This review demonstrates that person-to-person transmission of HBV infection during blood glucose monitoring has been documented repeatedly since 1990. In each outbreak HBV transmission resulted from sharing blood-contaminated equipment. For example, transmission was frequently associated with sharing of spring-loaded finger-stick devices that were intended for individual use. Even when the endcap and lancet on these devices was changed, the barrel may have become contaminated with blood and resulted in exposure of subsequent patients. Similarly blood glucose testing meters were shared in these outbreaks but were not adequately cleaned between uses. A multicenter survey of blood glucose testing meters in routine use in hospital settings showed that 30% had blood detectable on their surfaces, and those with on-meter test-strip dosing format were associated with significantly higher rates of contamination.19
Blood-contaminated devices provide opportunities for the transfer of infective viruses into the finger-stick wound of a susceptible person when the device is brought in contact with the patient or via contamination of a health care worker's hands.
Despite explicit recommendations for preventing blood-borne pathogen transmission during diabetes care,4,8
HBV infection outbreaks have continued to occur. Of additional concern is the fact that the frequency of these outbreaks appears to have increased: five were identified and reported from 2006 to 2008. This trend will likely continue in the absence of appropriate prevention measures and technological advances.
One challenge is that equipment designed for personal use might be marketed or selected for use in health care settings despite the availability of safer alternatives. For example, many of the outbreaks we summarized involved multiuse spring-loaded finger-stick devices, despite the widespread availability of disposable safety lancets that permanently retract after a single use. Insulin pens provide another example of the potential for bloodborne pathogen transmission when these devices, designed for individual use, are inappropriately used for multiple patients. Two reports of insulin pens being used on multiple patients in hospitals suggest this is an emerging issue that warrants attention from the diabetes technology community.20,21
In one incident over 2000 patients had to be notified and advised to undergo testing for HBV, hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
The main limitation of this review is that it likely under-represents the burden of bloodborne infections attributed to poor blood glucose monitoring and diabetes care practices. First, most (50–67%) adults newly infected with HBV are asymptomatic,10
and thus many infections are unrecognized and go undiagnosed.12
Second, health care is under-recognized as a mode of viral hepatitis transmission in the United States,22
and the receipt of diabetes care may be overlooked as a risk factor for infection, particularly among elderly LTC residents.8,18
Third, because outbreak investigations have not prospectively followed the health outcomes of infected persons, the long-term hepatitis B morbidity and mortality among this vulnerable population is not known. Nonetheless, our review did find a striking 4.1% mortality rate among those with outbreak-associated HBV infection, demonstrating the considerable impact of acute hepatitis B disease among older persons. Considering these factors, the outbreaks summarized here likely underestimate the magnitude of the true burden of HBV infections attributable to unsafe diabetes care practices. Another limitation is that the information needed to determine a denominator of the persons potentially exposed during these outbreaks was not uniformly reported, thus the risk of infection could not be estimated. It is essential, however, to remember the expected number of infections transmitted during blood glucose monitoring should be zero, as the receipt of health care should not be a risk factor for acquiring bloodborne pathogens.22
Nursing homes and assisted-living facilities have been the primary setting for HBV transmission during diabetes care. These settings are heterogeneous with respect to their resident populations and levels of health care, nursing care, and physician input.23
One common characteristic is that residents of these facilities are typically elderly and require assistance with management of chronic medical conditions. For example, approximately one-fourth of nursing home residents have diabetes, and the typical facility performs hundreds of glucose monitoring procedures each week.24,25
Compared to acute care hospitals, these facilities have less well-trained staff, fewer resources, and less infection-control training and oversight.23,26–28
Yet hospital patients may also face increasing risks in association with increasing reliance on blood glucose monitoring.29
Given these ongoing challenges, prevention efforts will need to go beyond staff education, training, and oversight to include more of a focus on design and safety-engineered equipment.
Diabetes technology advancements can aid the effort to prevent bloodborne pathogen transmission among persons receiving diabetes care. The potential impact of appropriate technologies is exemplified by development and adoption of engineering controls (e.g., safety devices) to reduce occupational needlestick injuries and blood-borne virus infections among health care personnel.30,31
Advances in diabetes technology to provide safer devices or to eliminate the need for percutaneous finger-stick procedures is much needed. Possible examples include further development of finger-stick devices and insulin pens that prevent use for multiple persons and blood glucose testing meters designed specifically for institutional use that feature off-meter test-strip dosing to reduce contamination potential and that can withstand frequent cleaning and disinfection. In addition, diabetes technologies such as noninvasive glucose monitoring methods hold further promise that the need for finger-stick procedures may be substantially reduced or eliminated altogether.
Prevention efforts derived from advances in diabetes technology that can provide safer blood glucose monitoring equipment and noninvasive glucose monitoring technologies are likely to have broad utility and a far-reaching impact. The problem of person-to-person HBV transmission among diabetes patients in LTC settings described here is not unique to the United States. Hepatitis B virus infection outbreaks of this nature have also been described and documented in France,32
the United Kingdom,34
In addition to HBV, the spread of other bloodborne pathogens such as HCV and HIV may also be possible when blood glucose monitoring equipment or insulin pens are used for more than one person.9
Indeed, HCV infections attributed to sharing blood glucose monitoring practices have already been described in France.40
The development and adoption of new diabetes technology is of particular importance and urgency, as persons aged 75 years and older are the fastest growing age cohort in the United States, and this population is expected to increase significantly over the next decade.41
Concurrently the prevalence of persons with diabetes42
and chronic HBV, HCV, and HIV infections will increase among residents of LTC settings.9,43
In summary, persons in hospitals, LTC, and other health care settings—or in group settings such as shelters, schools, and correctional facilities—may face an increased risk for infection from bloodborne pathogens such as HBV when blood glucose monitoring or other diabetes care equipment is improperly handled or shared. Through lack of awareness or failure to follow prevention recommendations, HBV infections associated with poor blood glucose monitoring practices among persons in LTC settings will likely continue to occur—and additional prevention strategies are needed. The diabetes technology community should be cognizant of the risk for bloodborne pathogen transmission when designing devices. Through the development and marketing of safety-engineered equipment, the diabetes technology community can play a significant part in eliminating unnecessary risks and reducing the disease burden from hepatitis viruses.