BACKGROUND: Between 2009 and 2012, five outbreaks of hepatitis B virus (HBV) occurred in Virginia assisted living facilities (ALFs), all of which were associated with assisted monitoring of blood glucose (AMBG). The 31 acute cases of hepatitis B discovered during these investigations were universally preventable. In recent years, CDC guidance has clarified that any AMBG should be conducted using single-use, auto-retractable fingerstick devices, and HBV vaccination recommendations have been updated to include unvaccinated adults with diabetes aged 19 to 59.
METHODS: An HBV Prevention Workgroup was established to discuss and formulate solutions to prevent these outbreaks from occurring in the ALF setting. Because the Virginia Department of Social Services (DSS) licenses ALFs and the Department of Health Professionals (DHP) licenses some ALF staff, the HBV Workgroup sought collaborative interagency solutions including educational, regulatory, and infection prevention components.
RESULTS: The HBV Prevention Workgroup reviewed DSS regulations and their inspection processes that pertain to infection prevention policies and practices, staff training requirements, medication pass observations, and staff hepatitis B vaccination record keeping. Public health staff:
- Collaborated with DSS to: (1) develop and disseminate educational materials related to blood glucose monitoring and infection prevention practices to both licensing inspectors and ALF providers; (2) create an ALF provider update regarding the practices and equipment that should be in place during AMBG to prevent bloodborne pathogen transmission; (3) draft revisions to DSS regulations to address the need for enhanced clinical oversight, strengthened infection prevention policies, and increased training requirements; and (4) develop an algorithm to investigate infection prevention breaches related to diabetes care that are identified during a facility inspection.
- Partnered with DHP to update curriculum content for certified medication aides to teach proper ABGM techniques and bloodborne pathogen prevention strategies.
- Clarified billing practices with the Virginia Department of Medical Assistance Services to remove financial barriers to Medicaid clients living in ALFs so that they may be prescribed single-use auto-retractable lancets for AMBG.
- Revised health department investigation protocols for HBV cases and outbreaks to reflect knowledge gained.
CONCLUSIONS: The Virginia HBV Prevention Workgroup is tackling this issue in ALFs with an interagency, multidisciplinary approach. The successes to date are attributed to strong relationships and partnership building with non-public health agencies. More than 18 months have elapsed since the last known HBV outbreak in a Virginia ALF, and efforts continue to educate providers and advocate for policy change to address this public health problem.