Health care-Associated Hepatitis B and C Outbreaks (≥ 2 cases) Reported to the Centers for Disease Control and Prevention (CDC) 2008-2019

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The tables below summarize health care-associated outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection reported in the United States during 2008-2019. Outbreaks previously reported in 1998-2008 can be found in Thompson, et al and Redd, et al. Because of the long incubation period (up to 6 months) and typically asymptomatic course of acute hepatitis B and C infection, it is likely that only a fraction of such outbreaks that occurred have been detected, and reporting of outbreaks detected and investigated by state and local health departments is not required. Therefore, the numbers reported here may greatly underestimate the number of outbreak-associated cases and the number of at-risk persons notified for screening.

Practical guidance on detecting and investigating such outbreaks may be found in the Health care Investigation Guide.

Resources for prevention include updated hepatitis B immunization guidelines, and infection control guidelines and resources.

Note: this page is available in printable form [PDF – 29 pages].

Summary

66 outbreaks (two or more cases) of viral hepatitis related to health care reported to CDC during 2008-2019; of these, 62 (94%) occurred in non-hospital settings.

Hepatitis B (total 25 outbreaks including two of both HBV and HCV, 183 outbreak-associated cases, 13,246 persons notified for screening):

  • 19 outbreaks occurred in long-term care facilities, with at least 133 outbreak-associated cases of HBV and approximately 1,679 at-risk persons notified for screening
    • 79% (15/19) of the outbreaks were associated with infection control breaks during assisted monitoring of blood glucose (AMBG)
  • 6 outbreaks occurred in other settings, one each at: an outpatient cardiology clinic, a free dental clinic in school gymnasium, an outpatient oncology clinic, a hospital surgery service, and two at pain remediation clinics (one outbreak of HBV and one with both HBV and HCV), with 50 outbreak-associated cases of HBV and 11,567 persons at-risk persons notified for screening

Hepatitis C (43 total outbreaks including two of both HBV and HCV , 328 outbreak-associated cases, >112,406 at-risk persons notified for screening):

  • 16 outbreaks occurred in outpatient or long-term care facilities (including the two outbreaks of both HBV and HCV also listed above), with 134 outbreak-associated cases of HCV and >80,293 persons notified for screening
  • 22 outbreaks occurred in hemodialysis settings, with 104 outbreak-associated cases of HCV and 3,134 persons notified for screening
  • Four outbreaks occurred because of drug diversion by HCV-infected health care providers, with at least 90 outbreak-associated cases of HCV and 28,989 persons notified for screening

Single identified cases are not included in the table and may be particularly difficult to confirm as health care-associated infection transmission events. However, although this list is not exhaustive, during 2008-2018 the following single cases were reported and confirmed as likely patient-to-patient health care-associated transmission:

Hepatitis B (HBV) Outbreaks by Setting
Hepatitis B (HBV) Outbreaks by Setting
Setting Year State Persons Notified for Screening1 Outbreak-Associated Infections2 Known or suspected mode of transmission3 Comments
Long-term care 4
Personal care home (1)
2016
PA
82
2
 Multiple infection control breaches primarily suboptimal universal precautions during provision of care including assistance with personal hygiene and blood glucose monitoring 2 staff members infected; all residents and staff screened. Source patient had very high viral load
Personal care home (2)
2014
PA
49
8
 Unsafe practices related to assisted blood glucose monitoring
Sub-acute unit of a skilled nursing facility (3)
2014
CA
158
7
 Infection control breaches related to instrument sterilization during the provision of podiatry care were identified; however, evidence was insufficient to implicate a specific source of transmission. Of the 7 outbreak cases, viral molecular sequencing of DNA from 4 acute infections matched into a cluster with one chronic case. Sequencing could not be performed for three cases with serology indicative of resolving acute infection.
Assisted living facility (4)
2012
VA
84
2
 Use of fingerstick devices for >1 resident
Assisted living facility (5)
(most residents with neuropsychiatric disorders)
2011
VA
103
7
 Use of fingerstick devices for >1 resident An additional 4 new chronic infections were detected; of these 3 had viral molecular sequencing and all matched into the cluster with the acute cases indicating likely outbreak-related cases.
Assisted living facility (6)
2011
CA
14
2
 Use of blood glucose meter for >1 resident without cleaning and disinfection
Failure to maintain separation of clean and contaminated podiatry equipment
Improper reprocessing of contaminated podiatry equipment
Failure to perform environmental cleaning and disinfection between podiatry patients		 Both infected residents received assisted monitoring of blood glucose as well as podiatry services.
Assisted living facility (7)
2010
CA
28
3
 Unsafe practices related to assisted blood glucose monitoring
Although a clear infection prevention breach was not identified at the time of the investigation, all infections were in residents receiving assisted monitoring of blood glucose by the same home health agency. The home health agency lacked written policies on infection control relating to blood glucose monitoring.
Assisted living facility (8)
2010
NC
87
8
 Use of fingerstick devices for >1 resident
Use of blood glucose meter for >1 resident without cleaning and disinfection		  

