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We describe a large outbreak of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) involving an acute-care hospital emergency department during December 2020 and January 2021, in which 27 healthcare personnel worked while infectious, resulting in multiple opportunities for SARS-CoV-2 transmission to patients and other healthcare personnel. We provide recommendations for improving infection prevention and control.

Between April 2020 and May 2021, the Centers for Disease Control and Prevention (CDC) awarded more than $40 billion to health departments nationwide for COVID-19 prevention and response activities. One of the identified priorities for this investment was improving infection prevention and control (IPC) in nursing homes.CDC developed a virtual course to train new and less experienced public health staff in core healthcare IPC principles and in the application of CDC COVID-19 healthcare IPC guidance for nursing homes.From October 2020 to August 2021, the CDC led training sessions for 12 cohorts of public health staff using pretraining reading materials, case-based scenarios, didactic presentations, peer-learning opportunities, and subject matter expert-led discussions. Multiple electronic assessments were distributed to learners over time to measure changes in self-reported knowledge and confidence and to collect feedback on the course. Participating public health programs were also assessed to measure overall course impact.Among 182 enrolled learners, 94% completed the training. Most learners were infection preventionists (42%) or epidemiologists (38%), had less than 1 year of experience in their health department role (75%), and had less than 1 year of subject matter experience (54%). After training, learners reported increased knowledge and confidence in applying the CDC COVID-19 healthcare IPC guidance for nursing homes (≥81%) with the greatest increase in performing COVID-19 IPC consultations and assessments (87%). The majority of participating programs agreed that the course provided an overall benefit (88%) and reduced training burden (72%).The CDC's virtual course was effective in increasing public health capacity for COVID-19 healthcare IPC in nursing homes and provides a possible model to increase IPC capacity for other infectious diseases and other healthcare settings. Future virtual healthcare IPC courses could be enhanced by tailoring materials to health department needs, reinforcing training through applied learning experiences, and supporting mechanisms to retain trained staff.

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the vulnerability of residents and staff members in long-term care facilities (LTCFs) (1). Although skilled nursing facilities (SNFs) certified by the Centers for Medicare & Medicaid Services (CMS) have federal COVID-19 reporting requirements, national surveillance data are less readily available for other types of LTCFs, such as assisted living facilities (ALFs) and those providing similar residential care. However, many state and territorial health departments publicly report COVID-19 surveillance data across various types of LTCFs. These data were systematically retrieved from health department websites to characterize COVID-19 cases and deaths in ALF residents and staff members. Limited ALF COVID-19 data were available for 39 states, although reporting varied. By October 15, 2020, among 28,623 ALFs, 6,440 (22%) had at least one COVID-19 case among residents or staff members. Among the states with available data, the proportion of COVID-19 cases that were fatal was 21.2% for ALF residents, 0.3% for ALF staff members, and 2.5% overall for the general population of these states. To prevent the introduction and spread of SARS-CoV-2, the virus that causes COVID-19, in their facilities, ALFs should 1) identify a point of contact at the local health department; 2) educate residents, families, and staff members about COVID-19; 3) have a plan for visitor and staff member restrictions; 4) encourage social (physical) distancing and the use of masks, as appropriate; 5) implement recommended infection prevention and control practices and provide access to supplies; 6) rapidly identify and properly respond to suspected or confirmed COVID-19 cases in residents and staff members; and 7) conduct surveillance of COVID-19 cases and deaths, facility staffing, and supply information (2).

Background Beginning in October 2016, the Centers for Medicare & Medicaid Services (CMS) issued expanded guidance requiring accrediting organizations and state survey agencies to report serious infection control breaches to relevant state health departments. This project sought to characterize and summarize The Joint Commission's early experiences and findings in applying this guidance to facilities accredited under the ambulatory and office-based surgery programs in 2017. Methods Surveyor notes were retrospectively reviewed to identify individual breaches, and then the Centers for Disease Control and Prevention's Infection Prevention Checklist for Outpatient Settings was used to categorize and code documented breaches. Results Of 845 ambulatory organizations, 39 (4.6%) had breaches observed during the survey process and reported to health departments. Within these organizations, surveyors documented 356 breaches, representing 52 different breach codes. Common breach domains were sterilization of reusable devices, device reprocessing observation, device reprocessing, disinfection of reusable devices, and infection control program and infrastructure. Eight of the 39 facilities (20.5%) were cited for not performing the minimum level of reprocessing based on the items' intended use, reusing single-use devices, and/or not using aseptic technique to prepare injections. Conclusion The CMS infection control breach reporting requirement has helped highlight some of the challenges faced by ambulatory facilities in providing a safe care environment for their patients. This analysis identified numerous opportunities for improved staff training and competencies as well as leadership oversight and investment in necessary resources. More systematic assessments of infection control practices, extending to both accredited and nonaccredited ambulatory facilities, are needed to inform oversight and prevention efforts.

