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Karen Morrow has a story to tell, the painful narrative of a single patient that humanizes the hellish experience of being infected with a bloodborne pathogen while undergoing routine medical care.
“Like any other tragedy, the first thing to enter a person’s mind is, “This can’t be happening to me,” she writes in a CDC blog. “It’s exactly what I thought. I absolutely knew that I was OK…until I read the test results. I still go back and read them now and can’t believe they are mine. Writing this now, I am crying. Even after all this time, it is still just so unbelievable to me. I was one of the patients notified that I might be at risk for serious disease during the 2008 hepatitis C outbreak in Las Vegas. Unbelievably, I tested positive for hepatitis C.”
In the Las Vegas outbreak more than 60,000 people were urged to seek testing for HCV, hepatitis B and HIV -- the largest such patient notification in history -- after receiving care at two endoscopy clinics. Syringe reuse caused contamination of single-use medications vials of propofol, which were then used on more than one patient. Nine patients were were infected with HCV in the clinics, and 106 other suspect cases of HCV “could have been linked to the clinics,” the Centers for Disease Control and Prevention reports.
Though the infection control breaches that lead to patient exposures are often surprisingly basic — reused needles and/or syringes, improper reentry and subsequent contamination of single and multidose medication vials — outbreaks that were once considered shocking outliers have become the new normal in ambulatory care. Since 2001 more than 150,000 patients have been urged to seek testing for bloodborne infections, according to the CDC. Though exposure incidents have occurred in hospitals, the vast majority of outbreaks were in outpatient clinics, medical offices, long-term care settings and hemodialysis centers.
The outbreaks reported to the CDC are almost certainly an undercount, as many infections caused by violations of basic infection control are likely missed due to inadequate surveillance systems and lack of public health resources to investigate hepatitis cases with no traditional risk factors (i.e., IV drug injection).
“If we can’t feel safe in the hands of our healthcare professionals, where can we feel safe?” Morrow writes. “... And unfortunately, the more I read, the more my eyes are opened to the fact that the stimulus of many of these acts seems to be financial motivation.”