Hepatitis B transmission in care homes linked to blood glucose monitoring, Belgium and United States.

In two nursing homes in Flanders, Belgium, four cases of acute hepatitis B infection have recently been detected, linked to the multiple use of blood capillary sampling (‘fingerstick’) devices on diabetic patients. Another outbreak of hepatitis B transmission in an elderly care home in Belgium, also linked to improper use of these devices, occurred in 2002/3 [1]. In addition, three outbreaks of hepatitis B in care homes for elderly residents, linked to poor infection control procedures during blood glucose monitoring have recently been reported in the United States [2]. In the 2002/3 Belgian outbreak, Flemish public health officials conducted a sero-epidemiological study of 94 residents and 47 nursing staff of a nursing home after a fulminant acute hepatitis B virus infection in an elderly patient was notified. Five residents were identified with acute hepatitis B and two of these died. None of the nursing staff tested positive. Patients with diabetes mellitus who were exposed to a shared fingerstick device for blood sampling were 8.7 times more likely to contract the disease. Other identified potential risks were the shared razor blade of the hairdresser and a pedicure. The outbreak in this home ended after infection control measures were implemented and susceptible residents vaccinated. In the first care home of the three reported on in the United States, a patient was identified as having an acute hepatitis B infection and later died. The home did not inform the state health department or conduct an internal investigation. After a second patient died of acute hepatitis B, and a third acute infection was reported, all 158 residents were tested. Including the two patients who had died previously, 15 cases of acute hepatitis B were found and 15 patients were immune. Of 38 patients whose blood glucose was routinely monitored, 14 had an acute hepatitis B infection. A review of infection control procedures at the home revealed that the glucose monitoring apparatus (glucometer) and spring-loaded barrel of the fingerstick device were not cleaned between use, although a new end cap and lancet were used each time. Insulin and other multidose medications were also not labelled with patient names or the dates when the vials were opened. An anonymous staff survey also revealed that some staff members had observed others re-using needles or failing to change their gloves between sampling different patients’ blood. In the second care home, four residents with both diabetes and acute hepatitis B were notified to the state health department. Twenty two of the 25 residents gave permission to be tested, and a further four patients with acute hepatitis B were identified. Six patients were immune and none had chronic infection. The blood glucose levels of all eight infected patients were sampled daily by nursing staff. None of the seven other patients who did their own blood sampling were infected with hepatitis B. Although residents had their own fingerstick devices, nurses reported occasionally using a device from their own kits on consecutive patients. One glucometer was used for all residents. The wearing of gloves by staff members was discouraged and hand hygiene was poor. In the third care home, after a case of HBV infection was discovered, all 192 residents were screened. Eleven had acute HBV, and 16 were immune. None had a chronic HBV infection. Of 45 patients whose blood glucose was monitored, eight had acute HBV. Interviews with staff revealed that only single lancets were used, and insulin vials were not shared among patients. However, one glucometer was used for many people, and gloves were not always changed between sampling blood for glucose testing. Although recommendations concerning standard precautions and the reuse of fingerstick devices have been Published in the US, these appear not to have been adhered to [3,4]. Blood on glucometers, insulin vials and other surfaces could have been transferred to gloves, other surfaces, and patients. Hepatitis B virus is stable at ambient temperatures and it is possible for infected patients to have a high amount of the virus in their blood or bodily fluid without having symptoms. Some of the residents in the third care home often had blood glucose monitored four times a day despite their blood glucose levels being consistently normal. The index cases described in the report were often not identified or investigated in a timely way, and opportunities to interrupt transmission were missed. Incidences of hepatitis B transmission linked to blood glucose monitoring in care homes have been reported since the early 1990s [4,5]. A recent outbreak of hepatitis B in a care home in the United Kingdom is currently being investigated, but the route of transmission is still unknown.