Question

Sam, a 42-year-old man, was booked for an endoscopy at a local clinic. Prior to the procedure he was injected with sedatives, but after several minutes the nurse noticed Sam seemed uncomfortable and required additional sedation. She used the same syringe, dipped it in the open sedative vial and re-injected him. The procedure continued as normal. Several months later, Sam, suffering from swelling of the liver, stomach pain, fatigue and jaundice, was diagnosed with Hepatitis C. The Centers for Disease Control was contacted, as 84 other cases of liver disease were linked to the clinic. It was believed that the sedative vial may have been contaminated from the backflow into the syringe and that the virus may have been passed on from the contaminated vial. Several health-care workers commented that reusing the syringe on the same patient (and thus dipping a used syringe into a common vial) was common practice.

Reference: Centers for Disease Control and Prevention, Atlanta. Syringe reuse linked to hepatitis C outbreak. Sonner, S., Associated Press

What do you think about this case (cases) that the CDC investigated? Should health care workers have anticipated that using a common vial between patients might lead to infection? How common do you think these types of incidents are?

Answer 1

Sequential steps about this case investigated by CDC:

1) On January 2, 2008, the Neveda State health division (NSHD) contacted CDC concerning surveillance reports received by the Southern Neveda Health District (SNHD) regarding two persons recently diagnosed with Acute Hepaititis C was reported following day,

2) This raised concerns about an outbreak because SNDH typically confirms fewer cases of hepatitis C per year,

3) Initial enquires found that all persons went procedure at the same endoscopy clinic,

4) Within 35 - 90 days illness was onset, A joint investigation by SNHD,NSHD and CDC initiate Jan 8, 2008,

5) The epidemiological and lab investigations revealed HCV transmission likely results from Reuse of Syringes on individual patients and Use of medication vails on multiple patients at the Clinic.

6) Health officials adviced clinic to stop unsafe injection practices immediately and approximately 40,000 patients of the clinic were notified about their potential risk for exposure to HCV and other blood born Pathogens.

Comprensive measures involving:

1) Viral Hepititis Survivalence,

2) Helath care Provider Education,

3) Public awareness,

4) Professional oversight,

5) Liciencing and

6) Improvement in medical devices can help detect and prevent transmission of HCV and other blood born pathogens in health care setting.

How common this type of Incidents and how to prevent this type of Medical errors:

This type of incidents we commonly termed as Health care associated Infections (HAIs), which are substantially contribute to morbidity, mortality and excess healthcare costs. Efforts to control and prevent the spread of HAIs require an inistitutional assessment of resources, priorities and commitment to infection control Practices.

Catheter related Blood stream Infections: (CRBSIS)

1) S.aureus, S.epidermis , aerobic gram negative species are common organisms associated with CRBSIs,

2) Subclavian Central Venous catheters are associated with lower CRBSIs than internal jugular CVCs while femoral CVCs have the highest rates and should be removed within 72 hrs of placement,

3) Stratagies for decreasing the incidence of CRBSIs include:

- proper hand hygiene,

- skin antisepsis,

- Maximal sterile barrier.

Infection control and Isolation Recommendations:

Standard precautions should be practiced on all patients at all times to minimise the risk of nosocomial infection,

- Perform hand hygiene,

- Wear gloves, gown, mask and protective eye wear,

- use proper respiratory hygiene and cough etiquette,

- safely dispose sharp objects and all disposable material,

- Specific isolation to the major node of microorganisms transmission,

- use a dedicated stethoscope and thermometer,

- Droplet precautions,

- limit the patient transport and activity outside their room,

- take air born precautions,

- assign the patient to a negative pressure room,

- wear a tightly fitting respirator that covers the nose and mouth with a filtering capacity,