Rebecca Greeley

Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009

BACKGROUND Transmission of bloodborne pathogens due to breaches in infection control is becoming increasingly recognized as greater emphasis is placed on reducing health care-associated infections. Two women, aged 60 and 77 years, were diagnosed with acute hepatitis B virus (HBV) infection; both received chemotherapy at the same physicians office. Due to suspicion of health care-associated HBV transmission, a multidisciplinary team initiated an investigation of the hematology-oncology office practice. METHODS We performed an onsite inspection and environmental assessment, staff interviews, records review, and observation of staff practices. Patients who visited the office practice between January 1, 2006 and March 3, 2009 were advised to seek testing for bloodborne pathogens. Patients and medical providers were interviewed. Specimens from HBV-infected patients were sent to the Centers for Disease Control and Prevention for HBV DNA testing and phylogenic analysis. RESULTS Multiple breaches in infection control were identified, including deficient policies and procedures, improper hand hygiene, medication preparation in a blood processing area, common-use saline bags, and reuse of single-dose vials. The office practice was closed, and the physicians license was suspended. Out of 2,700 patients notified, test results were available for 1,394 (51.6%). Twenty-nine outbreak-associated HBV cases were identified. Specimens from 11 case-patients demonstrated 99.9%-100% nucleotide identity on phylogenetic analysis. CONCLUSION Systematic breaches in infection control led to ongoing transmission of HBV infection among patients undergoing invasive procedures at the office practice. This investigation underscores the need for improved regulatory oversight of outpatient health care settings, improved infection control and injection safety education for health care providers, and the development of mechanisms for ongoing communication and cooperation among public health agencies.

Under the Weather: Legionellosis and Meteorological Factors

The incidence of legionellosis, caused by the bacteria Legionella which are commonly found in the environment, has been increasing in New Jersey (NJ) over the last decade. The majority of cases are sporadic with no known source of exposure. Meteorological factors may be associated with increases in legionellosis. Time series and case-crossover study designs were used to evaluate associations of legionellosis and meteorological factors (temperature (daily minimum, maximum, and mean), precipitation, dew point, relative humidity, sea level pressure, wind speed (daily maximum and mean), gust, and visibility). Time series analyses of multi-factor models indicated increases in monthly relative humidity and precipitation were positively associated with monthly legionellosis rate, while maximum temperature and visibility were inversely associated. Case-crossover analyses of multi-factor models indicated increases in relative humidity occurring likely before incubation period was positively associated, while sea level pressure and visibility, also likely preceding incubation period, were inversely associated. It is possible that meteorological factors, such as wet, humid weather with low barometric pressure, allow proliferation of Legionella in natural environments, increasing the rate of legionellosis.

Multiple introductions and subsequent transmission of multidrug-resistant Candida auris in the USA: a molecular epidemiological survey

BACKGROUND Transmission of multidrug-resistant Candida auris infection has been reported in the USA. To better understand its emergence and transmission dynamics and to guide clinical and public health responses, we did a molecular epidemiological investigation of C auris cases in the USA. METHODS In this molecular epidemiological survey, we used whole-genome sequencing to assess the genetic similarity between isolates collected from patients in ten US states (California, Connecticut, Florida, Illinois, Indiana, Maryland, Massachusetts, New Jersey, New York, and Oklahoma) and those identified in several other countries (Colombia, India, Japan, Pakistan, South Africa, South Korea, and Venezuela). We worked with state health departments, who provided us with isolates for sequencing. These isolates of C auris were collected during the normal course of clinical care (clinical cases) or as part of contact investigations or point prevalence surveys (screening cases). We integrated data from standardised case report forms and contact investigations, including travel history and epidemiological links (ie, patients that had shared a room or ward with a patient with C auris). Genetic diversity of C auris within a patient, a facility, and a state were evaluated by pairwise differences in single-nucleotide polymorphisms (SNPs). FINDINGS From May 11, 2013, to Aug 31, 2017, isolates that corresponded to 133 cases (73 clinical cases and 60 screening cases) were collected. Of 73 clinical cases, 66 (90%) cases involved isolates related to south Asian isolates, five (7%) cases were related to South American isolates, one (1%) case to African isolates, and one (1%) case to east Asian isolates. Most (60 [82%]) clinical cases were identified in New York and New Jersey; these isolates, although related to south Asian isolates, were genetically distinct. Genomic data corroborated five (7%) clinical cases in which patients probably acquired C auris through health-care exposures abroad. Among clinical and screening cases, the genetic diversity of C auris isolates within a person was similar to that within a facility during an outbreak (median SNP difference three SNPs, range 0-12). INTERPRETATION Isolates of C auris in the USA were genetically related to those from four global regions, suggesting that C auris was introduced into the USA several times. The five travel-related cases are examples of how introductions can occur. Genetic diversity among isolates from the same patients, health-care facilities, and states indicates that there is local and ongoing transmission. FUNDING US Centers for Disease Control and Prevention.

Notes from the Field: Injection Safety and Vaccine Administration Errors at an Employee Influenza Vaccination Clinic--New Jersey, 2015.

On September 30, 2015, the New Jersey Department of Health (NJDOH) was notified by an out-of-state health services company that an experienced nurse had reused syringes for multiple persons earlier that day. This occurred at an employee influenza vaccination clinic on the premises of a New Jersey business that had contracted with the health services company to provide influenza vaccinations to its employees. The employees were to receive vaccine from manufacturer-prefilled, single-dose syringes. However, the nurse contracted by the health services company brought three multiple-dose vials of vaccine that were intended for another event. The nurse reported using two syringes she found among her supplies to administer vaccine to 67 employees of the New Jersey business. She reported wiping the syringes with alcohol and using a new needle for each of the 67 persons. One of the vaccine recipients witnessed and questioned the syringe reuse, and brought it to the attention of managers at the business who, in turn, reported the practice to the health services company contracted to provide the influenza vaccinations.

Multistate Outbreak of Burkholderia cepacia Complex Bloodstream Infections After Exposure to Contaminated Saline Flush Syringes — United States, 2016–2017

Background Burkholderia cepacia complex (Bcc) has caused healthcare-associated outbreaks, often in association with contaminated products. The identification of four Bcc bloodstream infections (BSIs) in patients residing at a single skilled nursing facility (SNF) within one week led to an epidemiological investigation to identify additional cases and the outbreak source. Methods A case was initially defined as a blood culture yielding Bcc in a SNF resident receiving intravenous therapy after August 1, 2016. Multistate notifications were issued to identify additional cases. Public health authorities performed site visits at facilities with cases to conduct chart reviews and identify possible sources. Pulsed-field gel electrophoresis (PFGE) was performed on isolates from cases and suspect products. Facilities involved in manufacturing suspect products were inspected to assess possible root causes. Results An outbreak of 162 Bcc BSIs across 59 nursing facilities in 5 states occurred during September 2016-January 2017. Isolates from patients and pre-filled saline flush syringes were closely related by PFGE, identifying contaminated flushes as the outbreak source and prompting a nationwide recall. Inspection of facilities at the saline flush manufacturer identified deficiencies which might have led to the failure to sterilize a specific case containing a partial lot of product. Conclusions Communication and coordination among key stakeholders, including healthcare facilities, public health authorities, and state and federal agencies, led to the rapid identification of an outbreak source and likely prevented many additional infections. Effective processes to ensure the sterilization of injectable products are essential to prevent similar outbreaks in the future.