Miriam E. Tucker is a senior writer with Elsevier Global Medical News.
ATLANTA — At least 17 hepatitis B virus infection outbreaks have occurred since 1996 in people living with diabetes in long-term care settings, including assisted living facilities, according to a Centers for Disease Control and Prevention scientist.
CDC has linked all the outbreaks, involving up to 26 people in one facility, to contamination of blood-glucose testing equipment, inadequate hand hygiene among staff who perform glucose testing, or both, said Nicola D. Thompson, PhD, at a meeting of CDC's Advisory Committee on Immunization Practices (ACIP).
Dr. Thompson, who works in the agency's division of viral hepatitis, presented the information as background for a possible future recommendation of vaccinations against hepatitis B virus (HBV) for all people with diabetes in long-term care.
The continued occurrence of these outbreaks despite existing guidelines for their prevention is a major concern, said Dr. Thompson in an interview (see box).
The first HBV outbreak associated with diabetes care in any health care setting was reported in a hospital in 1990. Another hospital outbreak was reported in 1996, along with one in a nursing home. Between 1999 and 2003, seven HBV outbreaks were reported in nursing home residents with diabetes. Since 2004, nine such outbreaks were reported in assisted living facilities but none in hospitals or nursing homes.
The shift in settings for these outbreaks—from hospitals to nursing homes to assisted living facilities—reflects the increased emphasis on infection control practices in hospitals and, more recently, nursing homes, said Dr. Thompson. In contrast to hospitals and nursing homes, where regulation and oversight occur at the federal level, assisted living facilities are not federally licensed, and oversight goes no higher than the state level, she commented.
In every outbreak, the HBV transmission was traced to blood contamination of a finger-stick device or a glucose meter used for multiple persons, or failure of staff to change or use gloves or perform hand hygiene between procedures. Hepatitis B remains stable in the environment for at least 7 days and may be present even in the absence of visible blood, Dr. Thompson noted.
CDC personnel conducted facility-wide seroprevalence surveys in their investigations of 13 of the outbreaks, covering 1,308 residents. Acute HBV infection was identified in 30.5% of the 338 of those residents with diabetes, but in just 0.9% of the 970 nondiabetics. Rates of past and chronic HBV infection were also higher in the people with diabetes.
In all 19 outbreaks reported to date, including the 2 at hospitals, a total of 153 people were identified with HBV infection. Their median age was 75 years (range 42–92 years). In all, 92% of the acute HBV infections occurred in people with diabetes who were monitoring their blood glucose or having it monitored. The rest were cases reported in roommates of these residents, nonresident family members, and staff.
One-third of the people with acute HBV infections (51) had jaundice, and of those, about a third (19) were hospitalized. Eight patients died from their acute HBV infection. Their median age was 85 years (range 64–92 years).
Among 29 individuals who were retested more than 6 months after an initial diagnosis, 50% had developed chronic HBV infection. This proportion is similar to those seen in other groups considered to be at high risk for chronic HBV. While CDC awaits advice from ACIP regarding HBV vaccinations, the agency is working to improve health care facilities' adherence to current infection-control recommendations and is promoting the development of safer blood-glucose devices, Dr. Thompson told the committee.
“This potentially has some serious implications for assisted living facilities, which is where the majority of these outbreaks occurred,” said Timothy Malloy, MD, CMD, a multi-facility medical director in Omaha, Neb. “I think states should be looking at this and considering regulations to address this in this care setting.”
Dr. Malloy suggested that assisted living facilities implement infection-control procedures similar to those that work in skilled nursing facilities. That includes education for staff coving issues such as hand washing, use of gloves, and proper use of lancets, he said. “With the low ratio of professional staff to caregivers in assisted living, up-to-date and ongoing education and training are essential.”
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