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FIGURE 2. Unsafe injection practices and circumstances that likely resulted in transmission of hepatitis C virus (HCV) at clinic ANevada, 2007
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 persons with acute HCV infections, 60%-70% are 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 breache that could lead to bloodborne pathogen transmission a recognized, including unsafe injection practices, potentia exposed persons should be notified and tested, even if trans mission has not been confirmed (9). Those persons who ar found to be infected can then obtain proper medical care. 2 addition to approximately 40,000 notifications that occurre as a result of this outbreak, in unrelated incidents, ursi injection practices at three other outpatient clinics in states have resulted in approximately 28,000 patient noti cations during the preceding year (CDC, unpublished dat 2008). These situations could have been avoided if standar infection-control precautions, which include basic sa injection practices, had been followed (Box) (10).
This outbreak highlights the importance of surveillara and investigation in detecting viral hepatitis transmission in health-care settings. Prevention of transmission in the settings requires understanding and adherence to recor mended infection-control practices. Medical and nursin school curricula and other health-care professional trair ing, licensing, and continuing education requirement should include infection-control content, including the sa handling and administration of parenteral medications, a areas of competency. Although hospitals employ infector control professionals and regularly evaluate infection control practices, such oversight might be limited outpatient settings that are not associated with hospitas As use of these settings grows, appropriate methods will b
X. Injection safety recommendations
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.
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://www.cdc.gov/ncidod/dhqp/gl_isolation.html.
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.
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 http://www.cdc.gov/ncidod/dhqp/bp_steps_for_eval_ic_ breach 1.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 http://www.cdc.gov/ncidod/dhqp/gl_isolation.html.
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
TABLE. Demographic characteristics, risk factors, surveillance status, and clinical information for 20 patients with hepatitis C vir (HCV) infection — postal code A, Buffalo, New York, November 2004-April 2007*
Data were compiled from standard surveillance forms and patient interviews.
1 Based on surveillance case definitions (available at http://www.cdc.gov/ncphi/disss/nndss/casedef/hepatitiscacutecurrent.htm and http://www.cdc.go ncphi/disss/nndss/casedef/hepatitisccurrent.htm).
Polymerase chain reaction.
†† Shared needles with a person known or believed to be HCV positive.
§§ Not reported.
11 With a partner known or believed to be HCV positive. *** With a sex worker.
Electronic Clinical Laboratory Reporting System generates databases containing any HCV-positive laboratory reports for persons aged <30 years; these data are then sent to local health departments. Investigation is conducted by local health department staff members with NYSDOH assistance and includes complete laboratory results collection, healthcare provider interview, medical record review, and patient interview.
In February 2007, NYSDOH staff members noticed an apparent high number of newly identified HCV infections. among persons aged <30 years who resided in the same postal code (postal code A), corresponding to a suburban community of Buffalo, New York. An initial retrospective review found eight cases dating back to May 2006 in persons who resided in postal code A (case numbers 11-18) (Table), one of which was in a patient who had acute hepa
titis C (7). All but one of the eight initially identified cas were in persons who reported a history of IDU. Furth analysis of cases in persons residing in postal code A indicated that during November 2004-April 2007, a total of 20 HCV-positive persons aged <30 years had been reported Fifteen of the 20 cases were diagnosed in 2006 or 200 The community (2000 population: 42,000) in which posta. code A is located is part of Erie County and had 47.5 new reports of HCV infection per 100,000 population aged < years during November 2004-April 2007. During the same period, Erie County had 18.6 new reports of HCV infe tion per 100,000 population; two suburban postal code with similar populations, socioeconomic composition, an proximity to the inner city as the investigated community had 7.0 and 4.9 new reports of HCV infection per 100,00 population, respectively. Because the incidence of new
BLE. (Continued) Demographic characteristics, risk factors, surveillance status, and clinical information for 20 patients with >atitis C virus (HCV) infection — postal code A, Buffalo, New York, November 2004-April 2007*
orts in the community per population appeared to be roximately twice that of the county and approximately times greater than that of any similar suburb, further estigation to characterize the cluster was warranted. With initial detection of the cluster, an epidemiologic estigation was launched by NYSDOH in collaboration h ECDOH. Patients were interviewed in person by a ›-person team at various locales, including correctional lities, rehabilitation clinics, patient residences, and other ations. Current CDC case definitions for acute and onic hepatitis C were used.* Four (20%) of the 20 ients had evidence of elevated serum alanine transamie levels and discrete symptom onset and were classified having acute hepatitis C. Sixteen (80%) other patients e asymptomatic or had illness that did not meet the te case definition and were classified as having chronic V infection. Median age of the 20 patients was 19 years ige: 17-29 years), all were white, 15 (75%) were male, 19 (95%) reported a history of IDU. Nineteen (95%) he 20 patients attended or had attended one of the two
e definitions available at http://www.cdc.gov/ncphi/disss/nndss/casedef/ atitiscacutecurrent.htm and http://www.cdc.gov/ncphi/disss/nndss/casedef/ atitisccurrent.htm.
high schools in postal code A (high school A) (Table). Fourteen (70%) had evidence of viremia by polymerase chain reaction; three (21%) of these 14 had a viral genotype reported. NYSDOH and ECDOH staff members successfully interviewed 11 of the 20 patients (one with acute hepatitis C and 10 with chronic HCV infection) using an integrated interview tool and a chart abstraction tool developed for this investigation; the remaining nine patients could not be contacted.
