Outbreaks of hepatitis B and C are on the rise among patients in nursing homes, hemodialysis clinics, and other nonhospital health care facilities, where such infections were assumed to be rare. Thompson and colleagues at the Centers for Disease Control and Prevention (CDC) reviewed reports of hepatitis B and C outbreaks in nonhospital care settings between June 1998 and June 2008 and found that 33 had occurred. A total of 173 people were infected in 18 outbreaks of hepatitis B, and 275 were infected in 16 outbreaks of hepatitis C; one outbreak involved both B and C. These outbreaks were estimated to have put more than 60,000 people in the facilities at risk for bloodborne infections.
The spread of infections among patients was attributed to staff member lapses in basic infection control practices, such as the reuse of fingerstick devices or using one saline bag for several patients. In hospitals, where infection control practices are more rigidly enforced, only seven outbreaks of health care–associated viral hepatitis were identified in the past decade. Because resources available to monitor hepatitis infection in nonhospital facilities are scarce and regulations differ among states, these findings probably represent the "tip of the iceberg," the authors write.
After a recent acute outbreak of hepatitis C at an outpatient endoscopy clinic in Las Vegas, Nevada, CDC investigators scrutinized the facility. They found that six patients had fallen acutely ill with hepatitis C within about a month of undergoing endoscopic procedures, and that five had been outpatients on the same day. Genetic typing of the virus pointed to a common source of infection. The CDC team identified several unsafe nursing practices that likely contributed to the outbreak, including inadequate handwashing between patients, reusing syringes, and using single-use medication vials with multiple patients. Two nurses told the CDC investigators that clinic managers instructed them to reuse syringes.
The hepatitis C outbreak at the Las Vegas clinic cost six nurse anesthetists their licenses. "It's a temporary surrender of their licenses pending the outcome of the investigation," says Debra Scott, executive director of the Nevada State Board of Nursing in Reno, which is investigating all 22 nurses who worked at the clinic. Some knew of the unsafe practices yet admitted they didn't come forward because they feared retaliation or loss of their jobs. "That doesn't excuse them," says Scott, "but it shows why we need laws to protect nurses." A new bill introduced in the state legislature, written by the Nevada Nurses Association, hopes to shield nurses who report practices that jeopardize patient safety.
"Nurses should never reuse a syringe or medical vial, even if they change the needle," says Barbara Goldrick, an infection control consultant in Chatham, Massachusetts. "The CDC guidelines, which are based on scientific studies, spell out how to prevent bloodborne infections like hepatitis B and C from happening. They should be incorporated into standards of care in all health care settings." But many outpatient clinics don't hire infection control specialists or consultants to train nurses. Even if your boss tells you to reuse a syringe, "if you harm a patient," Goldrick warns, "you're culpable."
Curtailing health care– associated infections is the goal of a five-year action plan released by the U.S. Department of Health and Human Services (DHHS) in January. Health care– associated infections accounted for 1.7 million infections and 99,000 deaths in 2002, and they raise health care costs a staggering $20 billion yearly. Yet many are preventable. To help control or stop these infections, the five-year plan calls for educating health care workers on best practices and how infections are transmitted, a systemic approach to reducing transmission of disease, and research that supports evidence-based infection control practices, such as handwashing. In its efforts to eliminate health care– associated infections the DHHS is committed to partnering with local governments and communities. To learn more about the plan, go to www.hhs.gov/ophs/initiatives/hai/infection.html.
Thompson ND, et al. Ann Intern Med 2009;150:33–9.