Guidelines Target Viral Hepatitis in the Hospital

A global public awareness campaign from the World Health Organization poses what appears as a simple question: “Am I number 12?” it asks.

The straightforwardness of the question underscores the shocking statistic to which it refers—namely, the disarming global prevalence of chronic hepatitis B and C. Taken together, these liver-scourging viruses are estimated to affect every one in 12 persons worldwide. For a strain of illness that can lead to severe liver damage, from scarring and liver cancer to complete liver failure and death, general awareness is astoundingly low. Part of the reason is attributed to the “silent” nature of these diseases, as an infected person can live virtually symptom-free for many years before a chance blood test or a routine exam reveals the truth. By then, however, the contagion will have had the chance to spread to others. According to the WHO, approximately 1 million people die of these two diseases every year.

While hepatitis B and C are transferred primarily through sexual contact and injections, respectively, one of the most significant threats to the health of countless
patients and health care practitioners occurs in the very place one would expect to be safe: the hospital. Over the past 10 years, more than 35 outbreaks of viral hepatitis have occurred within hospitals due to unsafe injection practices that range from syringe re-use to contamination of medical vials or intravenous bags.

In response to continued outbreaks, the Association for Professionals in Infection Control and Epidemiology in late July released the position paper Safe Injection, Infusion and Medication Vial Practices in Healthcare, which outlines seven key areas where intervention can stop the spread of illness and save lives. The paper provides action steps on the following areas: aseptic technique, IV solutions, flushing, syringes, vials, blood glucose monitoring devices, and health care workers. 

“We’ve been more concerned every year with the outbreaks going on around the country. It’s been very difficult to identify sources,” says APIC’s immediate past president Christine Nutty, RN, MSN, CIC. “Sometimes it’s simply a matter of health care practitioners not realizing an action may be harmful. For instance, they may not realize a virus can go into IV tubing and collect in a port and contaminate the next person. So this [position paper] gives them a lot more support.”

Hepatitis Hits Home

In 1991, during a code at the hospital where she was working as a nurse, Robin Boltz was stuck with a discarded needle. Among others, her floor contained HIV patients, but no one was sure whose needle it had been. Boltz was tested immediately for HIV and the results came back negative. But two years later the health care veteran and former case manager received a letter from the Red Cross after she had donated blood—saying she had hepatitis C. At the time, hepatitis C was not considered a serious disease. Her doctor assured her that there was nothing to worry about, that she could live a full life despite the disease. She never even filed a workers’ compensation claim. “At the time hepatitis C wasn’t even on the radar,” she says.

Fast forward 15 years and the situation has changed dramatically. As the complications of hepatitis C became better known, so too did a cluster of treatments that have proven effective in a majority of patients. After tests revealed liver scarring and the onset of symptoms like vascular pain and numbness in her legs, Boltz decided to undergo treatment. It is generally a grueling treatment plan, and for Boltz it consisted of a 48-week schedule of interferon injections and ribavirin pills, which resulted in side effects, such as anemia and a shortness of breath, similar to those seen with chemotherapy treatment. Two years removed from the end of her treatment regimen, Boltz, now 51, is virus-free. She is also an embodiment of a sea change surrounding the disease, as the physical threats of the virus became more appreciated. But not, first, without some missteps.

“The first advice I got was that you will live with it and die of something else,” she says of her initial consultations with medical professionals regarding hepatitis C. “But while we had that attitude, it spread all over the world.”

Closing In on Safe Care

An inflammatory liver disease that results in direct liver cell damage, hepatitis B is thought to affect one in 20 Americans. Spread primarily through sexual contact, roughly 5 percent of those affected bear a chronic infection. Unlike hepatitis C, a vaccine exists. A far greater percentage of those who carry hepatitis C are chronically infected, yet because of its silent nature it can take anywhere from 10 to 40 years to cause serious liver damage. Hepatitis C is spread primarily through the transfer of blood, thus the reason why users of injection drugs, or syringes, are at greatest risk.

Unsafe practices sit at the heart of the APIC paper, which categorizes the risk of outbreak into four groups:
a) Syringe reuse between patients during parenteral medication administration to multiple patients.
b) Contamination of medication vials or intravenous (IV) bags by accessing them with a used syringe and/or needle.
c) Failure to follow basic injection safety practices when preparing and administering parenteral medications to multiple patients.
d) Inappropriate use of fingerstick devices and glucometer equipment between patients.

As a way to shield against preventable transmission, the paper spells out practical steps to making facilities and their practices safer. Each of the seven areas of focus includes a sort of how-to guide that organizations can adopt. Under the topic of syringes, for example, comes a series of best practice guidelines: “Remove sterile needle/cannula and/or syringe from package just prior to use” and “Never use medication in a syringe for more than one patient even if the needle is changed between patients. Changing the needle but not the syringe is unacceptable.”

While there may be a minimal cost increase to facilities for additional supplies, the overall cost of not enforcing strict guideline implementation may be stratospherically larger, bearing in mind that a liver transplant can cost upward of a quarter million dollars and drugs can easily reach into the thousands of dollars. And that fails to account for the cost of human suffering, says Nutty.

“It is very difficult to measure how devastating an outbreak can be when it’s identified,” she says. “I don’t think it’s a matter of money, it’s a matter of the right thing to do. There’s no choice about it.”

Online Exclusive: Read Robin Boltz’s comprehensive assessment of bloodborne pathogens at dorlandhealth.com.