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A Large Outbreak of Hepatitis B Virus Infections Associated With Frequent Injections at a Physician's Office

  • Taraz Samandari (a1) (a2), Naile Malakmadze (a3) (a2), Sharon Balter (a4), Joseph F. Perz (a1), Marina Khristova (a1), Leah Swetnam (a5), Katherine Bornschlegel (a4), Michael S. Phillips (a2) (a4), Iqbal A. Poshni (a4), Preeti Nautiyal (a4), Omana V. Nainan (a1), Beth P. Bell (a1) and Ian T. Williams (a1)...



To determine whether hepatitis B virus (HBV) transmission occurred among patients visiting a physician's office and to evaluate potential transmission mechanisms.


Serologic survey, retrospective cohort study, and observation of infection control practices.


Private medical office.


Those visiting the office between March 1 and December 26, 2001.


We identified 38 patients with acute HBV infection occurring between February 2000 and February 2002. The cohort study, limited to the 10 months before outbreak detection, included 91 patients with serologic test results and available charts representing 18 case-patients and 73 susceptible patients. Overall, 67 patients (74%) received at least one injection during the observation period. Case-patients received a median of 14 injections (range, 2-25) versus 2 injections (range, 0-17) for susceptible patients (P < .001). Acute infections occurred among 18 (27%) of 67 who received at least one injection versus none of 24 who received no injections (RR, 13.6; CI95, 2.4-undefined). Risk of infection increased 5.2-fold (CI95, 0.6-47.3) for those with 3 to 6 injections and 20.0-fold (CI95, 2.8-143.5) for those with more than 6 injections. Typically, injections consisted of doses of atropine, dexamethasone, vitamin B12, or a combination of these mixed in one syringe. HBV DNA genetic sequences of 24 patients with acute infection and 4 patients with chronic infection were identical in the 1,500-bp region examined. Medical staff were seronegative for HBV infection markers. The same surface was used for storing multidose vials, preparing injections, and dismantling used injection equipment.


Administration of unnecessary injections combined with failure to separate clean from contaminated areas and follow safe injection practices likely resulted in patient-to-patient HBV transmission in a private physician's office.


Corresponding author

Division of Viral Hepatitis, MS G-37, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333. ,


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1.McQuillan, GM, Coleman, PJ, Kruszon-Moran, D, Moyer, LA, Lambert, SB, Margolis, HS. Prevalence of hepatitis B virus infection in the United States: the National Health and Nutrition Examination Surveys, 1976 through 1994. Am J Public Health 1999;89:1418.
2.Margolis, HS, Coleman, PJ, Brown, RE, Mast, EE, Sheingold, SH, Arevalo, JA. Prevention of hepatitis B virus transmission by immunization: an economic analysis of current recommendations. JAMA 1995;274:12011208.
3.Centers for Disease Control and Prevention. Disease Burden From Viral Hepatitis A, B and C in the United States. Atlanta, GA: Centers for Disease Control and Prevention; 2004. Available at pdf. Accessed August 16, 2005.
4.Goldstein, ST, Alter, MJ, Williams, IT, et al.Incidence and risk factors for acute hepatitis B in the United States 1982-1998: implications for vaccination programs. J Infect Dis 2002;185:713719.
5.Williams, IT, Perz, JF, Bell, BP. Viral hepatitis transmission in ambulatory healthcare settings. Clin Infect Dis 2004;38:15921598.
6.Hutin, YJ, Goldstein, ST, Varma, JK, et al.An outbreak of hospital-acquired hepatitis B virus infection among patients receiving chronic hemodialysis. Infect Control Hosp Epidemiol 1999;20:731735.
7.Alter, MJ, Ahtone, J, Maynard, JE. Hepatitis B virus transmission associated with a multiple-dose vial in a hemodialysis unit. Ann Intern Med 1983;99:330333.
8.Carl, M, Francis, DP, Maynard, JE. A common-source outbreak of hepatitis B in a hemodialysis unit. Dialysis & Transplantation 1983;12:222229.
9.Polish, LB, Shapiro, CN, Bauer, F, et al.Nosocomial transmission of hepatitis B virus associated with the use of a spring-loaded finger-stick device. N Engl J Med 1992;326:721725.
10.Quale, JM, Landman, D, Wallace, B, Atwood, E, Ditore, V, Fruchter, G.Déjà, vu: nosocomial hepatitis B virus transmission and fingerstick monitoring. Am J Med 1998;105:296301.
11.Kent, GP, Brondum, J, Keenlyside, RA, LaFazia, LM, Scott, HD. Alarge outbreak of acupuncture-associated hepatitis B. Am J Epidemiol 1988;127: 591598.
12.Canter, J, Mackey, K, Good, LS, et al.An outbreak of hepatitis B associated with jet injections in a weight reduction clinic. Arch Intern Med 1990;150:19231927.
13.Swenson, PD, Riess, JT, Krueger, LE. Determination of HBsAg subtypes in different high risk populations using monoclonal antibodies. J Virol Methods 1991;33:2738.
14.Garfein, RS, Bower, WA, Loney, AM, et al.Factors associated with fulminant liver failure during an outbreak among injection drug users with acute hepatitis B. Hepatology 2004;40:865873.
15.Hoofnagle, JH, Di Bisceglie, AM. Serologic diagnosis of acute and chronic viral hepatitis. Semin Liver Dis 1991;11:7383.
16.Fleiss, JL.Statistical Methods for Rates and Proportions, ed. 2. New York: John Wiley & Sons; 1981:6467.
17.Kleinbaum, DG.Logistic Regression: A Self-Learning Text. New York: Springer-Verlag; 1994.
18.Dankert, J, Uitentuis, J, Houwen, B, Tegzess, AM, van der Hem, GK. Hepatitis B surface antigen in environmental samples from hemodialysis units. J Infect Dis 1976;134:123127.
19.Bond, WW, Favero, MS, Petersen, NJ, Gravelle, CR, Ebert, JW, Maynard, JE. Survival of hepatitis B virus after drying and storage for one week. Lancet 1981;1:550551.


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