September 20, 2014 —  The Brant News (Canada) reported on January 23, 2014, that human error is likely to blame for at least one instance of hepatitis C infection following gastrointestinal (GI) endoscopy.

Click here to read this news source’s article “Hep C probe continues at BGH.”

Brantford General Hospital (“BGH”) is located in Brantford, Ontario (Canada), and is a member of the Brant Community Healthcare System (“BCHS”).

BCHS has set up a dedicated webpage that discusses this apparent breach in sterile technique —  click here to read this webpage, which is entitled: “Update:Possible Breach in Medication Administration and Documentation. Frequently Asked Questions (FAQ).”

Attention: Readers may recall that in November, 2013, 243 patients of a hospital outside of Chicago (IL) were notified of the potential for patient-to-patient transmission of the antibiotic-resistant bacteria known as “CRE” following “ERCP,” which is a type of gastrointestinal (GI) endoscopic procedure.

At least 38 of this hospital’s patients have been found to be either infected or colonized with this superbug.  Click here to read one of the articles that Lawrence F Muscarella, PhD, this article’s author, wrote about this CRE outbreak, which is the largest ever recorded in the U.S. or Canada.

The following is a timeline of events associated with BGH’s investigation of possible hepatitis C transmission during GI endoscopy as reported by the Brant News, the Brantford Expositor and as discussed on BCHS’s aforementioned webpage:

January, 16, 2014: On this day BGH announced during a news conference that its staff had become aware, in mid-November, 2013, that one of its patients — known as an “index patient” — had been infected with the hepatitis C virus. This patient had undergone GI endoscopy at this hospital six months earlier, on May 29, 2013.

January 17, 2014: Reported by the Brantford Expositor on this day (click here), BCHS feared patient-to-patient transmission of the hepatitis C virus and therefore had contacted and tested for infection nine other potentially affected patients who also underwent GI endoscopy on the same day (May 29, 2013) and in the same procedure room used to perform GI endoscopy on this index patient.

  • This testing determined that a patient who underwent GI endoscopy immediately before the index patient — the likely “source patient” — was also infected with the hepatitis C virus, having been infected with this virus, however, prior to undergoing GI endoscopy at BGH on this day (i.e., pre-existing infection). No other possible instances of transmission of the hepatitis c virus were identified.

Also in January, 2014, BCHS became aware of a 2nd “index patient” who recently became infected with the hepatitis C virus and had also undergone GI endoscopy at BGH — but this time on November 8, 2013.

  • Like before, hospital officials contacted and tested potentially affected patients, this time five “at risk” patients, who also underwent GI endoscopy on this same day (November 8, 2013) and in the same procedure room.
  • Again, a possible “source patient,” who underwent GI endoscopy immediately before this 2nd “index” patient’s procedure, believed to have been infected with the hepatitis C virus, however, prior to undergoing GI endoscopy at BHG on this day (i.e., pre-existing infection). Again, no other possible instances of transmission of the hepatitis c virus were identified.

February 21, 2014 – UPDATE: The Brantford Expositor reports on February 21, 2014, that BGH is advising about 800 patients to undergo blood testing for evaluation of hepatitis C infection, after it was definitively confirmed through the results of blood tests that the aforementioned 2nd index patient was indeed infected with hepatitis C during GI endoscopy performed at BGH on November 8, 2013. — click here.

Previously on January 17, 2014, officials of BCHS had announced that there was “no confirmation of transmission.”

Also previously, the Brantford Expositor reported on January 17, 2014, that, according to hospital officials, all patients who might have been affected by this possible breach in sterile technique have been contacted and tested, and “no additional patients will be tested at this time.”

Hospital officials report that they believe that the cross-contamination of medication supplies may have been responsible for these two cases of possible patient-to-patient disease transmission.

Such cross contamination might have occurred, for example, if a syringe previously used to administer a IV medication during GI endoscopy to a patient already infected with the hepatitis C virus (source patient) were reused on a subsequent patient (index patient).

