title: Hepatitis C Virus Infections Associated with Unsafe Injection Practices at a Pain Management Clinic, Michigan, 2014-2015.
abstract: In 2015, the Michigan Department of Health and Human Services (MDHHS) was notified of an acute case of hepatitis C virus (HCV). The patient had no traditional HCV risk factors. The only known subcutaneous exposure was health care received at a pain management clinic.
  
  
  
  A field investigation was undertaken to determine the likely route of HCV acquisition and assess potential risk to other patients.
  
  
  
  The investigation involved a free-standing outpatient pain management clinic and its patients with a subcutaneous exposure.
  
  
  
  Investigators utilized the Centers for Disease Control and Prevention’s (CDC) viral hepatitis health care-associated infection investigation protocol to guide field investigation, assess risk to patients, perform patient notification, and test patients for blood-borne pathogens.
  
  
  
  The index case was found to be the final patient seen in the clinic’s operating room for the week. Examining the MDHHS viral hepatitis registry revealed another acute HCV patient seen immediately before the index case. The second acute case was preceded by a patient chronically infected with HCV. Due to the possibility of patient-to-patient HCV transmission, 122 patients were recommended to be tested for blood-borne pathogens. Ninety-two patients presented for testing. No additional transmission events were discovered.
  
  
  
  Health care-associated transmission of HCV likely occurred at an outpatient pain management clinic; possibly the result of multiple patient use of single-dose vials. Because no other cases were discovered this may represent an isolated incident as opposed to a systematic breakdown in infection control standards. This circumstance highlights the need for continued vigilance and adherence to CDC’s Minimum Expectations for Safe Care in Outpatient Settings.
authors.affiliation: Michigan Department of Health and Human Services, Communicable Disease Division, Bureau of Disease Control and Prevention, Lansing, Michigan, USA.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Coyle
authors.affiliation: Michigan Department of Health and Human Services, Communicable Disease Division, Bureau of Disease Control and Prevention, Lansing, Michigan, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: Goerge
authors.affiliation: Ingham County Health Department, Lansing, Michigan, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Kacynski
authors.affiliation: Ingham County Health Department, Lansing, Michigan, USA.
authors.forename: Ruby
authors.initials: R
authors.lastname: Rodgers
authors.affiliation: Ingham County Health Department, Lansing, Michigan, USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Raines
authors.affiliation: Ingham County Health Department, Lansing, Michigan, USA.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Vail
authors.affiliation: Ingham County Health Department, Lansing, Michigan, USA.
authors.forename: Sugandha
authors.initials: S
authors.lastname: Lowhim
mesh_terms: D000554:Ambulatory Care Facilities; D003428:Cross Infection; D005260:Female; D006526:Hepatitis C / Q000635:transmission*; D006801:Humans; D017053:Infection Control; D008824:Michigan; D059408:Pain Management / Q000379:methods; D018570:Risk Assessment
keywords: Hepatitis C Virus; Outbreak Investigation; Health Care-Associated Infection; Injection Safety; Standard Precautions