BACKGROUND: Hepatitis B virus (HBV) is an infectious disease spread through blood or bodily fluids which can cause both acute and chronic infections. On October 24, 2016, we identified two cases of acute HBV in employees of a facility caring for individuals with intellectual disabilities. The facility consisted of four residential homes and a day program. We investigated to determine if the employees’ infections were related, the extent of the outbreak and to implement control measures.
METHODS: Three onsite visits were conducted in November and December. We performed direct observations of infection control practices including hand hygiene and diabetic care. We also interviewed staff, and reviewed resident records and policies including the employee HBV vaccination program. We recommended bloodborne pathogen testing for 51 current and 19 former staff and 11 residents, followed by HBV vaccination. HBV-positive specimens were sent to CDC to quantify viral DNA and for whole genome sequencing (WGS). We initiated weekly conference calls in November to provide ongoing guidance.
RESULTS: We observed cross-contamination of clean and dirty body sites during routine hygiene, overfilled sharps containers, inadequate hand hygiene and gloving, and use of inappropriate cleaning products. Personnel records showed 68/72 (94%) employees declined HBV vaccination, most without record of previous vaccination. Records for bloodborne pathogen and diabetic care education showed that 50/51 (98%) and 15/51 (29%) of current staff completed trainings, respectively. Per facility records, no residents had a history of chronic HBV. However, our testing identified one diabetic resident as a chronic carrier with a high viral load (HBV DNA >170,000,000). Specimens from the 2 employees with acute infection and the HBV-positive resident were identical by WGS. All residents were vaccinated for HBV. Despite weekly calls with group home administrators, testing and vaccination recommendations for employees were inadequately addressed; only 6/51 (12%) of current employees had documented HBV vaccination. In response, we provided individual education to employees via telephone followed by an onsite HBV vaccination clinic on December 21.
CONCLUSIONS: Lack of training on diabetic care, low rates of employee HBV vaccination, and suboptimal infection control likely contributed to HBV transmission in a group home. Employee exposure to an unrecognized HBV chronic carrier with a high viral load highlights the importance of standard precautions during all resident care. In addition, determining the management’s understanding of employee HBV vaccination and importance of infection control training was a priority in implementing control measures