Transmission of hepatitis B virus associated with assisted monitoring of blood glucose at an assisted living facility in New York State

ArticleinAmerican journal of infection control 40(8):726-31 · January 2012with55 Reads
Impact Factor: 2.21 · DOI: 10.1016/j.ajic.2011.11.002 · Source: PubMed
Abstract

Hepatitis B virus (HBV) transmission has been reported after patient-to-patient blood exposure during assisted monitoring of blood glucose (AMBG). Three assisted-living facility (ALF) residents who underwent AMBG developed acute HBV infection (HBVI) within 10 days. We investigated HBV transmission and implemented preventive measures. A retrospective cohort study was conducted. Infection control practices were assessed. HBVI screening was conducted for all staff and epidemiologically linked residents. Viral DNA sequences were compared for a subset of isolates. Lancing devices and glucometers were shared among residents without proper sanitization. Serologic testing of all 34 residents with diabetes and 12 epidemiologically linked residents present during the exposure period detected 6 residents with diabetes with current HBVI and 4 residents with diabetes and 1 epidemiologically linked resident with previous HBVI. A cohort study of 32 individuals with diabetes identified AMBG as a significant risk factor for HBVI (relative risk, 6.7; 95% confidence interval, 1.7-26.3). Viral DNA sequences for 5 AMBG-exposed residents' isolates were identical, suggesting a common source. AMBG was significantly associated with HBVI in ALF residents with diabetes. Despite clear preventive recommendations, bloodborne pathogen transmission continues to occur in the setting of AMBG. Strengthening direct care provider, infection preventionist, and health department partnerships with ALFs is crucial to ensure safe AMBG practices and prevent HBV transmission.

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Available from: Lilia Ganova-Raeva
Major article
Transmission of hepatitis B virus associated with assisted monitoring of blood
glucose at an assisted living facility in New York State
Joshua K. Schaffzin MD, PhD
a
,
*, Karen L. Southwick MD
a
, Ernest J. Clement MSN, CIC
a
,
Franciscus Konings PhD
a
, Lilia Ganova-Raeva PhD
b
, Guoliang Xia MD
b
, Yury Khudyakov PhD
b
,
Geraldine S. Johnson MS
a
a
Bureau of Communicable Disease Control, New York State Department of Health, Albany, NY
b
Molecular Epidemiology & Bioinformatics Laboratory, Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
Key Words:
Cross-infection
Diabetes mellitus
Humans
Infection control
Long-term care
Background: Hepatitis B virus (HBV) transmission has been reported after patient-to-patient blood
exposure during assisted monitoring of blood glucose (AMBG). Three assisted-living facility (ALF) resi-
dents who underwent AMBG developed acute HBV infection (HBVI) within 10 days. We investigated HBV
transmission and implemented preventive measures.
Methods: A retrospective cohort study was conducted. Infection control practices were assessed. HBVI
screening was conducted for all staff and epidemiologically linked residents. Viral DNA sequences were
compared for a subset of isolates.
Results: Lancing devices and glucometers were shared among residents without proper sanitization.
Serologic testing of all 34 residents with diabetes and 12 epidemiologically linked residents present
during the exposure period detected 6 residents with diabetes with current HBVI and 4 residents with
diabetes and 1 epidemiologically linked resident with previous HBVI. A cohort study of 32 individuals
with diabetes identied AMBG as a signicant risk factor for HBVI (relative risk, 6.7; 95% condence
interval, 1.7-26.3). Viral DNA sequences for 5 AMBG-exposed residents isolates were identical, sug-
gesting a common source.
Conclusions: AMBG was signicantly associated with HBVI in ALF residents with diabetes. Despite clear
preventive recommendations, bloodborne pathogen transmission continues to occur in the setting of
AMBG. Strengthening direct care provider, infection preventionist, and health department partnerships
with ALFs is crucial to ensure safe AMBG practices and prevent HBV transmission.
Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.
Assisted monitoring of blood glucose (AMBG) is monitoring
performed by a health care provider or other caregiver for indi-
viduals who are unable to perform blood glucose self-monitoring.
1
Inappropriate AMBG technique has been identied as a source of
transmission of hepatitis B virus (HBV) in health care facilities
including hospitals
2-4
and long-term skilled nursing facilities
(SNFs).
