Infection Management for Geriatrics in Long Term Care Facilities

328 Harrington and Barrett sick employees, hand washing, and surveillance, as well as other infection control issues. Isolation practice guidelines are fundamental components of infection con- trol, and CDC has formulated one that calls for a two-tiered system. The first, Standard Precautions, are recommended for all patients and was previously known as universal precautions. These guidelines emphasize hand washing and use of gloves. Avoidance of needlestick and other “sharps” injuries are also em- phasized. Transmission-Based Precautions, that is airborne, droplet, and contact precautions, the second type of isolation practice, is recommended for patients with suspected contagious pathogens (38) (see Chapters 8 and 9). The work of numerous investigators has identified the most common pathogens that afflict residents in LTCFs, as well as the epidemiology of these agents. Urinary tract infections, respiratory infections, tuberculosis, and skin in- fections have comprised the greatest number of clinical problems in recent decades, but diarrheal illness and antibiotic-resistant bacteria have also posed challenges to physicians. In comparison, viral hepatitis is much less common. However, because of the serious nature of the disease, and because individuals may harbor inapparent infections, it deserves close attention. The biology of the three major types of viral hepatitis has been described in previous sections. For the purposes of discussion, infection control measures for viral hepatitis can be divided into those that address agents involving transmission predominantly by the oral route (e.g., hepatitis A virus) or by the parenteral route (e.g., hepatitis B or hepatitis C virus). A. Hepatitis A 1. Frequency of HAV Infection in LTCFs In recent decades, the occurrence of HAV infection in LTCFs has been rare. Clearly, the potential remains for transmission from infected food handlers to res- idents, residents to healthcare workers (HCWs) (e.g., fecal incontinence), and even from resident to resident by the classic fecal-finger-oral route. However, cur- rent food preparation systems and a significant prevalence of host immunity in pa- tients and HCWs seem to have been sufficient to minimize this threat. In patients older than age 70 in the United States, more than 75% have been found to have an- tibody to HAV, testifying to previous infection or vaccination (39,40). Before dis- missing HAV as a potential problem, however, we must acknowledge the uncer- tain impact of ongoing economic pressures on regulatory compliance of LTCFs, with the resulting potential for a relaxing of current infection control standards. 2. Screening for HAV Acute hepatitis from HAV in older adults is unusual, and no testing for it is indi- cated in asymptomatic patients admitted to an LTCF. Furthermore, in contrast to

Hepatitis 329 HBV and HCV, HAV does not produce a chronic, infectious form of disease that could serve as a rationale for testing. 3. Vaccination Clinical guidelines have been developed to identify patients who should receive vaccination against HAV as primary prevention (Table 4). It has been recom- mended that patients with chronic liver disease should be vaccinated to prevent Table 4 Hepatitis A Vaccine: Indications and Schedule Persons who should receive hepatitis A vaccine 1. Persons traveling to or working in countries outside of the U.S. (except for Northern and Western Europe, New Zealand, Australia, Canada, and Japan) 2. Children (younger than 2 years) in communities that have high rates of hepatitis A and periodic hepatitis A outbreaks 3. Men who have sex with men 4. Illegal drug users (injecting and noninjecting) 5. Persons who have occupational risk for infection 6. Persons who have chronic liver disease 7. Persons who have clotting factor disorders 8. Food handlers where health authorities or private employers determine vaccination to be cost-effective Vaccination schedule Two doses are required The minimal interval between doses is 6 months Recommended dosages of HAVRIX® (Merck) Vaccinee’s age (years) Dose (EL.U.) Volume (ml) No. doses Schedule (months) 2 0,6–12 2–18 720 0.5 2 0,6–12 Ͼ18 1,440 1.0 No. doses Schedule (mos) Recommended dosages of VAQTA® (Merck) 2 0,6–18 2 0,6 Vaccinee’s age (years) Dose (EL.U.) Volume (ml) 2–17 25 0.5 Ͼ17 50 1.0 Source: Ref. 39.