Background:The US Census Bureau’s County Business Patterns (CBP) series provides a unique opportunity to describe the healthcare sector using a single, national data source.Methods:We analyzed CBP data on business establishments in the healthcare industry for 2000–2016 for all 50 states and the District of Columbia. Setting and facility types were defined using the North American Industry Classification System.Results:In 2016, CBP enumerated 707,634 US healthcare establishments (a 34% increase from 2000); 86.5% were outpatient facilities and services followed by long-term care facilities (12.5%) and acute-care facilities (1.0%). Between 2000 and 2016, traditional facilities such as general medical surgical and surgical hospitals (−0.4%) and skilled nursing facilities (+0.1%) decreased or remained flat, while other long-term care and outpatient providers grew rapidly.Conclusion:This analysis highlights the steady growth and increased specialization of the US healthcare sector, particularly in long-term care and outpatient settings.

Objectives To summarize patient notifications resulting from unsafe injection practices by health care personnel in the United States and describe recommended actions for prevention and response. Patients and Methods We examined records of events involving communications to groups of patients, conducted from January 1, 2012, through December 31, 2018, in which bloodborne pathogen testing was recommended or offered because of potential exposure to unsafe injection practices by health care personnel in the United States. Information compiled included: health care setting(s), type of unsafe injection practice(s), number of patients notified, number of outbreak-associated infections, and whether evidence suggesting bloodborne pathogen transmission prompted the notification. We compared these numbers with a similar review conducted from January 1, 2001, through December 31, 2011. Results From 2012 through 2018, more than 66,748 patients were notified as part of 38 patient notification events. Twenty-one involved exposures in non-hospital settings. Twenty-five involved syringe and/or needle reuse in the context of routine patient care; 11 involved drug tampering by a health care provider. The majority of events (n=25) were prompted by identification of unsafe injection practices alone, absent any documented infections at the time of notification. Outbreak-associated hepatitis B virus and/or hepatitis C virus infections were documented for 11 of the events; 8 involved patient-to-patient transmission, and 3 involved provider-to-patient transmission. Conclusions Since 2001, nearly 200,000 patients in the United States were notified about potential exposure to blood-contaminated medications or injection equipment. Facility leadership has an obligation to ensure adherence to safe injection practices and to respond properly if unsafe injection practices are identified.

A surgical heater-cooler unit has been implicated as the source for Mycobacterium chimaera infections among cardiac surgery patients in several countries. We isolated M. chimaera from heater-cooler units and patient infections in the United States. Whole-genome sequencing corroborated a risk for these units acting as a reservoir for this pathogen.

Context The Centers for Disease Control and Prevention awarded $85 million to health care-associated infection and antibiotic resistance (HAI/AR) programs in March 2015 as part of Infection Control Assessment and Response (ICAR) activities in the Epidemiology and Laboratory Capacity cooperative agreement Domestic Ebola Supplement. Program One goal of this funding was to assess and improve program capacity to respond to potential health care outbreaks (eg, HAI clusters). All 55 funded programs (in 49 state and 6 local health departments) participated. Implementation The Centers for Disease Control and Prevention developed guidance and tools for HAI/AR programs to document relevant response capacities, assess policies, and measure progress. HAI/AR programs completed an interim assessment in 2016 and a final progress report in 2017. Evaluation During the project period, 78% (n = 43) of the programs developed new investigation tools, 85% (n = 47) trained staff on outbreak response, and 96% (n = 53) of the programs reported hiring staff to assist with outbreak response activities. Staffing and expertise to support HAI outbreak response increased substantially among awardees reporting staffing limitations on the interim assessment, including in domains such as on-site infection control assessment (n = 20; 83%), laboratory capacity (n = 20; 91%), and data management/analytics (n = 14; 67%). By 2017, reporting requirements in 100% of the programs addressed possible HAI/AR outbreaks; 93% (n = 51) also addressed sentinel events such as identification of novel AR threats. More than 90% (n = 50) of programs enhanced capacities for tracking response activities; in 2016, these systems captured 6665 events (range, 3-1379; median = 46). Health departments also reported wide-ranging efforts to engage regulatory, public health, and health care partners to improve HAI/AR outbreak reporting and investigation. Discussion Broad capacity for responding to HAI/AR outbreaks was enhanced using Ebola ICAR supplemental funding. As response activities expand, health department programs will be challenged to continue building expertise, reporting infrastructure, investigation resources, and effective relations with health care partners.

