| Issue Number
9, October 3, 2003 |
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| Contents of this Issue |
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(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.
***********************
[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
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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.
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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
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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
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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.
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Prepare medications in areas
physically separated from those with potential blood contamination.
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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
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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.
***********************
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.
***********************
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.
************************
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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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:
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"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
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"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
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"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
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"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
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"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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