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CDC mulling hep B shots in nursing homes
In light of continuing outbreaks of hepatitis in ambulatory and long-term care, the Centers for Disease Control and Prevention is considering recommending hepatitis B virus vaccination for diabetic residents of nursing homes.
Though such a move still would leave residents vulnerable to hepatitis C virus — for which there is no vaccine — immunizing residents for HBV could help minimize the impact of two converging trends: the graying of America and continuing outbreaks of bloodborne infections in nursing homes and ambulatory care settings.
"It potentially could be a recipe for disaster as more and more people receive their care in long-term settings," says Nicole Thompson, PhD, MS, an epidemiologist in the division of viral hepatitis told Hospital Infection Control & Prevention.
Thompson is the lead author of a recently published CDC report that concluded, "preventing HBV infections among residents of long-term care facilities is of particular importance and urgency, as the number of persons in the United States 65 years of age or older is expected to double to more than 70 million by 2030."1
Outbreak investigations in long-term care settings have repeatedly demonstrated person-to-person transmission of HBV infection, including many deaths, as a consequence of inappropriate blood glucose monitoring practices, the CDC noted. "Predominately in the U.S., we have seen hepatitis B virus transmission as a result of poor practices during blood glucose monitoring," Thompson says. "That type of transmission itself is a red flag for overall general poor infection control practices. Currently, [we are] evaluating the use of HBV vaccine in these elderly populations as an intervention, but we must also recognize that by vaccinating for HBV, we will not prevent the transmission of other bloodborne infections that may be associated with these poor infection control practices. So, perhaps in conjunction with HBV vaccine, we must improve [infection prevention] in these settings."
During blood glucose monitoring, such equipment as fingerstick devices and glucometers, or the hands and gloves of health care personnel, can become contaminated with blood, the CDC warns. Therefore, careful attention to long-standing recommendations against the sharing of fingerstick devices, specific guidance for blood glucose monitoring procedures in long-term care, and related aspects of Standard Precautions (for example, reusable patient care equipment and devices or instruments) is needed. "In addition, ongoing outbreak activity supports consideration for augmenting hepatitis B vaccination recommendations to include diabetic long-term care residents," the CDC noted.
Some epidemiologists think the CDC should go further and recommend universal HBV vaccination — and not just in long-term care. "Personally, I actually think we should have universal HBV vaccination," says Marion Kainer, MD, MPH, FRACP, medical epidemiologist and director of the hospital infections and antimicrobial resistance program at the Tennessee Department of Health in Nashville. "If we did it for everybody, we could just about wipe it out."
Several outbreaks of HBV infection among residents in long-term care facilities have been linked to shared devices and other breaks in infection control practices related to blood glucose monitoring.2 The devices are used to check blood glucose levels as a routine component of diabetes care. Because outbreaks of HBV infections have been associated with glucose monitoring, the CDC has long recommended that fingerstick devices be restricted to individual use.
In one nursing home outbreak, the spring-loaded barrel of a fingerstick device was used for multiple patients. In an assisted living center, nursing staff members routinely administered fingersticks without wearing gloves or performing hand hygiene between patients, and spring-loaded fingerstick devices also were occasionally shared. The causes of some other outbreaks are less clear, particularly one where HBV was transmitted despite the correct use of single-use fingerstick devices and insulin medication vials that were dedicated for individual patient use. However, HBV can persist in the environment and on inadequately disinfected equipment. Moreover, HBV-infected patients may lack clinical symptoms while their viral titers steadily increase, making each individual blood exposure more likely to result in transmission.
To prevent patient-to-patient transmission of infections through cross-contamination, health care providers should avoid carrying supplies from resident to resident and avoid sharing devices, including glucometers, among residents, the CDC recommends. The outbreaks also underscore the need for education, training, adherence to standard precautions, and specific infection control recommendations targeting diabetes care procedures in long-term care settings.
Another major aspect of the problem is that health departments are not contacted in a timely fashion. In an outbreak at a Mississippi nursing home during November and December of 2003, the index case turned out to be a fatal infection. 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, the CDC reported. Although the patient was found to have a positive test for HBV and the finding was noted in the patient's chart, the nursing home 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 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, the CDC reported. 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. The outbreak investigations 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. In such 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 appropriate medical management, the CDC recommends.