Nursing homes (NHs) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NHs were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff.To assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps.We incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering 6 domains: visitor restrictions; health care personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility.Health department-referred NHs that agreed to TeleICAR consultation.We assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment.During April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NHs across 19 states. Overall, 524 (83%) had ≥1 implementation gap identified; the median number of gaps was 2 (interquartile range: 1-4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625; 68%) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620; 47%).TeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NHs across the United States early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

OBJECTIVES: Pharmacy-compounded sterile preparations (P-CSPs) are frequently relied upon in U.S. health care but are increasingly being linked to outbreaks of infections. We provide an updated overview of outbreak burden and characteristics, identify drivers of P-CSP demand, and discuss public health and patient safety lessons learned to help inform prevention. METHODS: Outbreaks of infections linked to contaminated P-CSPs that occurred between January 1, 2001, and December 31, 2013, were identified from internal Centers for Disease Control and Prevention reports, Food and Drug Administration drug safety communications, and published literature. RESULTS: We identified 19 outbreaks linked to P-CSPs, resulting in at least 1000 cases, including deaths. Outbreaks were reported across two-thirds of states, with almost one-half (8/19) involving cases in more than 1 state. Almost one-half of outbreaks were linked to injectable steroids (5/19) and intraocular bevacizumab (3/19). Non-patient-specific compounding originating from nonsterile ingredients and repackaging of already sterile products were the most common practices associated with P-CSP contamination. Breaches in aseptic processing and deficiencies in sterilization procedures or in sterility/endotoxin testing were consistent findings. Hospital outsourcing, preference for variations of commercially available products, commercial drug shortages, and lower prices were drivers of P-CSP demand. CONCLUSIONS: Recognized outbreaks linked to P-CSPs have been most commonly associated with non-patient-specific repackaging and nonsterile to sterile compounding and linked to lack of adherence to sterile compounding standards. Recently enhanced regulatory oversight of compounding may improve adherence to such standards. Additional measures to limit and control these outbreaks include vigilance when outsourcing P-CSPs, scrutiny of drivers for P-CSP demand, as well as early recognition and notification of possible outbreaks. Language: en

Background: Medications, medical devices, biological products, and other medical products can cause healthcare-associated infections related to contamination in production or transportation (intrinsic contamination) or contamination at the point of use (extrinsic contamination). Rapid identification of contaminated medical products can lead to actions to decrease further patient harm. We sought to describe events that prompted public health investigations of contaminated medical products in healthcare facilities. Methods: We reviewed records of CDC consultations with health departments and healthcare facilities from January 2015 through August 2019 to identify public health investigations in which medical products were identified as a likely source of patient infection or pathogen transmission to at least 1 patient. We collected data on products, contamination type, pathogens, route of patient exposure, healthcare setting where exposure occurred, and resulting actions. Results: There were 34 investigations involving medications (n = 15, 44%), medical devices (n = 12, 35%), biological products (n = 3, 9%), and other medical products (n = 4, 12%). Intrinsic contamination was suspected in 15 investigations (44%), with 13 (87%) based on isolation of a pathogen from unopened products and 2 (13%) based on isolation of similar pathogens from patients in contact with a medical product at multiple facilities. Extrinsic contamination was suspected in 19 investigations (56%) based on evidence of pathogen transmission at a single healthcare facility and concurrent infection control gaps at that facility supporting a mechanism of contamination. The most common pathogens prompting investigation were nontuberculous mycobacteria (n = 9, 26%), Burkholderia spp (n = 7, 21%), Klebsiella spp (n = 3, 9%), Serratia spp (n = 2, 6%), and other environmental and commensal organisms. Patients were most commonly exposed in hospitals (n = 19, 56%) and outpatient settings (n = 9, 26%). The most common patient exposures that resulted in transmission of the pathogen were infusions and injections (n = 15, 44%), diagnostic and therapeutic procedures (n = 9, 26%), and surgery (n = 5, 15%). Patient were notified and offered testing in at least 6 investigations (18%) . Interventions included product removal, healthcare provider alerts, patient notification and testing, modification of injection safety practices and other general infection control practices, correction of improper storage and handling, and changes in product design, manufacturing processes, or instructions for use. Conclusions: Public health investigations identified intrinsic and extrinsic contamination of medications, devices, and other products as a cause of healthcare-associated infections. Healthcare facilities should consider contaminated products in investigations of healthcare-associated infections, take steps to identify local infection control concerns, and alert public health authorities to events that could suggest widespread contamination.Funding: NoneDisclosures: None

