Hepatitis B and C Overview, Outbreaks, and Recommendations Elizabeth Lawlor, MS Healthy Kansans living in safe and sustainable environments. Viral Hepatitis Language Acute infection is when the infection is newly acquired Chronic infection lasts 6 months or more and is usually life-long unless treated Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Types of Viral Hepatitis Resolved or cleared infection is the body getting rid of the hepatitis infection usually in the acute stage 1
Types of Viral Hepatitis Types of Viral Hepatitis Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Route of Transmission: Fecal Oral Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Routes of Transmission: Bloodborne Sexually (rare for hepatitis C) Perinatally (primarily hepatitis B) Types of Viral Hepatitis Types of Viral Hepatitis Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Vaccine preventable Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Coinfection with hepatitis B only 2
Types of Viral Hepatitis Hepatitis Symptoms Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Can have chronic infections All cause similar symptoms Fever Malaise Anorexia Nausea, vomiting, diarrhea, abdominal pain Rash, itchy and dry Joint pain Jaundice Dark urine, scleral icterus Hepatitis B Virus Hepatitis B - Prevalence 3
Hepatitis B - Transmission Hepatitis B - Transmission Sexual Parenteral Perinatal Low/Not High Moderate Detectable blood serum wound exudates semen vaginal fluid saliva urine feces sweat tears breast milk Hepatitis B Outcome of Infection Hepatitis B Outcome of Infection Infection 100 100 Resolved Immune Asymptomatic Asymptomatic Chronic infection Cirrhosis Liver cancer Resolved Immune Symptomatic acute hepatitis B Asymptomatic Chronic infection Cirrhosis Liver cancer Chronic Infection (%) 80 60 40 20 0 Birth Symptomatic Infection Chronic Infection 80 60 40 20 0 4
HBsAg Hepatitis B Virus Lab Tests HBsAg: Hepatitis B Surface Antigen Marker of infectivity Present in both acute and chronic cases Anti-HBs: Antibody to hepatitis B surface antigen Indicates an immune response to hepatitis B or vaccination HBcAg HBeAg Lab Tests Anti-HBc total: Antibody to hepatitis B core antigen Marker of acute, chronic or resolved HBV infection Anti-HBc IgM: IgM antibody subclass of anti-hbc Indicates recent infection with HBV ( 6 mo) Presence indicates acute infection Lab Tests HBeAg: Hepatitis B e antigen Indicates HIGH level of HBV replication Anti-HBe: Antibody to hepatitis B e antigen May be present in infected or immune persons 5
Lab Tests HBV-DNA: Marker of viral replication Typical lab results: number of copies PCR Titer Acute Hepatitis B Infection Serological Course HBsAg HBeAg Symptoms anti HBe IgM anti HBc Total anti HBc anti HBs 0 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure Chronic Hepatitis B Infection Serological Course Acute (6 months) HBeAg IgM anti HBc 0 4 8 12 16 20 24 28 32 36 52 Chronic (Years) HBsAg Weeks after Exposure anti HBe Total anti HBc TRANSMISSION OF HBV THROUGH ASSISTED BLOOD GLUCOSE MONITORING DEVICES 6
Outbreaks Since 2004, at least 16 outbreaks of HBV associated with assisted monitoring of blood glucose (AMBG) Many more likely go unrecognized Frequently occurs in long-term care facilities (but they can occur anywhere!!) Results from improper use of single-use blood glucose monitoring devices Risk of transmission with improper use of insulin pens and fingerstick devices http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6006a5.htm NC Outbreak A local hospital notified the department of health of four patients with suspected acute HBV infection All were residents of the same assisted-living facility 8 residents were diagnosed with acute hepatitis B and 6 of them died from the illness All 8 were among the 15 patients who had assisted blood glucose monitoring performed NC Outbreak Unsafe practices identified: Sharing reusable fingerstick lancing devices (single patient only) Shared blood glucose meters without cleaning and disinfection between patients Remediation Individually assigned blood glucose meters Signal-use, autodisabling fingerstick lancing devices 7
Unsafe Practices Using fingerstick devices for more than one person Using a blood glucose monitor 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 fingerstick procedures Best Practices Fingerstick devices CDC recommends never using reusable fingerstick devices for more than one person Single-use, auto-disabling fingerstick devices should be used Blood glucose meters Whenever possible, they should not be shared If they are shared, the device should be approved for multipatient use, and cleaned and disinfected after every use, per manufacturer s instructions Best Practices Insulin pens Should be assigned to individual persons and labeled appropriately They should never be used for more than one person Insulin Vials Multi-dose vials should be dedicated to a single person, when possible If it must be used for more than one person: Store and prepare it in a dedicated medication preparation area (outside the patient care environment) Vials should always be entered with a new needle and new syringe Training and Oversight Review regularly individual schedules for persons requiring assistance with blood glucose monitoring and/or insulin administration Vaccinate all previously unvaccinated staff for hepatitis B whose activities involve contact with blood or body fluids 8
Training and Oversight Hepatitis C Virus Periodically observe staff who perform or assist with insulin administration and blood glucose monitoring and tracking use of supplies Report to public health authorities (1-877-427-7317) any suspected instances of a newly acquired bloodborne infection, such as hepatitis B, in a patient, facility resident, or staff member Additional information: http://www.cdc.gov/injectionsafety/blood-glucosemonitoring.html Hepatitis C - Prevalence Hepatitis C - Basics In 2003, ~30,000 new infections in US ~4 million in US have been infected Incubation period average 6-7 weeks Often no symptoms If resolved, no protective antibodies 9
