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A Common-Source Outbreak of Fulminant Hepatitis B in a Hospital

Ilana Oren, MD; Ronald C. Hershow, MD; Edna Ben-Porath, PhD; Norberto Krivoy, MD; Noam Goldstein, MD; Shmuel Rishpon, MD; Daniel Shouval, MD; Stephen C. Hadler, MD; Miriam J. Alter, PhD; James E. Maynard, MD; and Gideon Alroy, MD
[+] Article and Author Information

Requests for Reprints: Ilana Oren, MD, Department of Internal Medicine A, Rambam Medical Center, Haifa 31096, Israel.

Current Author Addresses: Drs. Oren, Krivoy, Goldstein, and Alroy:

Department of Internal Medicine A, Rambam Medical Center, Haifa 31096, Israel.

Dr. Ben-Porath: Virology Laboratory, Rambam Medical Center, Haifa 31096, Israel.

Dr. Rishpon: Israel Ministry of Health, Haifa 31095, Israel.

Dr. Shouval: Liver Unit, Hadassah Medical Center, Jerusalem 91120, Israel.

Drs. Hadler and Alter: Hepatitis Branch, Centers for Disease Control, Atlanta, Georgia 30333.

Dr. Hershow: School of Public Health, University of Illinois at Chicago, Chicago, IL 60612.

Dr. Maynard: PATH, 4 Nickerson Street, Seattle, WA 98109-1699.


Ann Intern Med. 1989;110(9):691-698. doi:10.7326/0003-4819-110-9-691
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A nosocomial outbreak of fulminant hepatitis B infection at a medical center in Haifa, Israel, between 7 and 26 June 1986, involved five patients who had been hospitalized previously in the medical ward in late April and early May (first generation). This outbreak had an unusual clinical course, with fulminant hepatic failure associated with acute renal failure from acute glomerulonephritis, leading to death within a few days. The onset dates of hepatitis were tightly clustered temporally and incubation periods were short. Extensive laboratory and epidemiologic evaluation showed that the probable common-source vehicle of transmission was a multiple-dose vial of heparin and normal saline flush solution that may have been contaminated by blood of a known HBsAg carrier, who was positive for anti-HBe, hospitalized at the same time. A sixth patient died in August 1986 (second generation), after his initial admission in June that coincided with the terminal hospitalizations of three first-generation patients. Those patients had marked coagulopathies, and transmission to the sixth patient most probably occurred through environmental contamination by patients or through cross-contamination between patients through staff. The unusually high mortality rate (5 of 6) in this outbreak has not been definitely explained.

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