5 infected with hepatitis C after undergoing heart test at hospital

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5 infected with hepatitis C after undergoing heart test at hospital

12/26/2007

By KENZO MATSUMOTO THE ASAHI SHIMBUN

CHIGASAKI, Kanagawa Prefecture--A municipal hospital's practice of reusing a disposable device for monitoring blood pressure during cardiac catheter tests resulted in five people developing hepatitis C as a result of the checkup. In a news conference at city hall here Tuesday, officials of Chigasaki Municipal Hospital disclosed details of this scandalous situation and apologized. They were joined by Chigasaki Mayor Nobuaki Hattori who also apologized. The male patients in their 60s and 70s underwent the test at the hospital's cardiovascular internal medicine department between December 2006 and April. They apparently became infected because the blood monitoring transducer was used on multiple patients. The manual compiled by the instrument's manufacturer says it must be discarded after use, according to the hospital. But the in-house manual did not stipulate that a new transducer should be used for each test. A clinical engineering technician in charge of using the device cited a busy schedule for the tests for failing to adhere to the maker's manual, according to the hospital. The disposal transducer costs about 4,600 yen and is not covered by medical insurance. The hospital pays the cost. "We have taken all measures to cut off any route that may result in infection, such as making changes so that used and new instruments do not come in contact with each other and reviewing manuals," said Masashi Nakamura, who heads the cardiovascular internal medicine department. The hospital is calling on people who underwent cardiac catheter tests to be tested for hepatitis. Hospital officials suspect 18 others could have been infected. The five people in question developed acute hepatitis C and have been treated for their symptoms. Officials said their liver functions are improving. The hospital said it will cover the cost of any further treatment that may be necessary for the five. The infections surfaced after two patients were diagnosed with hepatitis at the hospital's gastroenterological internal medicine department in November. The hospital found that the two had undergone heart catheter tests on the same day. A hospital investigation revealed that a patient already infected with hepatitis C who underwent a heart catheter test last December passed on the virus to a patient taking the same test. In March this year, the hepatitis carrier infected another individual who underwent the catheter test. Then in April, three people were infected by the patient who contracted hepatitis as a result of the March test. Officials admitted that the hospital knew from the outset that the patient who became the source of infections was a hepatitis C patient. The officials said the transducer used in the cardiac catheter tests was the likely catalyst in spreading the infection. The instrument is used to monitor blood pressure during catheter exams because of possible bleeding. The device is linked to the catheter via tubing filled with normal saline solution. Therefore, the reuse of the transducer likely resulted in blood from the hepatitis C patient infecting others in succession. A total of 276 catheter tests were conducted at the hospital January through October this year. But only 170 transducers were used instead of a new one for each patient. Nakamura, the head of the cardiovascular department, said he was shocked when he learned of the situation. "As a doctor, I thought the disposable devices were being discarded each time they were used," he said.(IHT/Asahi: December 26,2007)

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