The New Hampshire Department of Health is reporting ten cases
of nosocomial hepatitis C associated with a cardiac cath lab. What is unusual
about this outbreak is that it is in a hospital where infection control is generally more
rigorously practiced. While the exact route of transmission in this outbreak
has yet to be determined, public health enemy number one has to be suspected.
In May of 2001 we did our very first hepatitis C outbreak
investigation. A doc in Brooklyn reported himself after he found four of his
own patients hospitalized with acute hepatitis C while on hospital rounds. He
had done endoscopy on all four within the recent past. Endoscopy, more
specifically colonoscopy, is recommended for screening and prevention of a big
killer, colon cancer. It is an
important medical procedure, but it has risks. One of which shouldn’t be a
risk, hepatitis C. When performing colonoscopy the physician reuses the
equipment. That was our first suspicion and while the steps to clean the
instruments didn’t follow the exact manufacturer’s instructions, we quickly
ruled out the scopes as the cause. We had uncovered twelve patients over a five
day period, many of who had their procedures back-to-back. There simple wasn’t
time to reuse the scopes. We next zeroed in on the other invasive part of the
procedure, anesthesia. We quickly discovered that all the patients had received
the same drugs in about the same quantities, but what really stood out was the vials.
They weren’t single use and thrown away. Meet the multi-dose vial (MDV).
Intended for a single patient, these are often used for multiple patients. Why?
They cost less. But it shouldn’t be a problem. As long as they are always entered
with a clean needle, that is. Unfortunately, that isn’t what happens. The
medical literature is littered with outbreaks traced to MDVs. We determined
that a patient known to be infected with hepatitis C underwent colonoscopy. He
woke up during the procedure. The anesthesiologist removed the needle and
syringe that had been bathing in the patient’s blood and reinserted this into a
MDV. The bottle was then used for the next fifteen or so patients, infecting twelve
of them with the virus.
