Healthcare-Associated Hepatitis B and C Outbreaks1 Reported to the Centers for Disease Control and Prevention (CDC) in 2008-2012
The tables below summarize healthcare-associated outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection reported in the United States during 2008-2012. Outbreaks previously reported in 1998-2008 can be found in Thompson, et al and Redd, et al. Because of the long incubation period (up to 6 months) and typically asymptomatic course of acute hepatitis B and C infection, it is likely that only a fraction of such outbreaks that occurred have been detected, and reporting of outbreaks detected and investigated by state and local health departments is not required. Therefore, the numbers reported here may greatly underestimate the number of outbreak-associated cases and the number of at-risk persons notified for screening.
Practical guidance on detecting and investigating such outbreaks may be found here.
Note: this page is available in printable form [PDF - 17 pages].
Summary
35 outbreaks of viral hepatitis related to healthcare reported to CDC during 2008-2012; of these, 33 (94%) occurred in non-hospital settings.
Hepatitis B (total 19 outbreaks, 153 outbreak-associated cases, >10,000 persons notified for screening):
- 15 outbreaks occurred in long-term care facilities, with at least 116 outbreak-associated cases of HBV and approximately 1,500 at- risk persons notified for screening
- 87% (13/15) of the outbreaks were associated with infection control breaks during assisted monitoring of blood glucose (AMBG)
- 4 outbreaks occurred in other settings, one each at: a free dental clinic in school gymnasium, an outpatient oncology clinic, a hospital surgery service, and a pain remediation clinic (one outbreak of both HBV and HCV), with 37 outbreak-associated cases of HBV and > 8,000 persons at-risk persons notified for screening
Hepatitis C (total 16 outbreaks, 160 outbreak-associated cases, >90,000 at-risk persons notified for screening):
- 8 outbreaks occurred in outpatient facilities (including the above mentioned outbreak of both HBV and HCV), with 42 outbreak-associated cases of HCV and >68,000 persons notified for screening
- 6 outbreaks occurred in hemodialysis settings, with 50 outbreak-associated cases of HCV and 1,353 persons notified for screening
- Two outbreaks occurred because of drug diversion by HCV-infected health care providers, with at least 67 outbreak-associated cases of HCV and >19,000 persons notified for screening
Resources for prevention include updated hepatitis B immunization guidelines, and infection control guidelines and resources.
Hepatitis B (HBV) Outbreaks by Setting |
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|---|---|---|---|---|---|---|
| Setting | Year | State | Persons Notified for Screening2 | Outbreak-Associated Infections3 | Known or suspected mode of transmission4 | Comments |
Long-term care |
||||||
Assisted living facility (2) |
2012 |
VA |
84 |
2 |
Use of fingerstick devices for >1 resident |
|
Assisted living facility (3) |
2011 |
VA |
103 |
7 |
Use of fingerstick devices for >1 resident |
An additional 4 new chronic infections were detected; of these 3 had viral molecular sequencing and all matched into the cluster with the acute cases indicating likely outbreak-related cases. |
Assisted living facility (4) |
2011 |
CA |
14 |
2 |
Use of blood glucose meter for >1 resident without cleaning and disinfection |
Both infected residents received assisted monitoring of blood glucose as well as podiatry services. |
Assisted living facility (5) |
2010 |
CA |
28 |
3 |
Unsafe practices related to assisted blood glucose monitoring |
|
Assisted living facility (6) |
2010 |
NC |
87 |
8 |
Use of fingerstick devices for >1 resident |
6 of 8 case patients died from complications of hepatitis |
Assisted living facilities (>10) in the same metropolitan area served by the same home health agency for diabetic care (7) Patients living at home in private residences served by the same home health agency above for diabetic care (7) |
2010 |
TX |
>400
≥19
|
23
1
|
Unsafe practices related to assisted blood glucose monitoring Although a clear infection prevention breach was not identified at the time of the investigation, all infections were in residents of assisted living facilities or at home who received assisted monitoring of blood glucose by the same home health agency. |
