Hepatitis B outbreak affects diabetics in long-term care

At least 17 hepatitis B virus infection outbreaks have occurred since 1996 in diabetes patients in long-term care settings, including assisted living facilities, according to a Centers for Disease Control and Prevention scientist.

CD has linked all the outbreaks, involving up to 26 people in one facility, to contamination of blood-glucose testing equipment, inadequate in hand hygiene among staff who perform glucose testing, or both said at a meeting of CDC’s Advisory Committee on Immunization Practices (ACIP).

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. “Infection control practices and oversight have traditionally been lacking in long-term care settings, and infection control programs have been poorly implemented.”

Such facilities typically have few licensed professionals on staff, and worker turnover is high, hampering training in infection control. With an aging population in need of long-term care services and an epidemic of diabetes, HBV outbreaks won’t go away without new preventive measures.

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.

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.

Although reuse of a lancet was not identified in any of the outbreak investigations, staff sometimes reused the disposable end caps that house lancets, and use meters without cleaning them between patients. Hepatitis B remains stable in the environment for at least 7 days and may be present even in the absence of visible blood.

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 people with diabetes.

In all 19 outbreaks reported due to date, 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 whose blood glucose was being 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). Among 29 individuals who were retested more than 6 months after an initial diagnosis, 50% had developed chronic HBV infection.

While the CDC awaits advice from ACIP regarding hepatitis B 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.