Transmission of hepatitis B virus associated with assisted monitoring of blood glucose at an assisted living facility in New York State

A Narrative Review on Strategies for the Reversion of Prediabetes to Normoglycemia: Food Pyramid, Physical Activity, and Self-Monitoring Innovative Glucose Devices

In 2019, "Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report" was published. This consensus report, however, did not provide an easy way to illustrate to subjects with prediabetes (SwPs) how to follow a correct dietary approach. The purpose of this review is to evaluate current evidence on optimum dietary treatment of SwPs and to provide a food pyramid for this population. The pyramid built shows that everyday consumption should consist of: whole-grain bread or potatoes eaten with their skins (for fiber and magnesium) and low glycemic index carbohydrates (GI < 55%) (three portions); fruit and vegetables (5 portions), in particular, green leafy vegetables (for fiber, magnesium, and polyphenols); EVO oil (almost 8 g); nuts (30 g, in particular, pistachios and almonds); three portions of dairy products (milk/yogurt: 300-400 g/day); mineral water (almost 1, 5 L/day for calcium intake); one glass of wine (125 mL); and three cups of coffee. Weekly portions should include fish (four portions), white meat (two portions), protein plant-based food (four portions), eggs (egg portions), and red/processed meats (once/week). At the top of the pyramid, there are two pennants: a green one means that SwPs need some personalized supplementation (if daily requirements cannot be satisfied through diet, vitamin D, omega-3, and vitamin B supplements), and a red one means there are some foods and factors that are banned (simple sugar, refined carbohydrates, and a sedentary lifestyle). Three to four times a week of aerobic and resistance exercises must be performed for 30-40 min. Finally, self-monitoring innovative salivary glucose devices could contribute to the reversion of prediabetes to normoglycemia.

Association between self-monitoring of blood glucose and hepatitis B virus infection among people with diabetes mellitus: a cross-sectional study in Gansu Province, China

OBJECTIVE

The purpose was to explore the association between self-monitoring of blood glucose (SMBG) and hepatitis B virus (HBV) infection among people with diabetes.

DESIGN

A cross-sectional comparative study.

SETTING

Six township hospitals in Gansu Province, China in October 2018.

PARTICIPANTS

408 patients with diabetes were systematically recruited, and based on their characteristics 408 people without diabetes were randomly matched 1:1.

INTERVENTIONS

Venous blood was collected for HBV serological testing and blood glucose testing.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was comparison of hepatitis B surface antigen (HBsAg) positive rates between the two groups. The secondary outcome was the relationship between frequency of SMBG and HBsAg positivity.

RESULTS

HBsAg positive rate in people without diabetes was 2.0% and in those with diabetes was 4.2%. Whether in people without diabetes or patients with diabetes, higher frequency of SMBG was associated with higher HBsAg positive rate. Increases in the duration of diabetes were correlated with increasing rates of HBsAg. Compared with people without diabetes, logistic regression identified an association between diabetes and HBV infection (OR=2.8; 95% CI 1.0 to 7.6), but impaired fasting glucose was not (OR=2.3; 95% CI 0.5 to 9.9).

CONCLUSION

Routine blood glucose monitoring at home was associated with HBV infection, which meant people with diabetes may be at high risk of HBV infection. China is a country with high prevalence of both HBsAg and diabetes, and the increased risk of HBV infection in populations with diabetes needs more attention.

Assessing Infection Risks among Clients and Staff Who Use Tattooing Services in Poland: An Observational Study

Across cultures and generations, people have tattooed their bodies. Although blood-borne infections from tattooing have been reduced, certain service aspects remain improperly managed. We assessed the infection risks associated with tattooing by conducting a cross-sectional study (2013–2014) in Poland using an anonymous questionnaire survey. Scoring procedures for blood-borne infection risks for tattooists and their clients were used. Overall, 255 tattooists were interviewed. A quasi-random selection of tattoo parlors was based on a service register. Knowledge, attitudes, and behavior regarding blood-borne infection risks were assessed using a questionnaire. Simultaneously, tattoo centers were audited. Tattooing had a higher infection risk for tattooists than for clients. Approximately 50% of respondents underwent training on postexposure procedures, which constituted almost one in five of the reported needlestick/cut injuries sustained while working. Furthermore, 25.8% had no knowledge regarding risk from reliable sources, and 2.1% had not broadened their knowledge. Tattooists and their clients are at a risk of infection, and knowledge concerning infection risks remains an underestimated preventative factor. Service quality surveillance and creation of a register for tattoo-related complications may help assess the scale of this public health issue. However, a lack of these records implies the challenges in developing effective organizational and legal protections.