Cases include residents of the assisted living facilities plus one family member of an infected facility resident who experienced a needlestick injury while assisting with the resident’s blood glucose monitoring. |
Two affiliated assisted living facilities (5, 8) |
2010 |
VA |
126 |
14 |
Use of fingerstick devices for >1 resident |
An additional 4 new chronic infections were detected and had viral molecular sequencing; 3 matched into the clusters with the acute cases indicating likely outbreak-related cases. |
Assisted living facility after transfer of a resident from assisted living facility above (3) |
2010 |
VA |
151 |
5 |
Use of fingerstick devices for >1 resident |
|
Skilled nursing facility (9) |
2010 |
NC |
116 |
6 |
Unclear mode of transmission; specific lapses in infection control not identified at the time of the investigation. |
|
Skilled nursing facility (10) |
2010 |
NC |
109 |
6 |
Specific lapses in infection control not identified at the time of the investigation. However, assisted blood glucose monitoring and insulin injection (received by 4 of 6 infected patients) associated with illness in case-control study. |
|
Assisted living facilities (n=2) (11) |
2009 |
FL |
65 |
9 |
Cross-contamination of clean supplies with contaminated blood glucose monitoring equipment used by home health agency |
|
Assisted living facility (3) |
2009 |
VA |
64 |
5 |
Unsafe practices related to assisted blood glucose monitoring |
An additional 5 new chronic infections were detected; of these 4 had viral molecular sequencing and all matched into the cluster with the acute cases indicating likely outbreak-related cases. 2 of 17 facility staff tested also had acute HBV. Investigators identified that after performing AMBG, personnel manually removed used, exposed lancets from the fingerstick device, placing themselves at risk for exposure via a sharps injury. Neither staff member received HBV vaccination. |
Assisted living facility (12) |
2008 |
IL |
21 |
7 |
Use of blood glucose meter for >1 resident without cleaning and disinfection |
|
Assisted living facility (13) |
2008 |
PA |
25 |
9 |
Use of fingerstick devices for >1 resident Use of blood glucose meter for >1 resident without cleaning and disinfection |
|
Skilled nursing facility (14) |
2008 |
CA |
143 |
9 |
Failure to maintain separation of clean and contaminated podiatry equipment |
|
(See footnote 5) |
|
|
||||
Totals |
>1,555 |
116 |
|
|
||
|
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Oral Health |
||||||
Free dental clinic conducted in school gymnasium (15) |
2009 |
WV |
>1,500 |
5 |
Multiple procedural and infection control breaches were identified during retrospective investigation; however, sparse documentation did not provide evidence to link specific breaches with infection. |
Of the 5 cases, 3 were patients and 2 were non-healthcare worker volunteers |
Totals |
>1,500 |
5 |
|
|
||
|
||||||
Other outpatient Settings |
||||||
Outpatient oncology clinic (16) |
2009 |
NJ |
4,600 |
29 |
Preparation of medications in same area where blood specimens were processed |
|
Totals |
4,600 |
29 |
|
|
||
|
||||||
Hospital |
||||||
Hospital-based surgery service (17) |
2009 |
VA |
329 |
2* |
HBV-infected orthopedic surgeon with high viral load performing exposure-prone procedures on patients |
*An additional 4 resolved HBV infections may also have been associated with this outbreak |
Outbreak of both Hepatitis B and Hepatitis C |
||||||
|---|---|---|---|---|---|---|
| Setting | Year | State | Persons Notified for Screening2 | Outbreak-Associated Infections3 | Known or suspected mode of transmission4 | Comments |
Outpatient |
||||||
Pain remediation clinic (18) |
2010 |
CA |
2293 |
HBV:1 HCV:1 |
Syringe reuse contaminating medication vials used for >1 patient |
|
Hepatitis C (HCV) Outbreaks by Setting |
||||||
|---|---|---|---|---|---|---|
| Setting | Year | State | Persons Notified for Screening2 | Outbreak-Associated Infections3 | Known or suspected mode of transmission4 | Comments |
Outpatient |
||||||
Hematology Oncology Clinic(19) |
2012 |
MI |
>300 |
10 |
Specific lapses in infection control not identified at the time of the investigation |
|
Pain management clinic (20) |
2011 |
NY |
466 |
2 |
Suspected syringe reuse contaminating medication vials |
|
Outpatient clinic (21) |
2010 |
FL |
3,929 |
5 |
Drug diversion (fentanyl) by an HCV-infected radiology technician |
|
Outpatient alternative medicine clinic (22) |
2009 |
FL |
163 |
9 |
