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Viral Hepatitis Awareness

May 2008 May 2008 marks the 13th anniversary of Hepatitis wareness Month in the United States. May 19 is World depatitis Day, which recognizes the importance of gloal commitments to prevent liver disease and cancer aused by viral hepatitis. This issue of MMWR includes report on an outbreak of acute hepatitis C associated ith unsafe injection practices at an endoscopy clinic nd a report on hepatitis C virus (HCV) infections among pung injection-drug users. Both reports highlight the ole of viral hepatitis surveillance in detecting outbreaks nd populations at risk. Development of effective state nd local surveillance for acute and chronic viral hepatis is a public health priority. HCV infection is the most common bloodborne illness, le leading cause of chronic liver disease, and the primary idication for liver transplantation in the United States. ICV is spread primarily through exposure to infectious lood; injection-drug use is the major contributor to HCV ansmission in the United States. Although HCV infecon can result in acute illness, most of its effects on the ver, including cirrhosis and liver cancer, are not apparent ntil years after exposure. Many of the estimated 3.2 milon persons living with chronic HCV infection in the nited States are unaware of their infection status. CDC recommends HCV testing for persons at risk (1). ersons with HCV infection also should be assessed regucly for severity of liver disease, onset of liver cancer, and le need for treatment. Additional information about ral hepatitis is available at eference CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19).

Acute Hepatitis C Virus Infections

Attributed to Unsafe Injection Practices at an Endoscopy Clinic

Nevada, 2007 On January 2, 2008, the Nevada State Health Division (NSHD) contacted CDC concerning surveillance reports received by the Southern Nevada Health District (SNHD) regarding two persons recently diagnosed with acute hepatitis C. A third person with acute hepatitis C was reported the following day. This raised concerns about an outbreak because SNHD typically confirms four or fewer cases of acute hepatitis C per year. Initial inquiries found that all three persons with acute hepatitis C underwent procedures at the same endoscopy clinic (clinic A) within 35–90 days of illness onset. A joint investigation by SNHD, NSHD, and CDC was initiated on January 9, 2008. The epidemiologic and laboratory investigation revealed that hepatitis C virus (HCV) transmission likely resulted from reuse of syringes on individual patients and use of single-use medication vials on multiple patients at the clinic. Health officials advised clinic A to stop unsafe injection practices immediately, and approximately 40,000 patients of the clinic were notified about their potential risk for exposure to HCV and other bloodborne pathogens. This report



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The MMWR series of publications is published by the Coordinating
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Suggested Citation: Centers for Disease Control and Prevention.
[Article title). MMWR 2008;57:[inclusive page numbers).
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focuses on the six cases of acute hepatitis C identified or ing the initial investigation, which is ongoing; additic". cases of acute hepatitis C associated with exposures at dr. A might be identified. Comprehensive measures involu viral hepatitis surveillance, health-care provider educatie public awareness, professional oversight, licensing, and inprovements in medical devices can help detect and prever: transmission of HCV and other bloodborne pathogens i health-care settings.

The objectives of the investigation were to conduct caxfinding and review health histories of infected persons, o determine the source of transmission and implement control measures, to identify other patients at risk for expi sure, and to assist in development of recommendations t. prevent HCV transmission in health-care settings. Perses with acute hepatitis C were interviewed, and blood sampis were obtained after these persons gave oral consent. Blooi samples were sent to CDC for testing for HCV genotype 2 the NS5b region and phylogenetic relatedness at 11. hypervariable 1 region (HVR1) to help determine whetha a common source of transmission existed (1). Specimen also were tested for other bloodborne infections (hepanos B virus (HBV]) and human immunodeficiency virus [HIV]). Case-finding activities included SNHD's review of acute hepatitis C surveillance records, cross-matching ei local HCV laboratory records with clinic A procedure logo review of medical records for patients who underwent procedures at clinic A on the same day as HCV-infected parsons, and serologic HCV, HBV, and HIV testing of staf An extensive review of the clinic practices and procedures also was conducted, including observation of several endscopic procedures and endoscopic reprocessing, observation of anesthesia practices, and interviews with staff members regarding their infection-control practices.