Background: Outbreaks of infections in healthcare negatively impact patient outcomes and experience. Transparency is critical to engendering trust and optimizing health. Consistent guidance is not available regarding when to report a possible outbreak of healthcare-associated infections (HAIs) to public health and when to notify a limited population or to publicly disclose the occurrence of HAI. Recent analyses of state public health policies revealed that most states address reporting of outbreaks using terms such as clusters, unusual occurrences, or incidences over baseline. Specific wording about healthcare outbreaks or guidance for notifying patients or public is often absent. Thus, HAI outbreak notification and disclosure guidance and practices vary significantly around the country. A best-practice guidance document will provide clarity for when such reporting should occur. Methods: The Council for Outbreak Response: HAI and Antimicrobial-Resistant Pathogens (CORHA) has undertaken the task of developing this guidance by forming a multidiscipline policy work group with representation from its partner organizations. This work group has been tasked with creating a general framework that will guide notification and disclosure in the context of a possible HAI outbreak. The draft guidance document has been developed over several months of telephone and in-person conferences among work group members. Results: The standardized actions stemming from the guiding principles and recommended practices for conducting step 1 (immediate notification, initial and critical communications that occur when an outbreak is first suspected), were arranged in a table format with rows representing stakeholders and constituents to be notified and columns demonstrating the actions to be taken (Fig. 1). As an investigation progresses, notification should be revisited, especially if an investigation’s scope expands. The principles and practices for step 2 (expanded notification) have also been drafted in a table format. Next, the draft guidance addresses step 3 (public disclosure), outlining indications, practical guidance, and considerations in an outline and/or summary format. Real-world examples demonstrating application of the framework are being developed as supplementary resources to the framework. Current work group activities include engaging bioethicists, media reporters and patient advocates to review and comment on the guidance to ensure that it is clear, consistent and practical. Discussion: The draft guidance provides a framework for standardized actions for HAI outbreak notification and disclosure in a stepwise fashion, modeling public health practices and grounded in bioethical principles. The final product will provide valuable, practical advice for effectively sharing information with affected or potentially affected individuals and their caregivers in a timely manner.Funding: NoneDisclosures: Dawn Terashita reports that her spouse has received honoraria rom the speaker’s bureaus of Novo Nordisk and Abbott.

To summarize patient notifications resulting from unsafe injection practices by health care personnel in the United States and describe recommended actions for prevention and response.We examined records of events involving communications to groups of patients, conducted from January 1, 2012, through December 31, 2018, in which bloodborne pathogen testing was recommended or offered because of potential exposure to unsafe injection practices by health care personnel in the United States. Information compiled included: health care setting(s), type of unsafe injection practice(s), number of patients notified, number of outbreak-associated infections, and whether evidence suggesting bloodborne pathogen transmission prompted the notification. We compared these numbers with a similar review conducted from January 1, 2001, through December 31, 2011.From 2012 through 2018, more than 66,748 patients were notified as part of 38 patient notification events. Twenty-one involved exposures in non-hospital settings. Twenty-five involved syringe and/or needle reuse in the context of routine patient care; 11 involved drug tampering by a health care provider. The majority of events (n=25) were prompted by identification of unsafe injection practices alone, absent any documented infections at the time of notification. Outbreak-associated hepatitis B virus and/or hepatitis C virus infections were documented for 11 of the events; 8 involved patient-to-patient transmission, and 3 involved provider-to-patient transmission.Since 2001, nearly 200,000 patients in the United States were notified about potential exposure to blood-contaminated medications or injection equipment. Facility leadership has an obligation to ensure adherence to safe injection practices and to respond properly if unsafe injection practices are identified.

