presenter disclosures

Promoting Healthy Lifestyles and a Clean and Safe Environment732-341-9700 • www.ochd.org

Maximizing health department resources to identify and prevent

outbreaks of healthcare associated transmission of viral hepatitis


Presenter Disclosures

Patricia High, MHS, MCHES

“No relationships to disclose”

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:


Learning Objectives

• Describe an investigation protocol for viral hepatitis that maximizes both local health department resources and public health impact.

• Name investigation triggers for viral hepatitis that prioritize acute cases and those with healthcare associated exposures.


Background• Transmission of viral hepatitis from healthcare

associated exposures is concerning in light of recently recognized outbreaks of hepatitis B and C.

• Prompt identification and investigation of suspected healthcare associated cases is needed to ascertain the source of illness and to implement appropriate control measures.

• Local health department resources are limited and the burden of hepatitis makes prioritization and investigation of cases difficult.


Background• Since 1999, 620 patients were infected in 51 outbreaks• Majority of outbreaks (42 out of 51) occurred in non-

hospital settings• 20% of outbreaks occurred between 7/2008 - 6/2009• In 2009 alone, more than 31,000 people notified of

healthcare associated exposure to bloodborne pathogens– Of those tested, 146 people were infected with HBV or HCV

and 5 were infected with HIV

Thompson NT et al. Abstract #396. A review of hepatitis B and C virus infection outbreaks in healthcare settings, 2008-2009. Fifth Decennial Conference on Healthcare-Associated Infections 2010.


New Jersey Outbreak• Two women diagnosed with acute HBV

infection; both received chemotherapy at the same physician’s office.

• Onsite inspection revealed multiple breaches in infection control and warranted notification of patients to be tested for bloodborne pathogens.

• Of 2,700 patients notified, test results were available for 1,394 (51.6%). Twenty-nine outbreak-associated HBV cases were identified.


New Jersey Outbreak• Specimens from 11 case-patients

demonstrated 99.9%-100% nucleotide identity on phylogenetic analysis at the CDC.

• Investigation underscores the need for prompt identification and investigation of healthcare associated transmission of HBV and HCV.

• Served as an impetus behind an in-depth look at local investigation practices in New Jersey.


Needs Assessment• Cross-sectional survey conducted to assess hepatitis

investigation practices in New Jersey. • Total of 114 local health jurisdictions in NJ, but only

58 respondents who completed the survey (50.8%). – 7 respondents (12%) from LINCS agencies– 51 respondents (88%) from local health departments

• Respondents were asked about the investigation of routine HBV and HCV reports as well as cases with healthcare associated exposures.


Needs Assessment• Fifty-two respondents reported having a total of

28,772 Hepatitis B and 49,720 Hepatitis C reports between 2007-2009.

TOTAL REPORTS Average by Respondent

# Hepatitis B Reports 28,772 553

# Confirmed Acute Cases 639 12

# Acute Cases ≥65 Years 155 3

# Hepatitis C Reports 49,720 956

# Confirmed Acute Cases 270 5

# Acute Cases ≥65 Years 36 1


HBV Investigation Protocol• For the purposes of HBV surveillance in New Jersey,

LHDs must investigate cases of acute HBV, newly diagnosed chronic HBV and perinatal HBV infection to identify clusters or outbreaks, provide counseling and ensure appropriate prophylaxis of contacts.

• In order to better focus efforts, individuals with isolated HBcAb-total, HBeAb or HBsAb do not need to be entered into CDRSS and do not require investigation. Individuals with HBsAg, HBeAg, HBcIgM and all HBV DNA testing results must be investigated.


Needs Assessment

• With lab test results suggestive of acute HBV infection, 33% of respondents, at least rarely, close out the case without investigation

• 17% will rarely or never contact the patient if the physician does not respond to an inquiry


HCV Investigation Protocol

• For the purposes of HCV surveillance in New Jersey, all cases of laboratory-confirmed HCV which have NOT been reported as ACUTE can be designated as CHRONIC-confirmed and closed without further investigation.


Needs Assessment

• Anti-HCV tests are often ordered as part of initial screening, are not confirmatory, and do not need to be reported to public health.


Needs Assessment

• If MD reports an acute HCV infection, 20% will rarely or never contact the patient

• Reasons for not contacting the patient:– Concerned about patients’

reaction– MDs don’t want LHDs to

contact their patients


Needs Assessment• If more than one acute case of HBV or HCV was

identified with the same healthcare exposures, 29.5% of respondents would document it in CDRSS and close the case without additional action.


Results• Reports of hepatitis, particularly HCV, are among the

most voluminous notifiable disease reports received by public health.

• The burden of investigating every hepatitis report can overwhelm local resources.

• By targeting investigations towards HBV and HCV cases that have the potential for an effective public health response, those with acute illness and those with possible healthcare exposures, local resources can be maximized and disease burden reduced.


Results

• Triggers for investigation of suspect acute or healthcare associated cases delineated

• Training needs identified– Laboratory test interpretation and case classification– Standardized hepatitis investigation guidelines and forms– Infection control for ambulatory care and other

healthcare settings -- PENDING


Triggers for Investigation

• Laboratory report of HBcIgM• Laboratory report of HBsAg in female aged 15-44 yrs• Positive hepatitis B or C markers in person ≥ 65 yrs• Positive hepatitis B or hepatitis C markers in person

who resides in a long-term care facility• Clinician-reported acute viral hepatitis• Clinician-reported viral hepatitis seroconversion


IgM anti-HBc

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100

Weeks after Exposure

Titer

HBeAg anti-HBe

Symptoms

anti-HBs

Total anti-HBc

HBV DNA

Window Period

HBV Serology and Immunology


Laboratory Test InterpretationHepatitis Serology

Serology as Recorded in CDRSS

HBsAg HBV SURFACE ANTIGEN - A protein on the surface of HBV; it can be detected in high levels in serum during acute or chronic HBV infection. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine.