3,4
More recently, outbreaks have been identied in assisted
living facilities (ALFs),
5,6
creating an emerging epidemiologic
challenge for providers and public health practitioners.
Investigators have proposed and identied a variety of trans-
mission mechanisms, including reuse of lancets and spring-loaded
lancing devices, failure to clean and disinfect glucometers, and lack
of appropriate hand hygiene or glove use. Numerous guidelines
delineate recommendations for proper infection control during
AMBG, including never using a lancing device on more than one
person, to prevent patient-to-health care worker and patient-to-
patient bloodborne pathogen transmission.
7,8
ALFs provide group living arrangements for individuals, such as
elderly persons, who cannot care for themselves independently.
Although these facilities provide assistance with activities of daily
living, they are based on a social, not a medical, model and typically
provide limited or no skilled nursing care.
9
In New York State, ALFs
are regulated by the New York State Department of Health (NYS-
DOH) according to a social model, with no specic requirements for
infection control monitoring or implementation. Residents of these
* Address correspondence to Joshua K. Schaffzin, MD, PhD, Division of General
and Community Pediatrics, MLC 2011, Cincinnati Childrens Hospital Medical
Center, 3333 Burnet Ave, Cincinnati, OH 45229.
E-mail address: Joshua.schaffzin@cchmc.org (J.K. Schaffzin).
Portions of this investigation were presented in abstract form at the Interna-
tional Conference on Emerging Infectious Diseases, Atlanta, GA, March 16-18, 2008.
Conict of interest: None to report.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of
Infection Control
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ajic.2011.11.002
American Journal of Infection Control xxx (2012) 1-6
Page 1
facilities typically are cared for by their own physicians and are
expected to manage their own basic medical care, such as medi-
cation administration and blood glucose monitoring. However,
many facilities do provide or arrange assistance for residents with
certain medical procedures that they otherwise would perform for
themselves, such as blood glucose monitoring.
5,9,10
An outbreak of acute HBV infection was identied in a 120-bed,
4-unit ALF in upstate New York. We conducted an infection control
assessment, serologic screening, and a retrospective cohort study to
identify the determinants that led to the outbreak and to guide
implementation of preventive measures.
METHODS
Public health surveillance
In New York State, cases of HBV infection must be reported to
and investigated by the local health department in which the
affected patient resides. Investigation involves conrmation of the
diagnosis based on national case denitions and interviews using
standardized reporting forms.
11
Interviews collect basic demo-
graphic and testing information, as well as data on an extensive list
of exposures that are known risk factors for HBV, including peri-
natal transmission, unprotected sex, street drug use, and health
care exposures. In some counties, the NYSDOH provides assistance
and auditing of case reports as part of the Centers for Disease
Control and Prevention (CDC) Emerging Infections Program.
Epidemiologic investigation
Laboratory results and reporting form information were
reviewed for all index cases. Multiple onsite observations and staff
interviews to assess AMBG and infection control practices in the
ALF were conducted with a focus on possible modes of bloodborne
pathogen transmission. All invasive procedures performed at the
ALF, including insulin administration, phlebotomy, vaccine
administration, and AMBG, were evaluated onsite. As a public
health response to a disease outbreak, this investigation was not
considered a human subjects research study.
All residents with diabetes living in the ALF between January
2006 and April 2007 underwent serologic testing for evidence of
HBV infection, including hepatitis B surface antigen (HbsAg),
hepatitis B surface antibody (anti-HBs), and IgM antibody to
hepatitis B core antigen (IgM anti-HBc). Total antibody to hepatitis
B core antigen (total anti-HBc) was measured in some residents.
Residents epidemiologically linked to a diabetic resident (dened
as residents who either shared a room or bathroom with or were an
intimate partner of a diabetic resident) were tested for HBV infec-
tion. HBV infection status of all direct care staff members, nurses,
and resident care assistants who worked during this same period
was obtained through medical records documentation or serologic
testing.
