Syringe Reuse and Patient Notification Following an Influenza Clinic--New Jersey 2015

BACKGROUND:  On September 30, 2015, the New Jersey Department of Health (NJDOH) was notified by an out-of-state health services company (HSC) that an experienced nurse had reused syringes for multiple persons earlier that day. The syringe reuse occurred at an employee influenza vaccination clinic at a New Jersey (NJ) business, which had contracted the company to provide the influenza clinic. Syringe reuse is a serious breach of injection safety practices.  NJDOH initiated a public health investigation.

METHODS:  NJDOH promptly interviewed the nurse to characterize the breach and assess risk.  NJDOH collaborated with the local health department (LHD), the Centers for Disease Control and Prevention (CDC), the HSC, the business, and the NJ Board of Nursing (BON) to organize a public health response. 

RESULTS:  Interview with the nurse revealed that influenza vaccines for several events were shipped to the nurse’s home and stored in her home refrigerator. Employees were to receive vaccine from manufacturer-prefilled single-dose syringes; however, the nurse brought three multiple-dose vials of vaccine that were intended for another event. She used two syringes to administer vaccine to 67 employees; a new needle was used for each employee. Additionally, the nurse used only two multiple-dose vials of vaccine (10 doses/vial) to administer vaccine to 67 adults; thus administering less than the recommended dose. In consultation with CDC, NJDOH recommended testing for hepatitis B, hepatitis C, and human immunodeficiency viruses; administering hepatitis B vaccine as postexposure prophylaxis (PEP); and revaccinating with influenza vaccine.  The LHD obtained email addresses for the employees; NJDOH created a dedicated email address and notified employees on October 2.  The LHD partnered with an urgent care center to administer the vaccines and perform testing on October 5 and 6. Forty-seven (47) of 67 employees attended these clinics; an unknown number consulted their private providers. The BON initiated an investigation; the nurse voluntarily surrendered her license.  Follow-up clinics were arranged at 1 month and at 4 months for hepatitis B vaccination and bloodborne pathogens testing.

CONCLUSIONS:  Established relationships among key stakeholders are critical to ensure a coordinated response when responding to reported breaches.  This event was unique in that the breach was reported on the day it occurred; thus timely administration of PEP was critical. Email notification and communication facilitated a timely response.  This investigation also raised concerns of vaccine handling, storage, and administration. Companies providing vaccination services and the businesses hiring them must ensure strict adherence to CDC guidelines.