Published Date: 2008-03-02 16:00:16
Subject: PRO> Hepatitis B & C, HIV, nosocomial (03): USA (NV)
Archive Number: 20080302.0854
HEPATITIS B & C, HIV, NOSOCOMIAL (03): USA (NEVADA)
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Date: Thu 28 Feb 2008
From: Julian Tang <firstname.lastname@example.org>
The dangers of using vials in a multi-dose way (either intentionally
or unintentionally) are well-recognised by clinical virologists.
There have been many outbreaks of bloodborne viruses (HIV, HBV, HCV)
reported in the literature related to this means of nosocomial
transmission, particularly during anesthetic procedures associated
I have included some references below, which also contain multiple
other references to similar transmission events. Even so called
single use vials (glass vials with breakable necks) can still be used
in a multi-dose manner when healthcare workers are under pressure.
Therefore, this outbreak in South Nevada, as recently reported in
ProMED-mail, is unfortunate but serves to demonstrate yet again that
lessons sometimes have to be learned the hard way.
Mortimer PP. Away with multi-use vials! AIDS. 1999 Sep 10;13(13):1779-81.
Katzenstein TL, Jorgensen LB, Permin H, Hansen J, Nielsen C, Machuca
R, Gerstoft J. Nosocomial HIV-transmission in an outpatient clinic
detected by epidemiological and phylogenetic analyses. AIDS. 1999 Sep
Massari M, Petrosillo N, Ippolito G, Solforosi L, Bonazzi L, Clementi
M, Manzin A. Transmission of hepatitis C virus in a gynecological
surgery setting. J Clin Microbiol. 2001 Aug;39(8):2860-3.
Bruguera M, Saiz JC, Franco S, Gimenez-Barcons M, Sanchez-Tapias JM,
Fabregas S, Vega R, Camps N, Dominguez A, Salleras L. Outbreak of
nosocomial hepatitis C virus infection resolved by genetic analysis
of HCV RNA. J Clin Microbiol. 2002 Nov;40(11):4363-6.
Julian W. Tang
MBChB, PhD, MRCP, FRCPath
Assistant Professor, Department of Microbiology
The Chinese University of Hong Kong
Hong Kong SAR
Date: Sat 1 Mar 2008
From: Ginger Switzer <EHPEC@comcast.net>
The Nevada Health Department website:
states the following: "Based on the information we discovered during
our investigation, it appears the injection practices that can lead
to the transmission of hepatitis C and other bloodborne infections
have been occurring at this clinic for several years."
It is one thing when an individual is unaware of an infection hazard.
It is quite another when the institution is aware of the hazard. It
has been 30 years since the HIV pandemic 1st drew attention to the
hazards of both occupational and nosocomial bloodborne diseases.
Similar incidents as the one which occurred in the Nevada clinic have
previously alerted us to the hazard of reusing either syringes in IV
lines of multiple patients or of just changing needles, as in this
case, and re-entering multidose vials.
That the institution allowed this known unsafe practice to continue
for several years suggests a much deeper problem than simple
malpractice. It suggests a failure to communicate information on
hazards, which are likely to be repeated or to exist at the same time
as such hazards are 1st discovered.
The 1st time it happened, we didn't know about the risk. The 2nd
time, we didn't communicate the risk.
Ginger Switzer, ARNP, COHN-S
EHPEC Employee Health Practitioners, Educators, and Consultants
[Previously, Ginger Switzer wrote: "What does that say about the way
we communicate standards of care, basic infection control standards,
and the way we communicate errors which 1st came to light over 2
decades ago and that continue to be repeated? It is bad enough that
we don't implement engineering controls and work practice controls to
eliminate medical errors caused by simple human error. But this is a
failure to communicate a basic infection control practice."
We concur with these sentiments. This thread is hereby cut. - Mod.CP]