hepatitis outbreak

A Survivor reacts to a new outbreak

Johnny and Janet Robertson
Johnny and Janet Robertson

Recently West Virginia health authorities announced that a cardiac clinic is at the center of an investigation of a potential outbreak of viral hepatitis through unsafe injection practices. Johnny Robertson of North Carolina is a survivor of a similar outbreak and is an active advocate of injection safety. We are grateful to Johnny for his leadership in patient advocacy. Following is his reaction to the outbreak.

In January 2008, I heard the words, “You have hepatitis C.” This diagnosis changed my life completely.

I contracted hepatitis C during a stress test at a cardiology clinic in North Carolina in 2007. Later, it was revealed that a medical technician administered saline solution to a patient who was infected with this life threatening disease, then reused the same syringe to re-enter the vial. This contaminated the vial of medication with the virus. Subsequent patients who received an injection from the saline solution vial were exposed to the virus. Five patients were infected with the virus, but many more were exposed and were urged by the state health department to be tested.

Several weeks ago, West Virginia’s Department of Health and Human Resources sent letters to 2,300 people potentially exposed to hepatitis B, hepatitis C and HIV through cardiac stress tests at Raleigh Heart Clinic in Beckley. From the recent article (“Hepatitis cases linked to Beckley clinic likely caused by human error,” March 29), we know that 12 patients have been infected with hepatitis C or hepatitis B.

This tragic news strikes an eerily similar tone.

In addition to the dozen patients who have been infected, my heart breaks for the patients who sit and wait and worry while results from blood tests come back. I offer them my deepest support.

Outbreaks like this one oftentimes affect entire communities. Families and friends and colleagues are affected. They take a toll on the human psyche, and they are complicated and costly.

The truth of the matter is this could have been prevented. It did not need to happen.

Generally, healthcare in the United States is very safe. But sometimes, unsafe practices are used—brought about by ignorance, desire to cut costs, or the demand to see more patients in a shorter amount of time.

But there are efforts to educate both healthcare providers and consumers about the absolute need for safe injections in all settings.

I work alongside colleagues at Hepatitis Outbreaks’ National Organization for Reform and North Carolina’s One & Only Campaign. I am proud to serve as a spokesman for this award-winning campaign. I tell my story to healthcare providers throughout the state to help reeducate and advocate for injection safety, urging them to use “One needle, one syringe, and only one time!”

Patients need to have a voice in healthcare. No one in the United States should be infected with hepatitis C while receiving healthcare. My hope is to support those who are going through this very difficult time and allow the conversation to begin about tighter safety protocols, in West Virginia and elsewhere. There is help out there for those who need it. I know because I was once in this same situation.

Johnny Robertson

Another plea for a national healthcare registry

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

News broke a few weeks ago about a possible drug diversion event in Colorado. The more we here about the details of this incident, the more we understand just why a national registry for healthcare workers is so important. Even with the current registry the state of Colorado has for surgical technologists, we see that we have still fallen short in regard to gaps in the system.

It appears the surgical tech who was caught with a syringe in an operating room where he was not scheduled has lost every previous hospital job due to drug violations. At least one other job he was caught stealing a syringe and in still another he tested positive for fetanyl. It appears 4 states are now involved in an ongoing investigation. Read more

Another Drug Diversion Event in Colorado

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

This past week we learned that there was another incident of drug diversion at Swedish Medical Center in Englewood, Colorado. This is not far from Rose Medical Center in Denver, the site of the 2009 drug diversion event which caused 19 patients to be infected with Hepatitis C. So if this seems eerily familiar, you are right, it is.

At last report, no exposure to any infectious diseases have been reported. My sincere hope is this remains to be the truth for the almost 3000 patients who were notified that they may have been put at risk.

But the cold hard facts remain. There was another drug diversion at an HCA hospital, the same hospital system which includes Rose Medical Center. And I am sure the most asked question is going to be “Why?” Why were there not better systems put into place to safeguard again this? Why did we not learn from the mistakes made in 2009?

We ask why because we know this was a completely preventable event. We ask why because despite any reliable data about the frequency of drug diversion in healthcare facilities, primarily due to the covert nature of this crime, we know it is always a possibility, always a risk. We ask why because there are many hospital systems who have successfully been able to monitor, assess and prevent drug diversion incidents.

So while my thoughts remain with those 3000 patients and their families and friends as they await news of their blood tests, I find comfort in knowing behind the scenes the Colorado Department of Public Health and Environment is doing what needs to be done to investigate, educate and keep the risks at a minimum. With the help of the CDPHE’s One and Only Campaign, awareness is being raised among patients and healthcare providers regarding safe injection practices. Or if more information is needed, please contact HONOReform at www.honoreform.org.

Below you will find a guest commentary which appeared in the Denver Post this past Saturday offering solutions for the future.