Evidence of current HBV infection was dened as a positive
HBsAg result, independent of other markers. Evidence of previous
HBV infection was dened as a negative HBsAg result and either
a positive IgM anti-HBc result or a positive anti-HBs result in
a patient with no documented history of HBV vaccination. Because
total anti-HBc was measured in only some residents, we did not
include these results in our case denitions. Acute HBV infection
was dened as serologic evidence of a current or previous HBV
infection with a discrete onset of symptoms consistent with acute
hepatitis.
11
The likely exposure period for an acute case was dened
as the 6 months to 6 weeks before the onset of HBV-related
symptoms (ie, the standard incubation period for HBV infection).
Cohort study
The cohort was dened as any resident with diabetes living in
the ALF between August 2006 and January 2007, the period
encompassing the exposure periods for all 3 index case patients. For
the purpose of the cohort study, a case was dened as any member
of the cohort with serologic evidence of current or previous HBV
infection. Diabetes was identied based on notation in the medical
record; distinctions between type 1 and type 2 diabetes and
specic conrmatory tests were not considered. All available
records of the residents with diabetes were reviewed using an
instrument developed for this investigation that solicited patient
demographic data, medical diagnoses including diabetes, health
care exposures (eg, AMBG, insulin therapy, vaccines), and transfers
to acute care facilities or SNFs. For residents with positive HBV
serology, the primary care physicians records and available
hospital admission records were reviewed using a standard
abstraction instrument that collected previous vaccination and
testing for HBV and known risk factors for bloodborne infections.
Statistical analyses were performed using Epi-Info 2002 software.
Relative risk (RRs), 95% condence intervals (CIs), and P values were
calculated for exposures. P values were determined using Fishers
exact test because expected cell counts were <5.
HBV genomic sequencing
Blood samples with a positive HBsAg result were sent to the
CDCs Molecular Epidemiology and Bioinformatics Laboratory in
Atlanta, Georgia for HBV sequence analysis. HBV DNA was extracted
from 100
m
L of serum, and an w2,000- to 3,000-bp region of the
HBV genome (PreS-S-Polymerase-X region of the genome) was
amplied by nested polymerase chain reaction, and the sequence
was examined to determine the genetic relatedness of HBsAg-
positive samples as described previously.
12
RESULTS
Epidemiologic investigation
In March 2007, the Orange County (NY) Health Department was
notied through standard reporting of 3 cases of acute HBV infec-
tion. Through routine investigation, the Health Department deter-
mined that all 3 affected persons were residents of the same ALF,
and immediately notied the NYSDOH. All 3 patients met the
standard case denition of acute HBV infection,
11
with onset within
10 days of one another (Table 1). One patient was hospitalized for
care of HBV infection, and all 3 patients survived. During each
patients likely exposure period, admissions to a local hospital
(hospital A) and an SNF adjacent to the ALF were noted, but
admission to the ALF was the only common exposure in all 3 cases
(Fig 1).
Table 1
Onset date, symptoms, and serologic results for index HBV cases among ALF
residents
Case
Onset
date
Age at
onset,
years Symptoms
Peak liver
function tests,
AST, units per liter HBsAg
IgM
anti-
HBc
1 2/27/07 85 Jaundice 1,241 Positive Positive
2 3/4/07 87 Abdominal pain 178 Positive Positive
3 3/7/07 70 Abdominal pain,
fever, cough
571 Negative Positive
AST, aspartate transaminase.
J.K. Schaffzin et al. / American Journal of Infection Control xxx (2012) 1-62
Page 2
The NYSDOH conducted multiple site visits to the ALF in March
and April 2007 to review resident information and assess infection
control practices. The 120-bed ALF is staffed by nurses and resident
care assistants, has both private and semiprivate rooms, and is
physically joined to the SNF via lockable re doors. Some of the
private rooms have private bathrooms, whereas others share
a bathroom with another private room. The ALF runs an adult day
health program for both residents and nonresidents living in the
community on the facility premises. There is no routine interaction
between SNF residents and ALF residents or day program partici-
pants. Staff members from the ALF or the SNF do not work in the
adult day health program while assigned elsewhere.
At the time of the study, the standard practice in the ALF was for
residents to self-monitor blood glucose and self-administer insulin.
