Hepatitis infection (lack of) control: Epic stupidity

This isn’t about MRSA, but it’s such a jaw-dropping example of infection control failure that I thought it was worth passing along.

A team from the Centers for Disease Control report today in the Annals of Internal Medicine that, in the past 10 years, infection control has failed so significantly that 448 people have become infected with hepatitis B or C and more than 60,000 had to be tested for potential infection. (And that is almost certainly an underestimate, since the team counted only previously recognized outbreaks of two or more infections, not single ones.)

Three are known to have died, though that again is probably an underestimate.

From the CDC press release (not yet online, I’ll link when it is):

In the United States, transmission of HBV and HCV while receiving health care has been considered uncommon. However, a review of CDC outbreak information revealed a total of 33 identified outbreaks outside of hospitals in 15 states, during the past decade: 12 in outpatient clinics, six in hemodialysis centers and 15 in long-term care facilities.

Here are some of the actions that caused these infections:

  • reusing syringes
  • contaminating multi-dose vials with unclean syringes
  • using single-dose vials for multiple patients
  • re-using end-caps from single-use syringes
  • using fingerstick devices on multiple patients without cleaning
  • using blood-sugar measuring devices on multiple patients without cleaning

Just jaw-dropping. Because let’s be clear: Hep B and C are potentially life-threatening diseases. These actions weren’t just careless: They were life-endangering. And really, how hard is this? None of these actions should have been difficult or foreign; They represent the most basic steps in Standard Precautions (what used to be called Universal Precautions), which any health care worker ought to know from the beginning of his or her career, but which every health care worker ought to have by heart in the age of AIDS.

And, infuriatingly, there are probably many more such infections that remain undetected. From the paper:

…the viral hepatitis outbreaks reported here probably represent only a portion of the true burden of infection attributable to the receipt of health care in the United States. First, we included only nonhospital health care settings. … Second, under-ascertainment of health care–associated viral hepatitis outbreaks is likely. Linking an outbreak to a single health care venue responsible for transmission is complicated by the long incubation period of HCV and HBV infection (up to 6 months)… Furthermore, many patients with HBV or HCV infection will be asymptomatic or have mild or nonspecific symptoms, resulting in infections that go undetected for many years. Finally, outbreak detection relies on thorough case investigation and successful identification of health care as a risk. Few health departments currently have the time, funds, personnel resources, or ability to address legal impediments to investigate viral hepatitis that may be health care–associated.

The cite is: Nicola D. Thompson, PhD, MS; Joseph F. Perz, DrPH, MA; Anne C. Moorman, BSN, MPH; and Scott D. Holmberg, MD, MPH. Nonhospital Health Care–Associated Hepatitis B and C Virus Transmission: United States, 1998–2008. Ann Intern Med. 2009;150:33-39.

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