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Lack of adherence to standard precautions and failure to implement long-standing recommendations against sharing fingerstick devices continue to place long-term care (LTC) residents at risk for acquiring bloodborne infections, the Centers for Disease Control and Prevention reports.

LTC hepatitis outbreaks linked to diabetes testing

Healthcare Infection Prevention

LTC hepatitis outbreaks linked to diabetes testing

Major IC breaches despite existing guidance

Lack of adherence to standard precautions and failure to implement long-standing recommendations against sharing fingerstick devices continue to place long-term care (LTC) residents at risk for acquiring bloodborne infections, the Centers for Disease Control and Prevention reports.1

In a finding that may be only the tip of the proverbial iceberg, the CDC reports some rather disturbing infection control breaches in three hepatitis B outbreaks. The CDC reports three recent outbreaks of HBV infection among residents in long-term care facilities that were attributed to shared devices and other breaks in infection-control practices related to blood glucose monitoring. The devices are used to check blood glucose levels as a routine component of diabetes care. Because outbreaks of HBV infections have long been associated with glucose monitoring, the CDC recommended 15 years ago that fingerstick devices be restricted to individual use.

"There have been recommendations since 1990 not to share glucose-monitoring equipment," says Lyn Finelli, PhD, chief of hepatitis surveillance at the CDC. "We have no idea how widespread this kind of poor infection control practice is. We know we have given technical assistance for these outbreaks in the past year, but many of these investigations may be handled by state or local health departments. We can’t really estimate the prevalence of these practices."

In one nursing home, 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.

"Those are the kind of facilities where people often live on their own and they just need a little bit of care," Finelli says. "They are more of a home-like environment. One could understand they may want to have as little of a clinical environment as possible, but standard precautions still need to be adhered to. If you are performing a clinical procedure, you need to wear gloves."

The causes of a third outbreak were less obvious, with HBV transmitted despite the correct use of single-use fingerstick devices and insulin medication vials that were dedicated for individual patient use. However, as ICPs are well aware, 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.

A small proportion of hepatitis B-infected patients go on to develop chronic infection, but about half of infected adults do not display symptoms. "So you can have no symptoms, not know you’re ill, and then develop chronic infection," Finelli says. Thus, infections may be going undetected in some nursing homes until a critical mass of transmission occurs.

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 LTC settings.

"It is probably a knowledge gap about the guidelines," Finelli says. "There is a deficit in understanding of how just [minor] departures from infection control practice can transmit bloodborne diseases. I think all of the providers out there want to do the right thing. If they knew and understood [these practices] could transmit hepatitis B and C, then they wouldn’t do it."

Another major aspect of the problem is that health departments are not contacted in a timely fashion. "When nursing homes have their first case, they may not be tuned into the fact that this could represent more widespread transmission," Finelli says. "Nursing homes should notify the state health department as soon as they have a single case of hepatitis B."

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. "If you are an elderly person and you have acute infection with hepatitis B, it can kill you," Finelli says. "But hepatitis B is reportable in all 50 states. That patient should have been reported immediately to the state health department."

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 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 appropriate medical management.

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. However, routine hepatitis B vaccination or screening of long-term care residents is not recommended, the CDC concluded.

Reference

  1. Centers for Disease Control and Prevention. 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. MMWR 2005; 54: 220-223.