|
Hepatitis C (HCV) Outbreaks by Setting
|
| Setting |
Year |
State |
Persons Notified for
Screening2 |
Outbreak-Associated
Infections3 |
Known or suspected mode of
transmission4 |
Comments |
|
Outpatient
|
| Hematology Oncology Clinic(20) |
2012
|
MI
|
>300
|
10
|
Specific lapses in infection control
not identified at the time of the investigation |
|
| Pain management clinic (21) |
2011
|
NY
|
466
|
2
|
Suspected syringe reuse contaminating
medication vials |
|
| Outpatient clinic (22) |
2010
|
FL
|
3,929
|
5
|
Drug diversion (fentanyl) by an
HCV-infected radiology technician |
|
| Outpatient alternative medicine clinic
(23) |
2009
|
FL
|
163
|
9
|
Syringe reuse contaminating medication
vials used for >1 patient
Use of single-dose vials for >1 patient |
|
| Endoscopy clinics (24) |
2009
|
NY
|
3287
|
2
|
Suspected syringe reuse contaminating
medication vials |
2009 investigation of cases occurring
in 2006- 2007 |
| Ambulatory surgical centers
(single-purpose endoscopy clinics) (n=2) (25,
26,
27) |
2008
|
NV
|
>60,000
|
9
|
Syringe reuse contaminating single-use
medications vials (propofol) that were used for >1 patient |
8 cases were from the first center and
one from the second. The health department identified an additional
106 infections that could have been linked to the clinics. Note:
this outbreak is also included in Thompson, et al, but at the time
of publication only
6 cases had been identified.
|
| Outpatient cardiology clinic (28) |
2008
|
NC
|
1,200
|
5
|
Syringe reuse contaminating multi-dose
vials of saline solution used for >1 patient |
An additional 2 new infections were
identified in probable source patients |
| Totals |
|
|
>69,345
|
42
|
|
|
|
|
|
Long-term care
|
| Skilled nursing (29) |
2013
|
ND
|
>500
|
46
|
Epidemiologic analysis suggested
podiatry care, phlebotomy, and nail care performed at the skilled
nursing facility were associated with HCV infection |
|
|
|
|
Hospital
|
| Hospital (30) |
2012
|
NH
AZ
GA
KS
MD
MI
NY
PA
|
>11,000
|
45
|
Drug diversion by radiology
technologist. |
Patients from 16 facilities in 8 states
were notified about potential exposure and recommended to undergo
testing for HCV infection. |
| Hospital-based surgery service (31) |
2009
|
CO
|
>8,000
|
26
|
Drug diversion (fentanyl) by an
HCV-infected surgical technician |
18 cases were linked by viral
sequencing to the surgical technician; an additional 8 infections
were determined to be epidemiologically linked but viral sequencing
was not able to be performed. The number screened includes patients
from three facilities where the surgical technician had worked. |
| Totals |
|
|
>19,000
|
71
|
|
|
|
|
|
Hemodialysis
|
| Outpatient hemodialysis facility (32) |
2014
|
WA
|
186
|
3
|
Breaches in environmental cleaning and disinfection
practices identified included: failure to consistently change gloves
and perform hand hygiene between patients, and breaches in
environmental cleaning and disinfection practices to prevent
cross-contamination between clean and dirty areas |
|
| Outpatient hemodialysis facility (33) |
2014
|
TN
|
62
|
2
|
Breaches in environmental cleaning and disinfection
practices |
|
| Outpatient hemodialysis facility (34) |
2014
|
NJ
|
69
|
4
|
Breaches in environmental cleaning and disinfection
practices identified included failure to: wash hands before and
after glove use; adequately clean surrounding area of the station,
the dialysis chair and priming bucket after use |
|
| Outpatient hemodialysis facility (35) |
2014
|
NJ
|
97
|
2
|
Breaches in environmental cleaning and disinfection
practices identified included failure to: appropriately separate
clean and contaminated supply areas, properly disinfect clamps in
the open position, adequately clean the dialysis chair and priming
bucket after use; ensure patients applying pressure to their own
hemodialysis access site wash their hands after doffing gloves and
prior to using the scale. |
|
| Outpatient hemodialysis facility (36) |
2012
|
PA
|
66
|
18
|
Multiple lapses in infection control
identified, including hand hygiene and glove use, vascular access
care, medication preparation, cleaning and disinfection |
18 new HCV infections between 2008–2013 |
| Outpatient hemodialysis facility (37) |
2012
|
CA
|
42
|
4
|
Specific lapses in infection control
not identified at the time of the investigation |
|
| Outpatient hemodialysis facility (38) |
2011
|
GA
|
89
|
6
|
Failure to maintain separation between
clean and contaminated workspaces |
|
| Outpatient hemodialysis facility (39) |
2010
|
TX
|
171
|
2
|
Specific lapses in infection control
not identified at the time of the investigation |
|
| Outpatient hemodialysis facility (40) |
2009
|
MD
|
250
|
8
|
Breaches in medication preparation and
administration practices
Breaches in environmental cleaning and disinfection practices |
|
| Hospital-based outpatient hemodialysis
facility (41) |
2009
|
NJ
|
144
|
21
|
Breaches in medication preparation and
administration practices
Breaches in environmental cleaning and disinfection practices |
All patients who received dialysis in
this facility since 2005 were notified for screening |
| Outpatient hemodialysis facility (42) |
2008
|
NY
|
657
|
9
|
Failure to consistently change gloves
and perform hand hygiene between patients. Breaches in environmental
cleaning and disinfection practices |
All patients who received dialysis in
this facility since 2004 were notified for screening |
| Totals |
|
|
1,833
|
79
|
|
|
