Transcript Presenter Disclosures Patricia High, MHS, MCHES

Maximizing health department
resources to identify and prevent
outbreaks of healthcare associated
transmission of viral hepatitis
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
Presenter Disclosures
Patricia High, MHS, MCHES
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
“No relationships to disclose”
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
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Background
• Since 1999, 620 patients were infected in 51 outbreaks
• Majority of outbreaks (42 out of 51) occurred in nonhospital 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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
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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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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
28,772
553
# Confirmed Acute Cases
639
12
# Acute Cases ≥65 Years
155
3
49,720
956
# Confirmed Acute Cases
270
5
# Acute Cases ≥65 Years
36
1
# Hepatitis B Reports
# Hepatitis C Reports
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
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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
If no information is received from
physician for possible acute HBV, how
often do you contact the patient?
60%
53%
50%
40%
30%
17%
20%
13%
8%
10%
9%
0%
Always
Often
Promoting Healthy Lifestyles and a Clean and Safe Environment
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Sometimes
Rarely
Never
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
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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.
LHD Response to Anti-HCV Screening Tests
Investigate by contacting physician
65%
If already in CDRSS, change case status to "not…
33%
Manually enter into CDRSS as "not a case"
22%
Discard/shred/delete
20%
Investigate by contacting laboratory
16%
Investigate by contacting patient
6%
0%
10%
20%
30%
40%
Promoting Healthy Lifestyles and a Clean and Safe Environment
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50%
60%
70%
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
If information is received from physician
indicating acute HCV infection, how
often do you contact the patient?
50%
45%
45%
40%
35%
30%
25%
19%
20%
13%
15%
13%
9%
10%
5%
0%
Always
Often
Promoting Healthy Lifestyles and a Clean and Safe Environment
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Sometimes
Rarely
Never
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.
Response to more than one acute case of HBV or HCV with similar
healthcare associated exposures
Call Regional Epidemiologist
77.3%
Call NJDHSS
72.7%
Contact implicated facility/physician
50.0%
Document in CDRSS and close case
29.5%
Perform chart review
27.3%
0%
10%
20%
30%
40%
50%
60%
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
70%
80%
90%
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
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
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
HBV Serology and Immunology
Symptoms
HBeAg
anti-HBe
Total anti-HBc
Titer
IgM anti-HBc
HBV DNA
anti-HBs
HBsAg
Window
Period
0
4
8
12
16
20
24
28
32
36
Weeks after Exposure
Promoting Healthy Lifestyles and a Clean and Safe Environment
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52
100
Laboratory Test Interpretation
Hepatitis
Serology
HBsAg
HBcIgM
HBsAb
HBeAg
Serology as Recorded in CDRSS
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.
HBV CORE IGM ANTIBODY - Positivity
indicates recent infection with HBV (<6 mos)
indicating acute infection.
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.
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
HBsAg
Negative
HBcIgM
Negative
HBsAb
Negative
HBsAg
Negative
HBcAb
Positive
HBsAb
Positive
HBsAg
Negative
HBcAb
Negative
HBsAb
Positive
HBsAg
Positive
HBcAb
Positive
HBcIgM
Positive
HBsAb
Negative
HBsAg
Positive
HBcAb
Positive
HBcIgM
Negative
HBsAb
Negative
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Interpretation
Susceptible
Immune due to
natural infection
Immune due to
hepatitis B
vaccination
Acutely infected
Chronically
infected
Laboratory Test Interpretation
Hepatitis Serology
Result
Interpretation
HBsAg
Positive
1.
2.
Chronically infected (HBcAb+)
Recent receipt of HBV vaccination possible (HBcAb-)
HBcIgM
Positive
1.
2.
3.
Acute infection (HBsAg+)
Resolving acute infection (HBsAg- <6 months)
Resolved infection with a failure of HBcIgM to seroconvert to HBcAb+
alone (HBsAg- >6 months)
HBsAg
Positive
HBcIgM
Positive
1.
Acute infection
HBeAg
Positive
1.
2.
Chronically infected, highly infectious (HBsAg+, HBcIgM-)
Acute infection, highly infectious (HBsAg+, HBcIgM+)
Promoting Healthy Lifestyles and a Clean and Safe Environment
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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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
Algorithm for Investigating Hepatitis B and Hepatitis C Reports
TRIGGERS FOR PUBLIC HEALTH INVESTIGATION
·
·
·
·
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
YES
NO
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
·
·
·
·
·
·
·
Sexual contact of HBV/HCV+ person
Incarceration
IVDU
Tattoos/Piercings
MSM
War veteran
Blood transfusion
·
·
·
Jaundice, dark urine
Abdominal pain, anorexia, nausea
LFTs ≥5x normal limit
Ask about traditional risk factors:
Standardized
Guidelines for
Investigating
cases of HBV
and HCV
ASYMPTOMATIC
Chronic
Pregnant?
(HBV only)
Ask if patient is symptomatic?
YES
Initiate perinatal
investigation
NO
Educate/Close
case in CDRSS
SYMPTOMATIC/ ACUTE
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)
RECENT BLOOD DONOR
TRADITIONAL RISK FACTORS
PRESENT
Contact NJDHSS
Educate/Close
case in CDRSS
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
HEALTHCARE RISK
FACTORS PRESENT
Document all invasive procedures/risks
in CDRSS
·
·
·
Procedure type/description
Date of procedure/risk
Performing clinician/facility
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Educate/Close
case in CDRSS
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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
Conclusion
• By prioritizing viral hepatitis investigation,
local investigation resources are optimized to
provide maximum public health impact.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org
Thank you!
Patricia High, MHS, MCHES
Ocean 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.
Promoting Healthy Lifestyles and a Clean and Safe Environment
732-341-9700 • www.ochd.org