Preventing Transmission of Bloodborne Pathogens in Healthcare Settings Joshua K. Schaffzin, MD, PhD Healthcare Epidemiology and Infection Control Program Bureau of Healthcare Associated Infections Outline The Problem and its Challenges The Usual Suspects Recent NYSDOH Investigation The Proposed Remedies Bloodborne Pathogens An agent able to cause disease in a human when transmitted through blood or body fluids Viral agents Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human Immunodeficiency Virus (HIV)
HBV and HCV Transmission in Health Care Settings Patient to patient Healthcare worker to patient Patient to healthcare worker Adapted from Clinical Infectious Diseases 2004; 38:1592 8 Growing Concern Increasing number of outbreak reports State, local, national level Across the healthcare spectrum Acute care Long term care Ambulatory/outpatient Home care Non-Hospital Outbreaks United States, 1998-2008 Review of outbreaks reported to CDC Increasing healthcare delivery in nonhospital settings Increasing long term care occupancy Lack of standardized infection control practices and oversight in these settings Thompson N, et al. Annal Int Med (2009) 150:33-39.
New York State, 2005-2008 HBV and HCV in dialysis centers HBV in assisted living HCV in plastic surgery clinic HBV and HCV in outpatient endoscopy HCV in private pain clinic Challenges - Detection Disease pathophysiology Long incubation periods Acute infection often asymptomatic Surveillance limitations Inconsistent statewide Not all facilities regulated Care and exposure settings unrelated Challenges - Investigation Multiple exposures Healthcare exposures Community-based exposures Viruses rarely cooperate Dormancy Clearance Mutation
Challenges - Notification Cohort identification Who had at-risk exposure(s) Can we ever be sure others are not at risk? Messaging Potentially life-threatening diagnosis Routine screening recommendations Practice Sites NYSDOH-Regulated Facilities 241 Acute care hospitals 770 Long-term care facilities Approximately 514 Diagnostic and Treatment Centers ~88 ambulatory surgery centers ~233 ESRD facilities Unknown number of office-based surgery sites National estimate is 40,000 sites
Possible Modes of Transmission Through a contaminated intermediate object or person Hands of healthcare personnel Patient care devices (e.g., glucometers) Inadequately reprocessed instruments (e.g., endoscopes) Medications and injection equipment Source: www.southernnevadahealthdistrict.org Investigation Summary April 2007 Three acute hepatitis B infections identified in residents of same Orange County assisted living facility On-site investigation Spring-loaded lancet holders used for routine blood glucose monitoring of residents Unlikely to be properly cleaned and disinfected Serosurvey Ten patients with evidence of current or resolved HBV infection Five matched by genetic sequencing
FSBGM Finger-stick Blood Glucose Monitoring Routine for most diabetics and other healthcare situations Equipment Glucometer Testing strips Lancet Lancet holder Video: How to Use a Glucometer http://www.ehow.com/video_4997540_useglucometer.html FSBGM CDC Recommendations 2005 http://www.cdc.gov/hepatitis/populations/glucosemo nitoring.htm Lancets and holders Fingerstick devices for individual patients Consider single-use equipment Glucometers Assign to individual patients If must be used for additional patients, clean and disinfect prior to reuse
NYS Regulations Assisted living = Adult Homes Non-Article 28 facilities Enriched housing social model No infection control oversight No expectation of medical care Equivalency Licensed professionals may conduct procedures residents would normally do themselves On-Site Assessment FSBGM Frequent sharing of lancet holders between residents Improper gloving procedure No cleaning or sanitizing of glucometers No records maintained Day program and adjacent nursing home No concerns noted Serological Testing Tested for hepatitis B virus All diabetic patients All roommates/contacts of diabetic patients All direct care staff Group Total Tested HBV + Percent Diabetic resident, FSBGM 12 12 8 67 Diabetic resident, no FSBGM 20 20 2 10 HBV case roommate HBV case sex partner 16 4 12 2 1 0 8.3 0 Direct care staff 40 31 1 3.2 Total 92 77 12 16
Chart review 32 of 36 diabetic residents Facility record Evidence of FSBGM, other exposures All 10 HBV positive patients Primary medical record Lifetime exposures, testing history Admissions During Exposure Period Pt Onset Aug 06 Sep 06 Oct 06 Nov 06 Dec 06 Jan 07 Feb 07 Mar 07 1 2/27/07 2 3/4/07 3 3/7/07 4 none 5 none 6 none 7 none 8 none 9 none 10 none ALF X SNF X Hospital A Onset date Incubation period Chart review 32 of 36 diabetic residents Evidence of FSBGM, other exposures HCF admissions Statistically significant exposures FSBGM Insulin injection
Risk factor Analysis Risk Factor # Ill # Exposed RR p-value Attended Day Health B12 Injection Phlebotomy FSBGM Influenza Vaccination Insulin Injection Wound/Skin Care Podiatry Hospitalization 4 2 9 8 5 7 1 4 6 6 8 25 12 22 9 6 17 12 2.9 0.8 2.5 6.7 0.5 6.0 0.5 0.6 2.5 0.06 0.5 0.3 0.002 0.1 0.001 0.4 0.3 0.1 Viral Sequencing Results All 5 patients matched One staff member unrelated Conclusions Transmission of HBV occurred Patient-to-patient Likely related to improper FSBGM practices Notification of patients necessary Anyone who may have had FSBGM
Recommendations Review healthcare in facility Who performs what Establish and enforce policies Follow CDC recommendations Diabetes care Injection safety Hand hygiene Next Steps Adult Homes Work to establish infection control expectations Ongoing infection control promotion Multidose vials Injection safety Infection Control training HBV and HCV Transmission in Health Care Settings Patient to patient Healthcare worker to patient Patient to healthcare worker Adapted from Clinical Infectious Diseases 2004; 38:1592 8
