks described in this report, health-care workers did not adhere to fundamental principles related to safe injection practices, suggesting that they failed to understand the potential of their actions to lead to disease transmission. In addition, deficiencies related to oversight of personnel and failures to follow up on reported breaches in infection-control practices resulted in delays in correcting the implicated practices. To prevent health-care-related transmission of bloodborne viruses, certification and training programs need to reinforce infection-control principles and practices, including aseptic techniques and safe injection practices. These principles should be reviewed with frequent in-service education for health-care staff, including those who work in outpatient settings, and practices should be monitored as part of the institutional oversight process. Finally, written policies and procedures to prevent patient-to-patient transmission of bloodborne pathogens should be established and implemented among all staff involved in direct patient care. CDC is working with professional organizations, advisory groups, and state and local health departments to address these issues.

[Contents of a box of information on infection-control and safe injection practices]
BOX. Infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens

Injection safety

  • Use a sterile, single-use, disposable needle and syringe for each injection and discard intact in an appropriate sharps container after use.
     
  • Use single-dose medication vials, prefilled syringes, and ampules when possible. Do not administer medications from single-dose vials to multiple patients or combine left-over contents for use later.
     
  • If multiple-dose vials are used, restrict them to a centralized medication area or for single patient use. Never re-enter a vial with a needle or syringe used on one patient if the vial will be used to withdraw medication for another patient. Store vials in accordance with manufacturer's recommendations and discard if sterility is compromised.
     
  • Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
     
  • Use aseptic technique to avoid contamination of sterile injection equipment and medications.

Patient-care equipment

  • Handle patient-care equipment that might be contaminated with blood in a way that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and surfaces.
     
  • Evaluate equipment and devices for potential cross-contamination of blood. Establish procedures for safe handling during and after use, including cleaning and disinfection or sterilization as indicated.

Work environment

  • Dispose of used syringes and needles at the point of use in a sharps container that is puncture-resistant and leak-proof and that can be sealed before completely full.
     
  • Maintain physical separation between clean and contaminated equipment and supplies.
     
  • Prepare medications in areas physically separated from those with potential blood contamination.
     
  • Use barriers to protect surfaces from blood contamination during blood sampling.
     
  • Clean and disinfect blood-contaminated equipment and surfaces in accordance with recommended guidelines.

Hand hygiene and glove

  • Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) before preparing and administering an injection, before and after donning gloves for performing blood sampling, after inadvertent blood contamination, and between patients.
     
  • Wear gloves for procedures that might involve contact with blood and change gloves between patients.

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To obtain the complete text of the article online, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5238a1.htm

To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5238.pdf

HOW TO OBTAIN A FREE ELECTRONIC SUBSCRIPTION TO THE MMWR:
To obtain a free electronic subscription to the "Morbidity and Mortality Weekly Report" (MMWR), visit CDC's MMWR website at: http://www.cdc.gov/mmwr Select "Free Subscription" from the menu at the left of the screen. Once you have submitted the required information, weekly issues of the MMWR and all new ACIP statements (published as MMWR's "Recommendations and Reports") will arrive automatically by email.
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(2 of 7)
October 3, 2003
CDC REPORTS ON GLOBAL PROGRESS TOWARD CHILDHOOD HEPATITIS B VACCINATION

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 9/15/03.]

The Centers for Disease Control and Prevention (CDC) published "Global Progress Toward Universal Childhood Hepatitis B Vaccination, 2003" in the September 12 issue of the "Morbidity and Mortality Weekly Report" (MMWR). The article is reprinted below, excluding references and a map.

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In 1992, the World Health Organization (WHO) set a goal for all countries to integrate hepatitis B vaccination into their universal childhood vaccination programs by 1997. This report summarizes the global progress achieved toward vaccination of children against hepatitis B virus (HBV) infection. Although many countries have introduced hepatitis B vaccination into their national vaccination programs, efforts are needed to increase coverage with the 3-dose hepatitis B vaccination series and expand vaccination programs into countries where the vaccine has not yet been introduced.

In 2001, the most recent year for which complete program data are available, 126 (66%) of 191 WHO member states had universal infant or childhood hepatitis B vaccination programs. Through these programs, an estimated 32% of children aged less than 1 year were vaccinated fully with the 3-dose hepatitis B vaccination series. In the six WHO regions, the proportion of children aged less than 1 year who were vaccinated fully was 65% in the Western Pacific Region, 58% in the Americas Region, 45% in the European Region, 41% in the Eastern Mediterranean Region, 9% in the South-East Asian Region, and 6% in the African Region.

