How safe are your facility's infection control and injection practices?

HCV cluster tied to one anesthesiologist at 10 clinics

News this past summer about a hepatitis virus C (HCV) cluster in New York City at outpatient facilities was a startling reminder of how ambulatory sites should monitor infection control practices by both staff, contracting physicians, and others.

Ten ambulatory clinics were contacted this past summer by city health officials about HCV cases that appear to have originated from IV anesthesia administered by one anesthesiologist who worked at all 10 outpatient practices.

New York City Department of Health and Mental Hygiene (NYCDOH) officials contacted about 4,500 people who had received IV anesthesia from the 10 ambulatory facilities over the past four years.

In the three cases disclosed so far, initial laboratory testing of the HCV indicated that the viruses were closely matched, New York City health officials said in their June 2007 report on the cluster. There were no updates through early August.

All people contacted were patients between Dec. 1, 2003, and May 1, 2007, and all had received IV anesthesia from one particular anesthesiologist, the city report states.

NYCDOH officials told the public there were no cases of HIV infection linked to the incident and that the spread of HIV through anesthesia is not common. They advised the thousands of people who had been treated by the anesthesiologist to be tested for HCV immediately even if they have no symptoms, which could include flu-like symptoms, pale feces, dark urine, and yellowing of the skin and whites of the eyes.

This type of situation is uncommon, but it has happened before, and it likely will continue to occur where standard infection control precautions are not being followed, experts say.

"It shouldn't be happening at all — it's completely preventable," says Miriam J. Alter, PhD, the Robert E. Shope professor in infectious disease epidemiology and director of the infectious disease epidemiology program at the Institute for Human Infections and Immunity at the University of Texas Medical Branch at Galveston.

"One of the biggest issues in the outpatient setting is they don't have the same infection control oversight that inpatient settings have," she says.

"There have been quite a few instances or episodes of [infectious disease outbreaks] occurring, and some involve anesthesia," Alter says. "But all of these were a result of unsafe therapeutic injection practices."

These problems are not accidents, she adds. "These are situations in which following appropriate practices like basic infection control techniques would completely prevent this from occurring," Alter says.

This latest HCV cluster reinforces the importance of prevention, says Elise Beltrami, MD, MPH, a medical epidemiologist with the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) of Atlanta.

"The cost of prevention is always much lower than the outbreak," she says. "Following infection control guidelines can prevent these things from happening."

The CDC has consulted with NYC officials about the recent HCV cluster, but the city is taking the lead on the situation, Beltrami says.

Similar outbreaks of hepatitis B and C viruses occurred 2000-2002 at outpatient settings in three states, according to a Morbidity and Mortality Weekly Report, published by CDC.1

"These cases all resulted from the same problem, which is what we call a failure to use safe techniques when preparing injections," Alter says.

Similar episodes in the United States or overseas have involved anesthesiologists at least four or five times in recent years, Alter reports.

In some of the cases, the anesthesiologist was infected with HCV and had started to share the patient's narcotics, contaminating the multiple-dose vials, she recalls.

This type of contamination also has occurred when multiple-dose vials were contaminated with a patient's hepatitis infection.

What happens is this: "You took a dose of whatever it was and gave it to the patient," Alter explains. "And if the patient needed more, you took the same needle and syringe and got more and then injected it into the IV line."

This is against antiseptic technique unless that multiple-dose vial is going to be used only for that one patient, she says.

"So most of these outbreaks have been the result of contamination of multi-dose vials and the reuse of needles and syringes," Alter says. "The multi-dose vial was contaminated and gets used by the next patient, and even though the needle and syringe are new, the vial is contaminated."

The average health care professional might think about wearing masks and gloves and sterilizing scalpels when they hear the words "infection control," Alter notes.

But each health care worker needs to be taught a great deal more about infection control techniques and universal precautions, Alter and Beltrami say.

Various medical societies offer infection control training, so anyone with a medical background can learn the basics, Beltrami says. (See table of recommended infection control practices.)

"There are infection control practitioners who are certified," she says. "There are nurses, medical technicians, and other disciplines who have specific training in infection control, and those are the kinds of people you want running these programs and employing existing guidelines for infection."


  1. Transmission of hepatitis B and C viruses in outpatient settings — New York, Oklahoma, and Nebraska, 2000-2002. MMWR 2003; 52(38):901-904.