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OBJECTIVES: To establish the etiology for outbreaks of hepatitis B virus (HBV) infections at two assisted living facilities (ALFs) and devise appropriate control measures.
DESIGN: Multisite outbreak investigations, retrospective cohort.
SETTING: Two ALFs in Illinois.
PARTICIPANTS: Facility A residents (n=120) and Facility B residents (n=105) and nursing staff (n=6).
MEASUREMENTS: For Facility A, a retrospective cohort study to identify risk factors for HBV infection through serological testing of all residents and a medical record extraction. For Facility A and B, investigation of fingerstick blood glucose monitoring techniques. For Facility B, serological HBV testing of nurses and residents receiving fingerstick blood glucose monitoring.
RESULTS: At Facility A, five confirmed acute, two probable acute, and one probable chronic HBV infections were identified in the 109 residents tested. All of the eight identified residents with HBV infection had diabetes mellitus. HBV deoxyribonucleic acid (DNA) sequences from the chronic and acute cases were identical. Transmission of HBV was associated with fingerstick blood glucose monitoring (relative risk (RR)=28.5, 95% confidence interval (CI)=1.6–498; P<.001) and insulin injections (RR=7.4, 95% CI=1.3–40.8; P=.03). At Facility B, seven of 21 residents (33.3%) receiving fingerstick blood glucose monitoring had evidence of recent HBV infection.
CONCLUSION: Nurses probably transmitted HBV infection from resident to resident during fingerstick blood glucose monitoring in two separate ALFs, causing outbreaks. Awareness of the high risk for HBV transmission during procedures for the care of diabetes mellitus was limited. Following established infection control measures is critical to prevent spread of this highly contagious virus.
Outbreaks of hepatitis B virus (HBV) infection have occurred in residents of long-term care facilities (LTCFs) with diabetes mellitus as a result of inappropriate sharing of equipment and inadequate aseptic technique during fingerstick blood glucose monitoring.1–3 Accumulating evidence suggests that such transmission may be more widespread than previously recognized, particularly in the assisted living environment.4
HBV is highly infectious and easily transmitted after percutaneous exposure. In studies of healthcare professionals who sustained injuries from needles contaminated with blood containing HBV, the estimated risk of developing serological evidence of HBV infection was 23% to 62%, far greater than that from exposure to hepatitis C virus (1.8%) or human immunodeficiency virus (0.3%).5 Similarly, the potential for transmission of HBV during blood glucose monitoring has long been established.6 HBV concentrations in blood can be high, and HBV is known to remain viable on contaminated surfaces for 1 week or longer.7 Unless meticulous attention is paid to preventing inadvertent environmental contamination with blood, fingerstick blood glucose monitoring can place diabetic residents at substantial risk for exposure to HBV and other bloodborne pathogens.
Depending on state- and facility-specific requirements, assisted living facilities (ALFs) can accommodate resident-performed and staff-assisted blood glucose monitoring. Typically, there is less regulation of infection control measures and assurance of trained personnel in ALFs than in facilities licensed as nursing homes.8–10
Delayed recognition of HBV transmission or missed acute HBV infections within a facility presents challenges to identifying the source of infection and prevention of additional cases. Elderly adults have few typical risk factors for infection (e.g., illicit drug use or high-risk sexual behaviors), and healthcare providers are often not familiar with the potential for HBV transmission during routine care for diabetes mellitus.11,12
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Outbreaks of HBV infection occurred in two ALFs, probably spread by nurses from resident to resident during fingerstick blood glucose monitoring. The HBV DNA sequencing results for Facility A supported the hypothesis of transmission within the facility.
Previous HBV outbreaks in patients with diabetes mellitus reported in the literature were primarily associated with sharing of spring-loaded, penlet fingerstick devices, despite long-standing instructions that these are personal care devices that should not be shared.1,3,4,13,14 Nevertheless, autodisabling, single-use lancets were used at both of the facilities reported here; HBV contamination of glucose meters, diabetic care supplies, or the hands of nurses was implicated as the source for both outbreaks. Opportunities for blood contamination of these sources has been identified during investigation of other LTCF HBV outbreaks,15 and a study testing shared glucose monitors in patient care areas at 12 hospitals revealed widespread blood contamination.16 Recommended practices for preventing patient-to-patient transmission of hepatitis viruses from diabetes care procedures in long-term care settings are summarized in Table 2.