As of May 2003, a total of 151 (79%) of 192 WHO member states had adopted universal childhood hepatitis B vaccination policies, including six that have policies for vaccinating adolescents. Of the 137 member states that have adopted universal childhood hepatitis B vaccination and for which data are available, 76 (55%) have a policy for administering the first dose of vaccine soon after birth (birth dose).

Of the 89 member states with historically high prevalences of chronic HBV infection (i.e., prevalence of hepatitis B surface antigen [HBsAg] of 8% or greater) and for which universal infant hepatitis B vaccination is recommended specifically, 64 (72%) have adopted universal infant hepatitis B vaccination. Of these 64 member states, 34 (53%) have a policy for administration of a birth dose of vaccine. Goals for global hepatitis B vaccination are for the vaccine to be introduced in all countries by 2007 and for coverage with the 3-dose hepatitis B vaccination series to reach 90% by 2010.

Editorial Note:

Each year, approximately 600,000 HBV-related deaths occur worldwide (CDC and WHO, unpublished data, 2003). An estimated 93% of these deaths result from the chronic sequelae of HBV infection: cirrhosis and hepatocellular carcinoma (HCC) (CDC, unpublished data, 2003). Approximately 21% of HBV-related deaths result from infection acquired in the perinatal period and 48% from infection acquired in early childhood (age 5 years or less) (CDC, unpublished data, 2003). Therefore, vaccination of infants and children is the highest priority for hepatitis B vaccination programs. Three doses of hepatitis B vaccine are 90%-95% efficacious in preventing HBV infection and its chronic sequelae. To prevent perinatal HBV transmission, the first dose of vaccine should be administered within the first 24 hours after birth.

Hepatitis B vaccination has been shown to reduce the prevalence of chronic HBV infection and the incidence of HCC dramatically. In The Gambia, the prevalence of chronic infection among children declined from 10.0% to 0.6% after implementation of universal infant hepatitis B vaccination. Similar declines in prevalence of chronic infection associated with infant and childhood hepatitis B vaccination have been demonstrated in China, Indonesia, Senegal, and Thailand, and among Alaska Natives. After implementation of universal infant hepatitis B vaccination in Taiwan, the incidence of HCC among children declined from 0.7 to 0.36 per 100,000.

Several important challenges remain to achieve the goal of global childhood hepatitis B vaccination introduction. Countries that have not yet introduced hepatitis B vaccine should do so. For many of these countries, this will require strengthening their existing vaccination program infrastructure to accommodate the addition of a new vaccine. In countries where the vaccine has been introduced already, coverage with the 3-dose hepatitis B vaccination series should be increased to that of the 3-dose diphtheria-tetanus-pertussis (DTP) series, and then to 90% or greater. Countries that do not have a policy for administration of a birth dose of vaccine should consider the feasibility of implementing such a policy. In countries with high hepatitis B vaccination coverage among children, consideration should be given to catch-up vaccination of older children, adolescents, and adult populations at increased risk for HBV infection.

A major barrier to the introduction of hepatitis B vaccination has been the high cost of hepatitis B vaccines. Although the price of monovalent hepatitis B vaccine for developing countries has decreased from approximately U.S. $3.00 per dose in 1990 to U.S. $0.30 per dose in 2001, the cost remains higher than that of the older vaccines (e.g., DTP, oral polio, and measles), which cost U.S. $0.06-$0.10 per dose. Since 1999, support from the Global Alliance for Vaccines and Immunization (GAVI) and the Vaccine Fund (VF) has accelerated introduction of hepatitis B vaccine in the world's poorest countries. As of May 2003, of 75 countries eligible for GAVI/VF support, 48 (64%) had received funding for hepatitis B vaccination introduction.

Administration of a birth dose of vaccine presents a challenge. Worldwide, approximately 50% of infants are born at home and do not have immediate access to health care. However, because hepatitis B vaccine has been shown to be heat stable, it could be administered by trained birth attendants to infants born at home. The feasibility of such a strategy has been demonstrated in Indonesia, where trained birth attendants were taught to administer the birth dose of vaccine to infants born at home by using a single-use, pre-filled injection device.