Objective:Water exposures in healthcare settings and during healthcare delivery can place patients at risk for infection with water-related organisms and can potentially lead to outbreaks. We aimed to describe Centers for Disease Control and Prevention (CDC) consultations involving water-related organisms leading to healthcare-associated infections (HAIs).Design:Retrospective observational study.Methods:We reviewed internal CDC records from January 1, 2014, through December 31, 2017, using water-related terms and organisms, excludingLegionella, to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare. We determined plausible exposure pathways and routes of transmission when possible.Results:Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, that involved the investigation of potential water-related HAIs or infection control lapses with the potential for water-related HAIs. Nontuberculous mycobacteria were involved in the greatest number of investigations (n = 40, 29.9%). Most frequently, investigations involved medical products (n = 48, 35.8%), and most of these products were medical devices (n = 40, 83.3%). We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices.Conclusions:Water-related investigations represent a substantial proportion of CDC HAI consultations and likely represent only a fraction of all water-related HAI investigations and outbreaks occurring in US healthcare facilities. Water-related HAI investigations should consider all potential pathways of water exposure. Finally, healthcare facilities should develop and implement water management programs to limit the growth and spread of water-related organisms.

Background: Domestically, the integration of public health into healthcare-associated infection (HAI) and antibiotic resistance (AR) prevention activities represents a major development. We describe CDC Funding: of public health HAI/AR programs through the Epidemiology and Laboratory Capacity (ELC) cooperative agreement to improve local capacity to prevent HAIs and detect and contain the spread of AR threats. Methods: We reviewed ELC budget reports and program documents to summarize the evolution of funded activities and programs from 2009 to 2018. Results: In 2009, 51 programs (49 states, 2 cities and territories) received US$35.8 million through the American Recovery and Reinvestment Act for an initial 28-month period. These funds supported each jurisdiction to establish an HAI coordinator and a multidisciplinary HAI advisory group, coordinate and report HAI prevention efforts, conduct surveillance and report HAI data, and maintain an HAI plan; ~27 programs were also funded to coordinate multicenter HAI prevention collaboratives among acute-care hospitals. Through 2011, 188 state or local HAI/AR program positions were at least partially funded by the CDC. From 2011 to 2015, investments from the Affordable Care Act (~US$10–11 million annually) were used to maintain the HAI/AR programs, with some expansion of program goals related to non–acute-care settings and antibiotic stewardship. In 2015, following the Ebola outbreak in West Africa, supplemental ELC funds were awarded to 61 programs (50 states, 11 cities and territories) totaling US$85 million over 36 months. These awards marked an expansion of HAI/AR program activities to develop healthcare provider inventories, to conduct data-driven education and training, and to perform onsite infection control assessments in healthcare facilities. In 2016, through its AR Solutions Initiative, CDC invested US$57.3 million in Funding: to 57 programs (50 states, 7 cities and territories), expanding laboratory capacities for AR threat detection (via the AR Laboratory Network) and epidemiologic activities to rapidly contain novel and targeted multidrug-resistant organisms. As of 2018, >500 state or local HAI/AR program positions were at least partially funded by the CDC. Conclusions: State and local HAI/AR programs have grown substantially over the 10 years of their existence, as reflected in major increases in funding, staffing, scope, and partnerships. CDC investments and guidance have supported the development of HAI/AR epidemiology prevention and response capacity.Funding: NoneDisclosures: None