6 of 8 case patients died from complications of hepatitis

Assisted living facilities (n=10) in the same metropolitan area served by the same home health agency for diabetic care (9)
2010
TX
>235
23
 Unsafe practices related to assisted blood glucose monitoring

Although a clear infection prevention breach was not identified at the time of the investigation, all infections were in residents of assisted living facilities or at home who received assisted monitoring of blood glucose by the same home health agency.

Cases include residents of the assisted living facilities plus one family member of an infected facility resident who experienced a needlestick injury while assisting with the resident’s blood glucose monitoring.
Patients living at home in private residences served by the same home health agency above for diabetic care (9)
≥19
1
Two affiliated assisted living facilities (7, 10)
(most residents with neuropsychiatric disorders)
2010
VA
126
14
 Use of fingerstick devices for >1 resident
Use of blood glucose meter for >1 resident without cleaning and disinfection
Failure to use gloves and perform hand hygiene between fingerstick procedures		 An additional 4 new chronic infections were detected and had viral molecular sequencing; 3 matched into the clusters with the acute cases indicating likely outbreak-related cases.
Assisted living facility after transfer of a resident from assisted living facility above (5)
2010
VA
151
5
 Use of fingerstick devices for >1 resident
Skilled nursing facility (12)
2010
NC
116
6
 Unclear mode of transmission; specific lapses in infection control not identified at the time of the investigation.
Skilled nursing facility (11)
2010
NC
109
6
 Specific lapses in infection control not identified at the time of the investigation.

However, assisted blood glucose monitoring and insulin injection (received by 4 of 6 infected patients) associated with illness in case-control study.

Assisted living facilities (n=2) (12)
Blood glucose monitoring at both assisted-living facilities provided by same home health agency
2009
FL
65
9
 Cross-contamination of clean supplies with contaminated blood glucose monitoring equipment used by home health agency
Investigators noted visible traces of blood on some of the blood glucose meters and one reusable fingerstick device.
Assisted living facility (5)
2009
VA
64
5
 Unsafe practices related to assisted blood glucose monitoring
A clear infection prevention breach was not identified. The facility did use reusable fingerstick devices but denied using them for >1 resident. In an analytic study, having diabetes and undergoing blood glucose monitoring (all 5 acute cases and 4 of 5 newly identified chronic cases) was significantly associated with infection		 An additional 5 new chronic infections were detected; of these 4 had viral molecular sequencing and all matched into the cluster with the acute cases indicating likely outbreak-related cases.

2 of 17 facility staff tested also had acute HBV. Investigators identified that after performing AMBG, personnel manually removed used, exposed lancets from the fingerstick device, placing themselves at risk for exposure via a sharps injury. Neither staff member received HBV vaccination.

