title: Passage from India: an outbreak of hepatitis B linked to a patient who acquired infection from health care overseas.
abstract: OBJECTIVE
  To investigate a nosocomial and community outbreak of hepatitis B to establish how the infections might have occurred.
  
  
  METHODS
  Descriptive study.
  
  
  METHODS
  Four cases of hepatitis B who had stayed in hospital during their incubation periods, a case in one of their household contacts, and three further cases in the community were all linked to a patient who had been infected during a renal transplant in India. Medical records from cases were reviewed to extract information about risk factors for infection. Working practices were reviewed to determine how nosocomial transmissions might have occurred. 'Look-back' exercises were conducted to identify and follow-up other patients and staff who might also be at-risk of infection. Hepatitis B viral sequences from all cases were examined to determine whether they were related.
  
  
  RESULTS
  Viral DNA sequences from all nine cases were identical. The primary case had an extremely high viral load due to underlying immunosuppression. Three of the nosocomial transmissions occurred whilst the primary and secondary cases shared general medical wards; two whilst the primary case was in standard isolation. No clear routes of infection were identified. The fourth was associated with a failure of infection control in operating theatres.
  
  
  CONCLUSIONS
  Invasive medical procedures in high-prevalence countries carry a clear risk of blood borne viral infections. There is a need for much better awareness of this risk, both among patients who are considering travelling for treatment, and the health professionals who will be caring for them on their return. Infections may be preventable through hepatitis B vaccination. Patients admitted to hospital following invasive medical procedures in high-prevalence countries should be nursed with stringent infection control measures until blood borne viral infections can be excluded. However, patients with hepatitis B who are highly infectious may transmit the virus despite high standards of infection control.
authors.affiliation: UCL Centre for Infectious Disease Epidemiology, Department of Primary Care and Population Sciences, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. richard.harling@wyreforest-pct.nhs.uk
authors.forename: Richard
authors.initials: R
authors.lastname: Harling
authors.forename: Deborah
authors.initials: D
authors.lastname: Turbitt
authors.forename: Michael
authors.initials: M
authors.lastname: Millar
authors.forename: Ines
authors.initials: I
authors.lastname: Ushiro-Lumb
authors.forename: Sandra
authors.initials: S
authors.lastname: Lacey
authors.forename: Gladys
authors.initials: G
authors.lastname: Xavier
authors.forename: Joanne
authors.initials: J
authors.lastname: Pope
authors.forename: Samreen
authors.initials: S
authors.lastname: Ijaz
authors.forename: Chong-Gee
authors.initials: CG
authors.lastname: Teo
mesh_terms: D003428:Cross Infection; D004196:Disease Outbreaks; D016021:Epidemiologic Studies; D006509:Hepatitis B / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology / Q000235:genetics / Q000276:immunology / Q000821:virology; D006801:Humans; D007194:India; D017053:Infection Control; D008485:Medical Audit; D014195:Travel; D006113:United Kingdom / Q000453:epidemiology