TABLE 1.

Pateint Notification Events for Bloodborne Pathogen Testing due to Unsafe Injection Practices—United States, January 2001–December 2011

State^*	Year Notified^†	Health Care Setting	No. Persons Notified^‡, n	Unsafe Injection Practices^§	Medication(s) Involved	Notified by Whom	References
Evidence of bloodborne pathogen transmission at the time notification was initiated^∥
Patient-to-patient transmission
New York	2001	Endoscopy clinic	2009	Suspected syringe reuse contaminating medication vials	Unspecified anesthesia medications	Health department	Centers for Disease Control and Prevention,⁷ New York City Department of Health and Mental Hygiene, unpublished data
New York	2002	Physician office	1042	Mishandling of medication vials and injection equipment, medication preparation in contaminated environment	Atropine, dexamethasone, and vitamin B₁₂	Health department	Centers for Disease Control and Prevention,⁷ Samandari et al¹¹
Oklahoma	2002	Pain management clinic affiliated with a hospital	908	Overt syringe reuse from one patient to another	Midazolam, fentanyl, and propofol	Affiliated hospital	Centers for Disease Control and Prevention,⁷ Comstock et al¹²
Nebraska	2002	Hematology/oncology clinic	613	Syringe reuse contaminating saline bags	Saline flush	Health department	Centers for Disease Control and Prevention,⁷ Macedo de Oliveria et al¹³
New York	2003	Endoscopy clinic	1199	Suspected needle or syringe reuse contaminating medication vials	Unspecified anesthesia medications	Health department	Marx et al,¹⁴ New York City Department of Health and Mental Hygiene, unpublished data
California	2003	Pain management clinic	52	Suspected syringe reuse contaminating medication vials	Lidocaine	Health department	San Diego County Department of Health and Human Services, unpublished data
Florida	2005	Alternative medicine clinic	253	Mishandling of medication vials, failure to prepare and store intravenous infusions under aseptic conditions	Unspecified chelating agent	Health department	Sanderson et al¹⁵
New York	2007^¶	Pain management clinic, physician office (orthopedic)	9000	Syringe reuse contaminating medication vials	Bupivacaine, ketorolac, triamcinolone, iohexol (contrast)	Health department	New York State Department of Health, unpublished data
New York	2007	Multiple endoscopy and ambulatory surgical centers	4490	Suspected syringe reuse contaminating medication vials	Propofol	Health department	Gutelius et al¹⁶
New York	2008	Endoscopy clinic	259	Suspected mishandling of single-dose vials for multiple patients	Propofol	Health department	New York City Department of Health and Mental Hygiene, unpublished data
Nevada	2008	Ambulatory surgical centers (single-purpose endoscopy clinics)	63,000	Syringe reuse contaminating medication vials	Propofol	Health department	Fischer et al,¹⁷ Centers for Disease Control and Prevention,¹⁸ Southern Nevada Health District¹⁹
North Carolina	2008	Cardiology clinic	1205	Syringe reuse contaminating medication vials	Saline flush	Health department	Moore et al²⁰
New Jersey	2009	Hematology/oncology clinic	4600	Mishandling of medication vials, medication preparation in contaminated environment, common-use saline bag for multiple patients	Saline flush, possibly unspecified chemotherapy agents	Health department	Greeley et al²¹
Florida	2009	Alternative medicine clinic	163	Syringe reuse contaminating medication vials, mishandling of medication preparation	Various infusion therapies, including EDTA and vitamin C	Clinic, health department	Florida Department of Health, unpublished data
New York	2009	Endoscopy clinic	3287	Suspected syringe reuse contaminating medication vials	Propofol	Health department	New York City Department of Health and Mental Hygiene, unpublished data
New Jersey	2010	Hospital	80	Suspected mishandling of single-dose vials for multiple patients	Propofol	Hospital	New Jersey Department of Health and Senior Services, unpublished data
New Jersey	2010	Long-term care facility	182	Suspected mishandling of insulin pens for multiple patients, mishandling of medication preparation	Insulin, other unspecified medications	Long-term care facility, health department	New Jersey Department of Health and Senior Services, unpublished data
California	2011	Pain management clinic	2293	Syringe reuse contaminating medication vials, mishandling of medication preparation	Lidocaine, iohexol (contrast), sodium bicarbonate	Health department	Los Angeles County Department of Public Health²²