Increased risk of hepatitis B virus infection amongst individuals with diabetes mellitus

There have been reports of hepatitis B outbreaks amongst diabetics in long-term care facilities, suggesting that risk of hepatitis B virus (HBV) infection is higher in this population. However, the magnitude of the risk and the incidence of HBV infection amongst the general diabetic population in China remains unknown. Data from a cohort study conducted in Mianyang City, Sichuan Province, China, were retrospectively analyzed in order to address this question. Demographic information was collected using a custom-designed questionnaire, and blood samples were tested for HBV using ELISA. We used multivariate logistic regression to explore the relationship between HBV infection and diabetes, while adjusting for age, sex, region, medical insurance, exposure history, and HBV vaccination. During 2013-2014, a total of 189766 adults were surveyed, of which 7382 were newly infected with HBV, corresponding to an incidence of 3.89%. In this study population, there were 4982 diabetic patients and 182710 non-diabetic individuals. Amongst those with diabetes, 265 (5.32%) were newly infected with HBV. In contrast, 7038 (3.85%) in the non-diabetic population were newly infected with HBV. The relative risk (RR) of HBV infection was 43% higher amongst those diagnosed with diabetes than amongst those not diagnosed (RR 1.43, 95% confidence interval (CI) 1.26-1.63). These results suggest that the risk of HBV infection is higher amongst individuals diagnosed with diabetes mellitus in Mianyang City, Sichuan Province, China. Hepatitis B vaccination and continuous infection control practices may help to reduce HBV infection in diabetic patients, and should be considered for diabetes management.

Prevalence of serological markers for hepatitis and potential associated factors in patients with diabetes mellitus

Objective:

to estimate the prevalence of serological markers for hepatitis B and C in patients with diabetes mellitus and analyze potential associated factors.

Method:

a cross-sectional study with 255 patients with diabetes mellitus. Demographic, clinical, and risk behavior factors for hepatitis B and C were selected. The markers HBsAg, Anti-HBc IgG, Anti-HBc IgM, Anti-HBs, and Anti-HCV were investigated. A questionnaire and venous blood collection and inferential statistical analysis were used.

Results:

16.8% of the patients had a total reactive Anti-HBc marker, 8.2% an isolated Anti-HBs, and 75% were non-reactive for all hepatitis B markers. No case of reactive HBsAg was found and 3.3% of the patients had a reactive anti-HCV marker. The prevalence of prior hepatitis B virus infection was directly associated with the time of diabetes mellitus and the prevalence of hepatitis C virus infection was not associated with the investigated variables. The prevalence of hepatitis B and C infection in patients with diabetes mellitus was higher when compared to the national, with values of 16.8% and 3.3%, respectively.

Conclusion:

the results suggest that patients with diabetes are a population of higher vulnerability to hepatitis B and C, leading to the adoption of preventive measures of their occurrence.

Demonstration of disinfection procedure for the development of accurate blood glucose meters in accordance with ISO 15197:2013

Despite measures to reduce disease transmission, a risk can occur when blood glucose meters (BGMs) are used on multiple individuals or by caregivers assisting a patient. The laboratory and in-clinic performance of a BGM system before and after disinfection should be demonstrated to guarantee accurate readings and reliable control of blood glucose (BG) for patients. In this study, an effective disinfection procedure, conducting wiping 10 times to assure a one minute contact time of the disinfectant on contaminated surface, was first demonstrated using test samples of the meter housing materials, including acrylonitrile butadiene styrene (ABS), polymethyl methacrylate (PMMA), and polycarbonate (PC), in accordance with ISO 15197:2013. After bench studies comprising 10,000 disinfection cycles, the elemental compositions of the disinfected ABS, PMMA, and PC samples were almost the same as in the original samples, as indicated by electron spectroscopy for chemical analysis. Subsequently, the validated disinfection procedure was then directly applied to disinfect 5 commercial BGM systems composed of ABS, PMMA, or PC to observe the effect of the validated disinfection procedure on meter accuracy. The results of HBsAg values after treatment with HBV sera and disinfectant wipes for each material were less than the LoD of each material of 0.020 IU/mL. Before and after the multiple disinfection cycles, 900 of 900 samples (100%) were within the system accuracy requirements of ISO 15197:2013. All of the systems showed high performance before and after the series of disinfection cycles and met the ISO 15197:2013 requirements. In addition, our results demonstrated multiple cleaning and disinfection cycles that represented normal use over the lifetime of a meter of 3-5 years. Our validated cleaning and disinfection procedure can be directly applied to other registered disinfectants for cleaning commercial BGM products in the future.

