Multidose Vials Linked to HCV Spread in Clinic
EIS officers report outbreaks, experience their own
Speaking at the 2023 EIS meeting, Alarcón said a patient with no other risk factors for HCV had visited the pain clinic to have a procedure performed that required administration of lidocaine. Investigators conducted a site visit and found a multidose vial of the anesthetic inside the procedure room by a patient bed.
“This was at odds with what the clinic staff stated, which was that all multidose medications were kept in a central area and medications were drawn and then taken into the procedure room,” she said. “Healthcare staff have used multidose vials primarily due to decreased cost. They’re cheaper to store and to buy.”
During the pandemic, single-dose vials became harder to acquire as the result of supply chain issues, she added.
If infection control practices are not implemented properly, the multidose vials can become contaminated and expose subsequent patients to pathogens, such as HCV.
In continuing to look at the clinic, investigators identified red flags, including unlocked cabinets containing controlled substances and inappropriate disposal of syringe needles.
“The staff noted that, to reduce cost, they were at times separating the needle from the syringe after use and only disposing of the needle in the sharps container,” Alarcón said.
This is a breach of the CDC’s “One and Only” campaign, which recommends using one needle and one syringe only one time.1
“Hepatitis C is a pretty robust virus,” she told EIS meeting attendees. “It doesn’t necessarily need a needle to get into places. There are instances where point-of-care glucose testing has led to outbreaks, even reuse of cotton balls by IV (intravenous) drug users.”
During the site visit, public health investigators found that, as recommended, multidose vials were kept for a maximum of 28 days after being opened. They compiled a list of 127 clinic patients who were seen within 28 days of the HCV case.
Two more patients with hepatitis C were identified. Both patients identified received procedures on the same day as the index patient. One patient was chronically infected, and the other patient had acute HCV. The viral loads were not high enough to do a phylogenic analysis, but all three patients had genotype 1B, the least common of the prevalent strains, Alarcón said. As outreach efforts continued, a fourth patient called the clinic, noting that he had been hospitalized with HCV during fall 2022.
At this point, investigators generated another list of 140 unique patients who were seen 30 days after the last HCV patient.
Of those, 45 patients had been tested, and another 30 patients were planning to take the test. However, 35 did not respond, three moved out of state, three refused to be tested, and one died — not related to hepatitis.
“The [index] patient with chronic hepatitis C was seen at the beginning of the day, and a breach of infection control practices took place that led to three more patients acquiring hepatitis C,” Alarcón said. “This was most likely
due to the use of multidose medication vials.”
EIS COVID-19 Outbreak
In a related development, somewhat ironically, the April 24-27 EIS meeting of the CDC’s vaunted gumshoe “medical detectives” was hit by a COVID-19 outbreak among participants.
According to a CDC update, about 1,800 people attended the conference and 1,443 responded to a survey from May 5-12 sent to all attendees.2 Of the respondents, 181 (13%) reported testing positive for SARS-CoV-2.
Of those who reported testing positive, 52% reported no known prior COVID-19 infection, the CDC reported. Of 1,435 respondents (99%) reported at least one COVID-19 vaccine dose. However, the survey did not ask EIS officers to clarify vaccine status in any detail, Hospital Infection Control & Prevention was informed when asking if any received the bivalent vaccine, which was heavily promoted by the CDC.
“The survey was designed to assess the extent of SARS-CoV-2 transmission among in-person conference participants rather than to capture detailed information on vaccination status,” says Melissa Brower, a CDC press officer. “As such, we did not collect information on whether participants had received the bivalent vaccine or on attitudes toward vaccination.”
Given this less than comprehensive follow-up, the CDC runs the risk of the last thing it needs: another public relations problem centering on the pandemic virus.
Although masks were not necessarily indicated (about 30% wore them) given the low prevalence of SARS-CoV-2 at the time, the sketchy report on the vaccine status of EIS officers runs counter to the CDC’s recent promise of transparency. It could have been a considerable time gap since some of the respondents to that question were immunized with “at least one vaccine dose,” and more than half reported no natural or hybrid immunity because of prior infection.
A skeptical public — and certainly anti-vaxxers — could claim the CDC’s frontline investigators have a cavalier attitude toward staying current with the pandemic vaccines, although that has been the agency’s urgent message to the public. As it stands, only 17% of the indicated national population has received the bivalent vaccine, which is expected to be issued again this fall in an updated iteration.
Overall, 49 of the EIS respondents who tested positive received antiviral medications, and all cases recovered without hospitalization.
- Centers for Disease Control and Prevention. One & Only Campaign. Last reviewed Dec. 3, 2019. https://www.cdc.gov/injectionsafety/one-and-only.html
- Centers for Disease Control and Prevention. Update on rapid assessment of SARS-CoV-2 transmission at 2023 EIS Conference. Published May 26, 2023. https://www.cdc.gov/media/releases/2023/s0526-eis.html
An outbreak of hepatitis C virus among four patients at a Los Angeles pain clinic in September 2022 likely was caused by improper use of needles and multidose vials of local anesthetic.
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