Quick action averts hepatitis A outbreak
RN's household exposure threatens other HCWs
Prompt infection control measures prevented what could have been a tragic and costly hepatitis A outbreak in a county hospital's neonatal intensive care unit (NICU), where 44 health care workers and 37 neonates were exposed to the virus by a registered nurse who failed to report her household-acquired infection.
That failure to report to supervisors was the breakdown in hospital infection control policy that could have led to disaster, says Joanne Selva, RN, BS, CIC, infection control director at the 3,000-employee Nassau County Medical Center in East Meadow, NY. The infected RN, who worked in the specialty NICU, had acquired HAV from her husband.
Selva reported on the hospital's outbreak-averting interventions at the recent annual conference of the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC), held in Atlanta.1
"The husband's primary physician did not report [the HAV infection] to the county health department, and [the RN] did not report to her supervisors at work that her husband had an infectious disease. We don't know why. Perhaps she did not want to be furloughed," says Selva, who surmises that the nurse would not have received worker's compensation benefits because the infection was not occupationally acquired.
The RN remained at work in the unit for two weeks during the incubation and dissemination phase of the disease. Infection control officials learned of the household illness from several other NICU nurses who had been invited to the infected RN's home for lunch during the active disease stage. The infected RN was immediately furloughed and counseled.
Infection control practitioners confirmed the HAV diagnosis, examined the mode of transmission, and established the time frame for exposure with a histogram, which plotted out the time of incubation and exposure to the neonates and other HCWs. Assessment of the RN's degree of contact with the other workers established that all had been exposed.
Selva emphasizes that standard precautions had been used consistently in the NICU, including barrier techniques such as gloves, masks, and gowns, as well as frequent handwashing. Assessing the infected nurse's degree of contact with co-workers and neonates was difficult because "even though it is our policy to use universal precautions, you don't always know if it's totally done. Therefore, we had to assume that all the babies and co-workers had direct exposure to her," she explains.
The employee health department assisted infection control practitioners in providing the exposed workers with serum immune globulin (ISG). All household contacts and sexual partners also were provided with ISG, as were all exposed neonates.
Two of the exposed HCWs refused ISG. "They thought they were going to get HIV from it because it is pulled from serum," Selva notes. "As much as we have educated them that this could not ever happen, they were under the old contention. They made an emotional decision out of fear." Their refusal required both workers to be furloughed for two weeks.
Multimillion-dollar lawsuits avoided
No secondary cases resulted from the exposure, but "it could have been a potential time bomb," Selva states.
Costs associated with the exposure were $10,722, which included notification of the neonates' families by telegram, ISG treatment for neonates and HCWs, lost work time, and furloughs.
Selva says the costs of an NICU outbreak could have been astronomical. Hospital estimates place potential costs at more than $100,000: morbidity, $50,320; furloughing 44 staff members, $43,120; closing the NICU, $7,122; ISG treatment for employees, $52; ISG treatment for infants, $26.
"If there were mortality, because the babies were high-risk, this could have escalated into multimillion-dollar lawsuits for the hospital," Selva notes.
She also points out that New York state law requires infection control education for all licensed health care professionals, and that all HCWs in the NICU had taken the mandated courses.
"That is why we were so astounded that a professional failed to report [HAV infection]," she says. "The course makes everyone aware of infectious diseases, their transmission, their potential morbidity and mortality, and good infection control practice."
'If you keep your hands clean . . .'
The averted outbreak now is used as an additional educational tool for employees to drive home the importance of reporting any community communicable disease exposure, Selva adds.
Linda Moyer, RN, an epidemiologist with the federal Centers for Disease Control and Prevention's hepatitis branch in Atlanta, says use of universal precautions should suffice for preventing hepatitis A transmission in health care facilities.
"If you keep your hands clean, there should be no issue of transmission in a hospital setting," Moyer says. "The incidence of hepatitis A in health care workers is no higher than in the general public."
A hepatitis A vaccine was approved last year, but the CDC does not recommend it for routine administration to HCWs. (See Hospital Employee Health, June 1995, pp. 82-83.) CDC officials say no data show that employment as an HCW is a risk factor for hepatitis A infection. Recommendations include administering immune globulin within two weeks post-exposure.
Reference
1. Selva J, Ninivaggi M, Howard R, et al. Hepatitis A exposure in a NICU: A lesson to be learned (Poster). Presented at the 23rd Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology. Atlanta; June 1996. *
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