New York	2011	Pain management clinic	466	Suspected syringe reuse contaminating medication vials	Propofol, midazolam, lidocaine	Health department	New York City Department of Health and Mental Hygiene, unpublished data
Provider-to-patient transmission
Texas, Virginia, District of Columbia	2004	Hospitals	543	Contamination of vials/syringes, narcotics diversion by provider	Fentanyl	Hospitals	Nahill,²³ CDC, unpublished data
Colorado, New York	2009	Hospitals, ambulatory surgical center	8690	Syringe reuse, narcotics diversion by provider	Fentanyl	Hospitals and ambulatory surgical center	Denver Channel,²⁴ Colorado Department of Public Health and Environment²⁵
Florida	2010	Multispecialty clinic affiliated with a hospital	3929	Syringe reuse, narcotics diversion by provider	Fentanyl	Hospital	Hellinger et al²⁶
Absence of known bloodborne pathogen transmission at the time notification was initiated
Rhode Island	2005	Physician office	669	Overt syringe reuse from one patient to another	Vitamin B₁₂	Health department	Rhode Island Department of Health, unpublished data
Michigan	2007	Physician office (dermatology)	13,500	Suspected overt syringe reuse and reuse of surgical instruments from one patient to another	Unspecified	Health department	Kent County Health Department²⁷
New York	2008	Physician office (obstetrics/gynecology)	36	Overt syringe reuse from one patient to another	Influenza vaccine	Physician office	New York State Department of Health²⁸
New York	2008	Hospital	185	Suspected overt reuse of insulin pen from one patient to another	Insulin	Hospital	NewsInferno²⁹
Texas	2009	Hospital	2114	Overt reuse of insulin pen from one patient to another	Insulin	Hospital	William Beaumont Army Medical Center³⁰
West Virginia^#	2009	Pain management clinic	110	Syringe reuse contaminating medication vials	Various medication including triamcinolone and lidocaine, iopamidol (contrast)	Health department	Radcliffe et al³¹
Florida	2009	Hospital	1851	Overt reuse of saline bag and intravenous tubing from one patient to another	Saline	Hospital	Broward General Medical Center³²
New York	2010	Physician office	25	Suspected overt syringe reuse from one patient to another	Influenza vaccine	Physician office	New York State Department of Health, unpublished data
Pennsylvania	2010	Outpatient clinic affiliated with a hospital	250	Overt syringe reuse from one patient to another	Botulinum toxin	Affiliated hospital	Fabregas³³
Colorado	2011	Outpatient clinic	171	Overt syringe reuse from one patient to another	Influenza vaccine	Clinic	Dickinson,³⁴ Colorado Department of Public Health and Environment, unpublished data
Mississippi^#	2011	Oncology clinic	623	Overt syringe reuse from one patient to another, and syringe reuse over multiple days contaminating saline bags and heparin bags	Heparin and saline flushes	Health department	Mississippi State Department of Health, unpublished data
Wisconsin	2011	Primary care clinic	2345	Overt reuse of insulin demonstration pen from one patient to another	Saline or possibly nonsterile water	Clinic	Seely,³⁵ Wisconsin Division of Public Health, unpublished data
Wisconsin	2011	Hospital	56	Overt reuse of insulin demonstration pen from one patient to another	Saline or possibly nonsterile water	Hospital	Wisconsin Division of Public Health, unpublished data

This indicates only the states where facilities associated with patient notifications were located and does not take into account additional states where affected patients might have been residing at the time of potential exposure or notification.

^†

For notification events that had multiple rounds of notifications, this indicates the year of first round of notifications.

^‡

Represents the estimated minimum number of patients notified.

^§

Indicates documented lapses (based on direct observations or interviews with the implicated provider) unless otherwise specified.

^∥

These notification events took place in the context of public health investigations in which health care was recognized as the source of hepatitis B or C virus transmission.

^¶

Preliminary investigation involved initial notification of 98 patients in 2005, but formal notification activities were not conducted until 2007.

Patient notifications prompted by breaches identified in the context of a bacterial outbreak: Staphylococcus aureus infections following epidural injections in West Virginia, Pseudomonas aeruginosa, and Klebsiella pneumoniae infections in Mississippi.

CDC indicates Centers for Disease Control and Prevention; EDTA, ethylenediamine tetraacetic acid.