People often associate hepatitis with intravenous drug use or getting tattoos or piercings at dirty parlors. They think it’s something that can’t happen to them. However, recent health-care associated outbreaks in Oklahoma and New Hampshire show that hepatitis is something that we all need to be aware of. The New Hampshire case, in particular, demonstrated how a rapid public health response can identify a hepatitis C outbreak and stop transmission.
In the spring of 2012, the New Hampshire Department of Health and Human Services, Division of Public Health Services began investigating a cluster of four people who were recently diagnosed with hepatitis C and who had been treated at the same hospital. The public health laboratory initially coordinated blood draws and performed hepatitis C virus (HCV) testing. Additionally, the public health lab performed DNA sequencing on the non-structure 5B region of the HCV genome to subtype the virus and sequenced the hypervariable region 1 of the HCV genome to determine if individuals who were infected were part of the same outbreak. When sequencing was performed on the initial cluster, the four individuals had matching HCV viral sequences indicating a common source of infection.
As the outbreak unfolded over the next few weeks, mounting evidence suggested that the mode of transmission was a drug diversion by a cardiac catheterization laboratory technologist at Exeter Hospital. The technician is accused of stealing Fentanyl syringes intended for patients, injecting his own arm, refilling the empty syringes with a saline solution, and returning the used syringes as if they were untouched. Those dirty needles were then used on patients.
Dr. Christine Bean, New Hampshire’s public health laboratory director, and Dr. Fengxiang Gao, New Hampshire’s public health laboratory virology and special testing program manager, said that in the initial phase of the investigation, where the primary concern was focused on testing patients who received care at the cardiac catheterization laboratory of Exeter Hospital, the laboratory tested 1,072 specimens. This was well over their normal testing volume of about 200 specimens per month. All testing was performed at the public health laboratory and positive specimens were sent to CDC for additional testing. When the investigation expanded to other units in the hospital that the technician had access to, an additional 3,300 patients needed testing. Community testing centers were set up to assist with rapid blood draws. In addition to the routine testing done at the public health laboratory, the clinics offered rapid HCV testing on site and also trained sentinel laboratories on rapid testing to help with the volume. Ultimately, 32 patients were identified as part of the NH outbreak, in addition to the infected technician. As the outbreak investigation expanded to include other states where the technician had previously worked, additional cases were found.
The overall response to the outbreak from the laboratory was phenomenal. Quick detection may have prevented additional infections. Dr. Bean emphasized that their success in responding to the outbreak depended on a strong public health laboratory system—the public health laboratory and epidemiologists working together and the public health laboratory’s capability and capacity to perform both serology and molecular tests for HCV.
In the May 10, 2013 issue of MMWR, CDC released Testing for HCV Infections: An Update for Guidance for Clinicians and Laboratorians. The updated guidelines emphasize identifying persons with current HCV infections as opposed to those who have had past infections that have been resolved and encourage laboratories to utilize newer testing technologies. The new recommended testing sequence includes an initial test with an FDA-approved test for HCV antibodies, followed by an FDA-approved nucleic acid test (NAT) intended for the detection of HCV RNA in serum or plasma if the initial serology assay is reactive.
May 19, 2013 marks the second National Hepatitis Testing Day during a month that is already dedicated to raising the awareness of viral hepatitis. The day is committed to testing people at risk for hepatitis and to educating providers and the public about chronic viral hepatitis and testing.
To find a Hepatitis Testing Event near you or to register your event, click here.