The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New Jersey Com-muni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

Continued from/on page x

Caption is this

Subhead

PHOTO BY: ANWAR WALKER, PUBLIC HEALTH REPRESENTATIVE

Funding to Expand continued from page 1

Hepatitis B virus (HBV) is ablood-borne andsexually-transmitted virus

that causes both acute and chronichepatitis. The risk for chronicinfection varies according to the ageat infection and is greatest amongyoung children. Approximately 90%of infants will remain chronicallyinfected with HBV. By contrast,approximately 95% of adults recovercompletely from HBV infection anddo not become chronically infected.Those chronically infected with HBVare not only at an increased risk ofcirrhosis and primary hepatocellularcarcinoma, but may also continue totransmit the virus to others.

HBV infection in a pregnant womanposes a risk to her infant, who may beexposed to the virus during birth andbecome infected. Perinatal HBVtransmission, however, can beprevented by identifyingHBV-infected pregnant women andproviding hepatitis B immuneglobulin (HBIG) and HBV vaccine totheir infants within 12 hours of birth.It is important that healthcareproviders screen all pregnant womenfor hepatitis B surface antigen(HBsAg) during each pregnancy. The HBV vaccine is safe andeffective. The Advisory Committeeon Immunization Practices (ACIP)

recommends that all newborns receivea dose of HBV vaccine prior tohospital discharge. Thisrecommendation is endorsed by theAmerican Academy of Pediatrics, theAmerican Academy of FamilyPhysicians, and the AmericanCongress of Obstetricians andGynecologists. In addition, the birthdose coverage rate has been adoptedas a measure of hospital quality by theNational Quality Forum.

Fall 2013

Communicable DiseaseService Mission StatementOur mission is to prevent communicable disease amongall citizens of New Jersey, andto promote the knowledge anduse of healthy lifestyles to maximize the health and well-being of New Jerseyans.

We will accomplish our mission through our leadership,collaborative partnerships, andadvocacy for communicable disease surveillance, research,education, treatment, prevention and control.

Chris Christie, Governor

Kim Guadagno, Lt. Governor

Mary E. O’Dowd, MPHCommissioner

COMMUNICABLE DISEASE SERVICEChristina Tan, MD, MPHState Epidemiologist/Assistant Commissioner

Gary Ludwig, MS, Director

Suzanne Miro, MPH, MCHESEditor, Research Scientist

Continued on page 4

By: Connie Wang, Intern and Andria Apostolou, Health Systems

Integration Program Scholar

C1978

Hepatitis B: What hospitals needto do to protect newborns inNew Jersey

Click here to view the Immunization ActionCoalition’s Complete Guide: Hepatitis B: WhatHospitals Need to Do to Protect Newborns

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

Page 2

Get more information athttp://nj.gov/health/cd/handwashing.shtml.

Hemodialysis is a necessarytreatment for most patientswith end stage renal disease

and is typically delivered in outpatientcenters that lack traditional infectioncontrol programs. To help protect thisvulnerable patient population, NewJersey passed the following law in2001, making it the first and only stateto have such a regulation:

New Jersey Administrative Code8:43A-14.1“The administrator, or designee, shall ensure the

development and implementation of an infectionprevention and control program.

The administrator shall designate an infectioncontrol professional who shall be responsible forthe direction, provision, and quality of infectionprevention and control services. The designatedperson shall be responsible for, but not limited to,developing and maintaining written objectives,policies and procedures, an organizational plan,and a quality improvement program for theinfection prevention and control service. Theinfection control professional may be aconsultant; however, there must be a health careprofessional on site who is responsible for theday to day activities related to infection control.

The infection control professional shall haveeducation or training in surveillance, prevention,and control of nosocomial infections. Theinfection control professional shall be certified ininfection control (CIC) within five years ofbeginning practice of infection control and shallmaintain certification through the CertificationBoard of Infection Control (CBIC).”

The Centers for Disease Control andPrevention (CDC) had knowledge ofthis regulation and reached out to NewJersey Department of Health

(NJDOH) to request a study to evaluatethe positive and negative aspects of thisregulation on various stakeholders.Colleagues from the NJDOHCommunicable Disease Service and theDivision of Health Facilities Evaluationand Licensing responsible for licensing,inspection, and certification of dialysiscenters, examined the growth ofdialysis delivery in New Jersey.

