State of New Hampshire HEPATITIS C OUTBREAK INVESTIGATION EXETER HOSPITAL PUBLIC REPORT
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State of New Hampshire HEPATITIS C OUTBREAK INVESTIGATION EXETER HOSPITAL PUBLIC REPORT Prepared by New Hampshire Department of Health and Human Services Division of Public Health Services June 2013 Hepatitis C Outbreak Investigation Exeter Hospital Public Report Table of Contents Content Pages List of Appendices 3 Abbreviations Used 4 Contributors 5 Summary 6-7 Chapter 1: Introduction 8-12 Chapter 2: Notification of Potential Cluster to DPHS and Initial Steps 13-15 Chapter 3: CCL Investigation 16-38 Chapter 4: Investigation of Other Units at Exeter Hospital 39-43 Chapter 5: Expansion of Testing to ICU and OR Patients 44-49 Chapter 6: Multi-State Outbreak Investigation 50-51 Chapter 7: Laboratory Response 52-57 Chapter 8: Communications and Information Sharing 58-62 Chapter 9: Conclusions and Final Recommendations 63-69 References 70 List of Data Tables and Figures within the Report Table 1: HCV Outbreak Investigation CCL and RR Initial Patient Testing Summary, May 34 15, 2012–May 1, 2013 Table 2: HCV Outbreak Investigation OR and ICU Initial Patient Testing Summary, May 48-49 15, 2012–May 1, 2013 Figure 1: Monthly CCL/RR Procedures among Persons Testing Positive for HCV, October 35 2010–May 2012 Figure 2: Monthly CCL/RR Procedures among Confirmed and Probable Cases vs. Patients 37 with Unrelated HCV Infection, October 2010–May 2012 NH Department of Health and Human Services Division of Public Health Services June 2013 Page 2 Hepatitis C Outbreak Investigation Exeter Hospital Public Report List of Appendices Appendix 1: Case Questionnaire Appendix 2: CCL Employee Questionnaire Appendix 3: Incident Command System Organizational Chart Appendix 4: Superior Court Notice of Decision Appendix 5: Testing Algorithm Appendix 6: Analysis of CCL Staff (Unit and Medical) Attendance at CCL on Days with Confirmed or Probably HCV Transmission Appendix 7: Standard Case Definitions Appendix 8: Summary of Case Characteristics Appendix 9: Criminal Affidavit Appendix 10: OR/ICU Employee Questionnaire Appendix 11: OSC/ENDO Employee Questionnaire Appendix 12: Patient Letter Appendix 13: Phase II Map Appendix 14: Clinics Testing Algorithm Appendix 15: Clinic Evaluation Summary Appendix 16: Phylogenetic Tree Appendix 17: Risk Notification Template Appendix 18: HCV Outbreak Investigation Summary of Initial Testing NH Department of Health and Human Services Division of Public Health Services June 2013 Page 3 Hepatitis C Outbreak Investigation Exeter Hospital Public Report Abbreviations Used in This Document AZ Arizona ICU Intensive Care Unit CCL Cardiac Catheterization Lab ID Infectious Disease CDC U.S. Centers for Disease Control and IR Interventional Radiology Prevention CEO Chief Executive Officer IRMS Integrated Resource Management System CLIA Clinical Laboratory Improvement IV Intravenous Amendments CMC Catholic Medical Center KS Kansas CMS Centers for Medicare and Medicaid KS DHE Kansas Department of Health and Environment Services DHHS New Hampshire Department of Health LIMS Laboratory Information Management System and Human Services DMV Department of Motor Vehicle LRN Laboratory Response Network DNA Deoxyribonucleic Acid MD Maryland DPHS NH Division of Public Health Services MI Michigan ED Emergency Department MMRS Metropolitan Medical Response System EH Exeter Hospital NH New Hampshire EIA Enzyme Immunoassay NS5B Non-Structural 5B ESU Emergency Services Unit NY New York EU Endoscopy Unit OR Operating Room FAQ Frequently Asked Questions OSC Outpatient Surgical Center FDA U.S. Food and Drug Administration PA Pennsylvania FTP File Transfer Protocol PCP Primary Care Provider GA Georgia PCU Progressive Care Unit GI Gastrointestinal PHL NH Public Health Laboratories HAN Health Alert Network PHR Public Health Region HBV Hepatitis B Virus PIO Public Information Office HCV Hepatitis C Virus POD Point of Dispensing HCW Healthcare Worker QS Quasispecies Analysis Analysis HeP NH Code of Administrative Rules RNA Ribonucleic Acid (Public Health) HIPAA Health Insurance Portability and RR Recovery Room Accountability Act HIV Human Immunodeficiency Virus RSA Revised Statutes Annotated HVR1 Hyper Variable Region 1 RT-PCR Reverse Transcriptase-Polymerase Chain Reaction ICD Implantable Cardioverter-Defibrillator SST Serum Separator Tube ICS Incident Command Structure U.S. United States NH Department of Health and Human Services Division of Public Health Services June 2013 Page 4 Hepatitis C Outbreak Investigation Exeter Hospital Public Report Contributors The Division of Public Health Services wishes to acknowledge the following entities who assisted in the response: Centers for Disease Control and Prevention (CDC) Division of Viral Hepatitis – Surveillance and Epidemiology Branch