Hepatitis outbreak from a health-care worker
A new case report from the Centers for Disease Control underscores the essential nature of universal precautions. The New York City Department of Health had two cases of Hepatitis C infection reported in 2007 and 2009 in patients who had no other risk factors for infection other than a previous outpatient medical procedure. Both cases have been deemed due to the procedure, and are consequently nosocomially-acquired iatrogenic infections, or infections that are directly caused by a medical procedure.
Hepatitis C is a contagious infection of the liver caused by the HepC virus, which is unrelated to the HepA or HepB viruses. Hepatitis C is mainly acquired via contaminated body fluids, and risk factors in the general population include intravenous drug use with shared needles, unsafe practices in tattoo and piercing facilities, and with unprotected sex with an infected partner. Acute infection generally does not occur with Hepatitis C, and instead long-term chronic infection is the norm leading to scarring (cirrhosis) of the liver and decreased liver function. Signs and symptoms associated with chronic Hepatitis C infection include abdominal pain, fever, fatigue, jaundice, nausea, and loss of appetite, and diagnosis is generally accomplished by detecting the presence of the virus in the bloodstream. Antiviral medications are available that can decrease and potentially eliminate the virus, however most health care providers refer to a “sustained virologic response” as opposed to a “cure” when discussing treatment outcomes with patients because of the difficulty in completely eliminating the virus. Long term infection due to HepC can result in complete liver failure or liver cancer.
In the first case reported to the NYC Dept of Health, a male patient in his 60’s contacted the DOH in May 2007 to report his recent HepC infection. He had none of the typical risk factors associated with HepC infection other than an outpatient endoscopy procedure in February 2007. Previous blood work from 2006 indicated that he was uninfected at that time. Review of the procedure with the gastroenterologist and anesthesiologist present were unaware of any other patients who were HepC positive. The anesthesiologist indicated that he did reuse a stock of propofol (single-use anesthetic) between patients, and further investigation by the DOH indicate that two of the previous patients were positive for Hepatitis C. The DOH advised that the anesthesiologist discontinue the practice of reusing the drugs between patients immediately. Further examination of 2900 patients treated by the anesthesiologist between January 2005 and November 2007 did not turn up any additional clusters of patients suggesting further transmission.
In the second case, a woman in her 40’s reported an acute Hepatitis C infection, following a gastroenterology procedure in a different outpatient clinic with a different gastroenterologist. The anesthesiologist however was the same, and the infection likely occurred during the time frame when the doctor reported using the single use vials of propofol for multiple patients. The NYC DOH then decided to notify all 3278 patients who received care from this anesthesiologist between January 2005 and July 2008, and recommend that they be tested for HepB, HepC, and HIV.
Editorial notes added to the cases by the CDC suggest that these isolated cases likely represent only the tip of the iceberg with HepC infections acquired during health care procedures. Transmission in these cases occurred due to breaches in aseptic technique, and the majority of previously identified patient to patient transmission cases also involve breakdowns in care. The CDC notes that timely investigation of these cases is hindered by the ability of local departments of health being able to devote appropriate resources in identifying the source of the infection. Best practices for controlling Hepatitis C and other infectious agents at the local level should include public health surveillance and reporting, complete investigation of reported cases to identify breaches in treatment, and investigation to identify other infected individuals in order to stop the spread of these infections.