Hepatitis B Virus Infection Risks among Diabetic Patients Residing in Long-Term Care Facilities

Sir—We read with interest Rajagopalan's review [1] of the wide range of serious bacterial and fungal infections that affect elderly patients with diabetes mellitus. In addition to being more susceptible to some infections due to reduced effectiveness of immune defenses, many elderly diabetic patients reside in long-term care facilities where exposure to certain infectious agents might be increased [2]. As numerous reports over the past 15 years have shown, hepatitis B virus (HBV) is a prime example of such agents, and HBV infection should be added to the list of infections that providers caring for elderly diabetic patients need to consider [3, 4]. Recently, we and our colleagues described 3 separate outbreaks of HBV infection in 2 nursing homes and an assisted living center [4]. Approximately 30 acute HBV infections and 2 deaths occurred among diabetic patients who received routine fingersticks from nursing staff in these facilities. Transmission was attributed to the use of shared equipment and lapses in aseptic technique or infection control practices associated with blood glucose monitoring. Initial symptomatic cases were not diagnosed, reported, or investigated in a timely fashion, resulting in missed opportunities to correct deficient practices and interrupt transmission. On the basis of results from these and other investigations, the Centers for Disease Control and Prevention (CDC) has made specific recommendations for preventing transmission of bloodborne diseases, such as HBV infection, among residents of long-term care facilities [4]. Evidence from our investigations suggests that acute infection with HBV is often not considered in the differential diagnosis, even when cardinal signs of hepatitis, such as jaundice, are present [4]. Although HBV infection occurs primarily among younger adults in association with high-risk sexual or drug use behaviors, health care providers should maintain a high index of suspicion for HBV and hepatitis C (HCV) infections when evaluating long-term care residents or other older patients whose illness includes unexplained hepatic dysfunction or substantially elevated aspartate or alanine amino transaminase levels [3, 5]. Evidence of acute viral hepatitis in any resident of a nursing home or other long-term care facility should be investigated and reported to public health authorities [4]. Cases involving a diabetic resident should prompt a thorough evaluation of fingerstick blood sampling and other diabetes care procedures. The CDC does not recommend routine hepatitis B vaccination or bloodborne pathogen screening of long-term care residents with diabetes. Bloodborne pathogen transmission in health care settings is entirely preventable by adherence to standards of care, including appropriate staffing and infection control [4]. Reducing the frequency of fingerstick procedures to the minimum necessary for appropriate glycemic control may also decrease opportunities for bloodborne pathogen transmission while reducing pain and discomfort [4, 6]. As the US population ages during the coming decades, chronic HCV and HIV infections, as well as diabetes, will likely become more prevalent among newly admitted long-term care residents. Because infection control errors that facilitate HBV transmission between diabetic patients also have the potential to spread HCV [7] or HIV, these risks demand increased attention. Potential conflicts of interest. J.F.P. and A.E.F.: no conflicts.