For this investigation, a person was defined as having health-care-associated acute hepatitis C if he or she lì hic symptoms of acute hepatitis within 6 months of having a procedure performed at clinic A during July-Decem!k! 2007; 2) had laboratory-confirmed HCV infectio (antibodies to HCV (anti-HCV]) by enzyme immunoza say (EIA) and recombinant immunoblot assay (RIBA 0 EIA with an appropriate signal-to-cutoff ratio for a grea assay, or presence of HCV RNA by polymerase chain reistion (PCR) in the absence of acute hepatitis A virus (HAVE and 3) did not have other risks for HCV infection.

In addition to the three persons identified initially, there other persons were determined to have health-carea associated acute hepatitis C, for a total of six cases diagg nosed during July-December 2007. One of the three case was identified by review of surveillance records, another

Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman

Virginia A. Caine, MD, Indianapolis, IN

David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ

Margaret A. Hamburg, MD, Washington, DC
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA

John K. Iglehart, Bethesda, MD
Dennis G. Maki, MD, Madison, WI
Sue Mallonee, MPH, Oklahoma City, OK

Stanley A. Plotkin, MD, Doylestown, PA
Patricia Quinlisk, MD, MPH, Des Moines, IA
Patrick L. Remington, MD, MPH, Madison, WI

Barbara K. Rimer, DrPH, Chapel Hill, NC
John V. Rullan, MD, MPH, San Juan, PR

Anne Schuchat, MD, Atlanta, GA
Dixie E. Snider, MD, MPH, Atlanta, GA

John W. Ward, MD, Atlanta, GA

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ss-matching local laboratory records with procedure ords at clinic A, and the third by physician report after c: start of the investigation. The six persons ranged in age ::n 37 to 72 years; four were female. All had signs and aptoms of acute hepatitis, including jaundice, abdomi

discomfort, and laboratory evidence of liver inflammain with alanine aminotransferase (ALT) levels of :-1,165 units/L.* Four of the six persons required hos

dization as a result of their HCV infection. "he six persons with acute hepatitis C had onset of sympis in late October 2007 and November 2007, 35-90 s after undergoing procedures at clinic A (Figure 1) and hin the typical incubation period of 15–160 days. None significant risk factors for HCV infection and none had er common exposures. One of the procedures was perned in July 2007; the other five were performed on the le day in September 2007. Five persons (four with proures on the same day) for whom blood specimens were ilable at the time of this report had HCV genotype la. - four who had procedures on the same day had viral uences with 99%-100% genetic similarity at HVR1, nting to a common source of infection. The viral uence from the HCV-infected person who had the proure in July 2007 was not genetically related to the other ster, suggesting a separate transmission incident. During the 2 days in which persons with health-careociated hepatitis C had procedures at clinic A, 120 itional persons had procedures at the clinic. HCV test ults for those persons are pending. Thirty-eight staff mbers at the clinic involved in direct patient care were ilable for testing during the investigation, and none had lence of previous or current HCV infection. None of the sons with health-care-associated acute hepatitis C and le of the staff tested positive for HBV or HIV infections. nappropriate reuse of syringes on individual persons and

of medication vials intended for single-person use on ltiple persons was identified through direct observation nfection-control practices at clinic A (Figure 2). Specifiy, a clean needle and syringe were used to draw medicai from a single-use vial of propofol, a short-acting avenous anesthetic agent. The medication was injected ctly through an intravenous catheter into the patient's 1. If a patient required more sedation, the needle was oved from the syringe and replaced with a new needle; new needle with the old syringe was used to draw more lication. Backflow from the patient's intravenous cathor from needle removal might have contaminated the

syringe with HCV and subsequently contaminated the vial. Medication remaining in the vial was used to sedate the next patient.

