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Health Care–Associated Hepatitis C Virus Infections Attributed to Narcotic Diversion

Walter C. Hellinger, MD; Laura P. Bacalis, RN; Robyn S. Kay, MPH; Nicola D. Thompson, PhD, MS; Guo-Liang Xia, MD, MPH; Yulin Lin, MD; Yury E. Khudyakov, PhD; and Joseph F. Perz, DrPH
[+] Article, Author, and Disclosure Information

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2527.

Reproducible Research Statement:Study protocol and statistical code: Not available. Data set: Molecular data are available from Dr. Khudyakov (e-mail, mailto:yek0@cdc.gov).

Requests for Single Reprints: Walter C. Hellinger, MD, Mayo Clinic, Division of Infectious Diseases, 4500 San Pablo Road, Jacksonville, FL 32224; e-mail, mailto:helling@mayo.edu.

Current Author Addresses: Dr. Hellinger: Mayo Clinic, Division of Infectious Diseases, 4500 San Pablo Road, Jacksonville, FL 32224.

Ms. Bacalis: Mayo Clinic, Division of Hospital Operations–Infection Control, 4500 San Pablo Road, Jacksonville, FL 32224.

Ms. Kay: Florida Department of Health, Division of Disease Control, Bureau of Epidemiology, 1217 Pearl Street, Hardy Building, Room 215, Jacksonville, FL 32202.

Drs. Thompson and Perz: Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Prevention and Response Branch, 1600 Clifton Road, Mailstop A-31, Atlanta, GA 30333.

Drs. Xia, Lin, and Khudyakov: Centers for Disease Control and Prevention, Division of Viral Hepatitis, Laboratory Branch, 1600 Clifton Road, Atlanta, GA 30333.

Author Contributions: Conception and design: W.C. Hellinger, N.D. Thompson, J.F. Perz.

Analysis and interpretation of the data: W.C. Hellinger, L.P. Bacalis, R.S. Kay, N.D. Thompson, G.L. Xia, Y. Lin, Y.E. Khudyakov, J.F. Perz.

Drafting of the article: W.C. Hellinger, N.D. Thompson, G.L. Xia, J.F. Perz.

Critical revision of the article for important intellectual content: W.C. Hellinger, L.P. Bacalis, R.S. Kay, N.D. Thompson, Y.E. Khudyakov, J.F. Perz.

Final approval of the article: W.C. Hellinger, L.P. Bacalis, N.D. Thompson, Y.E. Khudyakov, J.F. Perz.

Statistical expertise: G.L. Xia.

Administrative, technical, or logistic support: W.C. Hellinger, N.D. Thompson, Y. Lin, Y.E. Khudyakov, J.F. Perz.

Collection and assembly of data: W.C. Hellinger, L.P. Bacalis, R.S. Kay, Y. Lin, Y.E. Khudyakov.

From Mayo Clinic, Jacksonville, Florida; Florida Department of Health, Tallahassee, Florida; and the Centers for Disease Control and Prevention, Atlanta, Georgia.

Ann Intern Med. 2012;156(7):477-482. doi:10.7326/0003-4819-156-7-201204030-00002
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Background: Three cases of genetically related hepatitis C virus (HCV) infection that were unattributable to infection control breaches were identified at a health care facility.

Objective: To investigate HCV transmission from an HCV-infected health care worker to patients through drug diversion.

Design: Cluster and look-back investigations.

Setting: Acute care hospital and affiliated multispecialty clinic.

Patients: Inpatients and outpatients during the period of HCV transmission.

Measurements: Employee work and narcotic dispensing records, blood testing for HCV antibody and RNA, and sequencing of the NS5B gene and the hypervariable region 1 of the E2 gene.

Results: 21 employees were recorded as being at work or as retrieving a narcotic from an automated dispensing cabinet in an area where a narcotic was administered to each of the 3 case patients; all employees provided blood samples for HCV testing. One employee was infected with HCV that had more than 95% NS5B sequence homology with the HCV strains of the 3 case patients. Quasi-species analysis showed close genetic relatedness with variants from each of the case patients and more than 97.9% nucleotide identity. The employee acknowledged parenteral opiate diversion. An investigation identified 6132 patients at risk for exposure to HCV because of the drug diversion. Of the 3929 living patients, 3444 (87.7%) were screened for infection. Two additional cases of genetically related HCV infection attributable to the employee were identified.

Limitation: Of the living patients at risk for HCV exposure, 12.3% were not tested.

Conclusion: Five cases of HCV infection occurring over 3 to 4 years were attributed to drug diversion by an HCV-infected health care worker. Studies of drug diversion and assessments of strategies to prevent narcotics tampering in all health care settings are needed.

Primary Funding Source: None.


Grahic Jump Location

Figure. Phylogenetic tree of 291 nucleotide sequences derived from the E1-HRV1 genomic region of hepatitis C virus intrahost variants obtained from 3 case patients, 1 licensed radiology technician, and 6 randomly selected NHANES III participants.

NHANES III = Third National Health and Nutrition Examination Survey.

Grahic Jump Location




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