WHO, in collaboration with CDC and other GAVI partners, conducted process evaluations of hepatitis B vaccination introduction in five African countries where the vaccine had been introduced recently. These evaluations demonstrated that hepatitis B vaccine introduction did not negatively impact the existing vaccination programs, including coverage with the other childhood vaccines. However, several problems were identified related to the management of this relatively costly vaccine: vaccine freezing during storage and shipment, and vaccine wastage. Outcome evaluations are needed to document the impact of vaccination on the prevalence of chronic HBV infection and HBV-related morbidity and mortality.

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To obtain the complete text of the article online, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5236a5.htm

To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5236.pdf
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(3 of 7)
October 3, 2003
IAC ADDS "MSM VACCINATION" PAGE TO ITS WEBSITE

The Immunization Action Coalition (IAC) recently launched a new web page devoted to the prevention of viral hepatitis infection among men who have sex with men (MSM).

MSM should be vaccinated against both hepatitis A and hepatitis B, yet many remain unprotected. The new web page includes links to journal articles, recommendations, and other resources to help health professionals provide appropriate viral hepatitis screening and preventive services to MSM.

"MSM Vaccination" is located under Topics of Interest in the right column of the IAC home page. To access the new web page, go to: http://www.immunize.org/msm
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(4 of 7)
October 3, 2003
CDC ISSUES HEALTH ADVISORY ABOUT A CURRENT MULTI-STATE OUTBREAK OF FOODBORNE HEPATITIS A

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 9/29/03.]

On September 26, the Centers for Disease Control and Prevention (CDC) issued a Health Advisory, "Multi-state, Foodborne Hepatitis A Outbreak--Tennessee, Georgia, September 2003." According to CDC, a Health Advisory "provides important information for a specific incident or situation; [it] may not require immediate action." The advisory is reprinted below in its entirety.

************************

This is an official CDC Health Advisory
September 26, 2003

MULTI-STATE, FOODBORNE HEPATITIS A OUTBREAK--TENNESSEE, GEORGIA, SEPTEMBER 2003

On September 18, the Knox County (Tennessee) Health Department (KCHD) alerted EpiX that four cases of hepatitis A had occurred in food handlers employed at the O'Charley's Restaurant. At this time there are at least 57 cases of hepatitis A associated with O'Charley's Restaurants in Tennessee, and several others associated with O'Charley's Restaurants in Georgia and potentially in at least one additional state. Most cases identified to date have onset dates clustered around early to mid-September. An investigation to determine the source of the outbreak is underway. Cases of hepatitis A should be interviewed regarding exposure to O'Charley's Restaurants. O'Charley's is a regional chain with restaurants located in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Carolina, Ohio, South Carolina, Tennessee, Virginia, and West Virginia. Cases of hepatitis A associated with this outbreak should be reported to CDC directly and to state or local health departments; available serum should be frozen and saved for molecular testing at CDC. Please call Dr. Joe Amon at CDC (404) 371-5461 to report cases and arrange shipment of serum.

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To access the Health Advisory, go to:
http://www.phppo.cdc.gov/HAN/Documents/AlertDocs/156.asp
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(5 of 7)
October 3, 2003
CDC OFFERS NEW RESOURCES FOR PREVENTING HEPATITIS A AT CONCERTS AND FESTIVALS

The Centers for Disease Control and Prevention (CDC) is investigating a multi-state outbreak of hepatitis A among young adults who attended outdoor concert and camping events featuring "jam bands." A total of 26 cases have been reported among residents of 10 states. Such concerts often involve camping on established or impromptu campgrounds, and sanitary conditions sometimes are poor.

In response to this outbreak, CDC has developed a new web page titled "Preventing Hepatitis A Among Concert-Goers." This page includes sanitation and health department links that health departments may find helpful in preparing for concerts in their area. For example, the Portable Sanitation Association International provides guidelines regarding the number of portable toilet units required based on expected crowd size, event length, mix of men and women, and whether or not alcohol is being served.

CDC has also developed a new flyer for the public: "What Can Concert-Goers Do to Prevent Hepatitis A?" This flyer can be downloaded from the site in color or black and white, and features 1960s-style "flower power" graphics.

Access "Preventing Hepatitis A Among Concert-Goers" at
http://www.cdc.gov/ncidod/diseases/hepatitis/jam_band.htm
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(6 of 7)
October 3, 2003
NEW: SEPTEMBER 2003 ISSUE OF "VACCINATE WOMEN" NOW ONLINE

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 9/29/03.]