In both of BGH’s confirmed cases of horizontal viral transmission, hepatitis C reportedly was transmitted from a patient already infected with the virus to the next patient who underwent GI endoscopy.

During GI endoscopy a flexible endoscope, such as a gastroscope or colonoscope, is inserted into a patient’s GI tract — for example, via the patient’s mouth or rectum, respectively — to diagnose and treat diseases and disorders of the examined internal viscera and organs.

Some additional facts about BGH’s breach that were reported by the Brant News include:

1. In response to these infections, hospital officials have announced that they are putting into place a number of “evidence-based” corrective actions to ensure patient safety and to prevent the breach’s recurrence.

2. Namely, the hospital will revise some of its practices to ensure:

  • the safe “preparation, labelling (sic), delivery, storage, documentation and discarding of all medications used in endoscopy,” and
  • the safe “storage, sterilization and disinfection of equipment.”

3. The hospital reports that staffers involved in performing endoscopy at BGH will undergo “additional training on sterilization techniques.”

Healthcare facilitiesClick here to learn about an auditing program developed by this blog’s author — Lawrence F Muscarella, PhD — to improve the quality of your medical facility’s infection-control practices.

According to the Brantford Expositor (January 21, 2014; click here), officials of BGH are investigating the possibility that the “needle used to inject sedative medications on a patient previously infected with hepatitis C was then used on the next patient causing transmission of the virus.”

The hepatitis C virus may also be transmitted during other types of medical procedures, including hemodialysis — for example, click here.

Update: Documenting other instances of hepatitis C transmission during GI endoscopy, the Toronto Star reported on September 27, 2014, that the public had not been told of three hepatitis C outbreaks infecting 11 patients at the same number of Toronto colonoscopy clinics in 2011, 2012 and 2013 — click here.

Whether similar instances of failing to report hepatitis C outbreaks to the public following GI endoscopy have occurred in the U.S. is unclear, but a lack of disclosure associated with other types of microbial outbreaks in the U.S. have been documented — see: “Fourth lawsuit filed against Children’s Hospital over fungal outbreak” (June 6, 2014) at this link.

Prior to BGH’s notification of 800 affected patients, as reported by The Brantford Expositor, samples of the virus collected from the infected “index” patients treated at BGH on May 29, 2013, and on November 8, 2013, were being genetically analyzed to determine whether the viruses are identical and these cases a definitive result of patient-to-patient transmission of the hepatitis C virus during GI endoscopy.

As reported on February 21, 2013, this testing confirmed transmission.

Only a few cases of patient-to-patient transmission of the hepatitis C virus during GI endoscopy have been previously reported. Some of these reports include, in addition to several outbreaks in Canada not previously disclosed until 2014 (see above):

  • Bronowicki JP, Venard V, Botté C, et al. Patient-to-patient transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997 Jul 24;337(4):237-40.
  • Patient-to-patient transmission of hepaititis C virus during colonoscopy diagnosis. Gonzalez-Candelas F, Guiral S, Carbo R, et al. Virology Journal 2010;7:217.
  • Muscarella LF. Recommendations for preventing hepatitis C virus infection: analysis of a Brooklyn endoscopy clinic’s outbreak. Infect Control Hosp Epidemiol 2001 Nov;22(11):669.

Recommendations:  A number of evidence-based recommendations by Dr. Muscarella, this article’s author, are provided in his related article “Recommendations to Prevent Viral Transmissions due to Improper Medical Practices: Review of a Case in Long Island in 2007″ click here.

These recommendations include using single-dose medicine vials, because the (improper) reuse of multi-dose vials poses an increased risk of viral transmissions.

Article by: Lawrence F Muscarella, PhD, president and owner of LFM Healthcare Solutions, LLC — click here for a list of its services. Article posted 9/30/2014.

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