In Dec 2013, South Eastern Sydney Public Health Unit issued a media release alerting patients who had attended a hair transplant clinic that there was a low risk of blood borne virus (BBV) infection because of evidence of poor infection control practises. Such warnings are occasionally issued by NSW Health, so we asked the Director of South Eastern Sydney Public Health Unit, Professor Mark Ferson how he first hears about these kind of risks, and the process for assessing and managing them.
We have been involved in five of these situations in the last few years - I think it is a growth industry for public health as the systems for regulating registered health professionals, such as doctors and dentists, evolve. As well, we seem to be improving our ability to detect cases of disease related to poor infection control, and members of the public may be more ready to make complaints of poor infection control practices by health professionals. These five situations have included a general practitioner conducting a vitamin clinic, a dental prosthetist practising as a dentist, an endoscopist, a general practitioner carrying out hair transplantation and a dentist. In all cases, investigation revealed weaknesses in infection control knowledge and practice.
These cases have come to light in a number of ways. Most commonly, an investigation by the Health Care Complaints Commission or the relevant professional registration board triggered by a patient complaint about the standard of practice finds evidence of poor hygiene to the extent that the investigators are concerned there may be a risk to the health of the public. Often there is blatant evidence that equipment which is being reused has not been cleaned or sterilised properly. On other occasions, we have been notified of clusters of disease in patients of a practitioner and the infection control assessment reveals problems.
If there is no actual case of disease reported, the process of risk assessment relies on a detailed analysis of the procedures being undertaken – often carried out with the assistance of a person practising in the same discipline as the practitioner being investigated, as well as a thorough infection control audit undertaken by an infection control practitioner. If there is a cluster of disease reported – for example multiple cases of acute hepatitis C – then an exhaustive epidemiological investigation is conducted based on review of the practitioner’s patient records, data matching against the notifiable diseases database, and use of often cutting edge molecular epidemiology undertaken by public health laboratories. This information is then presented to the NSW Health Blood Borne Virus Panel, who advise the Chief Health Officer on the presence and degree of risk to patients or a particular category of patients.
Assuming we have good patient records to review, we can take the Panel’s determination of higher risk procedures and, based on this, determine which patients were at increased risk of blood borne virus infection.
If records are clear, we can contact patient direct, usually by mail, to inform them of their risk. If the matter is more urgent, for example where there is evidence of recent virus transmission to patients, we may wish to contact the highest risk patients by phone, to explain the situation and to offer testing as a matter of priority. Where patient records are very disorganised or just do not exist, the only way we have of informing patients is by going public using the mass media and other networks.
It is the role of public health to inform patients of unusual risks to which they may have been exposed, and in most of these cases, the Panel concludes that patients are at an elevated risk of blood borne virus infection, but that this degree of additional risk is small. We then advise them that as a precaution they should visit their family doctor for testing for infection with hepatitis B, C and HIV. We tend to find that some patients are quite blasé whilst others are terrified, especially if the mass media latch onto the story and emphasise the HIV aspect of the risk (which is usually the least likely to be transmitted).
I am getting a bit more relaxed about managing these incidents, and my perception is that – when there is no report of disease to start with – we seem to have accumulated little if any evidence that transmission occurs. The ethics of this require careful consideration – in one incident, a patient wrote to me about how best to balance any potential damage to a practitioner resulting from the publicising of a case and the need for patients to be aware of the risk. This comment exemplifies the often difficult balance between the rights of the individual and the public good, and justifies the process whereby the NSW Health Blood Borne Virus Panel – a group of experts that includes an ethicist – is asked to weigh the evidence and provide considered advice to the Chief Health Officer regarding public health action.