Nicola D. Thompson, PhD, MS; Joseph F. Perz, DrPH, MA; Anne C. Moorman, BSN, MPH; Scott D. Holmberg, MD, MPH
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Nicola D. Thompson, PhD, MS, Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, MS G-37, Atlanta, GA 30333; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Thompson and Holmberg and Ms. Moorman: Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, MS G-37, Atlanta, GA 30333.
Dr. Perz: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, MS A-31, Atlanta, GA 30333.
Author Contributions: Conception and design: N.D. Thompson, J.F. Perz, S.D. Holmberg.
Analysis and interpretation of the data: N.D. Thompson, J.F. Perz, A.C. Moorman, S.D. Holmberg.
Drafting of the article: N.D. Thompson, J.F. Perz, S.D. Holmberg.
Critical revision of the article for important intellectual content: N.D. Thompson, J.F. Perz, A.C. Moorman, S.D. Holmberg.
Final approval of the article: N.D. Thompson, J.F. Perz.
Obtaining of funding: S.D. Holmberg.
Administrative, technical, or logistic support: J.F. Perz, A.C. Moorman, S.D. Holmberg.
Collection and assembly of data: N.D. Thompson, J.F. Perz, A.C. Moorman, S.D. Holmberg.
Thompson N., Perz J., Moorman A., Holmberg S.; Nonhospital Health Care–Associated Hepatitis B and C Virus Transmission: United States, 1998–2008. Ann Intern Med. 2009;150:33-39. doi: 10.7326/0003-4819-150-1-200901060-00007
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Published: Ann Intern Med. 2009;150(1):33-39.
In the United States, transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) from health care exposures has been considered uncommon. However, a review of outbreak information revealed 33 outbreaks in nonhospital health care settings in the past decade: 12 in outpatient clinics, 6 in hemodialysis centers, and 15 in long-term care facilities, resulting in 448 persons acquiring HBV or HCV infection. In each setting, the putative mechanism of infection was patient-to-patient transmission through failure of health care personnel to adhere to fundamental principles of infection control and aseptic technique (for example, reuse of syringes or lancing devices).
Difficult to detect and investigate, these recognized outbreaks indicate a wider and growing problem as health care is increasingly provided in outpatient settings in which infection control training and oversight may be inadequate. A comprehensive approach involving better viral hepatitis surveillance and case investigation, health care provider education and training, professional oversight, licensing, and public awareness is needed to ensure that patients are always afforded basic levels of protection against viral hepatitis transmission.
Connie R Deline
January 22, 2009
Opening our eyes to Healthcare Associated Hepatitis
The authors of this article focus attention on the transmission of HBV and HCV in nonhospital healthcare settings, where adherence to infection-control guidelines is thought to be more seriously suboptimal as compared with hospital settings. Nosocomial transmission of HBV and HCV has been associated with breaks in sterile technique, contamination of single-use vials and multi-dose vials, and inadequate sterilization of equipment (endoscopy, hemodialysis, glucometers). These transmissions are clearly markers of lapses in infection control which place patients at risk of acquiring one or more bloodborne infections at the time of accessing healthcare. While there is increasing awareness that these are occurring in outpatient and long-term care settings, I am concerned that, perhaps unintentionally, this article may convey that there is less concern about transmissions in the hospital setting. "One-at-a-time" transmissions are often uninvestigated or unreported and as noted by the authors: "financial, legal and personnel resource barriers to investigation can be considerable", which deters delineation of the scope of the problem.
I happen to be a physician who acquired HCV through a medical procedure as a patient. After review of the published literature, I have learned that healthcare-associated HCV is more common than I ever understood. We don't think about it, we don't look for it, so we don't see it. When other physicians learn of my infection, the first (incorrect) assumption is that the transmission was thru an occupational needle-stick. The second assumption is that healthcare associated HCV is a rare occurrence. But is it?
Several studies looking at the contemporary transmission of HCV have revealed that accessing healthcare indeed appears to be a prominent risk factor for infection, and in those over age 40, the largest risk factor. While we have seen success in reducing the transmissions associated with blood products and IVDU, we have largely been unaware of the healthcare associated transmissions that are not related to blood products. The next time you see a patient with HCV with "no known risk factors", consider access to healthcare in any setting as a risk factor (1,2,3).
The primary factor influencing the risk of transmission of bloodborne pathogens in healthcare settings is inadherence to standard infection-control precautions. Whenever these lapses occur, the risk is higher when the prevalence of the infection in the treated population is higher, and when the volume of procedures being done (any cutaneous or IV access) is higher.
HCV is relatively common, 1.6% of the US population [NHANES 1999-2002], excluding incarcerated and homeless populations. The prevalence of HCV is known to be higher in middle-aged patients (~4%). Inpatient populations have been found to have a higher prevalence of HCV than outpatient populations as well. In Baltimore, one study found that at least 15% of surgical patients were HCV positive (4). If the prevalence of HCV is higher in the inpatient setting in locations other than Baltimore, then breaches in adherence to infection control guidelines carry an amplified statistical risk of transmission of bloodborne pathogens.
As an example of risk amplification, look no further than the routine glucose monitoring done with glucometers not only in long-term care settings, but in hospitals. As a result of the high prevalence of obesity and diabetes with the attendant increased perioperative morbidity and mortality, one local hospital has implemented routine glucose monitoring of surgical patients every 6 hours. This is being done with a single glucometer for multiple patients carried from bedside to bedside, with less-than-ideal adherence to standard infection control practices and certainly no decontamination of the glucometers between patients. This use of glucometers does not adhere to infection control guidelines, is being done with increasing frequency, on a population with a higher prevalence of HCV (middle-aged hospitalized patients), clearly setting the stage for a substantially increased risk of bloodborne HAIs for surgical patients. I fear that unless there is a very clear directive from the CDC with respect to glucometer use in hospitals as well as long term care settings, the burden of HBV and HCV is likely to increase further.
