A recent Centers for Disease Control and Prevention (CDC) investigation details the transmission of hepatitis B virus (HBV) between two residents of a skilled nursing facility (SNF) where blood glucose monitors were shared, despite being disinfected between uses. The report, published in the Morbidity and Mortality Weekly Report on August 7, 2025, underscores the risks of shared medical equipment in long-term care settings, particularly for residents undergoing assisted monitoring of blood glucose (AMBG).
In May 2024, a 69-year-old resident was hospitalized and diagnosed with acute HBV shortly after being transferred from the facility. The resident, who had diabetes and no history of hepatitis B vaccination, had received AMBG at the facility for 10 months. Laboratory testing confirmed acute hepatitis B, prompting an investigation by state and local health departments in collaboration with the CDC.
An infection control assessment found that glucometers were shared among residents and disinfected between uses according to manufacturer instructions. No other infection control breaches were identified. Facility-wide testing identified one resident with a previously unreported chronic HBV infection who had also received AMBG during the likely transmission window and lived in close proximity to the newly infected resident.
AMBG records showed that both residents had been tested with one of two glucometers located on the same medical cart, often within a minute of each other. Investigators concluded that even brief intervals between uses may not allow for adequate disinfection. Whole genome sequencing confirmed the HBV strains in both residents were genetically identical.
The report concludes that even with disinfection, sharing glucometers can lead to HBV transmission. The CDC continues to recommend assigning glucometers to individual residents and offering routine hepatitis B vaccination to those with diabetes. While hepatitis B vaccination is recommended for adults with diabetes, coverage remains low among those aged 60 and older.
The findings underscore the importance of maintaining infection control protocols, using dedicated equipment, and supporting efforts to improve hepatitis B vaccination coverage in skilled nursing facilities.
Compliance Perspective
Issue
HBV can be transmitted in healthcare settings through shared medical equipment that comes into contact with blood. A recent CDC investigation confirmed HBV transmission between two residents of a skilled nursing facility who received AMBG using shared glucometers. Although the devices were disinfected between uses, transmission still occurred, underscoring that even when protocols are followed, shared equipment may pose a risk. According to the CDC, assigning blood glucose monitors to individual residents and improving hepatitis B vaccination coverage are key strategies to reduce the risk of HBV transmission in long-term care settings. Infection prevention and control is a critical focus in skilled nursing facilities to reduce the risk of bloodborne pathogen transmission and protect resident health. Federal regulations require nursing homes to maintain effective Infection Prevention and Control Programs (IPCPs) to prevent the spread of communicable diseases, including HBV.
Discussion Points
- Review policies and procedures to ensure the facility’s infection prevention and control plan includes effective strategies to prevent bloodborne pathogen transmission during assisted monitoring of blood glucose and other resident care activities. Consider engaging external expertise to assist in identifying gaps and strengthening compliance.
- Provide ongoing training for all staff on infection prevention and control protocols, emphasizing the importance of proper device handling, disinfection practices, and vaccination where appropriate. Med-Net Academy offers the course Maintaining Proper Infection Control Procedures, which covers CDC recommendations, hand hygiene, PPE use, facemasks, resident placement, and safe aerosol-generating procedures.
- Conduct audits to verify compliance with infection prevention protocols and policies. Consider working with a consultant to support audit processes, identify areas for improvement, and strengthen infection prevention practices.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*