The 3 cases sellectchem of HBsAg sero-conversion reported during the enhanced surveillance were considered not to be part of the epidemic cluster either on the ground of pre-admission HBV status or the results of molecular typing. In our opinion they should be considered as cases of reactivation of silent HBV infection which may occur in 4%�C30% of anti-HBsAg positive subjects as the consequence of severe immunosuppression for cytotoxic chemotherapy [18]�C[19]. In fact, all these subjects underwent chemotherapy and 2 out 3 were known to be anti-HBcAg positive at pre-admission, while the other was proved to be infected with a different HBV molecular variant though we had no information about his pre-admission HBV status.

Our findings are consistent with other published studies which emphasize that HBV, and other blood-borne pathogens, can be transmitted by means of multi-patient lancing devices [2], [5]. The role of multi-patient lancing device in cross infection has already been suspected in a considerable number of HBV [2]�C[4], HCV [20]�C[21] and malaria [22] hospital outbreaks. In particular, due to its high infectivity (50% minimum infectious dose as low as 10 copies) [23] and its remarkable endurance in the environment (up to 7 days viability in dried blood) [24], HBV seem to be a top candidate for being transmitted through blood contaminated multi-patient lancing device; moreover a recent multicentre study conducted in the USA showed that multi-patient lancing devices used for capillary blood sampling in HCS may be easily contaminated with patients’ blood [25].

The issue of HBV cross infection by means of multi-patient lancing device in HCS is not unique to Italy. Over the last few years similar outbreaks have occurred in other developed countries such as the USA [3], the UK [4], Germany [26], and the Netherlands [27]. This evidence highlights that patients undergoing capillary blood sampling AV-951 may face an unacceptable increased risk for HBV whenever shared multi-patient lancing device are used in HCS. In fact, even when the end-cap and lancet of these devices are correctly replaced for each subsequent patient, the lancet holder can be contaminated resulting in the exposure of subsequent patients. Therefore we believe that multi-patient lancing devices should be banned from HCS and replaced with disposable safety lancets that permanently retract to prevent the use of the same device on multiple patients, as also suggested by a recent CDC guideline [28]. The use of non-disposable lancing devices should be restricted to individual use at patients’ homes.