The September 2003 issue of "VACCINATE WOMEN" is now available on the website of the Immunization Action Coalition (IAC). This publication was supported by a cooperative grant by the Division of Viral Hepatitis at the Centers for Disease Control and Prevention.

The new issue is filled with reliable, practical information intended to assist obstetricians/gynecologists and others who provide health care to women in providing immunization services in their health care settings.

Here are three ways to access "VACCINATE WOMEN" or its featured articles online. (1) View each of the five main articles by clicking on the direct links below. (2) Download any article from the publication's table of contents toward the end of this article. (3) Download the entire issue from the Web by clicking the link at the very end of this article.

Following are descriptions of and direct links to each of the main "VACCINATE WOMEN" articles:

  1. "Ask the Experts"
    CDC immunization expert William L. Atkinson, MD, MPH, answers general immunization questions. Hepatitis specialists Eric Mast, MD, and Linda A. Moyer, RN, answer hepatitis questions.
     
    PDF: http://www.immunize.org/vw/expert3.pdf
     
  2. "States Report Hundreds of Medical Errors in Perinatal Hepatitis B Prevention"
    Written by IAC's epidemiologist consultant, Teresa Asper Anderson, DDS, MPH, and executive director, Deborah L. Wexler, MD, this article summarizes data collected from state and local hepatitis B coordinators. Based on reports of more than 500 errors regarding perinatal hepatitis B prevention, the article makes a compelling case for giving the birth dose of hepatitis B vaccine to ALL newborns before hospital discharge.
     
    HTML: http://www.immunize.org/catg.d/p2062.htm
    PDF: http://www.immunize.org/catg.d/p2062.pdf
     
  3. "How to Administer IM and SC Injections to Adults"
    This invaluable one-page professional-education sheet presents information and drawings that instruct professionals on which vaccines are administered IM and which SC, where on the body each is administered, which needle size is appropriate for each, and proper needle insertion for each.
     
    PDF (PDF file is in two-page format):
    http://www.immunize.org/catg.d/p2020.pdf
     
  4. "Standing Orders for Administering Hepatitis B Vaccine to Adults" and "Standing Orders for Administering Influenza
    Vaccine to Adults"
    Each of these one-page professional-education sheets covers the purpose, policy, and procedure for using standing orders to administer these vaccines, as well as information about medical contraindications, precautions, and maintaining medical and personal immunization records.
     
    Standing Orders for Administering Hepatitis B Vaccine to Adults PDF:
    http://www.immunize.org/vw/hepb3.pdf
     
    Standing Orders for Administering Influenza Vaccine to Adults PDF:
    http://www.immunize.org/vw/flu3.pdf
     
  5. "Seize the Day: Get Ready for Influenza Vaccination Season NOW!"
    In less than a page, Deborah L. Wexler, MD, IAC's executive director, gives medical professionals five practical, easy-to-implement suggestions for getting themselves and their staff up to speed in time for influenza vaccination season.
     
    PDF: http://www.immunize.org/vw/back3.pdf

To view a table of contents with links to the text version (HTML format) of individual articles, go to:
http://www.immunize.org/vw

To download a camera-ready copy (PDF) format of the entire September 2003 issue (289,311 bytes), go to: http://www.immunize.org/vw/vw0903.pdf

WARNING: The PDF format of the entire publication is a very large file, and some printers are unable to print a file of this size. For some helpful tips on downloading and printing PDF files, click here: http://www.immunize.org/nslt.d/tips.htm
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(7 of 7)
October 3, 2003
TAKE A CLOSER LOOK AT CDC'S HEPATITIS RESOURCE CENTER

The Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), invites you to take a closer look at the educational materials available through their redesigned Hepatitis Resource Center.

The Hepatitis Resource Center offers brochures, posters, PowerPoint slide sets, fact sheets, and links to other organizations. Materials are free and can be ordered online or by printing out a PDF order form and faxing or mailing it to CDC.

Linda Moyer, RN, an epidemiologist with the Division of Viral Hepatitis, recommends ordering online or printing out a new order form before requesting materials. This will ensure you will always know about new offerings and aren't trying to order outdated pieces.

Explore and bookmark the Division's Hepatitis Resource Center and use it often!
http://www.cdc.gov/ncidod/diseases/hepatitis/resource/index.htm


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