Vials of injectable medication meant for more than one patient pose an infection risk and should no longer be used, says a leading Ontario infection control expert.
“Don’t get me started on multi-dose vials. We should not be using multi-dose vials in this day and age,” said Dr. Allison McGeer, director of infectious disease control at Mount Sinai Hospital.
The Star reported on Saturday that 11 patients contracted hepatitis C during separate outbreaks at three Toronto colonoscopy clinics between 2011 and 2013.
Toronto Public Health said it is “possible” that use of multi-dose vials was the cause.
Multi-dose vials are small glass or plastic bottles that contain more than one dose of liquid medication. They are used in conjunction with needles and syringes.
A vial can become contaminated if the same syringe or needle is used for multiple patients.
Public Health Ontario, on its website, states that “unsafe injection practices” involving the vials can cause disease transmission. When a patient infected with hepatitis C is injected with medication, for example, backflow of traces of blood can contaminate the syringe.
When additional medication is then drawn from the vial and given to the same patient, the needle is often replaced, but the same syringe is used. The vial gets contaminated from the syringe, and the next patient to be injected with medication from it is then placed at risk.
The problem of health-care professionals inadvertently spreading infection has been underestimated, McGeer said.
“I think that it is only recently that we’ve started taking seriously the possibility that medical procedures are a potential risk for hepatitis, so most physicians, nurses, etc., think it doesn’t happen. But in truth, this has been happening on an ongoing basis. We need to be doing better to prevent it,” she warned.
According to TPH, three patients were infected with hepatitis C at the Downsview Endoscopy Clinic in 2011, three at the North Scarborough Endoscopy Clinic in 2012 and five at the Ontario Endoscopy Clinic in 2013.
Other places around the world have experienced outbreaks related to multi-use vials.
“You walk into any endoscopy unit or any pain clinic or any of the places where people use intravenous medication, and there will be deficiencies with multi-dose vials. I guarantee it. There is nobody who is using them properly. I hope we are finally going to move on it,” McGeer said.
The microbiologist, who said she has been on a “multi-dose-vial mission for 20 years,” noted the ampoules continue to be used in Ontario clinics, hospitals and outpatient offices. They are cheaper than single-dose vials and easier to store.
“We should be using single-dose vials of (injectable) medication, for the same reason that you have to have your foot on the brake when you put your car in gear, and you have ground-fault interrupters in bathroom electrical sockets, and you have railings on decks more than three feet above the ground, and there are automatic shut-off valves in car gas tanks so they don’t overflow,” she said.
“These are all examples of situations in which we force safety functions because we know that people are likely to make mistakes,” she continued.
Despite Garber’s assertion that the vials can be used safely, a Public Health Ontario committee steers clinicians away from using them. A best-practices guide from the Provincial Infectious Diseases Advisory Committee states: “Outbreaks associated with the use of multi-dose vials in outpatient settings are a frequent and a recurring problem. The use of multi-dose vials should be avoided whenever possible.”
But Dr. Gary Garber, medical director of infection prevention and control for Public Health Ontario, defended the use of the vials.
“Multi-dose vials can be used safely if the appropriate procedures are used,” he said, explaining, for example, that clinicians should wash their hands and never re-enter a vial with a used needle.
“If you want to look at the number of injections that go on every day in any given hospital or in any given city or health department, and then you look at the occasional infection that has happened, it is minuscule,” Garber said.
Theresa Boyle Health