Friday, May 16, 2008

Acute Hepatitis C from Unsafe Injections

The CDC has concluded an investigation of a clinic in Nevada that reported an outbreak of Hepatitis C Virus (HCV) in 6 people that resulted from unsafe injection procedures. Here's what happened:

Hepatitis C is a reportable infection to the health department and when 3 people were reported in 2 days it raised concern about an outbreak. It turned out that all three persons underwent procedures at an endoscopy clinic within 35-90 days of the illness onset. Three more cases turned up from the same clinic for a total of six cases.

The incubation period for HCV is 15-160 days. Hepatitis C causes liver inflammation, jaundice, abdominal pain and elevated liver enzymes. Four of the six patients required hospitalization and four had procedures within a two day period. An additional 120 persons had procedures at the clinic during the time period and they are currently undergoing testing.

Investigators observed that improper injection practices were being done at the free-standing private endoscopy clinic that performed 50-60 colonoscopies and upper endoscopies a day. The staff members used clean needles and syringes to draw up anesthesia (propofol) medication and injected it directly into a patient 's IV catheter. If a patient required more sedation, the same syringe was used to draw more medication. Backflow from the patient's IV catheter contaminated the syringe with HCV and subsequently contaminated the vial. Medication remaining in the vial was used to sedate the next patient and on and on.

The Nevada Health Department is now contacting 40,000 patients who underwent procedures requiring anesthesia at the clinic to undergo screening for HCV, Hepatitis B and HIV infections from March 1. 2004 until the practice was stopped on Jan 11, 2008.

For Health Care Professionals:
  • Never administer medications from the same syringe to more than one patient, even if the needle is changed
  • Do not enter a vial with a used syringe or needle.
  • Never use medications packaged as single-use vials for more than one patient
  • Do not use bags or bottles of IV solution as a common source of supply for more than one patient
  • Follow proper infection-control practices during the preparation and administration of injected medication
Adapted from Centers for Disease Control


Paul Eilers said...

Oh my.

You would think that the proper procedures that you listed would already be in place. Why were they not being used? Laziness? Carelessness? Pressure to get more done in less time?


Anonymous said...

I thought this was common sense as well as safe and infectious control and sterile technique standard procedure , that was being followed for years.
I also thought this was under the CDC and JACHO policies and standards to protect patients from situations like this.

lucky said...
This comment has been removed by a blog administrator.
Toni Brayer MD said...

To Anon and Paul: JCAHO does not accredit ambulatory facilities, only in-patient hospitals. The CDC has no regulatory arm. Most ambulatory sites are state accredited and the rules and oversight vary greatly. Thanks for your comments.

jackpot said...
This comment has been removed by a blog administrator.
Toni Brayer MD said...

To readers of EverythingHealth: I am deleting comments that are phony and take you to a gambling site. I have never had to delete a real comment and I welcome controversy. TB

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