Barbara Boughton
April 8, 2008
The routine clinical use of shared medical equipment, such as multivial drugs and multipatient devices for capillary blood sampling in glucose monitoring, can be responsible for patient-to-patient transmission of hepatitis B virus in healthcare settings, according to a review study published online April 8 in BMC Medicine.
In the study, researchers analyzed 30 papers that reported on 33 outbreaks of hepatitis B virus infection among 471 patients, including 16 fatal cases, in the United States and European Union. The highest number of outbreaks occurred in dialysis units (30.3%), followed by medical wards and nursing homes (21.2%), surgery wards (15.2%), and outpatient clinics (15.2%). The reasons for the hepatitis B virus outbreaks included routine clinical practices such as the use of multivial drugs (30.3%) and nondisposable devices for performing capillary blood sampling in diabetic patients (27.2%), the spread of blood droplets during transvenous endomyocardial biopsy procedures (9.1%), and multiple errors in applying standard infection control measures (9.1%).
"We have found that several breaches in infection control measures, related to some routine clinical practices thought to be risk-free (e.g. point of care blood glucose monitoring or preparation and administration of common parenteral drugs with multi-vial compounds) could result in patient-to-patient transmission of the hepatitis B virus within healthcare settings," write Simone Lanini, MD, and colleagues from the Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani in Rome.
"Moreover some outbreak reports underlined that heart-transplant recipients are at risk of contracting hepatitis B virus infection during the transvenous endomyocardial biopsy (TEB) procedure through indirect contact with infected blood as a result of environmental contamination," the authors note.
The authors analyzed studies published between January 1992 and December 2007 and considered only outbreaks in the United States and the European Union because they both have high health standards and comparable sociodemographic indicators. The researchers excluded cases of healthcare worker-to-patient transmission of the hepatitis B virus. A PubMed search resulted in 93 papers, 23 of which met the researchers' inclusion criteria; 7 additional papers came from references and the Outbreak Database, the worldwide database for nosocomial outbreaks.
The researchers found that dialysis units had the highest number of hepatitis B virus outbreaks but that these outbreaks had the shortest duration and the fewest cases. The authors note that dialysis units have improved mandatory protocols for surveillance of blood-borne infections, which might explain the higher frequency of hepatitis B virus outbreak reports in these settings.
"Consistent with the Centers for Disease Control and Prevention (CDC) data, the results of this review strengthen the idea that dialysis itself is nowadays a rather safe procedure and that outbreaks are largely due to 'substantial deficiencies in recommended infection control practice, such as the use of multi-vial drugs, as well as failure to vaccinate hemodialysis patients against hepatitis B,' " according to the authors. In June 2007, the CDC recommended against the use of multivial compounds in its guidelines on preventing infection in healthcare settings.
The authors also note that multipatient capillary blood sampling devices for glucose monitoring in diabetic patients are presumed to be safe because of their disposable lancets. However, the transmission of the hepatitis B virus through the nondisposable components of these multipatient devices is possible, and they should be reserved for personal home use, according to the authors.
Heart transplant recipients are also at increased risk for infection with hepatitis B virus, largely through the TEB procedure, a method used to evaluate the status of cardiac transplant rejection. In the reports analyzed by the authors, however, infection occurred through the spread of blood droplets during purging of syringes and catheter withdrawal in TEB. These blood droplets can contaminate unwrapped TEB biopsy material and could then contaminate the next patient to undergo the procedure, the authors write.
The authors found no outbreaks related to endoscopic procedures and little difference in the pattern of outbreaks observed in the United States and European Union. Most of the outbreaks originated among patients already suffering some degree of immunosuppression, such as those with end-stage renal disease, diabetes, or neoplasms or those undergoing heart transplantation.
To prevent the transmission of blood-borne pathogens such as hepatitis B virus, healthcare workers should strictly adhere to standard safety procedures as well as infection control principles, the authors caution. They conclude that using sterile single-use disposable needles and avoiding multivial compounds is crucial. "These principles and practices need to be made explicit in institutional policies and reinforced through in-service education for all personnel involved in direct patient care," the researchers write.