Hepatitis C -Transmission Hepatitis C Clinical Course Primarily transmitted by direct blood-to-blood contact Most common transmission through sharing of drug paraphernalia Also blood transfusions & products before 1992 Needle stick/healthcare exposure Other blood risks low/unknown risk: tattooing/piercing, intranasal cocaine use, shared personal items 15% - 45% Resolve (15) 80% Stable (68) 75% Stable (13) 100 People 55%-85% Chronic (85) 20% Cirrhosis (17) 25% Mortality (4) Time Leading Indication for Liver Transplant Acute Hepatitis C Infection Serological Course Chronic Hepatitis C Infection Serological Course Titer Symptoms +/ HCV RNA Anti HCV Titer Symptoms +/ HCV RNA Anti HCV ALT ALT Normal 0 1 2 3 4 5 6 1 2 3 4 Months Years Time after Exposure Normal 0 1 2 3 4 5 6 1 2 3 4 Months Years Time after Exposure 10
Hepatitis C Testing NV Hepatitis C Outbreak Through routine surveillance 3 acute hepatitis C cases were identified All had procedures at the same endoscopy center on two days in July and September 2007 Inspection was performed Unsafe injection practices Reusing syringes to access vials and then vials were reused for subsequent patients NV Hepatitis C Outbreak Approximately 63,000 patients were potentially exposed ~ 57,000 tests for HCV ~ 54,000 tests for HBV ~ 54,000 tests for HIV 9 linked cases of hepatitis C 106 possibly linked cases Largest reported outbreak of health careassociated hepatitis C infections in the US 11
OK Dental Outbreak Investigation initiated when a routine blood donor tested positive for hepatitis C Had dental surgery during the probable exposure window Site investigations revealed numerous infection prevention breaches: Administration of IV sedative medications by uncertified dental assistants Improper dating/storage of multi-dose vials of controlled drugs Lack of autoclave monitoring and maintenance Rusty instruments OK Dental Outbreak As of 06/27/2013 4,087 persons tested 77 patients positive for hepatitis C 5 patients positive for hepatitis B 4 patients positive for HIV Unknown how many are attributable to the clinic There has been genomic testing which indicates that several of the hepatitis C cases are from a single source RECOMMENDATIONS FOR HEPATITIS POSITIVE HEALTHCARE PROVIDERS 12
Background 1991 recommendations No restriction for providers who do not perform invasive (exposure-prone) procedures Exposure-prone procedures should be defined at each institution Providers who perform exposure prone procedures should know their HBsAg status, and if applicable HBeAg status HBsAg and HBeAg positive providers should seek counsel from and perform procedures under the guidance of an expert review panel http://www.cdc.gov/mmwr/pdf/rr/rr6103.pdf http://www.shea online.org/view/articleid/46/guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus Hepatitis C V.aspx Exposure-Prone Procedures Procedures known or likely to pose an increased risk of percutaneous injury to a health-care provider Major abdominal, cardiothoracic, and orthopedic surgery, Repair of major traumatic injuries Abdominal and vaginal hysterectomy Caesarean section Vaginal deliveries Major oral or maxillofacial surgery (e.g., fracture reductions) Techniques Causing Provider Percutaneous Injury Digital palpation of a needle tip in a body cavity Health care provider s fingers and a needle or other sharp instrument or object (e.g., bone spicule) in a poorly visualized or highly confined anatomic site 13
Hepatitis B Vaccination and Screening All healthcare workers should receive hepatitis B vaccination and post-vaccination testing (anti-hbs > 10 miu/ml) Revaccinate providers who do not obtain a protective level of antibodies If provider doesn t achieve an adequate response, they should be tested for HBsAg Hepatitis B Vaccination and Screening Prevaccination testing (HBsAg and anti-hbs) needed for: At risk individuals (those born to mothers in or from endemic countries and sexually active men who have sex with men) Providers performing exposure-prone procedures Expert Panel Oversight Not necessary for: Providers performing non-exposure-prone activities (non- or minimally invasive procedures) Recommended: Surgeons (including oral surgeons, obstetrician/gynecologists, surgical residents) and other individuals performing exposure-prone activities Recommended Panel Oversight Procedures should be guided by review regarding the procedures that they can perform and prospective oversight of their practice Positive providers can conduct exposure-prone procedures if a low or undetectable viral load is documented with testing at least every 6 months 14
Recommended Panel Oversight Recommended HBV and HCV viral load threshold SHEA: 1,000 GE/ml CDC: 1,000 IU/mL (5,000 GE/ml) Recommended HIV viral load threshold SHEA: 500 GE/ml Institutional Policies and Procedures Policies for the identification and management of HBV-infected health-care providers, students, and school applicants Ability to identify and convene an expert review panel http://cid.oxfordjournals.org/content/56/2/218.long During baseline testing following a needlestick injury, an orthopedic surgeon found to be HBeAg positive and a viral load >17 million IU/mL A patient was diagnosed with acute HBV and had no risk factors except a surgery by this surgeon 237 (72%) of the notified patients were tested 1 additional case with acute hepatitis B 6 resolved infections 4 with no risk factors http://cid.oxfordjournals.org/content/56/2/218.long Patient 1: total knee replacement Patient 2: total hip replacement 6 resolved infections 3: total knee replacement 3: total hip replacement Of 229 patients who tested negative, 183 had either total knee or total hip replacements No breaches in infection control or surgical technique 15
Questions? www.kdheks.gov Elizabeth Lawlor, MS Advanced Epidemiologist Bureau of Epidemiology and Public Health Informatics Kansas Department of Health and Environment 785-368-8208 elawlor@kdheks.gov Healthy Kansans living in safe and sustainable environments. 16