Investigating Outbreaks in Health Care Settings: Step 5

Purpose

This page outlines how to respond if a breach in infection control is identified, and other potential follow-up steps to consider, including taking measures within the facility, evaluating epidemiological links, reporting to CDC, and performing ongoing monitoring, as well as helpful resources available.

Step five: Respond

During the site visit, you may identify a major breach in infection control. This could include staff reusing the same syringe or needle among multiple patients or reentering medication vials that are being used for more than one patient with the same syringe or needle. It is not safe to change the needle and reuse the syringe as this practice can transmit disease. If an investigator identifies such a breach, they should immediately correct the behavior and advise the staff to notify all patients who were potentially exposed.

Health departments can consult the following resource for more information on high-risk breaches: Outbreaks and infection control breaches in health care settings: considerations for patient notification.

In the event of a major breach, you should immediately:

  • Advise the facility to stop unsafe practices.
  • Notify potentially impacted people and HCPs for testing. A patient notification recommending bloodborne pathogen testing should be conducted for all potentially exposed patients, even if additional cases and/or a source patient are not identified. The scope of notification may depend on how long the unsafe practice has been occurring in the facility.
  • Report the facility to the appropriate regulatory authority.

Consider these steps whether a major breach is detected or not

1. Evaluate links

Evaluate the likelihood of epidemiologic links between identified cases (potential source case(s), index case, additional cases) based on their temporal and spatial overlap in the facility. Additionally, it's important to identify shared medications and equipment, as well as potential exposures.

2. Reach out to CDC

Reach out to CDC to discuss the possibility of conducting viral genetic sequencing. This can be an important step to fully evaluate epidemiologic links between identified cases. A finding that patient samples are very closely related based on viral genetic sequencing is consistent with associated cases being part of the same chain of transmission. However, note that a finding of more distantly related patient samples does not rule out transmission occurring in the facility (for example, there may have been multiple or unidentified source cases). If viral genetic sequencing cannot be performed, viral genotype information, sometimes available from medical records, may be considered when evaluating epidemiologic links between identified cases.

3. Identify additional cases

Attempt to identify additional cases through targeted patient notification and testing. Note that potential source case patients may present to a health care facility sporadically, and infection control breaches may be regular or intermittent. Some past investigations have identified multiple, temporally distinct transmission clusters at a single facility.

For example, an investigation of a hepatitis C outbreak in an outpatient cardiology clinic detected two separate transmission clusters in June and December of the same year (see Transmission of Hepatitis C Virus During Myocardial Perfusion Imaging in an Outpatient Clinic); also, an investigation of a hepatitis C outbreak in a dialysis center identified cases involving patients infected over a period of more than 5 years (see Hemodialysis-Associated Infections). CDC is available to consult about best practices for conducting patient notifications and sharing lessons learned from previous investigations.

4. Respond

If the index or potential source case patient(s) declines to provide samples, or available sample volume is insufficient for additional testing, consider attempting to identify additional cases through targeted patient notifications.

If results of viral genetic sequencing suggest that the index or potential source case patient(s) is not part of the same chain of transmission:

  1. Send a follow-up letter to all health care facilities identified during the investigation to remind them to review their infection prevention practices.
  2. Continue to monitor state/local health department surveillance data for additional cases that may be linked to the facility or provider in question.

If only the index case is identified (with no potential source case(s) or additional cases), consider sending follow-up letters to health care facilities where the index case had percutaneous exposures during the likely exposure period and continuing to monitor surveillance data.

Resources

To assess and respond to need for notification, see the following resources:

  • Patient Notification Toolkit: This is a communications framework for state and local health departments to use for public notification as part of public health response to possible bloodborne pathogen exposures in a variety of health care settings.

CDC is available to assist at any time. Contact us!

Thank you!

CDC would like to thank the health departments who graciously reviewed and provided comment on this algorithm.
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Content Source:
Division of Viral Hepatitis