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Notes from the Field: Deaths from Acute Hepatitis B Virus Infection Associated with Assisted Blood Glucose Monitoring in an Assisted-Living Facility --- North Carolina, August--October 2010

Sharing of blood glucose monitoring equipment in assisted-living facilities has resulted in at least 16 outbreaks of hepatitis B virus (HBV) infection in the United States since 2004 (1,2). On October 12, 2010, the North Carolina Division of Public Health (NCDPH) and the Wayne County Health Department were notified by a local hospital of four residents of a single assisted-living facility with suspected acute HBV infection. NCDPH requested HBV testing of all persons who had resided in the facility during January 1--October 13, 2010, and defined an outbreak-associated case as either 1) positive hepatitis B surface antigen and core immunoglobulin M (IgM) results or 2) clinical evidence of acute hepatitis (jaundice or serum aminotransferase levels twice the upper limit of normal) with onset ≥6 weeks after admission to the facility. Records were reviewed for potential health-care--associated exposures and HBV-related risk factors. Infection control practices were assessed through observations and interviews with facility staff.

The investigation identified unsafe practices, including sharing of reusable fingerstick lancing devices approved for single patient use only and shared use of blood glucose meters without cleaning and disinfection between patients. Of 87 persons who had resided in the facility during the study period, 47 were excluded from analysis because of HBV immunity (20 persons), chronic infection (one person), or unknown HBV status (26 persons). Of the remaining 40, eight met the case definition. Of these, all were hospitalized, and six died from hepatitis complications. All eight were among the 15 residents whom facility staff had assisted with blood glucose monitoring; none of 25 residents who had not been assisted with blood glucose monitoring were infected.

Despite long-standing and recently expanded infection control recommendations (2,3), HBV transmission continues to occur through sharing of fingerstick lancing devices and other blood glucose monitoring equipment. These practices put residents at risk for severe illness and death. In accordance with NCDPH recommendations, the facility now uses individually assigned blood glucose meters and single-use, autodisabling fingerstick lancing devices. The facility also offered HBV vaccine to all susceptible residents. NCDPH and the state licensing agency issued a notification to all health-care providers and licensed health-care facilities statewide warning of the potential for HBV transmission through unsafe diabetes-care practices. This outbreak underscores the need for increased efforts to promote compliance with infection-control guidelines in assisted-living facilities.

Reported by

Z Moore, MD, J-M Maillard, MD, M Davies, MD, North Carolina Dept of Health and Human Svcs; N Dailey, MD, EIS Officer, CDC.


  1. CDC. 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--3.
  2. CDC. Infection prevention during blood glucose monitoring and insulin administration. Atlanta, GA: US Department of Health and Human Services, CDC; 2010; Available at Accessed February 10, 2011.
  3. Food and Drug Administration. Use of fingerstick devices on more than one person poses risk for transmitting bloodborne pathogens: initial communication: update 11/29/2010. Washington, DC: US Department of Health and Human Services, FDA; 2010; Available at Accessed February 10, 2011.

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