At the time of interview, all of the 11 interviewed patients were aware that they had tested HCV positive. However, three (27%) of the patients interviewed believed that their test results were false and that they were no longer (or never were) HCV infected. Ten (91%) interviewed patients reported previous but not current IDU (including use of heroin, cocaine, loritabs, oxycodin, morphine, valium, or crack cocaine) and sharing of drug-use equipment; some patients shared equipment with other identified patients. All 10 patients reported purchasing heroin in the same inner-city Buffalo location. Noninjectable-drug use, reported by 10 (91%) patients, was initiated at a median age of 14 years (range: 9-17 years); IDU was initiated at a median age of 16.5 years (range: 14-26 years).
At least four partnerships involving drug equipment sharing and high-risk sexual activity were reported among the 20 patients. The members of these partnerships knew other members who had experienced symptoms consistent with acute hepatitis, such as jaundice. However, documented HCV infection in these members, as evidenced by a report in the NYSDOH Chronic Hepatitis Registry, could not be verified. Among interviewed patients, median reported number of lifetime sex partners was 10 (range: four to 100). Six (54%) patients claimed they had private health insurance, two reported having Medicaid, and three reported that they had no health insurance. Seven of the interviewed patients reported having a primary-care physician; four of these seven reported seeing a specialist for their HCV infection. None of the interviewed patients had received HCV treatment. Several barriers to potential treatment were cited, including concerns regarding the side effects of medication, lack of information regarding the availability of treatment services, lack of health insurance reimbursement, and a perceived lack of health-care providers capable or willing to treat HCV in patients with comorbidities such as IDU or mental health issues.
Several initiatives were launched by NYSDOH and ECDOH throughout Erie County to address the apparent clustering of HCV infection among injection-drug users. Staff members from NYSDOH, the NYS Office of Alcoholism and Substance Abuse Services, and ECDOH conducted cross-training sessions and developed a resource manual to help identify primary care, sexually transmitted disease (STD)/human immunodeficiency virus (HIV) screening, drug treatment, harm reduction, and HCV treatment services for patients. All interviewed patients were referred to ECDOH counselors for HIV/acquired immunodeficiency syndrome (AIDS) risk assessment and personalized intervention development. ECDOH conducted multiple events held at various community locations and ECDOH clinics, offering HCV, HIV, and STD screening, referral for services, and education on prevention, risk reduction, and family planning; these services are ongoing at all five ECDOH clinics. Presentations on hepatitis epidemiology, diagnosis and testing, and prevention were conducted at medical practices that serve high-risk communities throughout Erie County. ECDOH also collaborated with the Erie County Department of Mental Health to integrate HCV messages into existing prevention programs and implement screening programs in target areas with high HCV infection rates. Finally, ECDOH worked with school district representatives and high schools to address prevention of IDU and HCV transmission.
Reported by: L Leuchner, H Lindstrom, PhD, GR Burstein, MD. E County Dept of Health, Buffalo; KE Mulhern, EM Rocchio, MA, GJo MS, J Schaffzin, MD, PhD, P Smith, MD, New York State Dept of He Editorial Note: One goal of the CDC-funded enhanc viral hepatitis surveillance protocols is high-priority followup of cases that are likely to represent acute HCV infe tion. Another goal is detection of clusters or outbreaks such cases, as this report describes. The markedly elevate. number of new reports of HCV infection per populat.or detected among persons aged <30 years in postal code A compared with the number of reports in the surrounding community, indicated an apparent cluster of recent infected patients. Nearly all of the identified patients: the cluster reported a history of IDU, and partnershipinvolving drug equipment sharing, which have beer described previously (8), were identified among the cluster. The cause of this cluster likely was IDU with share. inadequately cleaned equipment. Because the investigation targeted only cases in persons aged <30 years, more direc links among members of this cluster involving persons ag >30 years might exist within the community. Furthermore although infections identified in persons aged <30 year are more likely to be new infections than those identific in persons aged ≥30 years, not all infections in the popu tion aged <30 years are new; a portion of the patients in this cluster likely had been infected with HCV for years. Although the number of new reports of HCV infection per population in postal code A was higher than the overa Erie County number during November 2004-April 2007 this analysis could not determine whether this elevated number of reports represented a previously established ar ongoing higher rate of HCV infection among persons age <30 years or a more recent phenomenon. Cases within th apparent cluster likely are a reflection of the ongoing HC epidemic among injection-drug users in the United State (9). Ongoing educational efforts and increased pub.. awareness of hepatitis C, particularly among injection-dr users, might have led to higher rates of testing, whic yielded additional reports. Because the prioritized algorith was not in place before January 2006, earlier reported case of HCV infection among this population might have go unrecognized. Continued enhanced surveillance is necce to complement routine surveillance for HCV infections t better understand the burden of hepatitis C and to ide tify and prevent new HCV infections.
The results of this investigation demonstrate the poten tial for improved and consistent national hepatitis C SL veillance to identify cases for investigation, estimate ta magnitude of HCV infection and disease, detect outbreaks