The authors have disclosed no relevant financial relationships.
BMC Med. Published online April 8, 2009.
In the study, researchers analyzed 30 papers that reported on 33 outbreaks of hepatitis B virus infection among 471 patients, including 16 fatal cases, in the United States and European Union. The highest number of outbreaks occurred in dialysis units (30.3%), followed by medical wards and nursing homes (21.2%), surgery wards (15.2%), and outpatient clinics (15.2%). The reasons for the hepatitis B virus outbreaks included routine clinical practices such as the use of multivial drugs (30.3%) and nondisposable devices for performing capillary blood sampling in diabetic patients (27.2%), the spread of blood droplets during transvenous endomyocardial biopsy procedures (9.1%), and multiple errors in applying standard infection control measures (9.1%).
"We have found that several breaches in infection control measures, related to some routine clinical practices thought to be risk-free (e.g. point of care blood glucose monitoring or preparation and administration of common parenteral drugs with multi-vial compounds) could result in patient-to-patient transmission of the hepatitis B virus within healthcare settings," write Simone Lanini, MD, and colleagues from the Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani in Rome.
"Moreover some outbreak reports underlined that heart-transplant recipients are at risk of contracting hepatitis B virus infection during the transvenous endomyocardial biopsy (TEB) procedure through indirect contact with infected blood as a result of environmental contamination," the authors note.
The authors analyzed studies published between January 1992 and December 2007 and considered only outbreaks in the United States and the European Union because they both have high health standards and comparable sociodemographic indicators. The researchers excluded cases of healthcare worker-to-patient transmission of the hepatitis B virus. A PubMed search resulted in 93 papers, 23 of which met the researchers' inclusion criteria; 7 additional papers came from references and the Outbreak Database, the worldwide database for nosocomial outbreaks.
The researchers found that dialysis units had the highest number of hepatitis B virus outbreaks but that these outbreaks had the shortest duration and the fewest cases. The authors note that dialysis units have improved mandatory protocols for surveillance of blood-borne infections, which might explain the higher frequency of hepatitis B virus outbreak reports in these settings.
"Consistent with the Centers for Disease Control and Prevention (CDC) data, the results of this review strengthen the idea that dialysis itself is nowadays a rather safe procedure and that outbreaks are largely due to 'substantial deficiencies in recommended infection control practice, such as the use of multi-vial drugs, as well as failure to vaccinate hemodialysis patients against hepatitis B,' " according to the authors. In June 2007, the CDC recommended against the use of multivial compounds in its guidelines on preventing infection in healthcare settings.
The authors also note that multipatient capillary blood sampling devices for glucose monitoring in diabetic patients are presumed to be safe because of their disposable lancets. However, the transmission of the hepatitis B virus through the nondisposable components of these multipatient devices is possible, and they should be reserved for personal home use, according to the authors.
Heart transplant recipients are also at increased risk for infection with hepatitis B virus, largely through the TEB procedure, a method used to evaluate the status of cardiac transplant rejection. In the reports analyzed by the authors, however, infection occurred through the spread of blood droplets during purging of syringes and catheter withdrawal in TEB. These blood droplets can contaminate unwrapped TEB biopsy material and could then contaminate the next patient to undergo the procedure, the authors write.
The authors found no outbreaks related to endoscopic procedures and little difference in the pattern of outbreaks observed in the United States and European Union. Most of the outbreaks originated among patients already suffering some degree of immunosuppression, such as those with end-stage renal disease, diabetes, or neoplasms or those undergoing heart transplantation.
To prevent the transmission of blood-borne pathogens such as hepatitis B virus, healthcare workers should strictly adhere to standard safety procedures as well as infection control principles, the authors caution. They conclude that using sterile single-use disposable needles and avoiding multivial compounds is crucial. "These principles and practices need to be made explicit in institutional policies and reinforced through in-service education for all personnel involved in direct patient care," the researchers write.
The authors have disclosed no relevant financial relationships.
BMC Med. Published online April 8, 2009.