Hepatitis B outbreak associated with a home health care agency serving multiple assisted living facilities in Texas, 2008-2010

We investigated a multifacility outbreak of acute hepatitis B virus infection involving 21 residents across 10 assisted living facilities in Texas during the period January 2008 through July 2010. Epidemiologic and laboratory data suggested that these infections belonged to a single outbreak. The only common exposure was receipt of assisted monitoring of blood glucose from the same home health care agency. Improved infection control oversight and training of assisted living facility and home health care agency personnel providing assisted monitoring of blood glucose is needed.

Infection prevention and control standards in assisted living facilities: are residents' needs being met?

BACKGROUND

Assisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities.

OBJECTIVES

Describe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training.

METHODS

We abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities.

RESULTS

Of the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating.

CONCLUSIONS

There is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.

Acute hepatitis B outbreaks in 2 skilled nursing facilities and possible sources of transmission: North Carolina, 2009-2010

OBJECTIVE

Acute hepatitis B virus (HBV) infections have been reported in long-term care facilities (LTCFs), primarily associated with infection control breaks during assisted blood glucose monitoring. We investigated HBV outbreaks that occurred in separate skilled nursing facilities (SNFs) to determine factors associated with transmission.

DESIGN

Outbreak investigation with case-control studies.

SETTING

Two SNFs (facilities A and B) in Durham, North Carolina, during 2009-2010.

PATIENTS

Residents with acute HBV infection and controls randomly selected from HBV-susceptible residents during the outbreak period.

METHODS

After initial cases were identified, screening was offered to all residents, with repeat testing 3 months later for HBV-susceptible residents. Molecular testing was performed to assess viral relatedness. Infection control practices were observed. Case-control studies were conducted to evaluate associations between exposures and acute HBV infection in each facility.

RESULTS

Six acute HBV cases were identified in each SNF. Viral phylogenetic analysis revealed a high degree of HBV relatedness within, but not between, facilities. No evaluated exposures were significantly associated with acute HBV infection in facility A; those associated with infection in facility B (all odds ratios >20) included injections, hospital or emergency room visits, and daily blood glucose monitoring. Observations revealed absence of trained infection control staff at facility A and suboptimal hand hygiene practices during blood glucose monitoring and insulin injections at facility B.

CONCLUSIONS

These outbreaks underscore the vulnerability of LTCF residents to acute HBV infection, the importance of surveillance and prompt investigation of incident cases, and the need for improved infection control education to prevent transmission.

Case-control study of hepatitis B and hepatitis C in older adults: Do healthcare exposures contribute to burden of new infections?

Reports of hepatitis B virus (HBV) and hepatitis C virus (HCV) transmission associated with unsafe medical practices have been increasing in the United States. However, the contribution of healthcare exposures to the burden of new infections is poorly understood outside of recognized outbreaks. We conducted a case-control study at three health departments that perform enhanced viral hepatitis surveillance in New York and Oregon. Reported cases of symptomatic acute hepatitis B and hepatitis C occurring in persons≥55 years of age from 2006 to 2008 were enrolled. Controls were identified using telephone directories and matched to individual cases by age group (55-59, 60-69, and ≥70 years) and residential postal code. Data collection covered exposures within 6 months before symptom onset (cases) or date of interview (controls). Forty-eight (37 hepatitis B and 11 hepatitis C) case and 159 control patients were enrolled. Case patients were more likely than controls to report one or more behavioral risk exposures, including sexual or household contact with an HBV or HCV patient, >1 sex partner, illicit drug use, or incarceration (21% of cases versus 4% of controls exposed; matched odds ratio [mOR]=7.1; 95% confidence interval [CI]: 2.1, 24.1). Case patients were more likely than controls to report hemodialysis (8% of cases; mOR=13.0; 95% CI: 1.5, 115), injections in a healthcare setting (58%; mOR=2.7; 95% CI: 1.3, 5.3), and surgery (33%; mOR=2.3; 95% CI: 1.1, 4.7). In a multivariate model, behavioral risks (adjusted OR [aOR]=5.4; 95% CI: 1.5, 19.0; 17% attributable risk), injections (aOR=2.7; 95% CI: 1.3, 5.8; 37% attributable risk), and hemodialysis (aOR=11.5; 95% CI: 1.2, 107; 8% attributable risk) were associated with case status.

