1. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Maximizing health department resources to identify and prevent outbreaks of healthcare associated transmission of viral hepatitis

2. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Presenter Disclosures Patricia High, MHS, MCHES “No relationships to disclose” The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

3. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Needs Assessment Fifty-two respondents reported having a total of 28,772 Hepatitis B and 49,720 Hepatitis C reports between 2007-2009. TOTAL REPORTSAverage by Respondent # Hepatitis B Reports28,772553 # Confirmed Acute Cases63912 # Acute Cases ≥65 Years1553 # Hepatitis C Reports49,720956 # Confirmed Acute Cases2705 # Acute Cases ≥65 Years361

10. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org IgM anti-HBc HBsAg 0481216 20 242832 36 52100 Weeks after Exposure Titer HBeAganti-HBe Symptoms anti-HBs Total anti-HBc HBV DNA Window Period HBV Serology and Immunology

20. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Laboratory Test Interpretation Hepatitis Serology Serology as Recorded in CDRSS HBsAg HBV SURFACE ANTIGEN - A protein on the surface of HBV; it can be detected in high levels in serum during acute or chronic HBV infection. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine. HBcIgM HBV CORE IGM ANTIBODY - Positivity indicates recent infection with HBV (<6 mos) indicating acute infection. HBsAb HBV SURFACE AB - The presence of anti-HBs is generally interpreted as indicating recovery and immunity from HBV infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B. HBeAg HBV SURFACE LITTLE E ANTIGEN - HBeAg screening typically is used for the management of patients with chronic infection. The presence of HBeAg correlates with high levels of viral replication. Hepatitis Serology ResultInterpretation HBsAgNegative Susceptible HBcIgMNegative HBsAbNegative HBsAgNegative Immune due to natural infection HBcAbPositive HBsAbPositive HBsAgNegative Immune due to hepatitis B vaccination HBcAbNegative HBsAbPositive HBsAgPositive Acutely infected HBcAbPositive HBcIgMPositive HBsAbNegative HBsAgPositive Chronically infected HBcAbPositive HBcIgMNegative HBsAbNegative

21. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Laboratory Test Interpretation Hepatitis SerologyResultInterpretation HBsAgPositive 1.Chronically infected (HBcAb+) 2.Recent receipt of HBV vaccination possible (HBcAb-) HBcIgMPositive 1.Acute infection (HBsAg+) 2.Resolving acute infection (HBsAg- <6 months) 3.Resolved infection with a failure of HBcIgM to seroconvert to HBcAb+ alone (HBsAg- >6 months) HBsAgPositive 1.Acute infection HBcIgMPositive HBeAgPositive1.Chronically infected, highly infectious (HBsAg+, HBcIgM-) 2.Acute infection, highly infectious (HBsAg+, HBcIgM+)

22. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Standardized Guidelines for Investigating cases of HBV and HCV

24. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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.

25. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org

26. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org Conclusion By prioritizing viral hepatitis investigation, local investigation resources are optimized to provide maximum public health impact.

27. Promoting Healthy Lifestyles and a Clean and Safe Environment 732-341-9700 www.ochd.org 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.