CDC reports case of HCV transmission following reuse of syringes

Results of a hospital investigation into a telemetry unit nurse’s reuse of saline flush prefilled syringes indicates that there was one transmission of hepatitis C genotype 4a to a previously uninfected patient, according to a press release from the CDC.

“This investigation illustrates a need for ongoing education and oversight of health care providers regarding safe injection practices,” according to the CDC. “Hospitals and other settings where injections are prepared and administered should perform routine audits. Syringe reuse, if identified, should be immediately corrected and patient notification should be included as part of the institutional response.”

In October 2015, the Texas Department of State Health Services (DSHS) was notified about the nurse’s reuse of syringes, which was discovered by a hospital investigation undertaken after the nurse was observed frequently leaving a partially filled syringe near a computer work station. According to the release, the nurse reported reusing syringes for the previous 6 months and believed that it was “a safe, cost-saving measure if no fluids were withdrawn into the syringe before injection of the saline flush.”

The hospital notified 392 patients who might have been cared for by the nurse between April 2014 and October 2015, her period of employment until the practice was recognized and corrected. In cases where patients were not initially reached, the hospital telephoned patients individually and the DSHS performed additional address investigation. Bloodborne pathogen screening was provided free of charge through a commercial laboratory.

As of October 2016, 262 patients had completed initial screening and 182 had completed all recommended testing. Two patients were newly diagnosed with HCV and two patients were newly diagnosed with hepatitis B. One patient with newly diagnosed HCV had been hospitalized on the same day as a patient with known HCV infection.

Quasispecies analysis found a less than 0.38% nucleotide variation among intrahost HCV sequences from the two patients, both infected with genotype 4a. Additionally, further epidemiologic investigation indicated that any prior contact between the two patients outside the facility was unlikely.

References: www.cdc.gov