Background: Documented transmission of infectious agents involving dental care is uncommon. However, increasing attention to dental infection control, along with several recent outbreaks, have identified infection control gaps in dental settings. We describe CDC consultations involving outbreaks or infection control lapses occurring in dental settings to identify areas for prevention efforts. Methods: We reviewed internal CDC records from January 1, 2010, through October 1, 2019, to identify consultations involving investigations of potential or confirmed disease transmission and infection control lapses in dental settings. We determined yearly number of consultations, number of patients infected, how disease transmission or infection control breaches were identified, suspected mode of transmission, type of infection control breaches identified, and whether at-risk patients were notified. Results: We identified 41 consultations, among 27 states, involving investigation of possible disease transmission or infection control lapses in dental facilities. The number of consultations increased from 11 to 30 between the first half (2010–2014) and the second half (2015–2019) of the period and involved at least 113 infections confirmed or suspected to be associated with dental procedures. Most investigations (n = 29, 71%) began with identification of infection control breaches absent known patient infections; 8 (20%) investigations were initiated after identification of a single patient infection raised concerns for possible transmission associated with dental care (eg, single case of acute hepatitis B infection absent other risk factors). Moreover, 4 investigations involved >1 patient infection; 3 were outbreaks confirmed to be due to poor infection control practices. The most common infection control breaches were lapses in dental instrument reprocessing (n = 28, 78%), for example, failure to sterilize dental handpieces or failure to use biologic indicators. Of the 23 consultations where patient notification activities were discussed, 17 (74%) resulted in notification; >20,000 patients received information about their potential exposure, usually accompanied by advice on seeking screening tests. Conclusions: Dental-related consultations have increased in recent years, and they highlight the need for improved infection control training of dental healthcare personnel, especially related to dental instrument reprocessing. The CDC Division of Oral Health and the Organization for Safety, Asepsis, and Prevention offers tools, training, and other resources to help dental facilities improve infection control practices. Not all investigations resulted in notifying at-risk patients, but notification should be strongly considered, especially when serious breaches are identified, to promote transparency and help identify disease transmission that could otherwise go undetected.Funding: NoneDisclosures: None

Background: When healthcare providers lack infection prevention and control (IPC) knowledge and skills, patient safety and quality of care can suffer. For this reason, state laws sometimes dictate IPC training; these requirements can be expressed as applying to various categories of healthcare personnel (HCP). We performed a preliminary assessment of the laws requiring IPC training across the United States. Methods: During February–July 2018, we searched WestlawNext, a legal database, for IPC training laws in 51 jurisdictions (50 states and Washington, DC). We used standard legal epidemiology methods, including an iterative search strategy to minimize results that were outside the scope of the coding criteria by reviewing results and refining search terms. A law was defined as a regulation or statute. Laws that include IPC training for healthcare personnel were collected for coding. Laws were coded to reflect applicable HCP categories and specific IPC training content areas. Results: A total of 278 laws requiring IPC training for HCP were identified (range, 1–19 per jurisdiction); 157 (56%) did not specify IPC training content areas. Among the 121 (44%) laws that did specify IPC content, 39 (32%) included training requirements that focused solely on worker protections (eg, sharps injury prevention and bloodborne pathogen protections for the healthcare provider). Among the 51 jurisdictions, dental professionals were the predominant targets: dental hygienists (n = 22; 43%), dentists (n = 20; 39%), and dental assistants (n = 18; 35%). The number of jurisdictions with laws requiring training for other HCP categories included the following: nursing assistants (n = 25; 49%), massage therapists (n = 11; 22%), registered nurses (n = 10; 20%), licensed practical nurses (n = 10; 20%), emergency medical technicians and paramedics (n = 9; 18%), dialysis technicians (n = 8; 18%), home health aides (n = 8;16%), nurse midwives (n = 7; 14%), pharmacy technicians (n = 7; 14%), pharmacists (n = 6; 12%), physician assistants (n = 4; 8%), podiatrists (n = 3; 6%), and physicians (n = 2; 4%). Conclusions: Although all jurisdictions had at least 1 healthcare personnel IPC training requirement, many of the laws lack specificity and some focus only on worker protections, rather than patient safety or quality of care. In addition, the categories of healthcare personnel regulated among jurisdictions varied widely, with dental professionals having the most training requirements. Additional IPC training requirements exist at the facility level, but this information was not analyzed as a part of this project. Further analysis is needed to inform our assessment and identify opportunities for improving IPC training requirements, such as requiring IPC training that more fully addresses patient protections.Funding: NoneDisclosures: None

