CDC Head: Problems at Nevada Clinic Could Be "Tip of Iceberg"
March 4, 2008
A Las Vegas clinics reuse of syringes and medication vials may reflect a more widespread practice across the country, CDCs director said Monday in Washington. Nevada health officials are trying to contact about 40,000 patients who had procedures at the Endoscopy Center of Southern Nevada between March 2004 and Jan. 11, 2008, advising them to be screened for hepatitis B, hepatitis C and HIV.
Health care accreditors would consider this a patient safety error that falls into the category of a never event, meaning this should never happen in contemporary health care organizations, Dr. Julie Gerberding told reporters after a meeting with Sen. Harry Reid (D-Nev.).
This is the largest number of patients that have ever been contacted for a blood exposure in a health care setting, said Gerberding. But unfortunately we have seen other large-scale situations where similar practices have led to patient exposures.
Our concern is that this could represent the tip of an iceberg and we need to be much more aggressive about alerting clinicians about how improper this practice is, but also continuing to invest in our ability to detect these needles in a haystack at the state level so we recognize when there has been a bad practice and patients can be alerted and tested, Gerberding said.
Reid said he would press to get CDC more resources in an emergency spending bill in April.
State health authorities do not know how many at-risk patients have been notified since the public was first alerted on Wednesday. Officials said they did not have the correct addresses for 1,400.
Five of six hepatitis C cases that officials traced to the clinic were genetically linked, said Brian Labus, head epidemiologist of the Southern Nevada Health District. With 4 percent of the population carrying hepatitis C, Labus expects a number of at-risk patients will be found to be infected, but he said determining which transmissions occurred at the clinic may be impossible.
3.04.2008; Erica Werner
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