CDC: Hepatitis C outbreak at surgery center isn't isolated
Improper infection control practices at a surgery center in Las Vegas that led to a hepatitis C outbreak, plus the nation's largest number of patient contacts — 40,000 — for blood exposure, may be replicated at other health care facilities across the country, according to the Centers for Disease Control and Prevention (CDC).
This statement from Julie Gerberding, MD, MPH, CDC director, is backed up by Nevada health inspectors who, in response to the hepatitis C outbreak, are investigating all of state's ambulatory surgery centers where several violations of standard practice were found, according to The Associated Press (AP).1 Since 1999, the CDC has reported 14 hepatitis outbreaks in the United States linked to improper injection practices.
In the Nevada outbreak, providers reused syringes, with new needles, and reused vials, according to CDC investigator Joseph Perz, PhD, who is acting team leader for prevention in the Division of Healthcare Quality Promotion. The practices reportedly were used with colonoscopy procedures. "That practice can result into the introduction of blood into the vial," Perz says. "Then downstream patients, who are not sharing the needle or syringe, are at risk." One AP story described it as a "type of scandal more often associated with Third World countries."2
Michael Bell, MD, associate director for infection control at the CDC, was quoted by AP as saying such improper procedures appear to be more common in ambulatory surgery centers, including endoscopy center. The AP story said surgery centers, unlike hospitals, usually don't have employees designated to monitor and educate staff members about best practices.
In testimony before a legislative committee on health care, Lisa M. Jones, MPA, REHS, chief, of the Nevada Bureau of Licensure and Certification, testified to a legislative committee on health care, "We're finding problems at a variety of different levels: medication reuse, in some cases syringe reuse in different procedures and functions. That's why one of our very first actions is the need to get the word out on the street."
Others are quick to say that such practices are not indicative of outpatient surgery providers. Texas Gustavson, RN, chairperson of the Nevada Ambulatory Surgery Center Association and Regional Director, Universal Health Services/ Ambulatory Surgery Center Division, says, "We have worked long and hard, and continue to work each day, to promote the best in patient care." In fact, data reports collected within the surgery center field routinely indicate infection rates well below 1%, she says. "These are due to strong infection control policies in place in ambulatory surgery centers [ASCs] across the country."
Gustavson's association supports efforts to define and ensure adherence to best practices, she says. "We do not support an individual provider who might choose to ignore the appropriate standards," she adds.
The Southern Nevada Health District has sent letters to the Las Vegas center's patients that urged them to be tested for hepatitis C and B, as well as HIV. The Endoscopy Center of Southern Nevada in Las Vegas has been shut down by city officials. The center's failure to follow standard infection control practices resulted in six patients contracting hepatitis C — five of them on the same day — and 40,000 more patients being put at risk, according to health officials. According to a statement released by the City of Las Vegas, individuals were instructed to reuse vials of medication. "Investigators were told by clinic staff that administrators ordered them to engage in the practice in order to save money," it said.
Donald M. Mathews, MD, associate chairman for academic affairs in the Department of Anesthesiology at St. Vincent's Hospital Manhattan in New York City, says, "This is obviously a gross violation of acceptable practice. I do not know if the primary cause was greed or ignorance, but either way it is pretty bad. Obviously, syringes should not be used with more than one patient."
The health district, the State Bureau of Licensure and Certification, and the CDC are investigating the center. Lawrence Sands, DO, MPH, chief health officer of the health district, is calling for better oversight, whistle-blower protection, and education within the medical community, according to AP.
The Endoscopy Center of Southern Nevada is being investigated by several law enforcement agencies, including the FBI, for possible criminal charges. Five nurses have surrendered their licenses, according to AP. Lawyers are seeking clients through TV advertisements labeled as "health alerts." A Las Vegas attorney Gerald Gillock, JD, represents one of the six people the health district officials believe were infected with hepatitis at the clinic. Gillock told the Law Vegas Sun that he suspects this situation to produce the state's largest-ever class action medical malpractice case. One lawyer told the AP that he is representing about 1,200 patients, and eight of those have tested positive for hepatitis C.2
The center's leader, Dipak Desai, MD, ran an open letter in the Las Vegas Review-Journal in which he expressed sympathy to patients and their families and said a foundation is being set up to cover the costs of testing. An AP story pointed out that Desai offered no apology and that he defended his center. Desai wrote, "The evidence does not support that syringes or needles were ever reused from patient to patient at the center." He also said the likelihood of contracting an infection at the center in most of the past four years was "extremely low."
Four affiliated centers in Nevada were shut down by city and county officials, although they said they had no evidence of blood exposure. Leaders in Clark County where three of the centers are located, said they were closing the centers as a precaution. Leaders in Hendersonville said they were closing one affiliated center because a public health emergency exists.
Expect the investigation in Nevada to spread, predicts Steven Sertich, CRNA, MAE, JD, president-elect of the Nevada Association of Nurse Anesthetists. "I would expect more state involvement in investigating centers around the state, evaluating practices, and addressing potential deficiencies more aggressively in the future."
Sertich points to other hepatitis C outbreaks in recent years have been linked with inappropriate infection control practice. "Based on those findings, I would expect a national review of the practice," he says."
Health care providers need to closely examine the practices in their facilities, Perz says. "They should review infection control practices of all staff under their supervision with an eye toward injection safety," he says. "Syringe reuse is not something that can be tolerated in terms of patient risk."
References
- Hennessey K. Vegas hepatitis exposure list incomplete. March 6, 2008. Accessed at http://ap.google.com.
- Hennessey K. Vegas clinic may have sickened thousands. May 5, 2008. Accessed at http://ap.google.com.
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