Background: Health departments have been increasingly called upon to monitor healthcare associated-infections (HAIs) at the hospital- or facility-level and provide targeted assistance when high rates are identified. Health department capacity to effectively respond to these types of signals depends not only on technical expertise but also the legal and regulatory authority to intervene. Methods: We reviewed annual reports describing HAI and antibiotic resistance (HAI/AR) activities from CDC-funded HAI/AR programs for August 2017 through July 2018. We performed a qualitative data analysis on all 50 state health department responses to a question about their regulatory and legal authority to intervene or assist facilities without invitation when outbreaks are suspected (as determined by the health department) or high HAI rates have been identified (eg, based on NHSN data). Results: When an outbreak is identified, 31 health departments (62%) indicated that they have the authority to intervene without invitation from a facility and 8 (16%) did not specify. Among the 11 health departments (22%) that indicated that they do not have this authority, 5 (45%) states noted that they operate under decentralized systems in which the local health department can intervene in outbreak situations and the state health department is available to assist. When a health department identifies high HAI rates, 14 health departments (28%) indicated that they have the authority to intervene without invitation, 22 (44%) indicated that they do not, and 14 (28%) did not specify. Among those in the latter categories, 3 stated they can work through their local health departments, which do have this authority and 8 described working through partners (eg, State Hospital Association, n = 3 or State Healthcare Licensing Agency, n = 5). Discussion: Assistance from state health departments (eg, HAI/AR programs) in the context of outbreaks and high HAI rates has value that is usually well recognized and welcomed by healthcare facilities. Nonetheless, there are occasions when a health department might need to exert its authority to intervene. The preliminary analysis described here indicated that this authority was more commonly self-reported in the context of outbreaks than when high HAI rates are identified. These 2 situations are connected, as high rates might be indicative of unrecognized or unreported outbreak activity, and these issues may benefit from further analysis.Funding: NoneDisclosures: None

Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, public health investigations by state and local health departments, and the Centers for Disease Control and Prevention, have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.

Background To inform development, targeting, and penetration of materials from a national injection safety campaign, an evaluation was conducted to assess provider knowledge, attitudes, and practices related to unsafe injection practices. Methods A panel of physicians (n = 370) and nurses (n = 320) were recruited from 8 states to complete an online survey. Questions, using 5-point Likert and Spector scales, addressed acceptability and frequency of unsafe practices (eg, reuse of a syringe on >1 patient). Results were stratified to identify differences among physician specialties and nurse practice locations. Results Unsafe injection practices were reported by both physicians and nurses across all surveyed physician specialties and nurse practice locations. Twelve percent (12.4%) of physicians and 3% of nurses indicated reuse of syringes for >1 patient occurs in their workplace; nearly 5% of physicians indicated this practice usually or always occurs. A higher proportion of oncologists reported unsafe practices occurring in their workplace. Conclusions There is a dangerous minority of providers violating basic standards of care; practice patterns may vary by provider group and specialty. More research is needed to understand how best to identify providers placing patients at risk of infection and modify their behaviors.

Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, there have been public health investigations by state and local health departments, and the Centers for Disease Control and Prevention have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.

On May 24, 2016, the New York City Department of Health and Mental Hygiene notified CDC of two cases of Exophiala dermatitidis bloodstream infections among patients with malignancies who had received care from a single physician at an outpatient oncology facility (clinic A). Review of January 1-May 31, 2016 microbiology records identified E. dermatitidis bloodstream infections in two additional patients who also had received care at clinic A. All four patients had implanted vascular access ports and had received intravenous (IV) medications, including a compounded IV flush solution containing saline, heparin, vancomycin, and ceftazidime, compounded and administered at clinic A.

In the spring of 2015, investigators in Switzerland reported a cluster of six patients with invasive infection with Mycobacterium chimaera, a species of nontuberculous mycobacterium ubiquitous in soil and water. The infected patients had undergone open-heart surgery that used contaminated heater-cooler devices during extracorporeal circulation (1). In July 2015, a Pennsylvania hospital also identified a cluster of invasive nontuberculous mycobacterial infections among open-heart surgery patients. Similar to the Swiss report, a field investigation by the Pennsylvania Department of Health, with assistance from CDC, used both epidemiologic and laboratory evidence to identify an association between invasive Mycobacterium avium complex, including M. chimaera, infections and exposure to contaminated Stöckert 3T heater-cooler devices, all manufactured by LivaNova PLC (formerly Sorin Group Deutschland GmbH) (2). M. chimaera was described as a distinct species of M. avium complex in 2004 (3). The results of the field investigation prompted notification of approximately 1,300 potentially exposed patients.* Although heater-cooler devices are used to regulate patients' blood temperature during cardiopulmonary bypass through water circuits that are closed, these reports suggest that aerosolized M. chimaera from the devices resulted in the invasive infections (1,2). The Food and Drug Administration (FDA) and CDC have issued alerts regarding the need to follow updated manufacturer's instructions for use of the devices, evaluate the devices for contamination, remain vigilant for new infections, and continue to monitor reports from the United States and overseas (2).