Syringe reuse contaminating medication vials used for >1 patient |
|
Endoscopy clinics (23) |
2009 |
NY |
3287 |
2 |
Suspected syringe reuse contaminating medication vials |
2009 investigation of cases occurring in 2006- 2007 |
Ambulatory surgical centers (single-purpose endoscopy clinics) (n=2) (24, 25, 26) |
2008 |
NV |
>60,000 |
9 |
Syringe reuse contaminating single-use medications vials (propofol) that were used for >1 patient |
8 cases were from the first center and one from the second. The health department identified an additional 106 infections that could have been linked to the clinics. |
Outpatient cardiology clinic (27) |
2008 |
NC |
1,200 |
5 |
Syringe reuse contaminating multi-dose vials of saline solution used for >1 patient |
An additional 2 new infections were identified in probable source patients |
Totals |
>69,345 |
42 |
|
|
||
|
||||||
Hospital
| ||||||
Hospital (28) |
2012 |
NH MD KS |
>11,000 |
43 |
Drug diversion by radiology technologist, investigation is ongoing |
Patients from 17 facilities in 8 states (AZ, GA, KS, MD, MI, NH, NY, PA) were notified about potential exposure and recommended to undergo testing for HCV infection. Testing is ongoing. |
Hospital-based surgery service (29) |
2009 |
CO |
>8,000 |
24 |
Drug diversion (fentanyl) by an HCV-infected surgical technician |
18 cases were linked by viral sequencing to the surgical technician; an additional 6 infections were determined to be epidemiologically linked but viral sequencing was not able to be performed. The number screened includes patients from three facilities where the surgical technician had worked. |
Totals |
>19,000 |
67 |
|
|
||
|
||||||
Hemodialysis |
||||||
Outpatient dialysis center (30) |
2012 |
CA |
42 |
4 |
Specific lapses in infection control not identified at the time of the investigation |
|
Outpatient hemodialysis facility (31) |
2011 |
GA |
89 |
6 |
Failure to maintain separation between clean and contaminated workspaces |
|
Outpatient hemodialysis facility (32) |
2010 |
TX |
171 |
2 |
Specific lapses in infection control not identified at the time of the investigation |
|
Outpatient hemodialysis facility (33) |
2009 |
MD |
250 |
8 |
Breaches in medication preparation and administration practices |
|
Hospital-based outpatient hemodialysis facility (34) |
2009 |
NJ |
144 |
21 |
Breaches in medication preparation and administration practices |
All patients who received dialysis in this facility since 2005 were notified for screening |
Outpatient hemodialysis facility (35) |
2008 |
NY |
657 |
9 |
Failure to consistently change gloves and perform hand hygiene between patients. Breaches in environmental cleaning and disinfection practices |
All patients who received dialysis in this facility since 2004 were notified for screening |
Totals |
1353 |
50 |
|
|
||
1 Outbreaks with two or more outbreak-related infections detected are included.
2 The number of persons notified for screening is dependent upon information and resources available at the time of investigation and may underestimate the total number of individuals at risk.
3 Outbreak-associated HBV and HCV infections are defined as those with epidemiologic evidence supporting healthcare related transmission and include patients/residents identified with acute infection, or previously undiagnosed chronic infections with epidemiologic evidence indicating that these were likely outbreak-related incident cases that progressed from acute to chronic. Patients/residents identified as likely (previously infected) sources for transmission are not included. In the outbreak investigation setting case definitions are based on laboratory profile and clinical evidence rather than CDC surveillance case definitions which omit asymptomatic cases. Acute HBV is typically defined as having a positive hepatitis B surface antigen and positive IgM core antibody, or positive surface antigen and negative total core antibody (early infection). Chronic HBV is typically defined as having a positive hepatitis B surface antigen, positive total core antibody and negative IgM core antibody. There are no serologic markers to differentiate between acute and chronic HCV infection; defining an infection as possible healthcare transmission is dependent upon epidemiologic evidence along with a new finding of hepatitis C antibody and/or RNA positivity in a person not previously known positive (whether or not symptoms or alanine aminotransferase [ALT] elevation are present).
