Hepatitis B and Hepatitis C Outbreaks What went wrong

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Hepatitis B and Hepatitis C Outbreaks What went
wrong

• Kristin Sweet, MPH
• Minnesota Department of Health
• Darla Groshens  RN, BAN
• Hennepin Faculty Associates
• APIC
• September 29, 2009

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Objectives

• Describe the epidemiology of the outbreaks
• Identify infection prevention breakdowns

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Hepatitis C in a hematology/oncology clinic
Nebraska, 2002
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Case Identification
Report source Gastroenterologist Number of
cases at initial report Four Link Chemotherapy
at the same hematology and oncology clinic
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Facility Investigation
Same syringe to draw blood from patients central
venous catheters and from saline bags used for
multiple patients.
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Case Finding

• 613 patients identified as at risk
• 486 tested
• 99 had clinic acquired hepatitis C infections
• 95 were known to be genotype 3a

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Infection Control Practices

• This was a rare genotype, raising suspicion
• The same syringe was used to draw blood from
  patients central venous catheters and to draw
  catheter-flushing solution from 500 mL saline
  bags that were used for multiple patients

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IPC, How can this possibly happen?

• Health-care workers did not adhere to fundamental
  principles related to safe injection practices
• HCW failed to understand the potential of their
  actions that lead to disease transmission
• Lack of oversight for basic infection control
  practices

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How can this be prevented?

• Certification and training programs need to
  reinforce infection-control principles and
  practices, including aseptic techniques and safe
  injection practices
• These principles should be reviewed with frequent
  in-service education for HCW and practices should
  be monitored as part of the oversight process

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IC Measures

• Do not use bags or bottles of IV solution as a
  common source of supply for multiple patients
• Use a sterile, single-use, disposable needle and
  syringe for each infection and discard intact in
  an appropriate sharps container after use

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However.

• Many small outpatient facilities do not have a
  staff member with advanced Infection Control
  training/education
• Providers, for the most part, do not have
  advanced IC education
• Staff are pressured to get ready for the next
  procedure/patient quickly
• In these economic time, staff can be ingenious in
  finding cost saving measures

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Have in Place

• Dedicated staff member for IC, with time allotted
  to perform this function
• Policies in place that have IC principles
• Resource listed, such as an IPC person at the
  hospital the clinic generally admits to
• Oversight and monitoring of above
• Empower staff

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Hepatitis C in an endoscopy clinic Nevada, 2007
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Case identification

• Report source
• Health department
• Number of cases at initial report
• Two
• Link
• Both had procedures at the same endoscopy clinic

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Facility Investigation

• Direct observation
• Syringes were being reused for the same patient
• Medication vials were being used for multiple
  patients

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Case Finding

• Methods
• Identification of patients from clinic records
• Media announcements
• Billing and claims data
• Number of patients possibly exposed
• Approximately 40,000
• Cases identified
• 6 acute cases
• 77 cases possibly associated with clinic exposure
  

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Infection Control

• Use single-dose vials whenever possible
• Do not administer medications from single-dose
  vials to multiple patients or combine left-over
  contents for later use
• If multiple-dose vials are used, restrict them to
  a centralized medication area or for single
  patient use. Never re-enter a vial with a needle
  or syringe used on one patient if that vial be
  used to withdraw medication for another patient
• Establish written policies and procedures

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Hepatitis C in a hospital and surgical center
Colorado, 2009
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Case identification

• Report source
• Health department
• Number of cases at initial report
• Two
• Link
• Both had surgery at the same hospital on
  sequential days and were genotype 1b

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Facility Investigation
Hospital report A hepatitis C positive health
care worker was dismissed for drug
diversion Healthcare worker interview Admitted
to using injecting herself with syringes filled
with fentanyl, refilling them with saline, and
returning them to be used on patients.
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Case Finding

• Methods
• Identification of patients from clinic records
• Number of patients possibly exposed
• Unknown
• 3,960 persons tested
• Cases identified
• 28 cases possibly associated with clinic exposure
  
• 1 was sequenced at CDC and matched the source
  case
• 27 are genotype 1b with further sequencing
  pending

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Infection Control

• Obviously, she broke aseptic technique, and
  utilized unsafe needle/injection use
• Hepatitis C (and B) can be transmitted on used
  needles. The viruss have also been found in
  contaminated vials.

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Infection Control

• Need for good policies and procedures in place
  that follow IC principles, refer to CDC for
  guidance
• Need for a monitoring system that all are
  following procedural policy
• Need an Infection Control staff member, or
  resource person

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Resources

• Acute Hepatitis C Virus Infections Attributed to
  Unsafe Injection Practices at an Endoscopy Clinic
  --- Nevada, 2007. MMWR. 57(19)513-517
• Department of Public Health and Environment,
  Viral Hepatitis Program Hepatitis C
  Investigation. http//www.cdphe.state.co.us/dc/Hep
  atitis/hepc/HepCInvestigation.html
• Transmission of Hepatitis B and C Viruses in
  Outpatient Settings --- New York, Oklahoma, and
  Nebraska, 20002002. MMWR. 52(38)901-906