Shared Glucose Meters Spread Hepatitis B in a North Carolina Nursing Home, 2024

Many people with diabetes in long-term care need help checking their blood sugar — assisted blood glucose monitoring, in which a nurse or other caregiver takes the reading. It carries a known risk: during 2008–2019, 15 hepatitis B outbreaks in long-term care facilities were linked to it. CDC recommends that each blood glucose meter be assigned to one person, and North Carolina’s Division of Public Health gives the same advice.

A case with no obvious source

In May 2024, the Surry County Health Department told the state that a 69-year-old hospital patient, just transferred from a skilled nursing facility, had been diagnosed with acute hepatitis B. The patient had diabetes, had lived at the facility for 10 months, and had their blood sugar checked with assistance there. There was no record of past hepatitis B or of hepatitis B vaccination.

The patient had been admitted for something unrelated, but jaundice, nausea and fatigue prompted testing for viral hepatitis. Raised liver enzymes, hepatitis B surface antigen, IgM antibody to the core antigen, and hepatitis B DNA confirmed an acute infection. State and county health officials, working with CDC, set out to find the source.

The investigation

Two infection-control visits found that the facility’s glucose meters were shared among several residents, though staff were seen disinfecting them between uses as the manufacturer instructed. No other lapses — in standard precautions or injection safety — were found.

North Carolina requires hepatitis B infections to be reported, but the state’s surveillance system held no record of any resident with the infection. So in mid-June every resident was tested. One turned out to have a chronic hepatitis B infection, diagnosed earlier but never reported. That resident had lived at the facility since early 2022, in a room close to the newly infected patient’s, and had also received assisted glucose monitoring during the window when the new infection was probably acquired — 9 to 21 weeks before the jaundice began.

Monitoring records from March–April 2024 showed that both residents had their blood sugar checked every day with one of two meters kept on the same medical cart, and that the newly infected resident was repeatedly tested less than a minute after the chronically infected one — possibly too little time to disinfect the device properly. The facility said its procedures had not changed in the months before that period. Whole-genome sequencing showed the two residents’ viruses were genetically identical.

Follow-up

In September 2024 the state wrote, by certified mail, to every former resident whose stay had overlapped with that of the chronically infected resident, explaining the possible risk and recommending blood tests. The state checked its registry for new infections 6 months after the letters and planned to check again at 12 months. As of March 2025, no further cases had been found.

Lessons

The evidence points to transmission from one resident to another through two shared glucose meters. Even when disinfection instructions are followed, sharing equipment that touches blood can spread hepatitis B. Two steps would lower the risk:

• Give each resident their own glucose meter.
• Vaccinate residents with diabetes against hepatitis B. The Advisory Committee on Immunization Practices recommends hepatitis B vaccination for everyone under 60, and, through shared clinical decision-making, for adults 60 and older at higher risk, such as those with diabetes. Clinicians weighing vaccination for older adults with diabetes should consider the risk that assisted glucose monitoring in nursing facilities poses.

Hepatitis B vaccination coverage among people 60 and older with diabetes remains low, and the investigators suggest skilled nursing facilities may be a good place to offer it.

Sources

Based on Moore JR, Breeyear T, Gowler CD, et al., "Notes from the Field: Hepatitis B Virus Transmission Associated with Assisted Blood Glucose Monitoring in a Skilled Nursing Facility — North Carolina, 2024," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; rewritten in hubnx’s own words. The report gives the chronically infected resident’s assisted monitoring as November 2023–February 2024 but also shows it continuing in March–April 2024, so neither range is given here as the full period.