quote from:
Centers for Disease Control and Prevention


CDC MMWR Weekly
March 11, 2005 / 54(09);220-223


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

Regular monitoring of blood glucose levels is an important component of routine diabetes care (1). 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 (2,3). 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 (2--5). The findings underscore the need for education, training, adherence to standard precautions, and specific infection-control recommendations targeting diabetes-care procedures in LTC settings (4--6) (Box 1).

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. [end quote}

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