Healthcare should not be a vehicle for transmission of hepatitis C virus☆
Article Outline
During the past 15 years, there have been more than 600 publications on the topic of nosocomial or iatrogenic hepatitis C virus (HCV) transmission not related to transfused blood, plasma-derived products, or transplantation (ISI Web of Science® at http://portal.isiknowledge.com accessed October 19, 2007). Most of them were from developed countries, such as those in Western and Northern Europe, the United States, Australia, and Japan. The most compelling of these publications are those reporting the results of outbreaks involving patient-to-patient transmission, and virtually all of them had one common theme, unsafe therapeutic injections. Unsafe therapeutic injection practices resulted in common source exposures to contaminated multiple-dose medication vials and saline bags from re-insertion of used needles/syringes; use of a single needle/syringe to administer intravenous medications to multiple patients; and use of a single spring-loaded finger-stick device, without changing the platform, to monitor blood glucose in multiple patients [1], [2], [3], [4], [5].
To appreciate the extent to which unsafe therapeutic injections contribute to the transmission of HCV in healthcare settings in developed countries, one must read beyond the titles and abstracts of many publications. Titles that suggest that risk factors for HCV infection include endoscopy, colonoscopy, sclerotherapy of varicose veins, pharmokinetic studies, and various surgical and anesthesia procedures are misleading [6], [7], [8]. On closer examination, these papers actually were reporting patient-to-patient transmission of HCV from failure to use aseptic techniques when preparing and administering injections from multiple-dose vials in patient treatment areas and procedure rooms, rather than from the medical or surgical procedures themselves [9], [10], [11]. Historically, chronic hemodialysis facilities were considered the setting most likely to place patients at risk for acquiring bloodborne virus infections. While patient-to-patient HCV transmission continues to be reported from these settings, most of the outbreaks reported in the past 15 years have involved a broad range of other settings including inpatient medical, oncology and hematology wards, inpatient and outpatient surgery, emergency rooms, and cardiology, gastroenterology, and other outpatient practices [12], [13], [14], [15].
In this issue of the Journal, Martinez-Bauer et al. [16] have again brought attention to the problem of healthcare as a source for HCV infection, and only last year, the Journal published an extensive review of global HCV transmission by medical procedures [7]. Much attention has been focused on the evidence of large-scale transmission of bloodborne pathogens, particularly HCV, in resource-poor countries due to overuse of injections, reuse of injection equipment, and administration of injections by nonprofessionals [17]. In developed countries, where these factors presumably should play little role, how many more articles do we need from hospitals, clinics and practices to recognize our failure to adhere to the fundamental principles of aseptic technique? Several studies, including that by Martinez-Bauer et al. [16], [18], [19], [20], have reported a long list of medical and surgical procedures as risk factors for HCV infection. Given the direct evidence from outbreak investigations, however, I would propose that the risk is not from each of the procedures per se, but more likely from unsafe injections administered as part of these procedures. Using this premise, we can focus on a specific set of prevention measures related to the safe preparation and administration of injectables.
The safe preparation and administration of injectables require aseptic technique. Aseptic means without microorganisms and aseptic technique applies not only to the establishment and maintenance of a sterile field in the operating room, but also to the handling and administration of injectable medications. Because the use of aseptic technique is considered a standard of care, it has not been included in general infection control recommendations. Recognition of the problem, however, has prompted the United States to include safe injection practices in its most recent update of recommendations for preventing transmission of infectious agents in healthcare settings (Table 1) [11]. Other countries might consider following suit. In addition, all certification and training programs need to reinforce these principles and practices which should be reviewed as part of frequent in-service education for healthcare staff in the broad range of settings that deliver care. It is our responsibility to ensure that healthcare is not a vehicle for the transmission of HCV or other bloodborne pathogens.
Table 1. Safe Injection Practices
•Use aseptic technique to avoid contamination of sterile injection equipment •Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient •Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set •Use single-dose vials for parenteral medications whenever possible •Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use •If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile •Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable •Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients |
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☆ The author declares that she does not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.
PII: S0168-8278(07)00584-3
doi:10.1016/j.jhep.2007.10.007
© 2007 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.
