The findings could portend a more widespread problem that endangers patients across the nation, the agency said.
Outbreaks of hepatitis B and C in New York, Oklahoma and Nebraska between 2000-2002 that infected more than 300 people stemmed from "unsafe injection practices, primarily reuse of syringes and needles or contamination of multiple-dose medication vials," CDC investigators write in the Sept. 26 issue of Morbidity and Mortality Weekly Report.
"People need to realize this is a potential problem in the United States," Ian Williams, a co-author of the study and medical epidemiologist with CDC's National Center for Infectious Diseases in Atlanta, told United Press International.
Both hepatitis B and C are viral illnesses that infect the liver. Most people will recover from hepatitis B but it can be deadly in some cases. Hepatitis C usually is not fatal but most people never rid themselves of the virus once infected and it is a leading cause of liver transplants.
The dangerous practices discovered in the investigation are of particular concern because they risk spreading not only hepatitis but "essentially pretty much any bacterial or viral pathogen ... that can be transmitted through blood," Williams said. Hardier pathogens, such as hepatitis B, are much more likely to be passed on "but the potential to transmit (other agents) is there," he said.
Williams said he hoped the report would serve as a "wake-up call" for the healthcare community and spur the profession to develop ways to prevent these problems from happening.
The severe consequences of needle reuse also underscore the need to reinforce fundamental infection control techniques among healthcare workers, he said. Doctors and nurses should be aware of the dangers of reusing needles, "but clearly these four outbreaks show that some people don't know this," he said.
Dr. Georges Benjamin, executive director of the American Public Health Association in Washington, told UPI these dangerous practices are probably happening in other doctor's offices across the United States. "I would suspect this is the tip of iceberg," Benjamin said, noting that he was "astounded that this kind of thing happens."
Dr. William Schaffner, professor of infectious diseases at Vanderbilt University's School of Medicine in Nashville, Tenn., said the study uncovered lapses in "terribly basic infection control practices and we ought to be shocked."
The seriousness of the findings are underscored by a growing body of studies suggesting that reusing needles and other dangerous practices in the healthcare setting are contributing to the spread of hepatitis and HIV in developing countries, Williams said.
Previous studies had indicated healthcare settings are not an important factor in spreading hepatitis in the United States, but "these four outbreaks were all extremely large and because most people with hepatitis seem to be asymptomatic there might be outbreaks we're missing," he said.
In the investigation, Williams' team found as many as 42 patients may have contracted hepatitis B and C in two separate incidences in doctor's offices in New York City in 2001. The infections appeared to stem from reuse of needles and improper use of multiple-dose medication vials. One office was allowed to resume practice after making changes to its infection-control procedures. In the other case, the physician subsequently retired and closed his practice.
Sixty-nine patients in Oklahoma acquired hepatitis C and 31 contracted hepatitis B at a pain clinic in 2002, apparently due to a nurse who routinely reused needles and syringes in as many as 24 consecutive patients. The nurse's license was revoked and a fine of $99,000 was imposed by the state board of nursing.
In an outbreak of hepatitis C in Nebraska in 2001-2002, as many as 184 patients may have acquired hepatitis C due to a health-care worker routinely reusing the same syringe on multiple patients in delivering chemotherapy at a hematology/oncology clinic. The clinic later closed.
The danger of these unsafe practices in the outpatient setting is exacerbated by the fact these clinics do not have the infection control oversight hospitals do, Williams said. Also, patients often come back to outpatient settings for multiple visits so if one patient is infected it can lead to a snowballing effect where other patients become infected, which in turn infects additional patients. "Bad practice (at a single office) can lead to very large outbreaks," he said.
Solutions to this problem should involve developing ways of oversight to ensure doctor's offices have proper infection control policies in place and are following them, Williams said.
One of the surprising findings of the investigation was some of the healthcare workers had been employing unsafe procedures "for years, even in the presence of other healthcare workers and nobody told them to stop doing this," he said. "Where was the oversight in these settings? Had there been appropriate oversight ... these practice wouldn't have continued," he said.
Another problem cited by investigators is the lack of disciplinary action against healthcare workers not following safe procedures. Two of the clinics involved in the outbreaks were shut down but "potentially these healthcare workers could go on to do this practice again in another setting or another state," Williams said.
Benjamin said focusing on the individual would "miss the boat," however. A better solution would be for public health authorities to make all doctors and nurses aware of the risks and work with them to develop safer protocols.
Safer delivery devices also should be considered, Benjamin said, noting at least one needle manufacturer has developed needles that retract after one use so they cannot be reused.
Schaffner, who serves as a consultant to the CDC, said the agency is actively discussing ways to prevent the unsafe practices with a variety of organizations who are stakeholders in outpatient management.
"Everyone is in agreement that these are fundamental and egregious flaws described in this study and our tolerance for that is zero," he said. "That does not mean there's an easy solution, but health professionals are putting their brains to this."