HBcIgM HBV CORE IGM ANTIBODY - Positivity indicates recent infection with HBV (<6 mos) indicating acute infection.

HBsAb HBV SURFACE AB - The presence of anti-HBs is generally interpreted as indicating recovery and immunity from HBV infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.

HBeAg HBV SURFACE LITTLE E ANTIGEN - HBeAg screening typically is used for the management of patients with chronic infection. The presence of HBeAg correlates with high levels of viral replication.

Hepatitis Serology

Result Interpretation

HBsAg Negative

SusceptibleHBcIgM Negative

HBsAb Negative

HBsAg NegativeImmune due to

natural infectionHBcAb Positive

HBsAb Positive

HBsAg Negative Immune due to hepatitis B

vaccination

HBcAb Negative

HBsAb Positive

HBsAg Positive

Acutely infectedHBcAb Positive

HBcIgM Positive

HBsAb Negative

HBsAg Positive

Chronically infected

HBcAb Positive

HBcIgM Negative

HBsAb Negative


Laboratory Test Interpretation

Hepatitis Serology Result Interpretation

HBsAg Positive 1. Chronically infected (HBcAb+)2. Recent receipt of HBV vaccination possible (HBcAb-)

HBcIgM Positive 1. Acute infection (HBsAg+)2. Resolving acute infection (HBsAg- <6 months)3. Resolved infection with a failure of HBcIgM to seroconvert to HBcAb+

alone (HBsAg- >6 months)

HBsAg Positive1. Acute infection

HBcIgM Positive

HBeAg Positive 1. Chronically infected, highly infectious (HBsAg+, HBcIgM-)2. Acute infection, highly infectious (HBsAg+, HBcIgM+)


Healthcare Associated Hepatitis• Several instances where the transmission of viral

hepatitis has occurred in healthcare settings owing to poor injection practices and other breaches in infection control.

• Preventable exposures are likely not being identified following the current investigation procedures.

• Acknowledging that resources for investigating HBV and HCV are limited, guidelines provide triggers for investigation that prioritize acute cases and cases requiring public health intervention.


Standardized Guidelines for Investigating cases of HBV

and HCV

TRIGGERS FOR PUBLIC HEALTH INVESTIGATION

Algorithm for Investigating Hepatitis B and Hepatitis C Reports

· HBcIgM+· HBsAg+· Anti-HCV with s/co ratio, HCV RIBA, HCV RNA PCR/NAT (65+ yrs or LTCF resident)· Clinician-reported acute HBV/HCV or seroconversion

Close case in CDRSS per NJDHSS disease chapter

Contact healthcare provider for:· Confirmation of diagnosis· Reason test ordered (i.e. 1st visit, elev. LFTs)· Date of 1st diagnosis/illness onset

Ask about traditional risk factors:· Sexual contact of HBV/HCV+ person· Incarceration· IVDU· Tattoos/Piercings· MSM· War veteran· Blood transfusion

Ask if patient is symptomatic?· Jaundice, dark urine· Abdominal pain, anorexia, nausea· LFTs ≥5x normal limit

YES NO

Chronic

Pregnant?(HBV only)

Initiate perinatal investigation

Educate/Close case in CDRSS

Contact patient for:· Previous hepatitis diagnosis· Illness onset date· Symptoms (see above)· Determining if patient donated blood or plasma

in prior 3 months· Traditional risk factors (see above)

ASYMPTOMATIC

SYMPTOMATIC/ ACUTE

YES NO

Contact NJDHSSRECENT BLOOD DONOR


TRADITIONAL RISK FACTORS PRESENT

NO TRADITIONAL RISK FACTORS

Ask about healthcare risk factors:(6 months prior to illness onset)

· Hospitalization/surgery· Residence in LTCF· Dialysis· Colonoscopy/endoscopy· IM Injection/vaccination· IV Infusion· Phlebotomy/outpatient finger stick· Dental procedures/surgery· Receipt of blood/blood products· Accidental needlestick/acupuncture


NO HEALTHCARE RISK FACTORS

Document all invasive procedures/risks in CDRSS

· Procedure type/description· Date of procedure/risk· Performing clinician/facility

HEALTHCARE RISK FACTORS PRESENT

Notify Regional Epidemiologist for further investigation


Conclusion• Training needs were incorporated into the local

investigation guidelines as locally-sponsored best practices.

• NJDHSS-sponsored training on investigating viral hepatitis was provided statewide to local public health investigators.– Still need training/skills in ambulatory care infection

control assessment

• New Jersey became one of only 3 states receiving a CDC grant to improve awareness of appropriate injection safety and control.


Conclusion

• By prioritizing viral hepatitis investigation, local investigation resources are optimized to provide maximum public health impact.


Thank you!

Patricia High, MHS, MCHESOcean County Health Department

Toms River, NJ 08754

Special thanks and acknowledgement to Kimberley Cervantes of the Cape May County Health Department for her partnership

in this assessment and the review of this presentation.

presenter disclosures

Documents