Background
Transmission of bloodborne pathogens due to breaches in infection control is becoming
increasingly recognized as greater emphasis is placed on reducing health care–associated
infections. Two women, aged 60 and 77 years, were diagnosed with acute hepatitis B
virus (HBV) infection; both received chemotherapy at the same physician’s office.
Due to suspicion of health care-associated HBV transmission, a multidisciplinary team
initiated an investigation of the hematology-oncology office practice.
Methods
We performed an onsite inspection and environmental assessment, staff interviews,
records review, and observation of staff practices. Patients who visited the office
practice between January 1, 2006 and March 3, 2009 were advised to seek testing for
bloodborne pathogens. Patients and medical providers were interviewed. Specimens from
HBV-infected patients were sent to the Centers for Disease Control and Prevention
for HBV DNA testing and phylogenic analysis.
Results
Multiple breaches in infection control were identified, including deficient policies
and procedures, improper hand hygiene, medication preparation in a blood processing
area, common-use saline bags, and reuse of single-dose vials. The office practice
was closed, and the physician’s license was suspended. Out of 2,700 patients notified,
test results were available for 1,394 (51.6%). Twenty-nine outbreak-associated HBV
cases were identified. Specimens from 11 case-patients demonstrated 99.9%-100% nucleotide
identity on phylogenetic analysis.
Conclusion
Systematic breaches in infection control led to ongoing transmission of HBV infection
among patients undergoing invasive procedures at the office practice. This investigation
underscores the need for improved regulatory oversight of outpatient health care settings,
improved infection control and injection safety education for health care providers,
and the development of mechanisms for ongoing communication and cooperation among
public health agencies.
Key Words
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Article Info
Publication History
Published online: June 10, 2011
Footnotes
This report was supported in part by an appointment of the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists and funded by Centers for Disease Control and Prevention Cooperative Agreement 1U38HM000414. The findings and conclusions of this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the Council of State and Territorial Epidemiologists, the New Jersey Department of Health and Senior Services, or the Ocean County Health Department.
Rebecca D. Greeley and Shereen Semple contributed equally to this work.
Conflict of interest: None to report.
Identification
Copyright
© 2011 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