As soon as improper injection practices were observed, health officials advised clinic A to stop these practices and educated staff about the risks. Clinic A is a free-standing private endoscopy clinic in southern Nevada that primarily performed upper endoscopies and colonoscopies (approximately 50–60 procedures a day, 5 days a week). For at least the 4 years that clinic A occupied its existing location, the unsafe injection practices had been commonly used among some staff members who administered anesthesia, according to those who were interviewed. On February 27, 2008, SNHD began notifying approximately 40,000 persons who underwent procedures requiring anesthesia at the clinic from March 1, 2004, through January 11, 2008, via mail and through the media, to undergo screening for HCV, HBV, and HIV infections. Results of this screening are pending. Reported by: B Labus, MPH, L Sands, DO, P Rowley

, Southern Nevada Health District, Las Vegas; IA Azzam, MD, Nevada State Dept of Health and Human Svcs. SD Holmberg, MD, Div of Viral Hepatitis, National Center

for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; JF Perz, DrPH, PR Patel, MD, Div of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases; GE Fischer, MD, M Schaefer, MD, EIS officers, CDC. Editorial Note: Although case-control studies have not indicated an increased risk for acquiring HCV from medical, surgical, or dental procedures in the United States (2), outbreaks of HCV in health-care settings have long been recognized (3). These outbreaks have been identified primarily through clusters of temporally related cases detected by routine viral hepatitis surveillance, a method that likely

e normal ALT range varies according to age, sex, and other factors. An upper it of 28–55 units/L is generally considered normal.

FIGURE 2. Unsate injection practices and circumstances that likely resulted in transmission of hepatitis C virus (HCV) at clinic ANevada, 2007

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underestimates the magnitude of transmission. Surveillance for viral hepatitis typically is passive, with little or no capacity to investigate cases suggestive of transmission during health care and determine their cause (4). Among per

with acute HCV infections, 60%-70% asymptomatic (2). Additionally, currently available laboratory tests cannot distinguish acute from chronic HCV infection, which makes identifying newly acquired cases difficult.

The investigation described in this report identified six cases of acute hepatitis C in persons who underwent procedures at clinic A 35-90 days before the onset of their illness. None of the persons had significant risk factors for HCV infection within the typical incubation period (15– 160 days before onset of symptoms), and five of the cases had procedures on the same day (September 21, 2007). The genetic relatedness of the viruses from case patients who had procedures on September 21, 2007, supports the epidemiologic findings and points to a common source of infection. The lack of genetic relatedness to the patient seen in July 2007 suggests a separate transmission incident. The two distinct clusters suggest patient-to-patient transmission rather than staff-to-patient transmission.

Most outbreaks of health-care-associated HCV have involved patient-to-patient transmission attributed to unsafe injection practices (3,5). The reuse of syringes and needles or mishandling of medication vials usually have been implicated (6–8). In some situations, syringes or needles used on HCV-infected persons were directly reused on other persons. In other instances, syringes or needles used on HCVinfected persons were reused to draw medication from a vial

from which medicine was then drawn and administered multiple persons, as was found in this investigation.

When gross errors or high-risk infection-control breathe that could lead to bloodborne pathogen transmission as recognized, including unsafe injection practices, potentia exposed persons should be notified and tested, even if tran: mission has not been confirmed (9). Those persons who as found to be infected can then obtain proper medical care. : addition to approximately 40,000 notifications that occurred as a result of this outbreak, in unrelated incidents, urs: injection practices at three other outpatient clinics in 5 states have resulted in approximately 28,000 patient noun cations during the preceding year (CDC, unpublished das 2008). These situations could have been avoided if standard infection-control precautions, which include basic sa's injection practices, had been followed (Box) (10).

