Causes and Effects of Hepatitis Outbreak in Oklahoma's Pain Remediation Clinic

During August 2002 in Oklahoma, USA in a pain remediation clinic, the Oklahoma State Department of Health (OSDH) received a report of six patients who tested positive for acute hepatitis C virus (HCV). Immediately after this incident was reported the OSDH conducted a study on the clinic patients, serologic survey, interviews, review of medical records, and staff infection control practices (Comstock, 2004). The occurrences founded in the clinic patients were either HCV or HBV (hepatitis B) which both can be contracted from the reuse of needles.

Following, a conclusion was made after the study and it was established the mechanism for patient transmission of HCV and HBV in this large hospital-acquired outbreak was the reuse of needles-syringes. Due to these findings, the OSDH had closed the clinic and continued for further investigation. Moreover, it was established that a total of 798 patients out of 908 were tested positive (87.6%); 71 hepatitis C infected patients (8.9%) and 31 hepatitis B infected patients (3.9%).

During the investigation, the OSDH examined and found out During medical sessions, a licensed registered nurse anesthetist (CRNA) regularly reused needles and syringes (Comstock, 2004). A single needle and syringe were used to treat up to 24 sequentially treated patients at each session with each of the 3 sedation medications (Center for Disease Control and Prevention, 2019). Treatment after a patient who was positive for anti-HCV during a medical session was a statistically significant risk factor for contracting the disease HCV infection (RR = 9.2; 95% CI = 3.7 – 22.5), the same was true for the treatment of patients with hepatitis B surface antigen-positive (RR = 8.5; 95% CI = 4.2--17.0). the final inference made after the initial complaint was filed was that the CRNA must cease the reuse of needles and the transmission of HCV and HBV had stopped and showed no evidence of reoccurrence.

Causative organism

The causative organism for the outbreak that occurred in that clinic largely was hepatitis C a member of the Hepaciviral C species of the family Flaviviridae (Stiles, 2008). Often known as HCV, it is a blood-borne virus with a positive RNA strand, a lipid envelope, and a nucleocapsid. The lipid envelope is a lipoprotein that allows the virus to penetrate the host cell by binding receptors to the cell membrane. Replication happens inside the host cell. Once inside the cytoplasm of the host cell, the infection loses its container to decipher a reciprocal negative-strand RNA. Hepatitis C is caused by exposure to small quantities of blood from the sharing of needles or other equipment that are from injecting into the body, this virus can cause major liver complications.

HCV displays short- and long-term problems, for a few people the disease is short term, and for the majority, it will become a long-term problem due to the fact that patients are not aware of the disease since it does not show clinically ill signs (Stiles, 2008).

HCV is divided into 2 forms based on how long the patient has had the condition; acute (less than 6 months) and chronic hepatitis C (more than 6 months), the symptoms can range from a mild illness that will last a few weeks to serious lifelong illness (ANON, 2019). In some cases, people can acquire acute hepatitis C and it will not lead to a life-threatening disease; 30% of infected persons spontaneously clear the virus within 6 months while the remaining 70% contract chronic hepatitis C. the incubation period ranges from 2 weeks to 6 months and from initial infection symptoms are not shown in 80% of people (ANON, 2019). But symptoms of hepatitis C may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, grey coloured feces, etc.

Although currently there is no vaccine for the disease, it can still be cured with proper treatment. Treatment consists first of correct diagnosis due to HCV being asymptomatic (showing no symptoms) so it can be undiagnosed till it is too late, the disease can be undetected for years and develop into chronic HCV infection (ANON, 2019). It can stay undiagnosed for decades until secondary to serious liver damage forms. There are 2 steps for diagnosis; first is testing for anti-HCV antibodies with a serological test to identify the infected people, then if the test is positive for the antibody, further tests are done to determine if the disease is still acute or progressed to chronic. Step two is done by a ribonucleic acid test checking for the HCV ribonucleic acid as confirmation. Once a diagnosis is made the liver should be assessed looking at fibrosis and cirrhosis, this is done by a liver by a biopsy or non-invasive techniques and once liver damage level is the standard for treatment and management.

Treatment of newly infected cases does not always require treatment because the immune response in some patients can clear the infection, but ongoing treatment for HCV is required when the infection occurs. Recommended treatment includes therapy with direct-acting antivirals (DAA’s), this treatment plan has a high success rate and can cure most people, the treatment duration is from 12-24 weeks depending on if there is cirrhosis present. DAA used to be an expensive treatment option but now due to the formation of more generic versions the prices have dropped. Getting tested and treatment is an imperative part in reducing the risk of acquiring and transmitting the disease and those that are risk of infection absolutely should get tested; like people who inject drugs, people in prison, facilities with inadequate infection control practices, users of intranasal drugs, people who have had tattoos or piercings, etc.

Impact on the public health

When an outbreak arises, it is the public health’s responsibility to take measures and bring the outbreak under control. That is why, following the occurrence and completion of the purpose, the State Nursing Board revoked the CRNA license and imposed a fine of $99'000 (Center for Disease Control and Prevention, 2019). The CRNA investigations was resource-intensive, including alerts, screening, treatment for hundreds of patients, and the Center for Disease Control and Prevention (CDC) collaborated with professional organizations, advisory committees, and the state and local health department to discuss the training of health care workers, the supervision of the administrative surveillance system, and the writing of the surveillance process, And writing strategies and techniques to predict patient-to-patient transmission. Likewise, in light of this flare-up, the American association of nurse anesthetists (AANA) sent mailings to all AANA individuals and understudies, nurture anesthesia school program chiefs, and emergency clinic executives Recall that needles and syringes are things of single-use and ought not to be reused (Balter, 2003).

Finally, general prevention is in place to reduce risks of Hepatitis C outbreaks, there is primary and secondary prevention. Primary prevention includes reducing the risk of infection and medical procedures, including safe and appropriate use of health care treatments, safe handling, and disposal of sharps and waste, blood donation screening for HBV and HCV, prevention of exposure to blood during pregnancy, and so on. (ANON, 2019). Secondary prevention is targeted at people who are infected, including hepatitis A and B vaccines so that coinfection from these viruses does not cause liver damage, early antiviral therapy, and regular monitoring of chronic liver disease. Moreover, all the links of the chain of transmission for this outbreak can be broken simply is done by proper use of needles and to dispose of the needles after use and absolutely no re-use of the needles/syringes.

Reflection and analysis

After, research and analysis of the Hepatitis C outbreak in a pain clinic I believe that the outbreak was handled and prevented in an appropriate approach. Initially, this outbreak cannot just be blamed on the clinic itself but mainly on the anesthetist nurse. Looking more into the nurse it has to be recognized he was licensed and had gone through proper training and education to be able to be qualified to acquire the job, but he still reused needles and didn’t comprehend what he was doing was immoral. This shows how easy it is to go wrong and contract a virus with just simple oversight with the procedure of infection prevention control.

In summary, the health department handled the outbreak by closing the clinic, suspending the clinic’s license while investigating, revoking the nurse’s license and fining him for malpractice. Doing this permits the complete stop of transmission of the virus within the clinic, while the health department can deal with infected patients’ proper treatment and minimization of the outbreak. A very efficient and effective prevention method done after this outbreak was the AANA sending all forms of associated nurses a mailing report reminding them of proper uses of needles and syringes.

This is a respectable prevention method because it acts as a reminder to the medical community the importance of following prevention procedures and sets this outbreak as an example of all the lives that can be affected due to lack of information and understanding.