CDC Grand Rounds: Preventing Unsafe Injection Practices in the U.S. Health-care System

Guthrie Birkhead, MD; Thomas E. Hamilton; Rachel Kossover, MPH; Joseph Perz, DrPH; Denise Gangadharan, PhD; John Iskander, MD

Disclosures

Morbidity and Mortality Weekly Report. 2013;62(21):423-425. 

In This Article

Scope of the Problem

Traditionally, injection safety has been recognized as a public health issue mainly in low- and middle-income country settings. Estimates of the global burden of disease associated with unsafe injections in the year 2000 included approximately 20 million new hepatitis B virus (HBV) infections, 2 million new hepatitis C virus (HCV) infections, and 250,000 new human immunodeficiency virus (HIV) infections.[2] The U.S. experience with outbreaks attributed to unsafe injection practices has grown substantially over recent years. Since 2001, at least 49 outbreaks have occurred because of extrinsic contamination of injectable medical products at the point of administration (CDC, unpublished data, 2013[3]). Twenty-one of these outbreaks involved transmission of HBV or HCV; the other 28 represented outbreaks of bacterial infections, primarily invasive bloodstream infections. Approximately 90% of these known outbreaks occurred in outpatient settings. Pain management clinics, where injections often are administered into the spine and other sterile spaces using preservative-free medications, and cancer clinics, which typically provide chemotherapy or other infusion services to patients who might be immunocompromised, are represented disproportionately relative to the overall volume of outpatient care.

Although hundreds of patients became infected in the outbreaks described, there is the additional burden of the estimated 150,000 patients during 2001–2012 who required notification advising them to undergo bloodborne pathogen testing after their potential exposure to unsafe injections (CDC, unpublished data, 2013[3]).

Unsafe injection practices fall into two overlapping categories: reuse of syringes and mishandling of medications. "Direct" syringe reuse occurs when a single syringe is used for more than one person, as when the same syringe is used to inject via intravenous tubing or only the needle is changed between patients. These unsafe practices are still encountered; recently, several large patient notification events have stemmed from reuse of insulin injection pens for multiple patients.[3,4] There is also growing recognition of provider-to-patient HCV transmission in the context of narcotics theft. In these scenarios, HCV infection is transmitted to patients as a consequence of overt syringe reuse (after the HCV-infected health-care provider had self-injected) or from contamination of medication that was accessed with a used syringe. Outbreaks involving infected health-care providers who obtained injectable drugs illicitly have affected large numbers of patients.[5] "Indirect" syringe reuse (i.e., accessing shared medication vials with a used syringe) often is identified during outbreak investigations. Mishandling of medications primarily involves reuse of single-dose vials, which are intended for single-patient use only, to obtain medication for multiple patients. Because single-dose vials typically lack preservatives, this practice carries substantial risks for bacterial contamination, growth, and infection. Similarly, intravenous solution bags often are mishandled, for example, when inappropriately used as a common source of supply for multiple patients.

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