Issue
Number 515
March 14, 2005
CONTENTS OF THIS ISSUE
- CDC reports on transmission of hepatitis B virus among
persons undergoing blood glucose monitoring
- IAC updates six viral hepatitis education pieces
- Florida Immunization Summit set for April 26-27
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ABBREVIATIONS: AAFP, American Academy of Family Physicians; AAP, American
Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices;
CDC, Centers for Disease Control and Prevention; FDA, Food and Drug
Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and
Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine
Information Statement; VPD, vaccine-preventable disease; WHO, World Health
Organization.
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March 14, 2005
CDC REPORTS ON TRANSMISSION OF HEPATITIS B VIRUS AMONG PERSONS UNDERGOING
BLOOD GLUCOSE MONITORING
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.
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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.
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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.
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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.
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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 7, 2005
IAC UPDATES SIX VIRAL HEPATITIS EDUCATION PIECES
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 14, 2005
FLORIDA IMMUNIZATION SUMMIT SET FOR APRIL 26-27
The Florida Immunization Summit will be held April 26-27, in Orlando.
The conference is sponsored by Central Florida AHEC [Area Health
Education Centers], Inc., and Florida Department of Health's Bureau of
Immunization.
For more information, go to:
http://www.ImmunizeFlorida.org/Summit2005 or email
marlo_peck@doh.state.fl.us |
