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]