Table 2. Recommended Practices for Preventing Patient-to-Patient Transmission of Hepatitis Viruses from Procedures for the Care of Diabetes Mellitus in Long-Term Care Settings
|Diabetes mellitus care procedures and techniques|
| • Prepare medications such as insulin in a centralized medication area; multiple-dose insulin vials or insulin pens should be assigned to individual patients and labeled appropriately.|
| • Never reuse insulin pens, needles, syringes, or lancets.|
| • Restrict use of fingerstick capillary blood sampling devices to individual patients. Select single-use lancets that permanently retract upon puncture.|
| • Dispose of used injection equipment, fingerstick devices, and lancets at the point of use in an approved sharps container.|
| • Environmental surfaces such as glucose meters should be cleaned and disinfected regularly and any time contamination with blood or body fluids occurs or is suspected.|
| • Glucose meters should be assigned to individual patients. If a glucose meter that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected.|
| • Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets.|
|Hand hygiene and gloves|
| • Wear gloves during fingerstick glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids.|
| • Change gloves between patient contacts. Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. Discard gloves in appropriate receptacles.|
| • Perform hand hygiene (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 residents.|
|Medical management, training, and oversight|
| • Review regularly individual patients' 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 mellitus and its complications.|
| • Provide a full hepatitis B vaccination series to all previously unvaccinated staff persons whose activities involve contact with blood or body fluids.|
| • Establish responsibility for oversight of infection control activities. Provide staff members who assume responsibilities involving percutaneous procedures with infection control training. Investigate and report any suspected case that may represent a newly acquired bloodborne infection.|
| • Assess adherence to infection control recommendations for blood glucose monitoring and insulin administration by periodically observing personnel and tracking use of supplies.|
|Adapted from Reference 3 and the Centers for Disease Control and Prevention, Blood Glucose Monitoring and the Risk of Viral Hepatitis. Available at http://www.cdc.gov/hepatitis/Populations/GlucoseMonitoring.htm|
Delays in diagnosis hampered the investigation of both outbreaks. Healthcare providers should consider acute HBV infection for residents of LTCFs with diabetes mellitus with nonspecific gastrointestinal symptoms.11,12 An estimated 50% to 70% of adults with acute hepatitis B infection are asymptomatic; infected individuals may not be diagnosed, and they pose an unrecognized risk to others. The probable chronic hepatitis B case believed to be the index case for the Facility A outbreak was not known to be HBV infected, and eight of the 14 acute cases (57%) identified during the two outbreak investigations were asymptomatic at the time of diagnosis.
The nurses at both affected facilities did not recognize that HBV could be spread from resident to resident during fingerstick blood glucose monitoring. Although the nurses had documentation of bloodborne pathogen and infection control training, that knowledge was not applied in practice or did not fully address infection prevention during diabetes mellitus care. Published guidelines exist for infection control and safe injection practices to prevent patient-to-patient, bloodborne pathogen transmission during diabetes mellitus care procedures.3,17,18 These guidelines include assigning separate glucometers to individual patients, keeping trays or carts with supplies outside of patient rooms, restricting multidose insulin vials to individual patients, wearing gloves during fingerstick glucose monitoring, and changing gloves and performing hand hygiene between patient contacts (Table 2).
Identification of a single LTCF resident with suspected acute HBV infection should trigger a rapid response, involving the local health department, to search for additional cases, evaluate fingerstick blood glucose monitoring practices, and identify other appropriate interventions. In the future, CCDPH will consider obtaining HBV serological testing for all residents of the facility undergoing fingerstick blood glucose monitoring whenever there is a single case of acute HBV infection in this population.
The two hepatitis B outbreaks described were difficult to detect, required considerable resources to respond to, and resulted in significant morbidity. A total of 14 acute HBV infections were identified in ALF residents; six persons were hospitalized. At least three residents did not clear the infection and developed chronic hepatitis B. Strict adherence to aseptic technique by the facility nurses, to prevent contamination of equipment with infected blood during fingerstick glucose monitoring, could have prevented these outbreaks. Medical directors, DONs, and ALF administrators are encouraged to review practices and ensure they do not have conditions in place that would facilitate this type of transmission.
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The authors would like to thank Yury Khudyakov, PhD, Head, Division of Viral Hepatitis Molecular Epidemiology Laboratory, CDC, for oversight of the HBV DNA sequence analysis; Craig Conover, MD, State Epidemiologist, Illinois Department of Public Health, for guidance during this outbreak and review of the manuscript; and Nicola Thompson, PhD, MS, Division of Viral Hepatitis, CDC, for review of the manuscript.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
Author Contributions: Catherine Counard was the lead investigator for the Facility A and Facility B outbreaks and was the lead author. Joseph Perz provided subject matter expertise, interpreted data, and prepared the manuscript. Purisima Linchangco was the investigator of the Facility A and Facility B outbreaks, compiled data from both outbreaks, and took part in manuscript preparation. Demian Christiansen analyzed the data from Facility A and prepared the manuscript. Lilia Ganova-Raeva and Guoliang Xia performed the HBV DNA sequencing analysis and took part in the manuscript preparation. Steven Jones compiled data from the Facility A outbreak and took part in the manuscript preparation. Michael Vernon supervised the Facility A and Facility B investigations, provided subject matter expertise, interpreted data, and took part in manuscript preparation.