Assisted living facility (13)
2008
IL
21
7
 Use of blood glucose meter for >1 resident without cleaning and disinfection
Failure to consistently wear gloves and perform hand hygiene between fingerstick procedures		 Note: this outbreak is also included in Thompson, et al.
Assisted living facility (14)
2008
PA
25
9
 Use of fingerstick devices for >1 resident

Use of blood glucose meter for >1 resident without cleaning and disinfection

Note: this outbreak is also included in Thompson, et al.
Skilled nursing facility (15)
(most residents with neuropsychiatric disorders)
2008
CA
143
9
 Failure to maintain separation of clean and contaminated podiatry equipment
Totals
>1,679
133
Oral Health
Free dental clinic conducted in school gymnasium (16)
2009
WV
>1,500
5
 Multiple procedural and infection control breaches were identified during retrospective investigation; however, sparse documentation did not provide evidence to link specific breaches with infection. Of the 5 cases, 3 were patients and 2 were non-health care worker volunteers
Totals
>1,500
5
Other outpatient Settings
Pain management clinic (17)
2013
SC
534
9
 Suspected reuse of syringes to access single-dose vials of contrast and Marcaine that were used for >1 patient One additional prevalent case was identified which may represent a source.
Outpatient oncology clinic (18)
2009
NJ
4,600
29
 Preparation of medications in same area where blood specimens were processed
Use of saline-bags for >1 patient
Use of single-dose vials for >1 patient
Totals
5,134
38
Hospital
Hospital-based surgery service (19)
2009
VA
329
2*
 HBV-infected orthopedic surgeon with high viral load performing exposure-prone procedures on patients *An additional 4 resolved HBV infections may also have been associated with this outbreak

 

 

Outbreak of both Hepatitis B and Hepatitis C
Outbreak of both Hepatitis B and Hepatitis C
Setting Year State Persons Notified for Screening1 Outbreak-Associated Infections2 Known or suspected mode of transmission3 Comments
Outpatient
Cardiology clinic (49)
2015
WV
2,311
HBV: 4
HCV: 8
 Reuse of syringes to access saline vials for an individual patient; Suspected use of these single-dose vials for >1 patient
Pain management clinic (20)
2010
CA
2,293
HBV:1
HCV:1
 Syringe reuse contaminating medication vials used for >1 patient
Use of single-dose vials for >1 patient
Totals
4,604
HBV: 5
HCV: 9

 

 

Hepatitis C (HCV) Outbreaks by Setting
Hepatitis C (HCV) Outbreaks by Setting
Setting Year State Persons Notified for Screening1 Outbreak-Associated Infections2 Known or suspected mode of transmission3 Comments
Outpatient
Outpatient primary care practice (60)

2019

NY

>3000

8

 IV (intravenous) infusions of vitamins, antibiotics, steroids, and other medications were prepared/administered using non-sterile technique. Scope of practice issues were identified: medical assistant prepared and administered injections and IV infusions. Investigation ongoing.
Outpatient clinic (56)

2018

CA

425

6

 Suspected unsafe injection safety practices
Alternative medicine practice (55)

2017

NY

584

5 (see comment)

 IV (intravenous) infusions were prepared using non-sterile glassware and tubing, which was not properly reprocessed between patients. Scope of practice issues were also identified with a phlebotomist preparing and administering injections and IV infusions. In addition to the 5 cases determined to be transmission-linked with HCV genetic sequencing, 3 clinic patients with resolved HCV may have had outbreak-associated infection
Vascular access clinic (59)

2016

PA

121

2

 Reuse of syringes to access multi-dose vials of ketamine that were possibly used for >1 patient; multi-dose vials accessed in the immediate patient treatment area; lack of disinfection of medication vials and medication preparation area
Prolotherapy clinic (46)

2015

CA

>1,500

5

 Syringe reuse contaminating medication vials used for >1 patient

Use of single-dose vials for >1 patient

Insulin infusion clinic (47)

2015

CA

92

9

 Unsafe practices related to assisted blood glucose monitoring including use of fingerstick devices for >1 person and inadequate cleaning and disinfection of glucometer before reuse.
Pain management clinic (48)

