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October 13, 2018
10/13/2018 3:30:00 PM - 10/13/2018 5:00:00 PM
Room North, Room 22
Can Sharing Medication Vials with Clean Needles and Syringes Lead to Healthcare-associated HCV Outbreaks?
Janet M. Van Vlymen, M.D., FRCPC, Julie Magnus, M.Sc., Sophie Breton, M.D., Rachel Phelan, M.Sc., Melanie Jaeger, M.D., FRCPC, Selena Sagan, Ph.D.
Queen's University, Kingston, Ontario, Canada
Disclosures: J.M. Van Vlymen: Funded Research; Self; OPTIMISE2 trial, RELIEF trial, APSF grant, CTAQ grant. J. Magnus: None. S. Breton: Funded Research; Self; APSF grant, CTAQ grant. R. Phelan: Funded Research; Self; APSF grant, CTAQ grant. M. Jaeger: Funded Research; Self; APSF grant, CTAQ grant. S. Sagan: Funded Research; Self; APSF grant, CTAQ grant.
Background: In the 1990’s, increasing healthcare-associated hepatitis C virus (HCV) outbreaks attributed to poor injection practices served as the impetus for the Center for Disease Control (CDC) to develop the “One & Only” campaign which advocated ‘1 syringe + 1 needle + 1 time’ (CDC Guidelines - Safe Injection Practices to Prevent Transmission of Infections to Patients, 2011). Despite the widespread dissemination of this infection control guideline, healthcare-associated HCV outbreaks continue to be frequently reported. In the province of Ontario, Canada, there have been four independent HCV outbreaks documented in outpatient endoscopy clinics in the past 5 years, resulting in 14 new HCV infections. Thorough investigation of each outbreak concluded that contaminated medications, administered by the anesthesiologist, were the likely source of patient-to-patient transmission. Most of the anesthesiologists involved however, adamantly denied reusing needles or syringes when accessing vials for multiple patients. The American Society of Anesthesiologists (ASA) and the CDC both caution against the reuse of needles or syringes and state that medication vials should only be used for a single patient (ASA Recommendations for Infection Control; CDC - Injection Safety, 2010). Nevertheless, it has remained common practice to share multidose medication vials between patients provided new needles and syringes are used with aseptic technique (Gounder et al., 2013; Kossover-Smith et al., 2017). This medication sharing practice, combined with the inadvertent contamination of an anesthesiologist’s workspace may be facilitating these outbreaks. Purpose: We hypothesized that when caring for HCV-infected patients, anesthesiologists may inadvertently contaminate the medication vial diaphragm, and that subsequent access with sterile needles and syringes can transfer HCV into the medication where it remains stable in sufficient quantities to infect subsequent patients. Methods: We simulated contamination of multidose medication vials in healthcare settings using cell culture-derived HCV (HCVcc) to determine: 1) whether HCV can be transferred, via a sterile needle and syringe, into a medication vial if the rubber access diaphragm is contaminated; 2) whether HCV remains viable in commonly used medications in sufficient quantities over time to initiate an infection; and 3) whether cleaning the diaphragm with 70% isopropyl alcohol is sufficient to eliminate infectivity. Results: Contamination of medication vials with 33υL (mean volume of inadvertent contamination) of HCVcc (800,000 IU/mL - the concentration considered the border between low and high viral loads) and subsequent access with sterile needles and syringes resulted in contamination of the vial contents in sufficient quantities of HCV to initiate an infection in cell culture. Second, HCV remains viable for ≥72h in propofol, dexamethasone, rocuronium, lidocaine, neostigmine and phenylephrine. Third, a single wipe of the vial diaphragm with 70% isopropyl alcohol was not sufficient to eliminate HCV infectivity. Conclusions: HCV can be transferred, via sterile needle and syringe, into medication vials if the diaphragm is contaminated with medically relevant quantities of HCV and the virus remains stable in several commonly used medications. Furthermore, a single wipe of the vial diaphragm with 70% isopropyl alcohol is not sufficient to eliminate HCV infectivity. These results from our laboratory experiments, in light of known survey data suggesting that sharing medication vials with more than one patient is a common practice, highlight the importance of changing our daily practices concerning medication administration. We recommend investment in education and knowledge translation across medical specialties, division (or elimination) of multidose vials, and use of single-dose vials to minimize nosocomial HCV infections.

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