The pages that follow contain information critical to protecting the health of your patients and the citizens of Colorado.

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1 Health Alert Network Tri-County Health Department Serving Adams, Arapahoe and Douglas Counties Phone 303/ Fax 303/ Richard L. Vogt, M.D. Executive Director The pages that follow contain information critical to protecting the health of your patients and the citizens of Colorado. Number of pages including cover: 5 Subject: Advisory - Improper Practices During Blood Glucose Monitoring Poses a Risk for Transmitting Blood Borne Viruses Message ID: 6/6/ :15:00 PM Recipients: HAN Community Members. From: TRI-COUNTY HEALTH DEPARTMENT Adams, Arapahoe and Douglas County, Colorado Recipient Instructions: Tri-County Health Department is forwarding you the attached HAN. You may have already received this broadcast if you are on the CDPHE distribution list, however, we wanted to ensure you did not miss this important information. No response is required. =========================================================================== You have received this message based upon the information contained within our Health Alert Network Notification System. If you have a different or additional or fax address that you would like us to use, or if you want to be removed from the list, call

2 HEALTH ALERT NETWORK BROADCAST MESSAGE ID: :30 FROM: CO-CDPHE SUBJECT: HAN Advisory Improper Practices during Blood Glucose Monitoring Poses a Risk for Transmitting Blood Borne Viruses RECIPIENTS: Local Public Health Agencies/IPs RECIPIENT INSTRUCTIONS: Local Health Departments please forward to healthcare providers This message can also be found on HEALTH ADVISORY Improper Practices during Blood Glucose Monitoring Poses a Risk for Transmitting Blood Borne Viruses June 5, 2013 KEY POINTS: CDPHE recommends that patients who had their blood glucose levels checked by Colorado Colorado Comprehensive Care, Inc., (7895 Morrison Rd, Lakewood, CO 80227, Jefferson county), a home health agency, from December 1, 2010 through March 1, 2013 receive testing for HIV, hepatitis B, and hepatitis C. Consistent with CDC guidance, CDPHE recommends the following measures to protect patients from the transmission of blood borne pathogens, including hepatitis B, hepatitis C, and HIV: o Finger stick devices should never be used for more than one person, even if lancets are changed and the device is cleaned and disinfected. o Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. o Insulin pens and other medication cartridges and syringes are for single-patient-use only and should never be used for more than one person. Unsafe practices during blood glucose monitoring and insulin administration have led to multiple outbreaks of hepatitis B and put patients at risk for exposure to other blood borne viruses, including HIV, and hepatitis C. Improper sharing of finger stick devices to check blood glucose levels has been linked to transmission of hepatitis B. Health care providers who supervise other health care staff that perform these procedures should be aware of these recommendations and assure that assisted blood glucose monitoring is performed correctly and safely. For more information about best practices during blood glucose monitoring, visit: Page 1 of 4

