IAC EXPRESS

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IAC EXPRESS

Subject: IAC EXPRESS #515

Date: Mar 14, 2005 4:23 PM

IAC EXPRESS

Immunization news from the Immunization Action Coalition

A web page version of this issue is available at

http://www.immunize.org/genr.d/issue515.htm

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Issue Number 515 March 14, 2005

CONTENTS OF THIS ISSUE

1. CDC reports on transmission of hepatitis B virus among

persons undergoing blood glucose monitoring

2. IAC updates six viral hepatitis education pieces

3. 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.

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

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.

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

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 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@...

===================================================================

We hope you will forward this e-newsletter to others.

Managing Editor: Dale (dale@...)

Editorial Assistant: Janelle Tangonan (janelle@...)

ISSN: 1526-1786

To subscribe or change your IACX email address, as well as to view

past issues, please visit http://www.immunize.org/express

This publication is supported in part by Grant No. U66/CCU524042

from the National Immunization Program, CDC, and Grant No.

U50/CCU523259 from the Division of Viral Hepatitis, CDC. Its

contents are solely the responsibility of IAC and do not necessarily

represent the official views of CDC.

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