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Hepatitis B outbreak related to multiple dose heparin vials should serve as a wake up call.

From the July 17,1996 Issue

PROBLEM: Several patients in a California hemodialysis center, previously HBsAg-negative, developed hepatitis B after they received heparin administered from multiple dose vials shared with a patient with chronic infection. The source patient was identified through genetic sequencing of virus isolates from all infected patients. Staff were frequently assigned to provide simultaneous care for the source patient and infected patients, and partially used heparin vials were routinely returned to a common area. These cases are among several discussed in a CDC report on outbreaks of hepatitis B among hemodialysis patients in California, Nebraska and Texas (Morbidity and Mortality Weekly Report 1996;45:285-9). These and earlier reports of hepatitis B transmission via heparin vials (Oren H et al. A common-source outbreak of fulminant hepatitis B in a hospital. Ann Intern Med 1989;110:691-8; Alter MJ et al. Hepatitis B virus transmission associated with a multidose vial in a hemodialysis unit. Ann Intern Med 1983;99:330-3) should serve as a wake-up call to establish safety measures wherever multiple dose vials of heparin (or sodium chloride) are used in association with vascular access devices. This is especially important since many health care institutions have been replacing safer unit dose sodium chloride 0.9% and heparin flush syringes with multiple dose vials, as they seek to reduce pharmacy related costs. Also potentially problematic: lidocaine and other local anesthetics in multiple dose containers. Up to 25% of health care personnel reenter vials with needles just injected into patients (Prott RT, Wagner RF, Trying SK. Iatrogenic contamination of multidose vials in simulated use. Arch Dermatol 1990;126:1441-4.).

SAFE PRACTICE RECOMMENDATION: Recognize that through either lack of knowledge or poor performance, some personnel do routinely reenter vials with used needles, without any realization that they are potentially contaminating vial contents. Therefore, where multiple dose vials are used, conduct educational programs and periodically monitor health care personnel to assure their understanding of necessary infection control measures. In addition, managers must monitor supplies used for infected patients to assure that they are isolated and for use only in that patient. Susceptible dialysis patients should be vaccinated against hepatitis B. If these measures are not undertaken, or controls cannot be assured, only prefilled syringes should be us ed. [D (nephrology, infectious disease), N, P, Q]

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