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Morbidity and Morality Weekly Report

 

"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"

 
 

"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"
Morbidity and Mortalilty Weekly Report Vol. 60; No. 06: P. 182 (02.18.11)


Z. Moore, MD; J.-M. Maillard, MD; M. Davies, MD; N. Dailey, MD

Sharing of blood glucose monitoring equipment at assisted-living facilities has been linked to at least 16 US outbreaks of hepatitis B virus infection since 2004. In the current report, state and CDC authors detail an HBV outbreak at such a facility in North Carolina.

On Oct. 12, 2010, a local hospital notified state and county health officials that four residents of a single assisted-living facility had suspected acute HBV infection. North Carolina Division of Public Health (NCDPH) requested HBV testing of all who were residents of the assisted-living facility Jan. 1-Oct. 13, 2010. Records were reviewed for possible care-associated exposures and HBV risk factors. A review of infection control practices included observations as well as interviews of staff.

Investigators discovered the sharing of reusable fingerstick lancing devices, though they were only approved for single-patient use, as well as the sharing of blood glucose meters without cleaning and disinfecting between patients. Of eight residents who met criteria for outbreak-associated HBV, all had been hospitalized and six had died from hepatitis complications. All were among the 15 facility residents assisted in monitoring blood glucose; no one who had not been assisted with blood glucose monitoring was infected.

"Despite long-standing and recently expanded infection control recommendations, HBV transmission continues to occur through sharing of fingerstick lancing devices and other blood glucose monitoring equipment," the report said. "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, auto disabling finger stick 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," the authors concluded.


 
 
 
     
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