4 All modes of transmission are patient-to-patient unless otherwise indicated.
5 One additional healthcare facility outbreak was reported during 2009, in an Illinois psychiatric long term care facility with 8 outbreak-related hepatitis B cases among 180 residents screened, and an additional three cases of chronic HBV infection detected at the time of screening. The likely mode of transmission was sexual contact, though other behavioral risk factors such as illicit drug use could not be ruled out.
Source: Jasuja S, Thompson N, Peters P et al. Investigation of hepatitis B virus and human immunodeficiency virus transmission among severely mentally ill residents at a long term care facility. Submitted.
1. Nosocomial hepatitis B virus infection associated with reusable fingerstick blood sampling devices -- Ohio and New York City, 1996. MMWR 1997; 46:217-221.
2. Unpublished data, Virginia Department of Health
3. Centers for Disease Control and Prevention. Multiple Outbreaks of Hepatitis B Virus Infection Related to Assisted Monitoring of Blood Glucose Among Residents of Assisted Living Facilities -- Virginia, 2009-2011 MMWR 2012; 61: 339-343.
4. Unpublished data, Los Angeles County Department of Public Health, 2011.
5. Bancroft E, Hathaway S. Hepatitis B Outbreak in an Assisted Living Facility. Acute Communicable Diseases Program, Special Studies Report 2010, Los Angeles County Department of Public Health, pages 41-44. http://publichealth.lacounty.gov/acd/reports/SpecialStudiesReport2010.pdf [PDF - 89 pages]
6. Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility — North Carolina, August–October
7. Unpublished data, Texas Department of Health, 2010. (Manuscript in preparation.)
8. Bender T, Wise E, Utah O, Moorman A, Sharapov U, Drobenuic J, Khudyakov Y, Fricchione M, White-Comstock MB, Thompson N, Patel P. Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility — Virginia, 2010. Submitted.
9. Colborn JM, Williams RE, Moorman A, Roberts H, Khudyakov Y, Thompson N, Schaefer M, Sena A, Moore Z. Acute Hepatitis B Virus Infection Outbreak in a Long-Term Care Facility – North Carolina, 2010. 60th EIS Conference, Atlanta, GA, April 11-15, 2011. (Manuscript in preparation.)
10. Unpublished data, North Carolina Division of Public Health, 2010. (Manuscript in preparation.)
11. Forero S, Alvarez J, Doyle T. Hepatitis B outbreak associated with home health care in South Florida. October 2010 Epi Update. Available at: http://www.doh.state.fl.us/Disease_ctrl/epi/Epi_Updates/2010/October2010EpiUpdate.pdf [PDF - 21 pages]
12. Counard C, Perz J, Linchangco P, et al. Acute hepatitis B outbreaks related to fingerstick blood glucose monitoring in two assisted living facilities. J Am Geriatr Soc 2010; 58:306-311.
13. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009;150:33-9.
14. Wise ME, Marquez P, Sharapov U, Hathaway S, et al. Outbreak of acute hepatitis B infections at a psychiatric long term care facility. Am J Infect Control 2012: 40: 16-21.
15. West Virginia Department of Health, unpublished data, 2009. (Manuscript in preparation.)
16. Greeley RD, Semple S, Thompson ND, et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009 Am J Infect Contr 2011; 39:663-70.
17. Enfield KB, Sharapov U, Hall K, et al. Transmission of hepatitis B virus to patients from an orthopedic surgeon. Presented at: 20th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America (SHEA), Atlanta, Georgia, March 20, 2010.
