Presenter Disclosures

1. Maximizing health department resources to identify and prevent outbreaks of healthcare associated transmission of viral hepatitis

2. 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”

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Needs Assessment • Fifty-two respondents reported having a total of 28,772 Hepatitis B and 49,720 Hepatitis C reports between 2007-2009.

10. 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.

11. 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

12. 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.

13. 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.

14. 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

15. 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.

16. 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.

17. 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 √ √

18. 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

19. Total anti-HBc IgM anti-HBc anti-HBs HBV Serology and Immunology Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg Window Period 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

20. Laboratory Test Interpretation

21. Laboratory Test Interpretation

22. 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.

23. Standardized Guidelines for Investigating cases of HBV and HCV

24. 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.

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

27. 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.