However, AMBG was a routine practice in the ALF, done by nurses
using the Ascensia Contour blood glucose monitoring system
(Bayer HealthCare, Mishawaka, IN). This system, which was
designed for personal use by a single patient, used a reusable
Microlet lancing device with a reusable adjustable end cap. Nurses
who provided care in the ALF to the 3 acute case patients reported
that all 3 had diabetes and received AMBG routinely. The nurses
reported they always changed the lancet but used the same end cap
between these and other diabetic residents, with no disinfection
between uses. This practice was likely common at the facility for at
least 11 years. AMBG practice in the SNF and the adult day health
program differed from that in the ALF. In both of those areas, nurses
performed blood glucose monitoring in residents using single-use
retractable lancets that did not involve the use of adjustable end
caps, lancet holders, or pens.
ALF staff reported that in response to the HBV cases, the AMBG
policy had been changed in February 2007 to mandate the exclu-
sive use of single-use diabetes care supplies. Existing blood glucose
monitoring systems were no longer used after this time. Each
diabetic resident was supplied with an individually labeled
container containing a glucometer (Ascensia Breeze blood glucose
monitoring system [Bayer HealthCare], Precision Xtra blood
glucose and ketone monitoring system [Abbott Diabetes Care,
Alameda, CA], or OneTouch Ultra blood glucose monitoring system
[LifeScan, Milpitas, CA]), along with test strips, clean gloves, alcohol
wipes, and single-use disposable safety lancets. Diabetes care
supplies were stored in the medication room and not in the
possession of patients undergoing AMBG.
Direct observation of AMBG practice identied additional
infection control breaches, including removing and pocketing
soiled gloves rather than disposing of them at the testing site as
recommended. These breaches were corrected immediately.
Evaluations of previous and current insulin injection practices in
the ALF, the SNF, and the adult day health program identied no
deciencies. In the ALF, insulin vials are individually labeled and
stored in a common refrigerator in individually labeled bags.
Insulin is administered only by licensed practicing or registered
nurses using retractable safety syringes. A similar situation was
described for the SNF. In the adult day health program, there was no
stock insulin. Participants either self-injected before arrival or
brought their own vials and were injected by staff using single-
patient use syringes and safety needles. Podiatric services were
offered to ALF residents by a visiting podiatrist, who was docu-
mented as HBV immune as early as 2007. A review of the podia-
trists procedures revealed proper infection control procedures,
including proper cleaning, disinfection, and sterilization of all
equipment.
Serologic testing for evidence of HBV infection was obtained for
46 residents, including 34 with diabetes and 12 epidemiologically
linked residents, and for 35 ALF staff members. Among the resi-
dents, 6 with diabetes (including the 3 index cases) had current
HBV infection, and 4 diabetic residents and 1 epidemiologically
linked resident had evidence of previous HBV infection. One staff
member had serologic evidence of current HBV infection. No acute
cases besides the 3 index cases were identied. Five of 10 (50%) ALF
residents with evidence of previous or current HBV infection
attended the adult day health program; 4 of these 5 had diabetes,
and 2 of those 4 received AMBG while attending the adult day
health program.
Cohort study
Records for 32 of 36 (89%) diabetic residents living at the ALF
during the exposure period for all 3 index cases were available and
reviewed. Ten cases and 22 noncases were included in the study.
Mean age as of August 1, 2006, was 80.2 years (range, 53.7-90.1
years). Risk factors for exposure to bloodborne pathogens, including
injections (eg, insulin, vitamin B12, inuenza or pneumococcal
vaccination), wound care, and podiatric care, were collected and
analyzed for association with current or previous HBV infection.
Results of the risk factor analysis are summarized in Table 2.
Statistically signicant risk factors included insulin administration
and AMBG. Nine of 32 (28%) diabetic residents had a record of
insulin injection, including 7 of the 10 cases and 2 of the 22 noncases
(RR, 6.0; 95% CI, 2.0-18.0). In addition, 12 of 32 (38%) diabetic resi-
dents received AMBG, including 8 cases and 4 noncases (RR, 6.7; 95%
CI,1.7-26.3). Eight of 32 (25%) diabetic residents had a record of both
insulin injections and AMBG; 7 of these residents had evidence of
HBV infection. Sex was not a signicant risk factor (P ¼ .22); infor-
mation on resident race and ethnicity was not collected.
