1,300 Covenant Health diabetes patients potentially exposed to hepatitis B and C
Possible exposure was during insulin training sessions in Edmonton between 2013 and 2016
More than 1,300 Covenant Health patients being treated for diabetes may have been exposed to hepatitis B and C during insulin training sessions, the organization revealed on Wednesday.
The health agency has mailed letters to a total of 1,307 patients who may be at risk due to "an infection control breach" at the Grey Nuns and Misericordia hospitals between 2013 and early 2016.
The breach relates to saline-filled demonstration pens and pillows used during the practice sessions where patients with diabetes or gestational diabetes take part in one-on-one lessons on the use of insulin pens.
'Incorrect training practice'
Though the needles were changed between each use and were never shared between patients, the saline reservoirs in the pens may not have been changed out properly. The "practice pillows" may also have been shared between patients.
The pens are meant for demonstration purposes only, but some of them were being injected into patients after they had been used on the contaminated pillows.
The "incorrect training practice" was stopped as soon as it was discovered, Dr. Owen Heisler, chief medical officer for Covenant Health told a news conference at the Grey Nuns Community Hospital in Mill Woods.
"We saw what it was and we stopped it," said Heisler. "While the risk is considered to be very low, we are erring on the side of caution and advising that anyone who receives a notification letter be tested.
"The risk is not ongoing."
The risk to patients is considered "very low." As a precaution, all patients will be tested for both strains of the virus. Children born to pregnant women who were exposed do not require testing, Heisler said.
The notification applies to patients with diabetes or gestational diabetes who received insulin training at the Grey Nuns education centre between March 2013 and Feb. 19, 2016, or at the Misericordia between May 2014 and Feb. 19, 2016.
The problem was first discovered in February 2016. The provincial risk assessment panel was notified one month later.
Covenant Health and AHS conducted separate investigations on the breach.
'Very low risk event'
Heisler said the "complexity" of those investigations is to blame for the 16-month delay in notifying patients.
"Immediately upon us finding out, our first efforts were that we identified the practice, we saw what it was and stopped it.
"And at that point, in the province there is a risk assessment panel that has the expertise to look at these kind of events in healthcare, to tell us what the risk is ... and it takes a fair amount of time to do that."
"And once we knew that, then part of our effort was making sure that we had a good list of who the patients were, to make sure we had the adequate information so we could let them know, and be as transparent with them as possible."
Hepatitis infections can cause acute and chronic disease, including jaundice, and in more serious cases, scarring of the liver and liver failure.
The virus is transmitted through contact with the blood or other body fluids of an infected person.
According to the World Health Organization, most people who get hepatitis B don't end up progressing to chronic hepatitis B, but hepatitis C tends to develop into chronic symptoms.
Patients named in the exposure are encouraged to contact their family doctor and get a standard blood tested as soon as possible.
"This is a very low risk event and we're apologetic that we're also creating anxiety in a lot of people," Heisler said. "But we want to do the safe thing and we encourage them to be tested right now."
Created in 2008, Covenant Health is a Catholic health-care organization which operates 18 hospitals and care facilities across the province, including the Grey Nuns, the Misericordia, the Edmonton General Continuing Care Centre, St. Joseph's Auxiliary Hospital and Villa Caritas.