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Healthcare-Associated Hepatitis B and C Outbreaks1 Reported to the Centers for Disease Control and Prevention (CDC) in 2008-2013

The tables below summarize healthcare-associated outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection reported in the United States during 2008-2013. 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.

Resources for prevention include updated hepatitis B immunization guidelines, and infection control guidelines and resources.

Note: this page is available in printable form [PDF - 14 pages].

Summary


38 outbreaks of viral hepatitis related to healthcare reported to CDC during 2008-2013; of these, 36 (94%) occurred in non-hospital settings.
Hepatitis B (total 20 outbreaks, 162 outbreak-associated cases, >10,500 persons notified for screening):

  • 15 outbreaks occurred in long-term care facilities, with at least 114 outbreak-associated cases of HBV and approximately 1,400 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)
  • 5 outbreaks occurred in other settings, one each at: a free dental clinic in school gymnasium, an outpatient oncology clinic, a hospital surgery service, and two at pain remediation clinics (one outbreak of HBV and one with both HBV and HCV), with 46 outbreak-associated cases of HBV and > 8,500 persons at-risk persons notified for screening

Hepatitis C (total 18 outbreaks, 228 outbreak-associated cases, >92,550 at-risk persons notified for screening):

  • 9 outbreaks occurred in outpatient facilities (including the above mentioned outbreak of both HBV and HCV), with 87 outbreak-associated cases of HCV and >68,500 persons notified for screening
  • 7 outbreaks occurred in hemodialysis settings, with 68 outbreak-associated cases of HCV and 1,319 persons notified for screening
  • Two outbreaks occurred because of drug diversion by HCV-infected health care providers, with at least 71 outbreak-associated cases of HCV and >19,000 persons notified for screening

Hepatitis B (HBV) Outbreaks by Setting
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)
(most residents with neuropsychiatric disorders)

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
Failure to maintain separation of clean and contaminated podiatry equipment
Improper reprocessing of contaminated podiatry equipment
Failure to perform environmental cleaning and disinfection between podiatry patients

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
Although a clear infection prevention breach was not identified at the time of the investigation, all infections were in residents receiving assisted monitoring of blood glucose by the same home health agency.  The home health agency lacked written policies on infection control relating to blood glucose monitoring.

 

Assisted living facility (6)

2010
NC
87
8

Use of fingerstick devices for >1 resident
Use of blood glucose meter for >1 resident without cleaning and disinfection

 

6 of 8 case patients died from complications of hepatitis

Assisted living facilities (n=10) in the same metropolitan area served by the same home health agency for diabetic care (7)

2010
TX
>235
23

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.

Patients living at home in private residences served by the same home health agency above for diabetic care (7)
≥19
1

Two affiliated assisted living facilities (5, 8)
(most residents with neuropsychiatric disorders)

2010
VA
126
14

Use of fingerstick devices for >1 resident
Use of blood glucose meter for >1 resident without cleaning and disinfection
Failure to use gloves and perform hand hygiene between fingerstick procedures

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 (9)

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) (10)
Blood glucose monitoring at both assisted-living facilities provided by same home health agency

2009
FL
65
9

Cross-contamination of clean supplies with contaminated blood glucose monitoring equipment used by home health agency 
Investigators noted visible traces of blood on some of the blood glucose meters and one reusable fingerstick device.

 

Assisted living facility (3)

2009
VA
64
5

Unsafe practices related to assisted blood glucose monitoring 
A clear infection prevention breach was not identified.  The facility did use reusable fingerstick devices but denied using them for >1 resident.  In an analytic study, having diabetes and undergoing blood glucose monitoring (all 5 acute cases and 4 of 5 newly identified chronic cases) was significantly associated with infection

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 (11)

2008
IL
21
7

Use of blood glucose meter for >1 resident without cleaning and disinfection
Failure to consistently wear gloves and perform hand hygiene between fingerstick procedures

 

Assisted living facility (12)

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 (13)
(most residents with neuropsychiatric disorders)

2008
CA
143
9

Failure to maintain separation of clean and contaminated podiatry equipment

 

(See footnote 5)

 
 
 
 

 

 

Totals

 
 
>1,390
114

 

 

 


Oral Health

Free dental clinic conducted in school gymnasium (14)

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
Pain management clinic
2013
SC
534
9
Procedure and infection control breaches related to injection safety were identified during the investigation, however, there was insufficient evidence to implicate a specific breach as the source of transmission One additional prevalent case was identified which may represent a source.

Outpatient oncology clinic (15)

2009
NJ
4,600
29

Preparation of medications in same area where blood specimens were processed
Use of saline-bags for >1 patient
Use of single-dose vials for >1 patient

 

Totals

 
 
5,134
38

 

 

 


Hospital

Hospital-based surgery service (16)

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 management clinic (17)

2010
CA
2293
HBV:1
HCV:1

Syringe reuse contaminating medication vials used for >1 patient
Use of single-dose vials 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(18)

2012
MI
>300
10

Specific lapses in infection control not identified at the time of the investigation

 

Pain management clinic (19)

2011
NY
466
2

Suspected syringe reuse contaminating medication vials

 

Outpatient clinic (20)

2010
FL
3,929
5

Drug diversion (fentanyl) by an HCV-infected radiology technician

 

Outpatient alternative medicine clinic (21)

2009
FL
163
9

Syringe reuse contaminating medication vials used for >1 patient
Use of single-dose vials for >1 patient

 

Endoscopy clinics (22)

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) (23, 24, 25)

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 (26)

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

 

 

 


Long-term care

Skilled nursing

2013
ND
>500
46

Preliminary epidemiologic analysis suggested podiatry care, phlebotomy, and nail care performed at the skilled nursing facility were associated with HCV infection

 

 


Hospital

Hospital (27)

2012
NH
AZ
GA
KS
MD
MI
NY
PA
>11,000
45

Drug diversion by radiology technologist.