HBV genomic sequencing
HBV genome was sequenced from 7 HBV-positive serum spec-
imens, 6 from residents and 1 from a staff member. The 6 resident
samples included 2 of the 3 index cases; all 6 had received AMBG.
Five of the resident viruses (Fig 2; NYX1-5) were genotype D3,
subtype ayw. A 3026-nucleotide sequence obtained from the
genome of these 5 viruses was identical, suggesting a common
source of infection. A sixth residents virus (NYX7) was also
Hospital A
Pt Onset Aug 06 Sep 06 Oct 06 Nov 06 Dec 06 Jan 07 Feb 07 Mar 07
1 2/27/07
2 3/4/07
3 3/7/07
ALF X SNF X Onset date Incubation periodHospital A
Pt Onset Aug 06 Sep 06 Oct 06 Nov 06 Dec 06 Jan 07 Feb 07 Mar 07
1 2/27/07
2 3/4/07
3 3/7/07
ALF X SNF X Onset date Incubation period
Fig 1. Facility admissions during likely exposure periods for the index cases. The numbering of cases correlates with that in Table 1. Dates of admission to assisted living facility
(white box), skilled nursing facility (dark-gray box), or local hospital A (black box), and onset date (diamond) and exposure period (black line) are depicted for the 3 index hepatitis B
cases.
J.K. Schaffzin et al. / American Journal of Infection Control xxx (2012) 1-6 3
Page 3
genotype D3, subtype ayw; however, the 2051-nucleotide sequence
obtained and analyzed was 0.7% different from case NYX1 and was
not considered related to the cluster. Virus from the staff member
(NYX8) was genotype C and unrelated to the cluster.
DISCUSSION
In this investigation, we found substantial epidemiologic and
molecular evidence of HBV transmission from resident to resident
through AMBG. Health care worker-to-resident transmission was
unlikely, because the only staff member with HBV infection
harbored a virus with a genetic sequence unrelated to the residents
viruses. We are unable to separate insulin injection from AMBG as
an independent risk factor based on our data, because the small
number of cases precluded a stratied analysis. However, insulin
injection was a less likely source of transmission, given that an
infection control review found no breaches associated with insulin
administration, in contrast to the signicant breaches identied
with AMBG.
This study has several limitations. Given the studys retrospec-
tive nature, we were unable to capture cases or observe practices in
real time, and were subject to a recall bias in staff and patient
interviews. We cannot rule out sharing of ngerstick devices in the
SNF. Although we do not suspect any false reports from the SNF, it
should be noted that had such evidence had been identied, the
SNF might have been subject to regulatory action according to
Centers for Medicare and Medicaid Services regulations.
13
Because
of poor documentation, we were unable to discern exactly how
many residents received AMBG, how often residents self-
monitored blood glucose and/or self-administered insulin, and
whether the risk for HBV infection differed between those who
self-administered and those who did not. Staff interviews sug-
gested that nearly all glucose monitoring was AMBG and the
majority of insulin injections were performed by ALF staff. Finally,
although podiatric practices and attendance at the adult day health
program apparently carried a low risk of HBV transmission, we did
not conduct formal case nding in either group, and thus it is
possible that the true number of cases associated with this
outbreak was underestimated.
This is not the rst reported instance of HBV transmission
through AMBG in health care facilities. In fact, such outbreaks have
been documented for nearly 2 decades,
2-6
and clear guidelines on
preventing such events are well established.
7,8
Nonetheless,
outbreaks of this vaccine-preventable disease continue to occur.
Practices leading to this and other outbreaks of HBV infection put
those exposed at risk of any bloodborne pathogen infection. For this
outbreak, the NYSDOH recommended that all persons tested for
HBV infection be offered testing for hepatitis C virus (HCV) and HIV
infection at the same time. Because there was no evidence of HCV
or HIV transmission in the facility, data relating to this testing were
not collected and are not presented here.
Diabetes care professionals should be aware of the potential for
blood exposure during AMBG, particularly in patients who require
assistance with activities of daily living.
1
Specically, all blood
glucose monitoring equipment, including lancets, lancing devices,
and glucometers, should be dedicated to individual patients. In
ALFs and other congregational care settings, the CDC recommends
exclusive use of autodisabling single-use lancets for AMBG. If
sharing of blood glucose monitors is absolutely unavoidable, then
these devices must be cleaned and properly sanitized before each
use.
