Unsafe Injection Practices A Global Public Health Problem

1. Unsafe Injection Practices A Global Public Health Problem

2. 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

3. Public Health Coordinated Response

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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 Testing Decisions

11. Media • Media leaks • Press Releases • Interviews • Live Reports • Talking Points

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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