330 Harrington and Barrett possible infection with HAV that could produce diagnostic confusion and result in a poor outcome because of diminished hepatic reserve. It may be difficult to make a definitive diagnosis of chronic liver disease in the setting of an LTCF, given the many causes of minor liver function test abnormalities. In some clinical situations, additional testing may be unwarranted, and physicians may wish to proceed with vaccination without additional interventions and X-rays. Consideration should also be given to vaccination of food handlers who work in LTCFs. However, in one investigation, rates of hepatitis A among food handlers were found to be similar to rates among the general population, and in general, the frequency of outbreaks in hospitals, institutions, and schools is not high enough to warrant routine hepatitis A vaccination of persons specifically be- cause they are in these settings (39,40). 4. Postexposure Protection In the rare instance in which an active case of hepatitis A is identified in an LTCF, use of immune globulin (IG) and vaccination with hepatitis A vaccine is recom- mended for susceptible persons who are in close contact with infected patients. Persons identified as candidates for postexposure management should receive a single intramuscular dose of IG (0.02 ml/kg) as soon as possible, and not later than 2 weeks after exposure. Hepatitis A vaccination should also be given, with the first vaccination administered as early as possible after exposure, and a second and fi- nal vaccination 6 to 12 months later. B. Hepatitis B Transmission of bloodborne pathogens presents a more complicated picture than orally transmitted infections. Generally, blood transfusions are not an important infection control issue in LTCFs because they are given infrequently in this set- ting, and because current blood-banking practices have been very effective in eliminating this source of hepatitis B virus and hepatitis C virus. Infection control measures must address issues that affect HCWs, such as injuries from sharps, as well as patient-to-patient transmission caused by contaminated instruments. Sev- eral examples of the latter have been reported over the past several years in dia- betics who have contracted viral hepatitis from contaminated lancets used for fin- gerstick glucose monitoring (12). A highly effective vaccine against HBV has been available for more than 20 years, however, this infection remains a threat to both HCWs and patients. Fed- eral regulations require all hospitals and LTCFs to offer vaccination to employees at no cost, yet a determined few decline and remain at risk for infection, whereas the majority of residents in LTCFs are also susceptible. Infection control measures must be in place to minimize risk for HBV transmission in these two populations.

Hepatitis 331 1. Frequency of HBV Infection in LTCF The frequency of HBV infection in LTCFs varies greatly, according to the cultural and socioeconomic background of the population in the facility. The likelihood that residents will be chronic carriers of HBV will vary from less than 1% for healthy, American-born individuals to 5% to 15% for recent immigrants, dialysis patients, and users of illicit parenteral drugs. 2. Screening for HBV Screening for HBV infection in residents admitted to LTCFs is not indicated on a routine basis but should be part of an evaluation of residents with acute and chronic liver disease or abnormal liver function tests. The critical issue to resolve, both for the individual and for the LTCFs, is whether the individual is an infec- tious carrier of HBV. Of the many serologic tests available in the laboratory, only the detection of the HBsAg and anti-HBc provides useful information about an in- dividual’s infectious status. Screening HCWs in LTCFs for HBV infection or immunity is not routinely necessary because vaccination during professional training or at the time of em- ployment is almost universal. 3. Vaccination Healthcare workers should be encouraged to undergo vaccination for HBV as early as possible in their professional training. Published guidelines recommend that all HCWs who perform tasks involving contact with blood, blood-contami- nated body fluids, other body fluids, or sharps should be vaccinated (Table 5). Prevaccination serological screening for previous infection is not indicated for persons being vaccinated because of occupational risk (41). For residents or pa- tients, those with chronic liver disease or unexplained abnormal liver function tests should be vaccinated to prevent a possible infection with HBV that could produce diagnostic confusion and have a poor outcome because of diminished hepatic reserve. 4. Postexposure Protection Prophylaxis should be considered for HCWs for any percutaneous, ocular, or mu- cous membrane exposure to blood, which is determined by the HBsAg status of the source person and vaccination status of the exposed individual. Treatment of an unvaccinated HCW after an exposure will include hepatitis B immune globu- lin (HBIG) and the initiation of an HBV vaccine series if the source person is un- known or has evidence of infection with HBV. (The reader is referred to CDC guidelines for more details [42]).

