Drug-Diverting Nurse Blamed for Washington HCV Outbreak

Diana Swift

April 25, 2019

In 2018, an outbreak of acute hepatitis C virus (HCV) infection occurred among patients who had been treated in the emergency department (ED) of a hospital in Washington state.

According to an investigation published online today in Morbidity and Mortality Weekly Report, the likely cause was traced to unsafe injections during "drug diversion" by a nurse who treated 13 patients, all of whom were infected with HCV genotype 1a.

Drug diversion refers to the shift of a prescribed drug from the intended recipient to another person for illicit personal use. All US healthcare facilities are required to prevent, identify, and report any loss, diversion, or theft of controlled substances.

The Washington outbreak came to the attention of local health authorities when routine surveillance identified two cases of acute HCV infection during a 2-month window, from January 22 to March 23, 2018. Neither patient had behavioral risk factors normally associated with new HCV infections.

Following further testing, investigators identified 10 additional cases of acute HCV infection among patients treated in the ED.

After examining the hospital's drug-dispensing log, epidemiological disease detectives identified two nurses who had accessed the automated drug-dispensing system much more frequently than normal (> 3 standard deviations above the staff mean). The nurses had been responsible for administering injectables such as narcotics, sedatives, and antihistamines to ED patients.

One of the nurses, who worked in the ED from August 2017 to March 2018, drew more scrutiny when it was found that she seroconverted to anti-HCV positive after previously testing negative. She also tested positive for HCV RNA, indicating recent infection. Moreover, she was the only common link to 13 patients, who all had genetically similar HCV, and she had administered injectable narcotic, sedative, or antihistamine drugs to each of them.

In contrast, patients with HCV not under this nurse's care carried strains that were genetically removed from one another and from the HCV genotype 1a subtype the group of 13 patients had been infected with.

Twelve patients with new-onset HCV and one with chronic HCV had received injections from this nurse, who may initially have acquired the virus from the chronic patient during a visit in November 2017. Ultimately, the nurse admitted to diverting patients' narcotics and antihistamines for her own use. Her license was subsequently suspended by the Washington State Nursing Commission.

This episode highlights gaps in carrying out recommended security measures for drug storage and monitoring. "Healthcare facilities and public health partners should recognize the potential for infections and other harms from drug diversion and minimize risks by storing controlled substances securely and routinely scrutinizing drug access logs," write Henry N. Njuguna, MD, Epidemic Intelligence Service, Centers for Disease Control and Prevention, and Washington State Department of Health, and colleagues.

"Protocols to respond to identified drug diversion should address testing of patients at risk for contracting illness and measures to prevent further transmission."

The authors have reported no relevant financial relationships.

MMWR. 2019;68:374-376. Full text

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