Charles John Palenik, MS, PhD, MBA
Last fall, the Centers for Disease Control (CDC) described four outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections that occurred in outpatient healthcare settings. Investigation of each outbreak indicated that unsafe injection practices led to patient-to-patient transmission. The primary cause was the reuse of syringes and needles or contamination of multiple-dose medication vials.
The four cases are among the largest healthcare-related outbreaks of viral hepatitis reported in the United States. All occurred in outpatient settings (physicians' offices and clinics versus hospitals) and were reported by clinicians who suspected the HBV and HCV present in their patients was related to treatment afforded in their facilities. The investigations involved review of procedures and materials used, then notification testing and counseling of hundreds of patients. Transmission most likely occurred indirectly from patient to patient after exposure to injection equipment with the blood of one or more source patients. All cases could have been prevented if the basic principles of aseptic technique concerning the preparations and administration of parenteral medications had been followed.
One of the cases involved a private physician's office in New York City. In December 2001, city health authorities were informed of two elderly (older than 75) patients who had acute HBV infections. Both were patients of the same physician. An initial investigation revealed an additional 17 cases. Eventually, health officials extended offers of HBV, HCV, and HIV testing to 1,042 other patients of the office. This screening revealed 19 more cases of acute HBV infection for a total of 38. Four other patients had chronic infections. HBV DNA sequences of 24 of the acute cases and the four chronic cases were identical in a 1,500 base pair region surveyed. No evidence of HCV or HIV transmission was observed.
The physician in question often gave injections of atropine, dexamethasone, and vitamin B12 from multiple-dose vials into a single syringe. The same workplace was used to prepare, dismantle, and dispose of injection equipment. Patients with HBV infection received a median of 14 injections (range 2-25). HBV did not develop in any patient who had not received an injection. Disease transmission was not universal. Only 27 percent of patients who had received at least one injection became infected.
In December 2001, New York City health authorities ordered the physician to stop giving injections. In April 2002, the physician retired and closed his practice permanently. Health officials then sent a letter to all city clinicians, outlining the need for all staff members to adhere to bloodborne pathogens precautions and proper infection control and prevention. This included single use of needles and syringes and appropriate use of multiple-dose vials to prevent cross-infections.
The issue of parenteral medications is addressed in the new CDC infection control guidelines for dentistry. The CDC makes four specific recommendations:
• Do not administer medication from a syringe to multiple patients, even if the needle on the syringe is changed.
• Use single-dose vials for parenteral medications when possible.
• If multiple-dose vials are used, then clean the access diaphragm with 70 percent alcohol before inserting a device into the vial, use a sterile device (e.g., needle and syringe) to access the vial and avoid touching the diaphragm, do not reuse a syringe even if the needle has been changed, keep the multiple-dose vial away from the immediate patient treatment area to prevent contamination by sprays or spatter, and discard the multiple-dose vial if sterility has been compromised.
• Use fluid infusion and administrative sets (e.g., IV bags, tubings, and connections) for one patient only and dispose of appropriately.
To better prevent transmission of bloodborne pathogens, healthcare professionals should adhere to standard precautions and fundamental infection-control principles, including safe injection practices and appropriate aseptic techniques.
OSAP, the Organization for Safety & Asepsis Procedures, is dentistry's prime source for evidence-based information on infection control and prevention and human safety and health. More information is available at www.osap.org.
Dr. Charles John Palenik is an assistant director of Infection Control Research and Services at the Indiana University School of Dentistry. Dr. Palenik has authored numerous articles, book chapters, and monographs, and is the co-author of the popular Infection Control and Management of Hazardous Materials for the Dental Team. He serves on the Executive Board of OSAP, dentistry's resource for infection control and safety. Questions about this article or any infection-control issue may be directed to firstname.lastname@example.org.