A survey with three variations wasdeveloped for distribution to theprimary stakeholders that are mostaffected by the regulation. Thesestakeholders included the NJDOHsurveyors, dialysis facilities, andinfection preventionists (IPs). Thesurveys were created to examine thenature of the arrangement between theIP and facility, the percentage of timethe IP dedicates to each facility, the IPsresponsibilities, and challenges ofhiring qualified IPs.

Infection Rejection: Bringing InfectionControl Programs to Outpatient DialysisCenters in New Jersey By: Jason Mehr, CDC/CSTE Applied Epidemiology Fellow

Continued on page 6

Video: Preventing Bloodstream Infection DuringHemodialysis

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

Page 3

In 2005, the NJCommuni-CABLE included anarticle about the

implementation of a newsurveillance stream in thenortheastern part of New Jersey. Atthat time, local hospitals in theLocal Information NetworkCommunication Systemjurisdictions, included in the USDepartment of Homeland Security’s“Urban Area Security Initiative,” wereconnected to an electronicsurveillance system. At about thesame time, Atlantic County separatelycontracted to connect the county’sfour facilities to the same system.

In 2011, with funding from the NJOffice of Homeland Security andPreparedness, the CommunicableDisease Service (CDS) began expandingthis capability for electronic emergencydepartment (ED) chief complaintsurveillance to allNJ acute care andsatellite ED facilities. EpiCenter™ isnow currently in place for 75 of thestate’s 81 EDs.

EpiCenter collectsanonymous chiefcomplaint andregistration datafrom existing EDcomputer systems inclinical and othersettings and displaysthem for hospitalstaff as well as publichealth departments.This surveillance

application monitors EDs forabnormal incidences of selectinfectious disease and othersyndromes by examining these data.In addition, EpiCenter providesdownloadable reports that are utilizedby CDS staff for submitting daily EDvolume and influenza-like illnesssurveillance data, saving 67 facilitiesfrom the process of manual data entryinto a survey each day. The system isflexible with anomaly detection,investigation logs, charting andmapping capabilities. By expandingthis system to include all of the ED’s inNew Jersey, the New JerseyDepartment of Health has been ableto follow, in near real-time, diseasepatterns and trends to monitor forunusual activity.

EpiCenter, in practice, goes beyondcommunicable diseases. In earlyMay 2013, two chemical spillsoccurred within high schools inAtlantic County. These incidents

Update on Emergency Department Surveillancein EpiCenter™ By: Teresa Hamby, Data Analyst, and Victor Pomary, Intern

Continued on page 7

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

Page 4

Administering a birth dose to allinfants serves as a safety net toprevent perinatal infection amonginfants born to HBsAg-positivemothers who are not identifieddue to errors in maternal HBsAgtesting or failures in reporting oftest results. The birth dose alsoprovides early protection to infantsat risk for infection after the

perinatal period. Moreover,administration of a birth dose has beenassociated with higher rates of on-timecompletion of the HBV vaccine seriesand, in certain populations, improvedcompletion rates for all other infantvaccines. Unfortunately, data from the2011 National Immunization Surveyindicates that only 47% of infants bornin New Jersey receive the HBV vaccinewithin three days of birth, compared to68% nationally.

In order to better assess HBV maternalscreening and newborn vaccinationpractices within New Jersey, a surveywas conducted between December 1,2012 and January 30, 2013. This surveyspecifically targeted health careprofessionals including physicians(pediatricians, OB-GYNs and familypractitioners), nurses, and nursemidwives practicing within NJ birthinghospitals. Of the 228 participants whocompleted the survey, approximately38% of respondents lacked knowledgeof the NJ birth dose coverage rates;only 8% correctly estimated the NJbirth dose rates. Seventy percent ofparticipants indicated that there was apolicy or pre-printed standing orders intheir hospital for a universal HBV birthdose. Participants identified barriers toimplementation of the universal birthdose including parental

refusal/hesitancy and infant primaryhealthcare provider not thinking thatthe hepatitis B vaccine is necessary formost of their patients. Educationmaterials for parents as well as themedical community, and strongerpolicies and enforcement of policieswere identified as ways to improveuniversal birth dose coverage.

