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Lessons from North American outbreaks – changing needles alone is not enough


[go to first injections page] [Note: Stephen F. Minkin (sfminkin@yahoo.com) submitted the following as a guest blog.]

The CDC [US Centers for Disease Control and Prevention] first reported on four large outbreaks of hepatitis B and hepatitis C at outpatient medical facilities between 2000 and 2002. Two outbreaks occurred in a private physician’s offices in New York, one at an Oklahoma pain remediation center, and one at a hematology/oncology clinic in Nebraska. A total of 247 patients were known to have been infected at these facilities.

In addition, unsafe practices were uncovered at a phlebotomy center in California in 2001, where needles for drawing blood were reused. As a result, 15,000 people had to be tested for HIV, hepatitis B, and hepatitis C.

Two more recent outbreaks discovered in Nevada and New York garnered considerable media attention. In November 2007, reports surfaced that a New York anesthesiologist reused syringes when withdrawing medicine from multi-dose vials. In the process he potentially exposed thousands of patients to blood-borne viruses. On December 14, 2007 the New York Department of Health contacted approximately 8,500 patients exposed by this practice and urged them to be tested for Hepatitis and HIV.

On February 29, 2008 health officials in Las Vegas closed the Endoscopy Center of Southern Nevada after six patients were diagnosed with hepatitis C.  The outbreak was traced to nurse anesthetists reusing syringes to draw up medicine from single use vials for multiple patients.

According to the CDC,

A clean needle and syringe were used to draw medication from a single-use vial of propofol, a short acting intravenous anesthetic agent.  The medicine was injected directly through an intravenous catheter into the patient’s arm.  If a patient required more sedation, the needle was removed from the syringe and replaced with a new needle; the new needle and old syringe was used to draw more medication.

This was a “common practice” at this center for at least 4 years. As a result 40,000 patients were potentially exposed to this risk of hepatitis and HIV infections.

The CDC suggests two possible ways the syringes could have been contaminated.

Backflow from the patient’s intravenous catheter or from needle removal might have contaminated the syringe with HCV (hepatitis C) and subsequently contaminated the vial. Medication remaining in the vial was used to sedate the next patient.

Investigators concluded that each of these outbreaks resulted from “unsafe injection practices primarily the reuse of syringes and needles or contamination of multiple-dose vials leading to patient to patient transmission” (page 901 in this link).

The changing of needles while reusing the syringe is very, very risky and is not a WHO recommended practice (page 35 in this link).

The 2002 Oklahoma outbreak was traced back to a nurse anesthetist supervised by an anesthesiologist at a hospital outpatient clinic. In response the American Association of Nurse Anesthetists (AANA) mailed copies of the AANA Infection Control Guidelines to its members

The organization also hired a research firm to conduct a random telephone survey of Certified Registered Nurse Anesthetists (CRNAs) and anesthesiologists “to learn more about practices and attitudes on needle and syringe reuse.”  A spokesperson termed the finding as “eye opening.”

Among the different categories of health professionals surveyed, 3 percent of anesthesiologists who responded indicated they reuse needles and/or syringes on multiple patients. CRNAs, other physicians, nurses and oral surgeons reported reuse at 1 percent or less.

Extrapolating the survey findings – 3 percent of anesthesiologists plus 1 per cent of CRNAs – equated in 2002 to approximately 1,000 anesthesia professionals who might have been exposing more than a million patients to the risks of contaminated needles and syringes.

They were forced to revisit the problem of the reuse because of the events in New York and Nevada. On March 6, 2008, Dr. Wanda Wilson, the AANA President, commented on the sad state of affairs.

It is astounding that in this day and age there are still nurse anesthetists, anesthesiologists and other health professionals who still risk using needles and syringes on more than one patient, or know of such activities and don’t report them. Published standards and guidelines dictate that single-use and disposal of these products is the best way to ensure patient safety. Patient safety is our primary focus – not cost savings, time savings, or any other factor

If the hepatitis C outbreaks in New York and Nevada demonstrated anything, it was that such incidents occur regardless of a provider’s degree, credentials, or title.  For any group to suggest otherwise is to put its collective head in the sand—it is irresponsible, negligent, and a sure invitation for yet another Nevada or New York situation to occur.

A 1990 study by Canadian researchers experimentally examined the risk of cross infection related to the multiple use of disposable syringes connected to IV tubing during anesthesia.  The authors were motivated because  “the practice of reusing disposable plastic syringes for several patients is still prevalent in North American operating rooms despite warnings about possible hazards.”

In some operating rooms, the usual practice is to reuse disposable syringes while changing needles.  This practice is based on the assumption, that since only needles enter the injection site, it is the only part that can be contaminated.  A high proportion of reused syringes were contaminated even if only the needle had contact with blood.  The probable mechanism of contamination is by aspiration into the syringe of blood remaining in the needle because of the negative pressure generated while removing the needle.

In view of these finding the authors emphasized that “changing needles alone is a useless procedure to prevent contamination.”

CDC PUBLIC HEALTH SYRINGE ADVISORY

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