Cluster of Hepatitis C Infections among Three Patients Seen by Same Anesthesiologist in New York

I've had at least two patients so far who've received a warning letter. Potentially thousands may need to be tested.

Please Distribute to All Clinical Staff in Anesthesia, Emergency Medicine, Primary Care, Infectious Diseases, Family Medicine, Laboratory Medicine, Gastroenterology, Surgery and Infection Control Staff

* DOHMH is investigating a cluster of hepatitis C infections in patients who had outpatient intravenous anesthesia from a particular anesthesiologist.
* DOHMH is notifying patients who received intravenous anesthesia from this provider that they should be tested for hepatitis B and C and HIV.
* Providers should use single dose vials for anesthesia when available. When multi-dose vials are necessary, extreme caution should be used to ensure that a new, sterile syringe and needle are used each time medications are drawn up.

June 15, 2007

Dear Colleagues,

The New York City Department of Health and Mental Hygiene (DOHMH) is investigating a cluster of three hepatitis C infections in patients who received intravenous anesthesia from a particular anesthesiologist during outpatient procedures performed in August 2006 in New York City. Initial laboratory testing of the hepatitis C viruses from these patients revealed that they closely match each other, suggesting that all three came from the same source.

Although the investigation is ongoing, the available evidence suggests that the infections occurred during the administration of anesthesia medications during outpatient medical procedures. There is no indication that the medical procedures themselves caused the infections. The anesthesiologist worked at approximately 10 different outpatient (non-hospital) practices, all of which are fully cooperating with the DOHMH. This anesthesiologist has stopped working during the investigation.

The DOHMH has not yet determined whether there were any other times when hepatitis transmission occurred during administration of anesthesia by this physician. Therefore, we are notifying all patients who received intravenous anesthesia from this anesthesiologist between December 1, 2003 and May 1, 2007 (the timeframe when the anesthesiologist practiced in New York City), and recommending that they be tested for hepatitis B and C, and HIV. We are recommending HIV testing as a precaution, since it is also transmitted by bloodborne exposure. However, spread of HIV through anesthesia is not common, and no HIV infections have been linked to this incident.

All patients who received anesthesia from this provider are being notified by mail by the DOHMH; the mailing includes a letter to bring to their provider. Patients who do not receive this letter do not need testing for this indication. Patients known to have been previously infected with either hepatitis B, hepatitis C, or HIV prior to receiving anesthesia from this physician, do not need testing for that specific virus; testing for the other viruses should still be done.

We are recommending the following tests for these patients:
For hepatitis B: Hepatitis B surface antigen (HbsAg), Hepatitis B surface antibody (HbsAb), and Hepatitis B core antibody Total (HbcAb).

For hepatitis C: Hepatitis C enzyme-linked immunosorbent assay (EIA) and if positive, a confirmatory test, such as HCV recombinant immunoblot assay (RIBA) or a polymerase chain reaction (PCR) should be done.

HIV: HIV EIA and if positive, a confirmatory Western Blot should be done.

Hepatitis B and C are reportable pursuant to the New York City Health Code §11.03 and New York State Sanitary Code §2.1. Because this is an ongoing investigation, we are requesting immediate reporting of results to the DOHMH so that we can determine if there were other instances where bloodborne disease transmission occurred during the administration of anesthesia by this anesthesiologist. Please report as follows:

Hepatitis B or C: Results should be reported to the Bureau of Communicable Diseases at 212-788-9830 (telephone) during normal business hours. When reporting, please mention that your patient was tested as part of this anesthesiology outbreak investigation. You can also fax the results to the attention of Dr. Bruce Gutelius at 212-788-4268.

HIV Infection: Positive tests for HIV infection or AIDS should be reported by completing a New York State Provider Report Form. For assistance in reporting a case of HIV, to receive Provider Report Forms, or to obtain more information, call the HIV Surveillance and Epidemiology Program at 212-442-3388 or refer to guidelines on the DOHMH website at: www.nyc.gov/html/doh/html/pub/pub.html.

This cluster appears to be related to a lapse in infection control technique during administration of intravenous anesthesia. This is similar to other outbreaks seen in NYC and elsewhere (Transmission of hepatitis B and C virus in outpatient settings. MMWR 2003;52(38):901-6). As a reminder, single-dose medication vials should always be used when possible to prevent such clusters. If no single dose preparation is available, all necessary medication should be drawn up in advance and labeled. Needles AND syringes should NEVER be reintroduced into a medication vial, even if they have only been in contact with the IV tubing (e.g., angiocatheter or heparin lock) in the patient. If you have any questions about this investigation or how to report, please call the Bureau of Communicable Disease during office hours at 212-788-9830. Thank you.

Sincerely,

Marcelle Layton, MD,
Assistant Commissioner,
Bureau of Communicable Disease