18. Bancroft E, Hathaway S, Itano A. Pain Clinic Hepatitis Investigation Report. Acute Communicable Diseases Program, Special Studies Report 2010, Los Angeles County Department of Public Health, pages 33-36. http://publichealth.lacounty.gov/acd/reports/SpecialStudiesReport2010.pdf [PDF - 89 pages]
19. Unpublished data, Michigan Department of Community Health
20. New York City Department of Health and Mental Hygiene, unpublished data, 2011.
21. Hellinger WC, Bacalis LP, Kay RS, Thompson ND, Xia GL, Lin Y, Khudyakov YE, Perz JF. Health care–associated hepatitis C virus infections attributed to narcotic diversion. Ann Intern Med 2012; 156: 477-82.
22. Sanderson R, Atrubin D, Santiago A, et al. 2010. Hepatitis C outbreak at an outpatient infusion clinic- Hillsborough County, Florida 2009. APIC 2010 Annual Conference and Meeting. New Orleans, July 11-15, 2010.
23. Centers for Disease Control and Prevention. Investigation of Case Reports of Viral Hepatitis Infection Possibly Related to Healthcare Delivery: One Local Health Department’s Approach. MMWR 2012; 61: 333-338.
24. Fischer G, Schaefer M, Labus B, et al. Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007-2008. Clin Infect Dis 2010; 51:267-273.
25. Centers for Disease Control and Prevention. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic — Nevada, 2007. MMWR 2008; 57: 513-517.
26. Southern Nevada Health District. Outbreak of hepatitis C at outpatient surgical centers, public health investigation report. December 2009. Available at: http://www.cchd.org/download/outbreaks/final-hepc-investigation-report.pdf [PDF - 266 pages]
27. Moore ZS, Schaefer MK, Hoffmann KK, Thompson SC, Guo-Liang X, Lin Y, et al. Transmission of hepatitis C virus during myocardial perfusion imaging in an outpatient clinic. Am J Cardiol. 2011;108:126-132.
28. Unpublished data, New Hampshire Department of Health and Human Services, Maryland Department of Health and Mental Hygiene, Kansas Department of Health and Environment
29. Unpublished data, Colorado Department of Health
30. Unpublished data, California Department of Public Health
31. Mbaeyi C. Outbreak of hepatitis C virus infections in an outpatient dialysis facility—Georgia, 2011. 61st Annual Epidemic Intelligence Service (EIS) Conference, Atlanta, April 16–20, 2012.
32. Janneh MD, Tran J, Cantu G, et al. Assessment of Hepatitis Screening and Infection Control in County Outpatient Hemodialysis Facilities. Presented at: 21st Annual Scientific Meeting of the Society for Healthcare Epidemiology of America (SHEA), Dallas, Texas, April 1, 2011. https://shea.confex.com/shea/2011/webprogram/Paper5086.html
33. Rao A, et al. Outbreak of acute hepatitis C virus infections at an outpatient hemodialysis facility. Fifth Decennial International Conference on Healthcare-Associated Infections, Atlanta, March 18-22, 2010.
34. New Jersey Department of Health and Senior Services, unpublished data, 2009.
35. Centers for Disease Control and Prevention. Hepatitis C virus transmission at an outpatient hemodialysis unit — New York, 2001–2008. MMWR 2009; 58:189-194.
Hepatitis B Immunization Guidelines
Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus (2011 update to 2006 guidelines below)
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm
A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States (2006)
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm
Immunization of Health-Care Personnel. Recommendations of the Advisory Committee on Immunization Practices (ACIP)
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm?s_cid=rr6007a1_e
Infection Control Guidelines and Resources
Evidence-based infection prevention guidelines for healthcare settings including those for disinfection and sterilization, environmental cleaning, and hand hygiene available at: http://www.cdc.gov/hicpac/pubs.html
Injection safety resources available at:
http://www.cdc.gov/injectionsafety/providers.html
http://www.oneandonlycampaign.org/
Infection prevention resources for assisted monitoring of blood glucose available at:
http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html
Setting specific resources available at:
Outpatient Oncology: http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/index.html
Hemodialysis: http://www.cdc.gov/dialysis/provider/index.html
Long-term care: http://www.cdc.gov/HAI/settings/ltc_settings.html
Dental: http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/index.htm and http://www.osap.org/?page=ChecklistPortable