This outbreak highlights the importance of surveillarand investigation in detecting viral hepatitis transmissiin health-care settings. Prevention of transmission in this settings requires understanding and adherence to recommended infection-control practices. Medical and nursschool curricula and other health-care professional train ing, licensing, and continuing education requiremen: should include infection-control content, including the wat handling and administration of parenteral medication areas of competency. Although hospitals employ infecto control professionals and regularly evaluate infectie control practices, such oversight might be limited .. outpatient settings that are not associated with hospitan As use of these settings grows, appropriate methods will be

* X. Injection safety recommendations

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- Never administer medications from the same syringe

to more than one patient, even if the needle is changed. Consider a syringe or needle contaminated after it has been used to enter or connect to a patients' intravenous infusion bag or administration set. Do not enter a vial with a used syringe or needle. Never use medications packaged as single-use vials for more than one patient. Assign medications packaged as multi-use vials to a single patient whenever possible. Do not use bags or bottles of intravenous solution as a common source of supply for more than one patient. Follow proper infection-control practices during the preparation and administration of injected medications.

į dapted from: CDC. Guideline for isolation precautions: preventing

ansmission of infectious agents in healthcare settings 2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at ttp://

ded to provide similar oversight for outpatient clinics. ter surveillance, education, and oversight are needed to ect and prevent bloodborne pathogen transmission in bulatory and other health-care settings. erences Patel PR, Larson AK, Castel AD, et al. Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies. JAMA 2006;296:2005-11. CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19). Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004;38:1592–8. CDC. Surveillance for acute viral hepatitis—United States, 2006. MMWR 2008;57(No. SS-2). Alter MJ. Healthcare should not be a vehicle for transmission of hepatitis C virus. J Hepatol 2008;48:2-4. CDC. Transmission of hepatitis B and C viruses in outpatient settings-New York, Oklahoma, and Nebraska, 2000–2002. MMWR 2003;52:901-6. Comstock RD, Mallonee S, Fox JL, et al. A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments. Infect Control Hosp Epidemiol 2004;25:576–83. Krause G, Trepka MJ, Whisenhunt RS, et al. Noscomial transmission of hepatitis C virus associated with the use of multidose saline vials. Infect Control Hosp Epidemiol 2003;24:122-7. CDC. Steps for evaluating an infection control breach. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at breach1.html. CDC. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at

Use of Enhanced Surveillance

for Hepatitis C Virus Infection to Detect a Cluster Among Young Injection-Drug Users New York,

November 2004-April 2007 Infection with hepatitis C virus (HCV) is a leading cause of chronic liver disease in the United States (1). Chronic hepatitis B and C virus infections were added to the nationally notifiable diseases list in 2003 (2). Approximately 3.2 million persons in the United States have chronic HCV infection (3). The most common risk factor for HCV infection is illicit drug use (specifically injection-drug use [IDU]) (3,4), although approximately one third to one half of cases have no identified risk factor (4; New York State Department of Health (NYSDOH), unpublished data, 2008). Because approximately 80% of acute HCV infections are asymptomatic and no serologic markers for recent infection exist, distinguishing recent from distant infection based on serology alone is challenging (5) and establishment of national HCV infection incidence is difficult. CDC provides funding to enhance surveillance for HCV infection and other forms of viral hepatitis in New York State (NYS) and seven other areas. One project of enhanced surveillance is to identify those HCV infections most likely to have been acquired recently. Since January 2006, NYSDOH has prioritized follow-up of positive laboratory markers for HCV infection among persons aged <30 years because they are more likely to be newly infected than older persons (6). In February 2007, NYSDOH detected a cluster of HCV infections among persons in this age group by using the prioritized algorithm. This report describes the subsequent investigation by NYSDOH and the Erie County Department of Health (ECDOH), which identified a group of patients with histories of IDU who were linked through a single high school that all the patients had attended at some time. The findings demonstrate how targeted enhanced surveillance can effectively detect clusters and outbreaks and guide appropriate interventions.

In 2004, the enhanced viral hepatitis surveillance project was launched in 34 of the 57 NYS counties outside of New York City. Detection and follow-up of reports of newly identified persons with HCV infections among NYS residents are given high priority to 1) collect accurate risk factor data, 2) guide prevention efforts, and 3) ensure patient referral to appropriate treatment. NYSDOH hepatitis surveillance staff members prioritize for immediate investigation any positive laboratory reports for markers of HCV infection among persons aged <30 years. Each week, the NYSDOH

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