3 BACKGROUND INFORMATION: During a recertification survey in February 2013, CDPHE discovered that a nurse employed by a home health agency (Colorado Comprehensive Care, Inc., 7895 Morrison Rd, Lakewood, CO 80227, Jefferson county) had been reusing a finger stick device to check blood glucose levels on multiple patients for approximately 6 months. The nurse did not correctly advance lancets or change the lancet cartridge between patients, effectively resulting in lancet reuse. Further investigation by CDPHE disease control staff, consisting of observations and interviews of home health agency staff, identified additional unsafe practices during assisted monitoring of blood glucose, including the reuse of finger stick devices on multiple patients after changing the lancet and attempting cleaning/disinfection between patients, and the use of blood glucose meters on multiple patients without cleaning and disinfecting between patients. A common misperception among these staff members was that finger stick devices can be used for multiple patients if the lancet is changed and the device is cleaned and disinfected between each patient use. Improper practices during assisted monitoring of blood glucose and insulin administration that have led to multiple outbreaks of hepatitis B virus and have put persons at risk for acquiring other blood borne pathogens, such as HIV and hepatitis C virus, include: Using finger stick devices for more than one person, even if the lancet is changed and the device is cleaned/disinfected Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses Using insulin pens for more than one person Failing to change gloves and perform hand hygiene between finger stick procedures The risk of infection is present in any setting where blood glucose monitoring equipment is shared, or those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control. Monitoring of blood glucose levels is routinely performed on persons with diabetes in order to guide therapy. Blood glucose monitoring and insulin administration can be accomplished in two ways: self-monitoring of blood glucose and insulin administration, where the individual performs the testing and insulin administration themselves, and assisted monitoring of blood glucose and insulin administration, where another person assists with or performs testing and insulin administration for the individual. Assisted monitoring of blood glucose and insulin administration can occur in hospitals, clinics, long-term care settings (nursing homes), assisted living facilities, senior centers, health fairs, correctional facilities, schools or camps, and other health care and non-health care settings. RECOMMENDATIONS / GUIDANCE: Consistent with CDC guidance, CDPHE recommends the following measures to protect patients from the transmission of blood borne pathogens, including hepatitis B, hepatitis C, and HIV: Finger stick devices should never be used for more than one person. o Even if lancets are changed and cleaning and disinfection of the device is attempted, microscopic blood contamination of the device that can remain and cannot be seen can result in transmission of blood borne pathogens. o In settings where assisted monitoring of blood glucose is performed, single-use, auto-disabling finger stick devices should be used. o If reusable finger stick devices are used, it should only be by individual persons using these devices for self-monitoring of blood glucose. Page 2 of 4

4 Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. o If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Insulin pens and other injection equipment (e.g., needles and syringes) are only approved for single-patient-use only and should never be used for more than one person. Wear gloves during blood glucose monitoring. o Always wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. o Change gloves between patient contacts. Change gloves that have touched potentially blood-contaminated objects or finger stick wounds before touching clean surfaces. Discard gloves in appropriate receptacles. o Perform hand hygiene before putting on gloves for patient contact, and immediately after removal of gloves and before touching other medical supplies intended for use on other persons. The above recommendations should be followed by anyone who performs or assists with blood glucose monitoring and/or insulin administration. These recommendations apply not only to licensed health care facilities but also to any setting where finger stick procedures are performed and/or insulin is administered. Health care providers who supervise other health care staff that perform these procedures should be aware of these infection control recommendations and assure that assisted blood glucose monitoring is performed correctly and safely. Protection from blood borne viruses (hepatitis B, hepatitis C, and HIV) and other infections is a basic requirement and expectation anywhere health care is provided. CDPHE recommends that patients who had their blood glucose levels checked by Colorado Comprehensive Care, Inc., (7895 Morrison Rd, Lakewood, CO 80227, Jefferson county) staff from December 1, 2010 through March 1, 2013 receive testing for HIV, hepatitis B, and hepatitis C. Patients are advised to contact their health care provider for testing. Health care providers that care for patients who meet this criteria should test patients upon notification and 6 months after the last exposure (last time blood glucose levels were checked by Colorado Comprehensive Care, Inc., staff). If 6 months have passed since the last exposure, testing only needs to be performed once. HIV antibody testing should be performed upon notification, and again 6 months after the last exposure. If positive, reflex confirmatory testing with Western blot or other approved confirmatory methods should be performed. Hepatitis B surface antigen, hepatitis B surface antibody, and total hepatitis B core antibody testing should be performed upon notification, and again 6 months after the last exposure. If the total hepatitis B core antibody is positive, then reflex core antibody IgM should be performed. Hepatitis C antibody testing upon notification, and again 6 months after the last exposure. If positive, HCV RNA (quantitative or qualitative) should be performed. (Reflex testing often is available for HCV RNA.) Alanine aminotransferase (ALT) test upon notification. ALT does not need to be repeated at 6 months. FOR MORE INFORMATION: For additional information on preventing blood borne pathogen transmission during blood glucose monitoring and insulin administration, including storing and transporting supplies and medications, hand hygiene, and training and oversight, please visit: For injection safety resources and blood borne pathogen training activities, please visit the One and Only Campaign: Page 3 of 4

5 For questions regarding these recommendations, please contact Sarah Janelle at or Wendy Bamberg at Disease control staff can be reached at Page 4 of 4