2015

MI

122

2

 Syringe reuse contaminating medication vials used for >1 patient
Hematology Oncology Clinic(21)
2012
MI
>300
10
 Specific lapses in infection control not identified at the time of the investigation
Pain management clinic (22)
2011
NY
466
2
 Suspected syringe reuse contaminating medication vials
Outpatient clinic (23)
2010
FL
3,929
5
 Drug diversion (fentanyl) by an HCV-infected radiology technician
Outpatient alternative medicine clinic (24)
2009
FL
163
9
 Syringe reuse contaminating medication vials used for >1 patient
Use of single-dose vials for >1 patient
Endoscopy clinics (25)
2009
NY
3,287
2
 Suspected syringe reuse contaminating medication vials 2009 investigation of cases occurring in 2006- 2007
Ambulatory surgical centers (single-purpose endoscopy clinics) (n=2) (26, 27, 28)
2008
NV
>60,000
9
 Syringe reuse contaminating single-use medications vials (propofol) that were used for >1 patient 8 cases were from the first center and one from the second. The health department identified an additional 106 infections that could have been linked to the clinics. Note: this outbreak is also included in Thompson, et al, but at the time of publication only 6 cases had been identified.
Outpatient cardiology clinic (29)
2008
NC
1,200
5
 Syringe reuse contaminating multi-dose vials of saline solution used for >1 patient An additional 2 new infections were identified in probable source patients
Totals
>72,189
71
Long-term care
Skilled nursing (30)
2013
ND
>500
46
 Epidemiologic analysis suggested podiatry care, phlebotomy, and nail care performed at the skilled nursing facility were associated with HCV infection
Hospital
Hospital emergency room (57)

2018

WA

2,762

12

 Narcotics tampering by nurse
Hospital (50)

2015

UT

7,217

7

 Drug diversion by nurse
Hospital (31)
2012
NH
AZ
GA
KS
MD
MI
NY
PA
>11,000
45
 Drug diversion by radiology technologist. Patients from 16 facilities in 8 states were notified about potential exposure and recommended to undergo testing for HCV infection.
Hospital-based surgery service (32)
2009
CO
>8,000
26
 Drug diversion (fentanyl) by an HCV-infected surgical technician 18 cases were linked by viral sequencing to the surgical technician; an additional 8 infections were determined to be epidemiologically linked but viral sequencing was not able to be performed. The number screened includes patients from three facilities where the surgical technician had worked.
Totals
>28,979
90
Hemodialysis
Outpatient hemodialysis facility (58)

2018

PA

108

2

 Specific lapses in infection control not identified, however, practices observed at the time of the investigation may have not represented usual facility practices. Case patients were dialyzed in close proximity and cared for by the same staff. Of these two new acute case-patients identified in 2018, one had HCV virus genetically related to virus from two facility patients with chronic infection who had been part of an earlier 2015 outbreak at this same location, listed below.
Outpatient hemodialysis facility (53)

2017

GA

47

2

 Patients were dialyzed in close proximity and cared for by the same staff

Lapses identified included environmental cleaning, hand hygiene

Outpatient hemodialysis facility (33)

2016

unspecified

203

2

 Specific lapses in infection control not identified at the time of the investigation
Outpatient hemodialysis facility (54)

2016

PA

154

2

 Breaches in environmental cleaning and disinfection practices identified included: lapses in hand hygiene, mixing of clean and dirty areas, inadequate cleaning of stations between patients
Outpatient hemodialysis facility (51)

2015

NJ

237

2

 Multiple lapses in infection control identified, including hand hygiene and glove use, vascular access care, medication preparation, cleaning and disinfection
Outpatient hemodialysis facility (51)

2015

NJ

84

2

 Multiple lapses in infection control identified, vascular access care, medication preparation, cleaning and disinfection
Outpatient hemodialysis facility (51)

2015

NJ

98

2

 Multiple lapses in infection control identified, including hand hygiene and glove use, vascular access care, medication preparation, cleaning and disinfection
Outpatient hemodialysis facility (52)

2015

PA

115

3

 Multiple lapses in infection control identified, medication preparation close to treatment area
Outpatient hemodialysis facility (52)

2015

PA

130

3

 Multiple lapses in infection control identified, medication preparation close to treatment area
Outpatient hemodialysis facility (52)

2015

PA

97

2

 Multiple lapses in infection control identified, medication preparation close to treatment area, Use of single-dose vials for >1 patient, no separation of dirty and clean areas (Philadelphia)
Outpatient hemodialysis facility (53