During February through July 2013, theNew Jersey Department of Health,Perinatal Hepatitis B PreventionProgram, conducted a review of NJbirthing hospital policies regardingmaternal HBsAg screening and infantHBV vaccination. Forty-two of the 53birthing hospitals provided maternalscreening or newborn vaccinationpolicies for review. Of the hospitalsproviding policies, 36 providedscreening policies and 38 hospitalsprovided vaccination policies. Thepolicies varied in detail and quality.Thirty-one of the 36 screening policiesmentioned screening upon admissionof mothers with unknown HBV status;none mentioned standing orders formaternal HBsAg screening. Of the 38hospital vaccination policies, 35addressed infants born toHBsAg-positive mothers, whereas only13 policies mentioned vaccination ofinfants born to HBsAg-negativemothers. Sixteen policies discussed auniversal birth dose. None mentionedstanding orders for administration ofthe universal birth dose, but onehospital that did not provide policiesprovided a standing order foradministration of the universal birthdose. Among all policies received, only14 policies had provisions for reportingHBsAg-positive mothers to state orlocal health department.

Hepatitis B, continued from page 1

Watch the Immunization ActionCoalition webinar about Hepatitus Bprevention.

Continued on page 5

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

NJ birthing hospitals are stronglyencouraged to review and updateperinatal prevention policies andprocedures to ensure they reflect thecurrent standard of care. Hospitalsshould have policies and procedures inplace, including appropriate standingorders, to ensure 1) administration ofhepatitis B vaccine to all newbornsweighing >2,000 g before hospitaldischarge and 2) identification of allinfants born to HBsAg-positive mothersand infants born to mothers withunknown HBsAg status and properlyinitiate postexposure prophylaxis within12 hours of birth. All healthcarepersonnel working with mothers andtheir newborns should be reminded ofthe importance of perinatal HBVprevention activities and the key rolethat delivery hospitals play in thenational strategy to eliminate HBVtransmission. For more information onsample text for policies and guidelinesfor developing admissions orders, pleasevisit:http://www.immunize.org/catg.d/p2130.pdfhttp://www.immunize.org/catg.d/p2131.pdf

ReferencesNew Jersey Department of Health,Perinatal Hepatitis B Prevention Programhttp://www.state.nj.us/health/cd/hepatitisb_perinatal/techinfo.shtml

National Immunization Survey (NIS):http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis

A Comprehensive Immunization Strategyto Eliminate Transmission of Hepatitis BVirus Infection in the United States:Recommendations of the AdvisoryCommittee on Immunization Practices

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Hepatitis B, continued from page 4 (ACIP). Part 1: Immunization of Infants,Children, and Adolescents. MMWR 2005;54: 1-32.www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm

Centers for Disease Control andPrevention, Hepatitis B Vaccinationhttp://www.cdc.gov/vaccines/vpd-vac/hepb/

Immunization Action Coalition,Hepatitis B Birth Dose:http://www.immunize.org/birthdose/

HepB Moms: http://hepbmoms.org/

Immunization Action Coalition: GiveBirth to the End of Hepatitis BOn July 16, 2013, the ImmunizationAction Coalition launched a major newproject urging hospitals and birthingcenters to “Give Birth to the end of HepB.” The project is aimed at increasingimplementation of the AdvisoryCommittee on Immunization Practices’recommendations to vaccinate everynewborn against hepatitis B beforehospital discharge. The initiative isendorsed by the American Academy ofFamily Physicians, the AmericanAcademy of Pediatrics, the AmericanCollege of Obstetricians andGynecologists, and the Centers forDisease Control and Prevention. TheImmunization Action Coalition has alsolaunched the Hepatitis B Birth DoseHonor Roll to recognize hospitals andbirthing centers that have attained highcoverage rates for administeringhepatitis B vaccine at birth. To find outmore information about the honor rolland to download the book “Hepatitis B:What Hospitals Need to Do to ProtectNewborns” please visit:http://www.immunize.org/protect-newborns/

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

The surveys were created and sent outelectronically via Hippocrates, NewJersey’s emergency preparedness andresponse system. Questions for thesurveys were created through focusgroups containing IP consultants andpartners at the Quality Insights RenalDialysis Network, and NJDOH staff.Once the questions were created andcontact lists were obtained, surveys werethen sent to 135 outpatient dialysisfacility administrators, 22 IPs, and fourNJDOH dialysis surveyors. Theseparticipants were given 22 days forsurvey completion.

Response rates for the surveys variedwith dialysis facility administratorscompleting 82% (111/135) of theirsurveys, while IPs completed only 41%(9/22) and NJDOH surveyorscompleted 75% (3/4).

