Viral Hepatitis: Health Care-Associated Outbreak Investigation Toolkit

What to know

  • Breaches in infection prevention and control practices in health care settings can lead to outbreaks.
  • It's important to investigate even single cases of viral hepatitis occurring in health care settings, as these can help identify the source of an outbreak or unsafe clinical practices that may put more people at risk.
  • Each investigation is unique and may require careful planning and periodic reassessment.
  • CDC is always available for consultation — contact us at viralhepatitisoutbreak@cdc.gov.

Overview

CDC is here to help by sharing lessons learned from many states' experiences. CDC can also share the best practices that states developed while addressing infection control breaches in specific settings. Guidance topics include:

  • Infection control observations.
  • Patient notification.
  • Screening for specific populations.
  • Laboratory testing, including molecular genetic investigation.

Reach out to CDC

For consultation and assistance on health care-associated viral hepatitis outbreaks, email viralhepatitisoutbreak@cdc.gov.

How to use this toolkit

This guide provides a framework for state and local health departments to investigate possible health care-associated viral hepatitis transmission events.

These steps are intended to address investigations in a variety of inpatient, outpatient, and long-term care settings. They do not include guidance for transplant- or transfusion-related transmissions.

Transmission of the hepatitis B virus (HBV) and hepatitis C virus (HCV) has occurred in health care settings by:

  • Patient-to-patient transmission through infection prevention and control breaches when handling shared medications or patient equipment (e.g., administering injections, performance of blood glucose monitoring).
  • Provider-to-patient transmission, largely through diversion of controlled substances by infected health care personnel (HCP).
  • Patient-to-patient transmission through infected blood, organs, and tissues.
  • In outbreak investigations, case definitions are based on laboratory profile and clinical evidence rather than surveillance case definitions, which may omit asymptomatic cases.

Investigation process

The investigative steps described in this toolkit are not rigid or linear; some steps may need to occur simultaneously or in a sequence that varies during an investigation.

What's included

Given CDC’s experience with such outbreaks, CDC has compiled the following toolkit of resources for health departments:

Investigating Outbreaks in Health Care Settings: Step 1

Step 1 in investigating single cases of HBV or HCV.

Investigating Outbreaks in Health Care Settings: Step 2 & 3

Steps 2 and 3 in investigating single cases of HBV or HCV.

Investigating Outbreaks in Health Care Settings: Step 4

Step 4 in investigating single cases of HBV or HCV.

Investigating Outbreaks in Health Care Settings: Step 5

Step 5 in investigating single cases of HBV or HCV.

Testing and notification guide

Suggested tests for bloodborne pathogens and help in notifying people who might have been exposed.

HCV molecular epidemiology

Support for investigating transmission links between patients.

Resources

Here are some resources and guidance for responding to health care-associated outbreaks of viral hepatitis:

PDFs and downloads

CDC resources

External resources