Drug Diversion Associated Hepatitis C Investigation and Response, Utah 2015

BACKGROUND: In July 2015 the Utah Department of Health (UDOH) initiated an acute hepatitis C virus (HCV) investigation on a frequent blood donor (‘index case’) with documented negative HCV tests who recently seroconverted. No behavioral risk factors were identified. Two interactions with the healthcare system (a dental visit and a hospital emergency room [ER] visit) were identified that may have resulted in HCV exposure.   

METHODS: UDOH and local health departments (LHD) investigated healthcare system interactions to determine the most likely source of HCV exposure. Site visits were conducted and the index case’s medical records were reviewed to identify high risk procedures. A search for corrective actions on healthcare providers’ licenses was also conducted. Once the facility where exposure likely occurred was established, UDOH enacted its incident command system (ICS) to carry out the investigation’s next steps to identify other persons who may have also been exposed to HCV.   

RESULTS: Neither the dental office nor the ER site visits identified lapses in infection prevention and control practices. At the dental office, the index case had a routine cleaning and no high risk procedures were performed. Review of dental office healthcare provider licenses revealed no corrective actions. At the ER, the index case received intravenous pain medication. Review of ER healthcare provider licenses revealed a nurse, who had provided care to the index case, had been dismissed due to drug diversion activities. The nurse tested positive for HCV. The nurse and the index case both had HCV genotype 2b with viral sequencing results showing 100% match between the viruses. The nurse also had evidence of diversion behavior at a second hospital per licensing records. The UDOH and LHDs worked with the facilities to contact all individuals who may have been exposed to HCV via the nurse. Patient notification letters were sent to 7217 potentially exposed patients, who were offered free HCV testing. As of January 4, 2015, 2590 (35.9%) patients had been tested; 31 (1.2%) were identified with current HCV infection. Fourteen currently infected patients had HCV genotype 2b. Results of viral sequencing are pending. 

CONCLUSIONS: The ICS structure provided a forum for clear communication and rapid decision making throughout the investigation. The index case was identified due to negative testing history. UDOH is now regularly collecting HCV negative results electronically to readily identify acute HCV cases, and thus potential outbreaks.