Standard Precautions Infection prevention and control strategies Combine major features of Universal Precautions and Body Substance Isolation Infectious agents may be found in: Blood Body fluids Secretions Excretions except sweat Nonintact skin Mucous membranes Prevention of Patient-to-HCW Transmission Primary prevention Vaccination (HBV) Standard Precautions Assume all patients infected Appropriate personal protective equipment Ask for assistance if patient movement likely to occur Prevention of Patient-to-HCW Transmission Injection safety Immediately discard needle/syringe units in sharps container Locate containers at point of use Do not recap needles Use devices with passive safety features whenever possible
Prevention of HCW-to-Patient Transmission Standard Precautions Do not perform invasive procedures with open sores or weeping lesions on arms or hands Exposure response Stop using sharp instrument if injury occurs Screen and prophylax patient and HCW per published guidelines Prevention of HCW-to-Patient Transmission Prevent abuse Monitor supplies Store medications in locked cabinet Monitor vials in preparation areas Do not leave open vials unattended Prevention of Patient-to-Patient Transmission Standard Precautions Assume all patients infected Standard Precautions for all patient care Hand hygiene Use of appropriate PPE for the task Remove PPE and perform hand hygiene when done
Prevention of Patient-to-Patient Transmission Environmental precautions Appropriate and effective cleaning, disinfection, sterilization of all reusable equipment Prompt and appropriate disposal of all disposable and single-use equipment Strict adherence to safe injection practices! Injection Safety One and Only Campaign Safe Injection Practices Coalition Safe Diabetes Care Procedures Assign to individual patients All meds and equipment when possible Clean and disinfect glucometer Centralized prep Do not carry supplies in pockets Point of use disposal Do not keep unused supplies
Administrative Controls Tailor measures to individual practice setting Designate responsibility clearly Oversight and monitoring Review staff practices, procedures, and responsibilities periodically Reporting and investigating breaches Points of Intervention Infection Control Training Required of certain professionals Update periodically Tailor for different medical specialties Incorporate into recertification/cme Develop broadly accessible training Offer multiple modalities Points of Intervention Accreditation Component of JCAHO survey Required for OBS Engineering Restrict multidose vial manufacture Promote passive safety features Direct communication Commissioner s letter, January 2008 Diabetes care advisory, February 2009
Summary Greater attention being paid to infection control All practitioners must strictly adhere to proper infection control practices Basic practices can prevent transmission NYSDOH continues to work to enhance infection control statewide Partnering with Federal, State, Local, professional partners Acknowledgments NYSDOH Gerry Johnson Ernie Clement Elena Rocchio Rich Gallo Karen Southwick Frank Konings Barbara Wallace Rachel Stricof CDC Joe Perz Priti Patel Nicola Thompson Contacts HEIC Program Central office: 518.474.1142 Josh Schaffzin (Director) Ernie Clement Monica Quinn Sarah Kogut Regional Offices (Regional Epidemiology) Western (Buffalo) 716.847.4503 Central NY (Syracuse) 315.477.8166 Capital District (Troy) 518.408.5396 MARO (New Rochelle) 914.654.7149
References Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004; 38:1592 8 Siegel JD et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007 35:S65-164. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html Thompson N, Perz J, Moorman A, Holmberg S. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Annal Int Med (2009) 150:33-39. Patel AS, White-Comstock MB, Woolard CD, Perz JF. Infection control practices in assisted living facilities: a response to hepatitis B virus infection outbreaks. Infect Control Hosp Epidemiol. 2009 Mar;30(3):209-14. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term-care facilities--mississippi, North Carolina, and Los Angeles County, California, 2003-2004. MMWR 2005 Mar 11;54(9):220-3. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm Resources CDC http://www.cdc.gov/ncidod/dhqp/injectionsafety.html http://www.cdc.gov/ncidod/dhqp/index.html Safe Injection Practices Coalition www.oneandonlycampaign.org NYSDOH http://www.health.state.ny.us/professionals/diseases/ reporting/communicable/infection/ Questions??
Each of the following is a significant bloodborne pathogen in healthcare EXCEPT: A. HIV B. Hepatitis B Virus C. Hepatitis C Virus D. MRSA For patients not known to be infected with bloodborne pathogens, transmission based precautions are less important. A.True B. False Identification of healthcare-related transmission of bloodborne pathogens is A. Easy because the NYSDOH has unlimited resources to dedicate to this activity B. Difficult because reliable tests do not exist to confirm infection and transmission C. Difficult because there is no precedent for such an event D. Easy because patients know immediately they are infected E. Difficult because of difficulty diagnosing infection and verifying the exposure that lead to transmission
Patients should be notified of any suspected transmission of bloodborne pathogen in a healthcare setting. Providers who are found to transmit bloodborne pathogens should lose their license to practice. Multidose vials should be banned in order to improve patient safety