Advertisement

Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wasley A.
        • Kruszon-Moran D.
        • Kuhnert W.
        • Simard E.P.
        • Finelli L.
        • McQuillan G.
        • et al.
        The prevalence of hepatitis B virus infection in the United States in the era of vaccination.
        J Inf Dis. 2010; 202: 192-201
        • Mitchell A.E.
        • Colvin H.M.
        • Beasley R.P.
        Institute of Medicine recommendations for the prevention and control of hepatitis B and C.
        Hepatology. 2010; 51: 729-733
        • Daniels D.
        • Grytdal S.
        • Wasley A.
        Surveillance for acute viral hepatitis: United States, 2007.
        MMWR Morb Mortal Wkly Rep. 2009; 58: 1-27
        • Shepard C.W.
        • Simard E.P.
        • Finnelli L.
        • Fiore A.E.
        • Bell B.P.
        Hepatitis B virus infection: epidemiology and vaccination.
        Epidemiol Rev. 2006; 28: 112-125
        • Williams I.T.
        • Perz J.F.
        • Bell B.P.
        Viral hepatitis transmission in ambulatory health care settings.
        Clin Infect Dis. 2004; 38: 1592-1598
        • Thompson N.D.
        • Perz J.F.
        • Moorman A.C.
        • Holmberg S.D.
        Nonhospital health care‒associated hepatitis B and C virus transmission: United States, 1998‒2008.
        Ann Intern Med. 2009; 150: 33-40
        • Perz J.F.
        • Thompson N.D.
        • Schaefer M.K.
        • Patel P.R.
        US outbreak investigations highlight the need for safe injection practices and basic infection control.
        Clin Liver Dis. 2010; 14: 137-151
        • Gutelius B.
        • Perz J.F.
        • Parker M.M.
        • Hallack R.
        • Stricof R.
        • Clement E.J.
        • et al.
        Multiple clusters of hepatitis virus infections associated with anesthesia for outpatient endoscopy procedures.
        Gastroenterology. 2010; 139: 163-170
        • Samandari T.
        • Malakmadze N.
        • Balter S.
        • Perz J.
        • Khristova M.
        • Swetnam L.
        • et al.
        A large outbreak of hepatitis B virus infections associated with frequent injections at a physician’s office.
        Infect Control Hosp Epidemiol. 2005; 26: 745-750
        • Macedo de Oliveira A.
        • White K.L.
        • Leschinsky D.P.
        • Beechman B.D.
        • Vogt T.M.
        • Moolenaar R.L.
        • et al.
        An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic.
        Ann Intern Med. 2005; 142: 898-904
        • Watson J.T.
        • Jones R.C.
        • Siston A.M.
        • Fernandez J.R.
        • Martin K.
        • Beck E.
        • et al.
        Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center.
        Arch Intern Med. 2005; 165: 2639-2643
        • Kamboj M.
        • Sepkowitz K.A.
        Nosocomial infections in patients with cancer.
        Lancet. 2009; 10: 589-597
        • Stevens M.P.
        • Edmond M.B.
        Health care‒associated transmission of hepatitis B and C in oncology care.
        Clin Liver Dis. 2010; 14: 69-74
        • Lanini S.
        • Puri V.
        • Lauria F.N.
        • Fusco F.M.
        • Nisii C.
        • Ippolito G.
        Patient-to-patient transmission of hepatitis B virus: a systematic review of reports on outbreaks between 1992 and 2007.
        BMC Med. 2009; 7: 15
        • Gunther S.
        • Li B.C.
        • Miska S.
        • Kruger D.H.
        • Meiselh H.
        • Will H.
        A novel method for efficient amplification of whole hepatitis B virus genomes permits rapid functional analysis and reveals deletion mutants in immunosuppressed patients.
        J Virol. 1995; 69: 5437-5444
        • Bond W.W.
        • Favero M.S.
        • Petersen N.J.
        • Gravelle C.R.
        • Ebert J.W.
        • Maynard J.E.
        Survival of hepatits B virus after drying and storage for one week.
        Lancet. 1981; 317: 550-551
        • Siegel J.D.
        • Rhinehart E.
        • Jackson M.
        • Chiarello L.
        • Healthcare Infection Control Practices Advisory Committee
        2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings.
        (Available from:) (Accessed March 10, 2011)
        • Dolan S.A.
        • Felizardo G.
        • Barnes S.
        • Cox T.R.
        • Patrick M.
        • Ward K.S.
        • et al.
        APIC position paper: safe injection, infusion, and medication vial practices in healthcare.
        Am J Infect Control. 2010; 38: 167-172
        • Patel P.R.
        • Larson A.K.
        • Castel A.D.
        • Ganova-Raeva L.M.
        • Myers R.A.
        • Roup B.J.
        • et al.
        Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies.
        JAMA. 2006; 296: 2005-2011
        • Pourkarim M.R.
        • Verbeek J.
        • Rahman M.
        • Amini-Bavil-Olyaee S.
        • Forier A.M.
        • Lemey P.
        • et al.
        Phylogenetic analysis of hepatitis B virus full-length genomes reveals evidence for a large nosocomial outbreak in Belgium.
        J Clin Virol. 2009; 46: 61-68
        • Jarvis W.R.
        Infection control and changing health-care delivery systems.
        Emerg Infect Dis. 2001; 7: 170-173
        • Maki D.G.
        • Crnich C.J.
        History forgotten is history relived: nosocomial infection control is also essential in the outpatient setting.
        Arch Intern Med. 2005; 165: 2565-2567
        • New York State Department of Health
        Health care provider infection control training.
        (Available from:) (Accessed March 10, 2011)
        • New Jersey Department of Health and Senior Services
        Hepatitis B outbreak investigation.
        (Available from:) (Accessed March 10, 2011)
        • Chiaramonte M.
        • Floreani A.
        • Naccarato R.
        Hepatitis B virus (HBV) in the elderly: an underestimated problem?.
        Biomed Pharmacother. 1987; 41: 121-123
        • Perz J.F.
        • Fiore A.E.
        Hepatitis B virus infection risks among diabetic patient residing in long-term care facilities.
        Clin Infect Dis. 2005; 41 ([letter]): 760-761
        • Kondo Y.
        • Tsukada K.
        • Takeucji T.
        • Mitsui T.
        • Iwano K.
        • Masuko K.
        • et al.
        High carrier rate after hepatitis B virus infection in the elderly.
        Hepatology. 1993; 18: 768-774
        • Junaidi O.
        • Di Bisceglie A.M.
        Aging liver and hepatitis.
        Clin Geriatr Med. 2007; 23: 889-903
        • Halpern M.T.
        • Yabroff K.R.
        Prevalence of outpatient cancer treatment in the United States estimated from the Medical Panel Expenditures Survey (MEPS).
        Cancer Invest. 2006; 26: 647-651