Patients from 16 facilities in 8 states were notified about potential exposure and recommended to undergo testing for HCV infection.

Hospital-based surgery service (28)

2009
CO
>8,000
26

Drug diversion (fentanyl) by an HCV-infected surgical technician

18 cases were linked by viral sequencing to the surgical technician; an additional 8 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
71

 

 

 


Hemodialysis

Outpatient hemodialysis facility

2012
PA
66
18

Multiple lapses in infection control identified, including hand hygiene and glove use, vascular access care, medication preparation, cleaning and disinfection

18 new HCV infections between 2008–2013

Outpatient hemodialysis facility (29)

2012
CA
42
4

Specific lapses in infection control not identified at the time of the investigation

 

Outpatient hemodialysis facility (30)

2011
GA
89
6

Failure to maintain separation between clean and contaminated workspaces 

 

Outpatient hemodialysis facility (31)

2010
TX
171
2

Specific lapses in infection control not identified at the time of the investigation

 

Outpatient hemodialysis facility (32)

2009
MD
250
8

Breaches in medication preparation and administration practices
Breaches in environmental cleaning and disinfection practices

 

Hospital-based outpatient hemodialysis facility (33)

2009
NJ
144
21

Breaches in medication preparation and administration practices
Breaches in environmental cleaning and disinfection practices 

All patients who received dialysis in this facility since 2005 were notified for screening

Outpatient hemodialysis facility (34)

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

 
 
  1419
68

 

 

 

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 may 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. PLoS ONE 2012; 7: e43252. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0043252

 

References:

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. Centers for Disease Control and Prevention. Notes from the Field – Ongoing transmission of HBV among ALF residents despite ongoing public health efforts, Virginia 2012.  Morbid Mortal Weekly Rpt 2013, 62(19);389-389.

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. 

6. Centers for Disease Control and Prevention. Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility — North Carolina, August–October 2010. MMWR 2011; 60: 182.

7. Zheteyeva Y, Tosh P, Patel P, Martinez D, Kilborn C, Awosika-Olumo D, Khuwaja S, Ibrahim S, Ryder A,   Tohme R, Khudyakov Y, Thai H, Drobeniuc J, Heseltine G, Guh A.  Hepatitis B outbreak associated with a home health care agency serving multiple assisted living facilities in Texas, 2008-2010.  American Journal of Infection Control 2014; 42: 77-81.

8. Bender TJ, Wise ME, Utah O, Xing J, Moorman AC, Sharapov UM, Drobeniuc J, Khudyakov Y, Fricchione  M, White-Comstock MB, Thompson N, Patel PR.  Outbreak of Hepatitis B Virus Infections Associated with Assisted Monitoring of Blood Glucose in an Assisted Living Facility — Virginia, 2010. PLoS One. 2012;7(12):e50012.

9. Seña A, Moorman A, Njord L, Williams R, Colborn J, Khudyakov Y, Drobenuic J,  Xia G-L, Wood H, Moore Z.  Acute hepatitis B outbreaks in two skilled nursing facilities and possible sources of transmission—North Carolina, 2009-2010.  Infect Control Hosp Epidemiol 2013;34(7):709-716

10. Forero S, Alvarez J, Doyle T. Hepatitis B outbreak associated with home health care in South Florida. October 2010 Epi Update.

11. 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.

12. 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.

13. 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.

14. Radcliffe R, Bixler D, Moorman A, Hogan V, Greenfield V, Gaviria D,  Patel PR, Schaefer M, Collins A, Khudyakov Y, Drobeniuc J, Cleveland J.  Hepatitis B Virus Transmissions Associated with a Portable Dental Clinic, West Virginia, 2009. J Am Dent Assoc 2013 144: 1110-1118.

15. 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.

16. 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.

17. 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/HepInfo.htm

18. Unpublished data, Michigan Department of Community Health

19. New York City Department of Health and Mental Hygiene, unpublished data, 2011.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. Southern Nevada Health District. Outbreak of hepatitis C at outpatient surgical centers, public health investigation report. December 2009.

26. 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.

27. State of New Hampshire. Hepatitis C Outbreak Investigation, Exeter Hospital, Public Report, June 2013. New Hampshire Department of Health and Human Services. Available on the New Hampshire Department of Health and Human Services website.

28. Unpublished data, Colorado Department of Health. Manuscript in preparation.

29. Unpublished data, California Department of Public Health

30. 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.

31. 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

32. Rao AK, Luckman E, Wise ME, MacCannell T, Blythe D, Lin Y, Xia G, Drobeniuc J, Noble-Wang J, Arudino MJ, Thompson ND, Patel PR, Wilson LE. Outbreak of hepatitis C virus infections at an outpatient hemodialysis facility: the importance of infection control competencies. Nephrology Nursing Journal 2013; 40(2), 101-110, 164.

33. New Jersey Department of Health and Senior Services, unpublished data, 2009.

34. 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:

 
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