Health Advisory: Preventing Exposure to Bloodborne Pathogens during Diabetes Care Procedures and Techniques
February 11, 2011
Please distribute immediately to Medical Director, Chief Nurse Executive, Infection Control, Infectious Disease Department, Nursing Units, and Staff Education.
The New York State Department of Health (NYSDOH) recently identified transmission of hepatitis B virus between two patients at a residential healthcare facility. Failure to follow standard infection control procedures for diabetes care may have contributed to this event. Specifically, staff were performing fingersticks using a shared lancet pen. The lancets were replaced after each test, but the pen was shared among multiple patients. NYSDOH conducted a similar investigation in 2007-08 in which lancet pens were shared and hepatitis B virus transmission was identified. In the past, FDA cleared some fingerstick devices for use on multiple patients, a practice that is now recognized as unsafe. The FDA recommends that all fingerstick devices be labeled for use only on a single patient. The purpose of this advisory is to urge facilities to carefully review and update infection control practices and procedures as necessary to prevent similar occurrences.
To prevent transmission of bloodborne pathogens such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus during delivery of diabetes care, the Centers for Disease Control and Prevention (CDC) and NYSDOH recommend the following:
- Fingerstick devices (including lancet pens and lancets) should never be used for more than one person.
- Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.
- Insulin pens and other medication cartridges and syringes are for single-patient-use only and should never be used for more than one person.
- After use, all sharp fingerstick equipment must be disposed of at the point of use in an approved sharps container.
The following references should be reviewed and used to assess and update your facility's infection control practices and procedures as necessary to prevent transmission of bloodborne pathogens.
- CDC's Infection Prevention during Blood Glucose Monitoring and Insulin Administration
- Food and Drug Administration's Alert: Use of Fingerstick Devices on More Than One Person Poses Risk for Transmitting Bloodborne Pathogens: Initial Communication: Update 11/29/2010
Thank you for your attention to this important matter.
Please contact the NYSDOH Regional Office with any questions or concerns regarding this advisory.
NYSDOH Regional Epidemiology and Infection Control Program Offices
- Western Regional Office: (716) 847-4503
- Central New York Regional Office: (315) 477-8166
- Capital District Regional Office: (518) 408-5396
- Metropolitan Area Regional Office: (914) 654-7149