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
•
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