Public health activities to identify and monitor persons at risk for Ebola virus disease in the United States include directing persons at risk to assessment facilities that are prepared to safely evaluate for Ebola virus disease. Although it is unlikely that a person with Ebola virus disease will unexpectedly present to a nonemergency ambulatory care facility, the Centers for Disease Control and Prevention have provided guidance for this setting that can be summarized as identify, isolate, and inform.

Background In December 2016, bacterial contamination of an organ preservation solution (OPS) was reported by Transplant Center A in Iowa. Annually, >20,000 abdominal organs are transplanted in the United States; OPS is used for organ storage. We investigated the scope of OPS contamination and its association with adverse events in patients. Methods We assessed infection control practices related to OPS at Transplant Centers A and B in Iowa and the local organ procurement organization (OPO). We issued national notifications about OPS contamination and requested transplant centers to report product-related concerns or potential patient harm. Among transplant recipients at Center A, we compared adverse events (fever, bacteremia, surgical site infection, peritonitis, or pyelonephritis within 14 days of transplantation) during October–December 2015 with October–December 2016, the presumed window of exposure to contaminated OPS. Isolates from OPS were characterized. Results No infection control deficiencies were identified at Transplant Centers A, B, or the OPO. In January 2017, contaminated OPS from the same manufacturer was reported by Transplant Center C in Texas. Nationally, there were no reports of patient harm definitively linked to OPS. Post-transplant adverse events at Center A did not increase between fourth quarter 2015 (5/12 [42%]) and 2016 (2/15 [13%]). Organisms recovered from OPS included Pantoea agglomerans and Enterococcus gallinarum (Center A) and Pseudomonas koreensis (Center C). Five Pantoea isolates from ≥3 opened OPS bags were indistinguishable by pulsed-field gel electrophoresis. The OPS distributor issued recalls and suspended production. The US Food and Drug Administration identified deficiencies in current good manufacturing practices at manufacturing and distribution facilities, including inadequate validation of OPS sterility. Conclusion Bacterial contamination of a nationally distributed product was identified by astute clinicians. The investigation found no illnesses were directly linked to the product. Prompt reporting of concerns about potentially contaminated healthcare products, which might put patients at risk, is critical for swift public health action. Disclosures All authors: No reported disclosures.

On September 30, 2015, the New Jersey Department of Health (NJDOH) was notified by an out-of-state health services company that an experienced nurse had reused syringes for multiple persons earlier that day. This occurred at an employee influenza vaccination clinic on the premises of a New Jersey business that had contracted with the health services company to provide influenza vaccinations to its employees. The employees were to receive vaccine from manufacturer-prefilled, single-dose syringes. However, the nurse contracted by the health services company brought three multiple-dose vials of vaccine that were intended for another event. The nurse reported using two syringes she found among her supplies to administer vaccine to 67 employees of the New Jersey business. She reported wiping the syringes with alcohol and using a new needle for each of the 67 persons. One of the vaccine recipients witnessed and questioned the syringe reuse, and brought it to the attention of managers at the business who, in turn, reported the practice to the health services company contracted to provide the influenza vaccinations.

Laser-assisted in situ keratomileusis (LASIK) eye surgery is increasingly common, with approximately 600,000 procedures performed each year in the United States. LASIK eye surgery is typically performed in an outpatient setting and involves the use of a machine-guided laser to reshape the lens of the eye to correct vision irregularities. Clinic A is an ambulatory surgery center that performs this procedure on 1 day each month. On February 5, 2015, the Toledo-Lucas County Health Department (TLCHD) in Ohio was notified of eye infections in two of the six patients who had undergone LASIK procedures at clinic A on January 9, 2015. The two patients experienced eye pain after the procedures and received diagnoses of infection with Mycobacterium chelonae, an environmental organism found in soil and water.