Three patients and two volunteers participating in a free dental clinic in West Virginia last summer contracted acute hepatitis B afterward, and health officials are now advising nearly 2,000 people who received treatment or volunteered during the clinic to be tested for the virus.
In June 2009, the United Way of the Eastern Panhandle and Healthy Smiles West Virginia provided free medical screenings and dental services to more than 1,100 patients at a Mission of Mercy dental clinic in Hedgesville.
— Danae Bixler, M.D., West Virginia
Bureau for Public Health
In November 2009, five cases of acute hepatitis B were reported to local health departments in West Virginia. Two of the individuals were volunteers at the clinic, and three were clinic patients who each had an extraction. One volunteer worked with patients, and the other had contact with equipment. Investigation of these cases did not reveal any other common exposures or risk factors.
All five individuals have now recovered, and no additional cases of hepatitis B have been found since the cluster of infections surfaced, said Danae Bixler, M.D., director of the Division of Surveillance and Disease Control's Infectious Disease Epidemiology Program for the West Virginia Bureau for Public Health.
The five infected individuals were residents of West Virginia, which has the highest rate of acute hepatitis B in the U.S., according to the bureau. Berkeley County Health Officer Diana Gaviria, M.D., M.P.H., attributed the high rate to IV drug use.
The West Virginia Bureau for Public Health said letters recommending testing are being sent to the clinic's 826 volunteers and 1,137 patients in West Virginia, Virginia, North Carolina, Maryland, Pennsylvania, and Washington, DC. The letters recommend that all the patients be tested for hepatitis B, C, and HIV, which are all transmitted by exposure to blood and body fluids. Volunteers and staff who had contact with medical equipment or patient care should also be tested for hepatitis B.
Common source suspected
Tests by the U.S. Centers for Disease Control and Prevention determined that the hepatitis B virus that was isolated from four of the five West Virginia cases matches at the molecular level, Dr. Bixler said, suggesting -- but not proving -- that the individuals were infected from a common source. In the fifth case, the hepatitis B patient declined to be tested, she said.
Three patients had previously tested positive for a hepatitis B surface antigen, and one of them could have been the source of the infection, Dr. Bixler said. "That's an open hypothesis," she said.
The state's investigation found that clinic providers "generally practiced within acceptable standards," but also showed that some equipment did not function as expected and that some equipment was not cleaned properly, Dr. Bixler said.
Some low-flow portable suction pumps could allow backflow into the tubing if the mouthpiece isn't elevated properly, Dr. Bixler explained. In addition, some of the handpieces were cold sterilized by being wiped down instead of heat sterilized before being used again.
However, "we don't know if these were the source of transmission," Dr. Bixler stressed to DrBicuspid.com.
"There are a lot of question marks in the whole investigation," Dr. Gaviria said. "It was a temporary clinic, and we relied on people's recall of what went on. There were some areas for improving infection control, but there was no particular breach which they could pinpoint as the source of infection."
Infection preventionist critical
The outbreak highlights the importance of maintaining infection control standards, especially given the rise in infectious diseases in recent years (Nature, February 21, 2008, Vol. 451:7181, pp. 990-993).
"That's the lesson from this: having good infection control procedures and the involvement of an infection preventionist," Dr. Bixler said. "Someone who has expertise in infectious diseases is critical for patients and occupational health and safety, and that person needs to be involved from planning through the end of the clinic to make sure all policies and procedures are adequate."
In a related case, patients at a Connecticut dental clinic were notified in May that potentially unsterilized instruments used during patient visits there earlier this year could have exposed them to illness.
Officials at the Generations Family Health Center in Willimantic said the sterilization process used to clean dental instruments might not have been completed properly and have told patients of a potential, but low, risk of contracting an illness, according to a story in the Hartford Courant. The patients have been prescribed preventive medication and blood tests.
Arvind Shaw, executive director of the center, told the Courant he was not aware of any patients being exposed to illness. The center follows universal precautions, a common healthcare infection-control strategy that calls for treating bodily fluids from patients as if they are infected with HIV, hepatitis B, and other pathogens even if they are not, the Courant reported.
The Connecticut Department of Public Health was notified when the problem was found and has initiated an investigation, spokesman William Gerrish told the Courant.
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