Cadieux Geneviève, Friedman Dara Spatz, Tilley Leslie, Mazzulli Tony, McDermaid Cameron
Ottawa Public Health, Ottawa, ON (when study was conducted).
Correspondence:
Can Commun Dis Rep. 2020 Feb 6;46(2-3):40-47. doi: 10.14745/ccdr.v46i23a04.
In April 2018, Ottawa Public Health identified a large-scale infection prevention and control (IPAC) lapse spanning 15 years related to inadequate reprocessing of reusable critical medical equipment used in a family medicine clinic.
To describe the public health response to, and estimate the risk of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission from, this IPAC lapse.
Patients who underwent a procedure of concern (during which reusable equipment may have been used) at this clinic were identified using Ontario Health Insurance Plan data and individually notified. Testing for HBV, HCV and HIV at the Public Health Ontario Laboratory was recommended, and the odds of infection were estimated.
Of 4,495 patients possibly exposed to improperly reprocessed equipment, 1,496 (33.3%) underwent testing within six months of notification. The prevalence of HBV, HCV and HIV infection in this group was lower than in the general Canadian population. Among patients first diagnosed with HBV after a procedure of concern, the odds of HBV transmission were not increased when the procedure occurred within seven or 28 days of another patient with a positive HBV test result (OR=0.59 95% CI: 0.14-2.51; OR=1.35, 95% CI: 0.62-2.93). The odds of HCV and HIV transmission could not be estimated because no patient was diagnosed with HCV or HIV after having a procedure of concern within 28 days of another patient with a positive HCV or HIV test result.
We found no evidence of HBV, HCV or HIV transmission associated with this IPAC lapse. However, transmission cannot be ruled out conclusively because only a third of possibly exposed patients underwent testing.
2018年4月，渥太华公共卫生部门发现一家家庭医学诊所存在与重复使用的关键医疗设备再处理不当相关的长达15年的大规模感染预防与控制（IPAC）失误。
描述公共卫生部门对此次IPAC失误的应对措施，并评估乙型肝炎病毒（HBV）、丙型肝炎病毒（HCV）和人类免疫缺陷病毒（HIV）因该失误而传播的风险。
利用安大略省医疗保险计划数据识别出在该诊所接受相关手术（在此期间可能使用了重复使用设备）的患者，并逐一通知。建议在安大略省公共卫生实验室对HBV、HCV和HIV进行检测，并估算感染几率。
在4495名可能接触到再处理不当设备的患者中，1496名（33.3%）在接到通知后的六个月内接受了检测。该组中HBV、HCV和HIV感染率低于加拿大普通人群。在相关手术后首次被诊断为HBV感染的患者中，当手术在另一名HBV检测结果呈阳性的患者的手术7天或28天内进行时，HBV传播几率并未增加（比值比=0.59，95%置信区间：0.