Thompson et al have presented data with discussion that is important and welcome. Unfortunately, while there is some increasing awareness of nonhospital transmission of HCV and HBV, physicians and hospitals still perceive that inpatient transmission of bloodborne HBV, HCV to be rare. It is apparent that healthcare associated transmissions are occurring in both hospital and nonhospital settings. The repeated outbreaks have shown us that these transmissions are far from isolated, yet it is likely that the single case transmissions go unrecognized or uninvestigated. To quote Miriam Alter in her editorial in the January 2008 issue of the Journal of Hepatology: "During the past 15 years, there have been more than 600 publications on the topic of nosocomial or iatrogenic hepatitis C virus (HCV) transmission not related to transfused blood, plasma-derived products, or transplantation. Most of them were from developed countries"¦ and virtually all of them had one common theme, unsafe therapeutic injections "¦how many more articles do we need from hospitals, clinics and practices to recognize our failure to adhere to the fundamental principles of aseptic technique (5)?"
1. Hospital admission is a relevant source of hepatitis C virus acquisition in Spain. - MartÃnez-Bauer E et al -J Hepatol - JAN-2008;48(1):20-7.
2. Acute hepatitis C in Israel: a predominantly iatrogenic disease? - Lurie Y - J Gastroenterol Hepatol - FEB-2007; 22(2):158-64.
3. A case-control study of risk factors for hepatitis C infection in patients with unexplained routes of infection. Karmochkine M et al - J Viral Hepat - NOV-2006;13(11):775-82.
4. Human immunodeficiency virus and hepatitis testing and prevalence among surgical patients in an urban university hospital Weiss ES - Am J Surg - JAN-2007; 193(1):55-60.
5. Healthcare should not be a vehicle for transmission of hepatitis C virus. - Alter MJ - J Hepatol - JAN-2008;48(1): 2-4.
INMI Lazzaro Spallanzani
February 3, 2009
HBV trasnsmission in healthcare settings and safety devices
TO THE EDITOR:
We read with great interest the review by Thompson ND and colleagues (1) about the transmission of viral hepatitis in non-hospital healthcare setting (HCS) and we were impressed by the rather high number of HBV outbreaks in USA. However the situation in the European Union does not seem to be much better. Recently, as a part of a HBV outbreak investigation within an haematological unit related to non-disposable lancing device (data not jet published), we made a systematic research of literature about patient-to-patient transmission of HBV in HCS. Between 1992 and 2007, 16 HBV outbreak-reports (11 in non-hospital and 5 in hospital setting) , involving 244 patients (13 of whom died), have been published in Europe. Consistent to Thompson findings, reuse of medical devices and compounds was found to be the leading cause of the transmission, although we found hints of potential involvement of the environment in the spreading of HBV.
In particular we identified 3 large outbreaks (2-4) among heart-transplant recipients, who underwent transvenous endomyocardial biopsy to assess the status of cardiac transplant rejection. In these events the authors excluded the reuse of medical devices and suggested that the transmission might be due to the contamination of unwrapped material and devices by blood droplets produced during the procedure. HBV has a striking resistance on environmental compounds and a low infective viral load and several studies have demonstrated the presence of HBV in the apparently clean environment surrounding an HBsAg-positive patient after invasive procedure such as dialysis (5). These evidences put across that HBV might be able to persist upon environmental surfaces in HCS and eventually to be transmitted to patients. Despite these evidences, the direct involvement of environmental contamination in HBV transmission has never been proved and a more comprehensive approach during HBV outbreak investigations, which should include the environmental sampling (e.g.: devices and surfaces nearby infected patients), would be helpful to better elucidate the actual role played by environment in the HBV transmission.
We strongly agree with Thompson on the emphasis about a more stringent application of aseptic technique, especially regarding non-disposable lancing devices and needle handling and reuse. In our opinion non-disposable lancing devices, as well as multi-vials, should be banned from HCS and replaced with safety lancets; at the same way also the utilization of safety needles should be implemented to avoid the possibility of needle reuse.
1. 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 6;150:33-9.
2. Rosenheim M, Cadranel JF, Stuyver L, Dorent R, Golliot F, Astagneau P, D Martino V, Delcourt A, Gandjbakhch I, Huraux JM, Lunel F. Nosocomial transmission of hepatitis B virus associated with endomyocardial biopsy.Gastroenterol Clin Biol. 2006 Nov;30(11):1274-80
3. Drescher J, Wagner D, Haverich A, Flik J, Stachan-Kunstyr R, Verhagen W Nosocomial hepatitis B virus infections in cardiac transplant recipients transmitted during transvenous endomyocardial biopsy. J Hosp Infect 1994;26:81-92.
4. Osterhaus AD, Vos MC, Balk AH, de Man RA, Mouton JW, Rothbarth PH, Schalm SW, Tomaello AM, Niesters HG, Verbrugh HA. Transmission of hepatitis B virus among heart transplant recipients during endomyocardial biopsy procedures. J Heart Lung Transplant. 1998;17:158-66.
5. Froio N, Nicastri E, Visco Comandini U, Cherubini C, Felicioni R, Solmone M, Di Giulio S, Petrosillo N. Contamination by hepatitis B and C viruses in the dialysis setting. Am J Kidney Dis. 2003; 42:546-50
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