Unsafe Injection Practices A Global Public Health Problem

Learning Objectives

• Examine how bloodborne pathogen transmission may occur

• Review the epidemiologic process in patient notification decision-making

• Describe the steps taken in a notification process

• Identify state and local resources

• Discussion on ways to improve collaboration

• Law Reform for the future

Public Health Coordinated Response

PUBLIC HEALTH OUTBREAK RESPONSE

LOCAL HEALTH DEPT.

DIDE

WVOLS

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The process of redrawing medication using the same syringe could have contaminated the vial from which the medicine was drawn with the blood of the patient.Vial labeled as a single use vial, but shared between patients.

Syringe reuse - A syringe (not a needle) that was used to administer medication to a patient was reused on the same patient to draw up additional medication.

IDENTIFICATION OF BLOODBORNE PATHOGEN OUTBREAKS

Decision-Making Process

“No evidence of seroconversion, there is a small theoretical risk of bloodborne pathogen transmission during procedures involving syringe reuse. Notifying patients of this exposure may be appropriate.”

Epi-Aid 2009-058 Trip Report: Investigation of Invasive Methicillin-Sensitive Staphylococcus aureus Infections at an Outpatient Pain Clinic

No evidence that any patient contracted hepatitis or HIV.

Patient Notification Considerations

• Involves a breach with lower likelihood of blood exposure

Consider the following factors in the decision:

• Potential risk of transmission

• Public concern

• Duty to warn vs. harm of notification

Identifying Patients at Risk

• Timeframe –– May 4 – 6 when MSSA infections occurred highest risk– Cohort -110 same patients used for MSSA outbreak

study – All had procedures between April 27 and May 13

• Exposed patients– Hepatitis B & C Registry – Chart Review

• Consultants– CDC, NYHD, MMWR, Previous Cases

Communication Materials

• Patient Packets mailed by KCHD (certified)– Provider letter

– Patient letter

– Fact Sheets for Hepatitis and HIV

– Data Collection Sheet

– Talking Points

– Press Releases

Communications & logistical issues

– Develop communication materials

– Determine who will conduct testing, obtain consent, and/or perform counseling, if appropriate

– Determine if follow-up testing needed

– Facilitate public inquiry and communication

– Address media and legal issues

Testing Decisions

• KCHD

• Other county HD’s

• Private Provider’s

• Private Labs

• Coordination of Testing

– Hepatitis B, Hepatitis C, HIV

– Initial Tests ASAP

– Second Tests – 6 months from date of procedure

Media

–Media leaks

– Press Releases

– Interviews

– Live Reports

– Talking Points

Facilitate public inquiry and communication

• Phone Calls from: – Patients who received letters

– Patients not in cohort

–Worried Well

– Other Health Departments

– Providers

– Labs

– State Partners

Complications

• Resource-intensive and disruptive

• Exposures not easily linked to unsafe injection practices.

• Unsafe injection practices may be occurring for years before identified if ever

• No clear regulatory agency

Results

• 1st Round testing completed

• 2nd Round testing in process

• Compile data

• Contacting outside providers for test results

• More reminder letters to patients

• Still need to compile data

Conclusions/Lessons Learned

• Time Consuming process

• Consult Lab/Epi for assistance and expertise

• Results may be disappointed

• Weigh the consequences of public media hype

• Still Ongoing

• Need to compile data

Collaboration

• Building public health cohesion

• Identify duties of investigation

• Which agency is responsible

• Take time to discuss process

• Agreement over who writes and reviews correspondence, decision making, arbitration, etc.

• Keep everyone informed

Proposed Law Reform • Requires the governor to determine if a public or health

emergency needs a coordinated response by a team of state officials. The other gives the Nevada State Health Division the power to immediately issue a cease-and-desist order at a facility where patient safety is in question.

• Another new law affirms that a health care professional's license can be suspended if the facility they own is investigated or disciplined for misconduct.

• Consider mandatory CME’s and CEU’s in infection control/injection safety.

WV OLS

• Expertise from prior outbreak investigations

• Provided resources on testing requirements

• Coordination of submission of specimens from other labs and health departments

• Created easy recognizable lab forms

• Served as advisors