and Viral Hepatitis Laboratory Branch Division of Healthcare Quality Promotion Seacoast Public Health Network Greater Derry Public Health Network Greater Manchester Public Health Network Strafford County Public Health Network Department of Health and Human Services Emergency Services Unit Manchester Health Department Nashua Health Department Leadership Preventive Medicine Residency (LPMR), Dartmouth-Hitchcock Medical Center For questions about this report, please contact: Bureau of Infectious Disease Control Division of Public Health Services NH Department of Health and Human Services 29 Hazen Drive, Concord, NH 03301-6504 Phone: (603) 271-4496 NH Department of Health and Human Services Division of Public Health Services June 2013 Page 5 Hepatitis C Outbreak Investigation Exeter Hospital Public Report Summary This report summarizes the events of a large outbreak of hepatitis C at Exeter Hospital in Exeter, New Hampshire in 2012. The New Hampshire Department of Health and Human Services, Division of Public Health Services (DPHS) was first notified on May 15, 2012 by Exeter Hospital (EH) of four patients with newly diagnosed hepatitis C virus (HCV). The initial investigation revealed that one of these recently diagnosed patients was also a healthcare worker (HCW), a technician in the Cardiac Catheterization Lab (CCL), at EH. On May 25, 2012, laboratory testing conducted at the New Hampshire Public Health Laboratories (PHL) confirmed that all four patients shared a genetically similar virus, indicating a common source of infection and confirming an HCV outbreak. DPHS initiated an investigation to determine the cause of the outbreak and impede further HCV transmission as well as to identify those who had been infected and connect them with appropriate care. The DPHS investigation determined, based on extensive evidence detailed in this report, that the cause of the outbreak was drug diversion (the stealing of narcotic pain medication intended for patients for self use) by the infected HCW. A criminal investigation was also commenced. In July 2012, the infected HCW was charged by federal law enforcement authorities and, at the time of the writing of this report, is awaiting trial. Testing of potentially exposed patients was conducted in two phases: Phase 1–CCL patient testing: DPHS recommended the testing of more than 1,200 patients who had procedures in the CCL at EH from October 1, 2010–May 25, 2012. Of the 1,074 who were tested, 32 patients were identified with active HCV infection with the NH HCV outbreak strain. 27 additional patients had evidence of past HCV infection (and their virus could not be tested) and 9 of them were categorized as probable cases (n=4) and suspect cases (n=5) based on epidemiological information. Phase 2–Operating Room and the Intensive Care Unit patient testing: After receiving information that the infected HCW had access to the Operating Room (OR) and the Intensive Care Unit (ICU), DPHS recommended the testing of patients who received care in those units at the time of his employment (April 2011–May 2012). More than 3,500 patients were indicated for testing. DPHS and local partners organized public clinics in August 2012 to assist with phase 2 testing and utilized, for the first time in an outbreak setting, rapid HCV testing on site. In phase 2, 2,679 patients were tested and, as of the writing of this final report in May 2013, no additional cases of active HCV infection matching the outbreak strain were identified. Additional investigation of other units in EH did not reveal sufficient evidence to suggest risk from the infected HCW. Since the infected HCW used to work as a traveling technician and was assigned to multiple hospitals in several states, the information about his activities was shared with the relevant states, which initiated independent investigations. The multi-state investigation was coordinated and led by the Centers for Disease Control and Prevention (CDC). As of May 2013, 13 other cases of the NH HCV outbreak strain were identified and confirmed in two other states (Kansas and Maryland). The outbreak investigation revealed multiple areas of concern regarding access, handling, and oversight of narcotics at Exeter Hospital and lack of appropriate follow up on concerns that were raised regarding the infected HCW at the time of his employment. Several public health recommendations are outlined as a result of this investigation in order to help reduce the likelihood of outbreaks of a similar nature occurring in the future. Given the access to narcotics in facilities and the increasing rates of prescription drug abuse in the U.S., healthcare facilities NH Department of Health and Human Services Division of Public Health Services June 2013 Page 6 Hepatitis C Outbreak Investigation Exeter Hospital Public Report should monitor for drug diversion