Swedish Medical Center infection scare didn’t have to happen – The Denver Post

Real fear in South Korea Hepatitis C outbreak

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

Prior to my 2009 Hep C infection I paid little, if any, attention to issues of safe injection practices, drug diversion or outbreaks. In my ordinary life, I had no concern for such things. In fact, I am not even sure I could adequately define any of those terms prior to the chaos of 2009 and the outbreak in Colorado.
But since, I have kept myself in the know, paying attention to trends, outbreaks and legislation to protect patients. My email inbox and social media accounts are littered with stories, mostly bad, about errors in patient care. I truly hope that some of the initiatives I have become a part of will put a stop to most of these incidents. However, in preparing for every situation in an attempt to prevent these events you will find a tale so far fetched you want to read the facts 2 or 3 times just to insure what you initially thought you heard was correct. Read more

Lesson learned? Medical office reopens after Hep C outbreak

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

Earlier this year, I commented on the closure of a medical office in Santa Barbara for various infection control violations. It was in the first half of the year and I was feeling hopeful because in 2014 none of the investigations which took place were found to have any infectious disease transmissions. And then in early April news spread the office of Dr. Allen Thomashefsky’s was being investigated.

I felt it important to report again on this situation almost 6 months later as the office was given the approval to re-open last month. Am I disappointed that his practice was able to stay open in Oregon with certain restrictions in place? Am I saddened that this California office was able to be re-opened? Not as long as the proper procedures are implemented.
Read more

The Dire Need for Injection Safety Activism in India, by Dr. Mudasir Firdosi

Dr Mudasir Firdosi shares his views on World Hepatitis Day activities
Dr Mudasir Firdosi shares his views on World Hepatitis Day activities

In this blog, reprinted with his permission from Greater Kashmir, our colleague, Dr. Mudasir Firdosi, reflects on World Hepatitis Day. Unlike many of the reflections on and around July 28 that appeared in the United States and throughout the developing world, it’s not happy news. Dr. Firdosi calls the fact that awareness and education programs hardly exist in India “a criminal silence.” At HONOReform, we continue to learn all we can about the need to shore up medical injection safety in India–and beyond. Our aim is to help make a difference, in the U.S. and throughout the world. No patient should ever receive an infection of hepatitis C while receiving healthcare. We thank our many colleagues, including Dr. Firdosi, for sharing their education and insight. We encourage you to read his full editorial here.

Hepatitis C and preventive measures by Dr Mudasir Firdosi

We would like to thank Dr. Mudasir Firdosi for helping to highlight Hepatitis C as a truly global issue. This is re-printed from a post which appeared in mid-May.

Kashmir valley is witnessing another disaster in the form of Hepatitis C epidemic. In some villages in Kokernag area, the number of cases is around 40% of the total population. In spite of media pressure, and demand from local population, authorities are still contemplating curbing the further spread of this infection. Similar scenario exists in other districts of the valley like Shopian, Kupwara, and Srinagar.

Hepatitis C is not transmitted by routine personal contact and there needs to be an actual transfer of the virus via blood, blood products and body fluids, from one person to another. From the sociodemographic profile of the rural population, one can easily exclude intravenous drug abuse or sexual contact as the cause of the current epidemic in majority of cases.
Read more

National Hepatitis Testing Day is May 19th

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

May is National Hepatitis Awareness month and this year the CDC is designating May 19th as National Hepatitis testing day. This is an excellent reminder for the healthcare community and others to get tested.

Not me, you say? Let me tell you why ignoring this might be a deadly mistake. According to the CDC over 4 million people in the US have chronic hepatitis C and most have no idea. Many of our baby boomers are infected and because they show no symptoms, they are clueless to the infection and the damage it is doing to their bodies. http://www.cdc.gov/hepatitis/TestingDay/index.htm
Read more

A heartfelt thank you to some very hard working epidemiologists

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

A huge thank you to the wonderful epidemiologists at both the Colorado Department of Public Health and Environment (CDPHE), Division of Disease Control and at the Centers for Disease Control and Prevention (CDC), Viral Hepatitis Division for their major article published this month in the American Journal of Infection Control. Their article, “Outbreak of hepatitis C virus infection associated with narcotics diversion by an hepatitis C virus-infected surgical technician,” outlines the happenings surrounding the Hepatitis C outbreak in Colorado in 2009. Their in-depth study of this situation brilliantly highlights the need for better health surveillance in identifying such outbreaks and the diversion which causes them.
Read more

Happy New Year!

Welcome back to the HONOReform blog, aka “Survivor Stories,” for our second full year of publication. We thank everyone who has had a role in making our blog a growing success—contributors and readers and everyone who has suggested to friends that they should check out our blog and pass it on to others.
And we encourage you to please continue to support our efforts.
Here at HONOReform, community-building is a key to emphasizing safe injection practices and doing all we can to educate the public and reeducate providers on the absolute necessity of injection safety.
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