The results of the surveys wereinformative and provided good insightinto how the stakeholders viewed theregulation and its requirements. Dialysisfacilities showed they met therequirement in a variety of ways anddidn’t have difficulties finding aqualified IP to consult with. Additionally,facilities generally felt that therequirement did not present a costlyburden, but did state that they could notfinancially support the spending ofadditional funds to further expand therequirement.

IPs consulting at these facilities provedto perform a wide array of tasks forfacilities, but the majority (87%) do notvisit facilities more than four times per

year. Additionally, most IPs and facilityadministrators believe their patientshave experienced fewer infections andthat staff have learned good infectioncontrol practices from the IPs. While 78% of IPs and 100% of NJDOHsurveyors agree that the regulationshould be expanded, a vast majority(80%) of facilities do not. Lastly, whenasked if their dialysis facilties neededan IP, 72% (80/111) indicated “yes.”

While this was a small survey andresponses not always consistent,stakeholders generally agreed that theregulation was not overly costly, andthat IPs were a valuable resource fordialysis facilities. Both the dialysisfacilities and NJDOH surveyors agreedthat the IP designee has the mostimportance in providing goodinfection prevention.

There were a few limitations to thisstudy. The response rate for the IPsurvey was low, partially because IPsfrom outpatient dialysis facilitieslocated within hospitals didn’t viewthemselves as consultants. Also, asthere was no reliable data regardinginfection rates prior to this regulation,those surveyed were only able toprovide their impressions as to anychanges that occurred.

Despite these limitations, NJDOHrecommends wider adoption of similarregulations to other states looking tohave an increased presence of infectionprevention and control in outpatientdialysis facilities.

Page 6

Infection Rejection, continued from page 2

Fall 2013

The NJDOHCommunicable DiseaseService includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are availableonline at:http://nj.gov/health/cd/pub.shtml.

Page 7

potential chemical exposure threatsfor further investigation withoutburdening local epidemiologistswith excessive notifications.

For more information on this projector on ED surveillance in general, tocontact either Teresa Hamby,MSPH, or Stella Tsai, PhD, CIH at(609) 826-5964 or via email atteresa.hamby@doh.state.nj.us orstella.tsai@doh.state.nj.us.

highlighted the need tostrengthen statewide syndromicsurveillance of illnesses causedby such exposures. In responseto these spills, a new ‘chemicalexposure’ classifier was createdin EpiCenter to track futureevents by monitoring hospitaldata taken from ED visits. Theprimary objective behindcreation of the new classifier wasto provide local epidemiologistswith prompt notification onceEpiCenter detected any abnormalincreases in the number of chemicalexposure cases. The newly-createdclassifier is currently configured tosend an immediate notification tolocal epidemiologists once two casesare recorded within a 24-hourwindow ending at midnight each day.Given that background levels acrossthe state are around 0-1 cases perday, an alert threshold of two casesshould be sensitive enough to flag

EpiCenter™, continued from page 3

As part of New Jersey’sSafe Injection initiative,“Keeping the InfectionOut of the Injection,”Dr. Barbara Montanaand the injection safetyteam presented twoevening presentationsfor regional oncologystaff in June. Theprogram was tailoredto address specific issues commonlyraised in oncology settings and describedlocal and national outbreaks of infectionsassociated with outpatient oncology

practices. More than 50 New Jerseyoncology professionals attended theworkshops.

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

Page 8

Each flu season, certain mythsabout influenza and the fluvaccine abound. These myths

can challenge health care providers(HCP) who wish to protect theirpatients through vaccination. Thefollowing materials can help HCPsdebunk myths about influenza andthe flu vaccine and educate theirpatients:

• The Flu I.Q.widget—aninteractivequiz to test fluknowledge.Place the FluI.Q. Widget onyour Web site,portal homepage or on yourblog to helpothers raise their flu I.Q.! http://tinyurl.com/kro4qbw

• Web Applications: New JerseyDepartment of Health (NJDOH)partnered with RutgersUniversity and an e-learningcompany to develop two webapplications: “Get Flu Savvy” and“Operating Under theInfluenza.” “Get Flu Savvy” usersstart with a 104.5-degree feverand lower their temperature tonormal by navigating a road mapback tohealthwhichincludestaking fluchallenges,