CONCLUSION

Healthcare exposures may represent an important source of new HBV and HCV infections among older adults.

Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility-Virginia, 2010

Introduction

In January 2010, the Virginia Department of Health received reports of 2 hepatitis B virus (HBV) infections (1 acute, 1 chronic) among residents of a single assisted living facility (ALF). Both infected residents had diabetes and received assisted monitoring of blood glucose (AMBG) at the facility. An investigation was initiated in response.

Objective

To determine the extent and mechanism of HBV transmission among ALF residents.

Design

Retrospective cohort study.

Setting

An ALF that primarily housed residents with neuropsychiatric disorders in 2 adjacent buildings in Virginia.

Participants

Residents of the facility as of March 2010.

Measurements

HBV serologic testing, relevant medical history, and HBV genome sequences. Risk ratios (RR) and 95% confidence intervals (CIs) were used to identify risk factors for HBV infection.

Results

HBV serologic status was determined for 126 (91%) of 139 residents. Among 88 susceptible residents, 14 became acutely infected (attack rate, 16%), and 74 remained uninfected. Acute HBV infection developed among 12 (92%) of 13 residents who received AMBG, compared with 2 (3%) of 75 residents who did not (RR  = 35; 95% CI, 8.7, 137). Identified infection control breaches during AMBG included shared use of fingerstick devices for multiple residents. HBV genome sequencing demonstrated 2 building-specific phylogenetic infection clusters, each having 99.8–100% sequence identity.

Limitations

Transfer of residents out of the facility prior to our investigation might have contributed to an underestimate of cases. Resident interviews provided insufficient information to fully assess behavioral risk factors for HBV infection.

Conclusions

Failure to adhere to safe practices during AMBG resulted in a large HBV outbreak. Protection of a growing and vulnerable ALF population requires improved training of staff and routine facility licensing inspections that scrutinize infection control practices.

Increased risk of acute hepatitis B among adults with diagnosed diabetes mellitus

INTRODUCTION

The risk of acute hepatitis B among adults with diabetes mellitus is unknown. We investigated the association between diagnosed diabetes and acute hepatitis B.

METHODS

Confirmed acute hepatitis B cases were reported in 2009-2010 to eight Emerging Infections Program (EIP) sites; diagnosed diabetes status was determined. Behavioral Risk Factor Surveillance System respondents residing in EIP sites comprised the comparison group. Odds ratios (ORs) comparing acute hepatitis B among adults with diagnosed diabetes versus without diagnosed diabetes were determined by multivariate logistic regression, adjusting for age, sex, and race/ethnicity, and stratified by the presence or absence of risk behaviors for hepatitis B virus (HBV) infection.

RESULTS

During 2009-2010, EIP sites reported 865 eligible acute hepatitis B cases among persons aged ≥23 years; 95 (11.0%) had diagnosed diabetes. Comparison group diabetes prevalence was 9.1%. Among adults without hepatitis B risk behaviors and with reported diabetes status, the OR for acute hepatitis B comparing adults with and without diabetes was 1.9 (95% confidence interval [CI] = 1.4, 2.6); ORs for adults ages 23-59 and ≥60 years were 2.1 (95% CI = 1.6, 2.8) and 1.5 (95% = CI 0.9, 2.5), respectively.

CONCLUSIONS

Diabetes was independently associated with an increased risk for acute hepatitis B among adults without HBV risk behaviors.