2015

CA

28

3

 Breaches in environmental cleaning and disinfection practices
Outpatient hemodialysis facility (34)
2014
WA
186
3
 Breaches in environmental cleaning and disinfection practices identified included: failure to consistently change gloves and perform hand hygiene between patients, and breaches in environmental cleaning and disinfection practices to prevent cross-contamination between clean and dirty areas
Outpatient hemodialysis facility (35)
2014
TN
62
2
 Breaches in environmental cleaning and disinfection practices
Outpatient hemodialysis facility (36)
2014
NJ
69
4
 Breaches in environmental cleaning and disinfection practices identified included failure to: wash hands before and after glove use; adequately clean surrounding area of the station, the dialysis chair and priming bucket after use
Outpatient hemodialysis facility (37)
2014
NJ
97
2
 Breaches in environmental cleaning and disinfection practices identified included failure to: appropriately separate clean and contaminated supply areas, properly disinfect clamps in the open position, adequately clean the dialysis chair and priming bucket after use; ensure patients applying pressure to their own hemodialysis access site wash their hands after doffing gloves and prior to using the scale.
Outpatient hemodialysis facility (38)
2012
PA
66
18
 Multiple lapses in infection control identified, including hand hygiene and glove use, vascular access care, medication preparation, cleaning and disinfection 18 new HCV infections between 2008–2013; (Philadelphia)
Outpatient hemodialysis facility (39)
2012
CA
42
4
 Specific lapses in infection control not identified at the time of the investigation
Outpatient hemodialysis facility (40)
2011
GA
89
6
 Failure to maintain separation between clean and contaminated workspaces
Outpatient hemodialysis facility (41)
2010
TX
171
2
 Specific lapses in infection control not identified at the time of the investigation
Outpatient hemodialysis facility (42)
2009
MD
250
8
 Breaches in medication preparation and administration practices
Breaches in environmental cleaning and disinfection practices
Hospital-based outpatient hemodialysis facility (43)
2009
NJ
144
21
 Breaches in medication preparation and administration practices
Breaches in environmental cleaning and disinfection practices		 All patients who received dialysis in this facility since 2005 were notified for screening
Outpatient hemodialysis facility (44)
2008
NY
657
9
 Failure to consistently change gloves and perform hand hygiene between patients. Breaches in environmental cleaning and disinfection practices All patients who received dialysis in this facility since 2004 were notified for screening
Totals
3,134
104

 

1 The number of persons notified for screening is dependent upon information and resources available at the time of investigation and may underestimate the total number of individuals at risk.

2 Outbreak-associated HBV and HCV infections are defined as those with epidemiologic evidence supporting health care related transmission and include patients/residents identified with acute infection, or previously undiagnosed chronic infections with epidemiologic evidence indicating that these were likely outbreak-related incident cases that progressed from acute to chronic. Patients/residents identified as likely (previously infected) sources for transmission are not included. In the outbreak investigation setting case definitions are based on laboratory profile and clinical evidence rather than CDC surveillance case definitions which may omit asymptomatic cases.
Acute HBV is typically defined as having a positive hepatitis B surface antigen and positive IgM core antibody, or positive surface antigen and negative total core antibody (early infection). Chronic HBV is typically defined as having a positive hepatitis B surface antigen, positive total core antibody and negative IgM core antibody. There are no serologic markers to differentiate between acute and chronic HCV infection; defining an infection as possible health care transmission is dependent upon epidemiologic evidence along with a new finding of hepatitis C antibody and/or RNA positivity in a person not previously known positive (whether or not symptoms or alanine aminotransferase [ALT] elevation are present).

3 All modes of transmission are patient-to-patient unless otherwise indicated.

4 One additional health care facility outbreak was reported during 2009, in an Illinois psychiatric long term care facility with 8 outbreak-related hepatitis B cases among 180 residents screened, and an additional three cases of chronic HBV infection detected at the time of screening. The likely mode of transmission was sexual contact, though other behavioral risk factors such as illicit drug use could not be ruled out.
Source: Jasuja S, Thompson N, Peters P et al. Investigation of hepatitis B virus and human immunodeficiency virus transmission among severely mentally ill residents at a long term care facility. PLoS ONE 2012; 7: e43252. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0043252

 

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2. Unpublished data, Pennsylvania Department of Health, 2014

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