332 Harrington and Barrett Table 5 Hepatitis B Vaccination: Indications and Schedule Persons who should receive hepatitis B vaccine 1. All babies at birth 2. Persons at occupational risk for exposure to blood 3. All adolescents 4. High-risk adults including the following conditions or behaviors: Household contacts and sex partners of HBsAg-positive persons Users of injectable drugs Heterosexuals with more than one sex partner in 6 months Men who have sex with men People with recently diagnosed sexually transmitted disease Patients receiving or likely to receive hemodialysis Recipients of certain blood products Healthcare workers and public safety workers who are exposed to blood Inmates of long-term correctional facilities Clients and staff of institutions for the developmentally disabled Vaccination schedule Three doses are needed on a 0, 1, 6 months schedule Alternative timing options for vaccination include 0, 2, 4 months 0, 1, 4 months There must be 4 weeks between doses 1 and 2, and 8 weeks between doses 2 and 3. Overall there must be at least 4 months between doses 1 and 3 Recommendations Vaccination Recombivax® HB Engerix® HB Group Dose (␮g) (ml) Dose (␮g) (ml) Infants of HbsAg-negative mothers 2.5 (0.5) 10.0 (0.5) and children aged 11 or younger Infants of HbsAg-positive mothers; 5.0 (0.5) 10.0 (0.5) prevention of perinatal infection Children and adolescents aged 11–19 5.0 (0.5) 20.0 (1.0) Adults aged 19 or older 10.0 (1.0) 20.0 (1.0) Dialysis patients and other 40.0 (1.0) 40.0 (2.0) immunocompromised persons Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR, 1991. Abbreviations: HBsAg, Hepatitis B surface antigen; HB, Hepatitis B. Source: Ref. 41.

Hepatitis 333 C. Hepatitis C Most of the principles and practices described above for HBV may be applied to infection control strategies for HCV. Unhappily, and in contrast to HBV, the prevalence of HCV is greater than HBV, immunization is not available, and post- exposure treatment is unsatisfactory. Hepatitis C virus is the most common chronic bloodborne infection in the United States, and in general, transmission patterns and population risk groups are similar to those for HBV. The frequency of HCV found among residents of LTCFs has ranged from 1% to 3% (42). 1. Screening Policies concerning screening for HCV infection in persons admitted to LTCFs are similar to those given in the previous section for HBV. Thus, screening is not indicated on a routine basis but should be part of an evaluation of residents with acute and chronic liver disease or abnormal liver function tests. Residents consid- ered at high risk for HCV should also be tested; this would include individuals who ever injected illegal drugs, those who received clotting factor concentrates, those requiring long-term hemodialysis, and recipients of organ transplants and transfusions before 1992. It is not necessary to screen HCWs for HCV because of the rarity of transmission of HCV infection from HCWs to patients or residents. 2. Vaccination No vaccination is available for HCV. 3. Postexposure Protection Healthcare workers should be tested routinely for HCV infection after needle- sticks, sharps injury, or mucosal exposure to HCV-positive blood. However, pro- phylaxis after HCV exposure with immunoglobulin or antiviral treatment has not been shown to be effective and is not recommended. For the 2% to 10% of HCWs who will have anti-HCV seroconversion after exposure to an HCV-positive source, combination treatment with interferon and another anti-viral drug should be considered. VI. CONCLUSION Knowledge of the epidemiology and biology of the various types of viral hepati- tis is essential for primary prevention and optimal management of residents ex- posed to infection in LTCFs. It is encouraging to consider that effective vaccines are now available for two of the three major types of viral hepatitis, and numer- ous, specific serological tests facilitate diagnosis of these infections. It is hoped