Resources for the 2013-2014 Influenza Season

reading historical facts, watchingvideos about the flu, learninghow to prevent the flu, andfinally, learning what to do ifthey become infected. Thesecond website, “OperatingUnder the Influenza,” is a flusimulation game that tracks thebusiness community of City Townas a flu pandemic hits. To play“Get Flu Savvy, visitwww.getflusavvy.com; OperatingUnder the Influenza” go tohttp://njlmn.rutgers.edu/jsp/ext/pfg/index.jsp

• Flu Basics Brochure: Thisbrochure provides basicinformation about flu symptoms,prevention, and treatment. It isavailable online in Englishhttp://www.nj.gov/health/flu/documents/flu_basics_eng.pdf andvarious other languageshttp://www.nj.gov/health/cd/flu/other_lan.shtml

• Flu Posters: The CDC has freeeducational posters available totarget special populations such aspregnant women and otherhigh-risk populations available athttp://wwwn.cdc.gov/pubs/ncird.aspx#Flu

The NJDOH, Vaccine PreventableDisease Program, also offers activitybooks and materials which targetthe pediatric population. For moreinformation, please contact609-826-4860.

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

During November 18-24, 2013, the annual Get Smart About Antibiotics Week willbe observed. As in past years, the effort will coordinate work of the Centers forDisease Control and Prevention (CDC) “Get Smart: Know When Antibiotics Work”campaign, state-based appropriate antibiotic use campaigns, non-profit partners,and for-profit partners during a one-week observance of antibiotic resistance andthe importance of appropriate antibiotic use. As with past observances,messages and resources for improving antibiotic use in healthcare settings fromCDC’s Get Smart for Healthcare campaign will be included. Get Smart forHealthcare is a program housed in CDC’s National Center for Emerging andZoonotic Diseases. The 2013 observance also marks the fourth year of aninternational collaboration, which will coincide with European AntibioticAwareness Day.

The New Jersey Department of Health encourages all public health care partnersto participate in this observance to raise awareness of appropriate antibioticprescribing and proper use. Please contact Suzanne Miro, Sr. HealthCommunication Specialist at suzanne.miro@doh.state.nj.us to order freeeducational materials for your agency. For more information and access to manyplanning tools and educational materials visit www.cdc.gov/getsmart/ orwww.cdc.gov/hai.

A new report, Antibiotic Resistance Threats in the United States, 2013 gives afirst-ever snapshot of the burden and threats posed by the antibiotic-resistantgerms having the most impact on human health. 

Each year in the United States, at least 2 million people become infected withbacteria that are resistant to antibiotics and at least 23,000 people die each yearas a direct result of these infections. Many more people die from other conditionsthat were complicated by an antibiotic-resistant infection.

Antibiotic-resistant infections can happen anywhere. Data show that most happenin the general community; however, most deaths related to antibiotic resistancehappen in healthcare settings such as hospitals and nursing homes. For moreinformation and to view the report visithttp://www.cdc.gov/drugresistance/threat-report-2013/

The American Academy of Pediatrics (AAP) is updating its guidelines for treatingacute otitis media (AOM), the type of ear infection that is one of the mostcommon illnesses in U.S. children. The evidence-based clinical guideline, “TheDiagnosis and Management of Acute Otitis Media,” published in the March 2013Pediatrics and released online Feb. 25, provides recommendations to physiciansmanaging uncomplicated AOM in children ages 6 months through 12 years.Compared to the previous guidelines issued in 2004, the new guidelines highlightmore stringent criteria to use in making an accurate diagnosis of AOM, which willenable clinicians to prescribe antibiotics most effectively. The guidelines includerecommendations for treatment with antibiotics and pain relievers, or observationalone, based on the child’s age and severity of symptoms.

Page 9

Antibiotic Resistance

NEWS.......................................In The

New Guidelines forManagement ofAcute Otitis Media

CDC’s Annual GetSmart Campaign

New Report About Antibiotic-Resistant Germs

Fall 2013

The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964

Vaccine Preventable Disease Program (VPDP): 609-826-4860

We’re on the Web!www.nj.gov/health/cd

Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.

Page 10

Be sure to visit the CDC Division of Viral

Hepatitis (DVH) website at

www.cdc.gov/knowmorehepatitis to view new

educational fact sheets for your use. For outreach to

promote hepatitis B testing among Asian and Pacific

Islander (API) populations, fact sheets are available in

multiple languages. Also available are fact sheets and

posters to promote hepatitis C testing for people born

from 1945-1965. Buttons and badges for you to put on

your websites can be found on the DVH website.

CDC/DVH Know More Hepatitis Campaign H