7,8
In response to the subject outbreak, the NYSDOH distributed
an advisory to all health care facilities and to the diabetes care
community in New York State emphasizing the need for proper
infection control measures during AMBG, and encouraging a review
of current practice and remediation where necessary.
14
CDC
investigators have since called on the diabetes care community to
examine practices related to AMBG and consider technological
advances that could improve patient safety and reduce opportu-
nities for blood exposures during blood glucose monitoring.
4
Infection preventionists, although less frequently involved
directly with ALFs, often have indirect connections through
patients in SNFs and hospitals. For example, the ALF in our study
was adjacent to a SNF, and patients often moved between the
facilities as their health care needs dictated (Fig 1). Infection pre-
ventionists need to be aware of the risk of bloodborne pathogen
transmission among patients who have undergone AMBG and are
admitted to facilities that they oversee. In addition, Association of
Professionals in Infection Control and Epidemiology chapters that
conduct community outreach may want to target ALFs, primary
care providers, and diabetes care providers to emphasize this and
other important infection prevention measures. Care providers play
an important role in the identication, reporting, and prevention of
bloodborne diseases in their patients. Providers should not
discount the risks and consequences of infection in elderly indi-
viduals, especially in light of this and other outbreaks that have
carried substantial hospitalization and mortality rates.
4-6
HBV
vaccination is a safe and effective means of prevention.
15
In October
2011, the Advisory Committee on Immunization Practices (ACIP)
recommended that unvaccinated adults aged <60 years with dia-
betes be vaccinated for HBV, and suggested that the HBV vaccine
may be safely administered to unvaccinated adults with diabetes
aged 60 years.
15
The benet of routine vaccination for adults aged
60 years is less obvious, because vaccine immunogenicity appears
to decrease with increasing age.
16
Two recent studies identied widespread deciencies in AMBG
practice in ALFs in Virginia and Florida.
5,10
It is likely that a similar
gap in awareness and practice exists on a wider scale in other
locations and other types of long-term care facilities. Local and
Table 2
Cohort study analysis of risk factors for HBV infection (n ¼ 32; 10 cases, 22 noncases)
Risk factor Total number exposed Number of cases exposed Attack rate, % RR 95% CI P value
Diabetes mellitus 32 10 31 Ref - -
Vitamin B12 injection 8 2 25 0.8 0.2-2.8 .50
Diagnostic phlebotomy 26 10 38 Undened .10
AMBG 12 8 67 6.7 1.7-26.3 .002
Heparin injection 1 1 100 3.4 2.0-6.0 .30
Vaccination* 23 5 22 0.4 0.2-1.0 .10
Insulin injection 9 7 78 6.0 2.0-18.0 .001
Invasive wound/skin care 6 1 31 0.5 0.1-3.1 .40
Overnight hospitalization 12 6 50 2.5 0.9-7.1 .10
Tuberculin skin testing 25 8 32 1.1 0.3-4.1 .60
Podiatric care 17 4 24 0.6 0.2-1.7 .30
Statistically signicant associations are in bold type.
*Includes inuenza (n ¼ 22) and pneumococcal (n ¼ 5) vaccinations. Four residents received both vaccines.
J.K. Schaffzin et al. / American Journal of Infection Control xxx (2012) 1-64
Page 4
Fig 2. Phylogenetic tree of HBV genotype C and D isolates. Representative sequences from the GenBank and CDC sequence databases (open box) were compared with those from 7
HBsAg-positive patients in this study (solid box).
J.K. Schaffzin et al. / American Journal of Infection Control xxx (2012) 1-6 5
Page 5
state health departments should examine how ALFs are regulated
in their jurisdictions and whenever possible partner with providers
to assess AMBG practices in ALFs, ensuring proper policies and
practices. Local and state health departments are important sources
of information and expertise and may be helpful resources for
diabetes educators and providers when establishing lines of
communication with ALFs and other regulated facilities.
Acknowledgment
The authors thank members of the Orange County (NY) Heath
Department, ALF staff, E. M. Rizzo from the New York State
Department of Health, and J. F. Perz, DrPH from the Centers for
Disease Control and Prevention for their assistance.
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