Patient Exposures to HIV During Nuclear Medicine Procedures

Although the potential for transmission of bloodborne pathogens to patients through transfusion of contaminated blood is well known, it is less widely recognized that such transmission can also occur during medical procedures involving withdrawal and reinjection of blood or blood products (e.g., nuclear medicine procedures). Since 1989, three patients (two in hospitals in the United States and one in the Netherlands) undergoing nuclear medicine procedures have been reported to have inadvertently received intravenous injections of blood or other material from patients infected with human immunodeficiency virus (HIV). Two of these patients are known to have become infected with HIV during these procedures; HIV test results are not available for the third patient. This report summarizes these three incidents and provides recommendations for preventive measures. *

In the first incident, a patient was inadvertently injected intravenously with an estimated 100-200 uL of fresh whole blood from an HIV-infected patient after a used syringe containing the blood was mistaken for another syringe containing red blood cells that had been treated (i.e., labeled) with a radioactive isotope (1). The second incident involved the inadvertent injection of a patient with white blood cells from an HIV-infected patient; the cells had been labeled with a radioactive isotope and were injected in the wrong patient when hospital personnel failed to correctly match the identification number of the recipient with that of the specimen of white blood cells (2,3). In both incidents, the recipient patient developed HIV infection despite prompt administration of zidovudine postexposure.

The third incident involved the inadvertent reuse of a syringe that had been used during a diagnostic procedure on an HIV-infected patient, resulting in injection of residual material into a second patient. Follow-up HIV test results from the recipient patient are not available (3).

Reported by: M Ginsberg, MD, San Diego Dept of Health; R Roberto, MD, E Trujillo, E Bray, E Bailey, P Edgerton, GW Rutherford, MD, State Epidemiologist, California Dept of Health Svcs. CM Sewell, DrPH, State Epidemiologist, New Mexico Health Dept. D Palmer, MD, S Wheeler, Veterans Administration Medical Center, Albuquerque. Center for Devices and Radiological Health, Food and Drug Administration. Nuclear Regulatory Commission. HIV Infections Br, Hospital Infections Program, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Nuclear medicine procedures most often involve the intravenous injection, inhalation, or oral ingestion of radioactive materials (i.e., radiopharmaceuticals or radiotracers) for diagnostic or therapeutic purposes. In the United States, approximately 7-10 million such procedures are performed annually in radiology, nuclear medicine, and cardiology departments and clinics. A small subset of these procedures involves withdrawing and then reinjecting a patient's blood after certain cells or elements (i.e., red blood cells, white blood cells, or platelets) are labeled with a radioactive isotope. The two errors in administration known to have led to HIV infection in patients described in this report involved these procedures.

All three instances of errors in administration of radiotracers to patients undergoing nuclear medicine procedures were preventable because they resulted from errors in the identification of the patient and/or materials to be injected. Two of the incidents also involved improper handling and disposal of used syringes.

Administration errors in nuclear medicine procedures are relatively rare. During 1981-1990, an estimated 38 million nuclear medicine procedures were performed in the 21 states where nuclear medicine is regulated by the U.S. Nuclear Regulatory Commission (NRC); the facilities in these states represent approximately 40% of those performing nuclear medicine procedures in the United States. During this period, 4164 errors (defined by the NRC as misadministrations (4)) were reported to the NRC (4), representing an overall error rate of approximately 1 per 10,000 diagnostic procedures performed. Most of these reported misadministrations involved an incorrect dosage or radiopharmaceutical and/or errors in patient identification.

Institutions or clinics in which nuclear medicine procedures are performed should assess policies and procedures to assure routine adherence to the following recommendations:

• All health-care providers, including those who perform nuclear medicine procedures, should receive proper training and routine in-service education on proper infection-control procedures (5).

• Written infection-control policies and procedures specific for nuclear medicine should be promulgated, made accessible, and disseminated in departments where nuclear medicine procedures are performed. These policies should outline procedures to follow in the event of a potential emergency (e.g., an administration error).

• All doses and syringes should be examined for identification and radioassayed (i.e., radiation level checked) before injection (6).

• All syringes should be labeled with appropriate identifying information, including the patient's name and the pharmaceutical (6); a unique identification number should also be used.

• Consideration should be given to implementing a system to be used when administering biologic products (e.g., labeled cells) that is similar to the system used for administering blood. Such a system requires that two persons be present to cross-check all labeling of product to be injected, the prescription, and patient identification.

• Contaminated and used syringes should be disposed of safely and appropriately. Disposal containers for syringes should be located as close as practical to the location of syringe use (6,7).

• All procedures should be documented; documentation should include, at a minimum, the date, name and amount of radiopharmaceutical, and route of administration (6). Ideally, the name or identifying information of the person administering the dose and the exact time of administration should be recorded either in the patient or departmental record.

• An administration error (e.g., administration involving the wrong patient or radiopharmaceutical) should be immediately reported to supervisory personnel and/or the physician in charge. Recommendations for the management of persons after a blood exposure in a health-care setting should be followed (7-9). All administration errors and narrowly avoided errors in administration should be carefully evaluated to determine whether additional precautions are necessary to prevent similar potential administration errors. Careful adherence to these recommendations should minimize the risk of patient or health-care worker exposure to bloodborne pathogens during nuclear medicine procedures.

Misadministrations, as defined by the NRC or by the equivalent state agency in states that have an agreement with the NRC to carry out similar functions, should be reported to the appropriate agency as required by law. In addition, to develop and evaluate additional measures for preventing bloodborne pathogen transmission in nuclear medicine departments and other health-care settings, CDC requests that incidents involving possible transmission of bloodborne pathogens to patients in a health-care setting be reported through local and state health departments to CDC's HIV Infections Branch, Hospital Infections Program, (telephone (404) 639-1547) or Hepatitis Branch, Division of Viral and Rickettsial Diseases (telephone (404) 639-3048).

References

1. Lange JMA, Boucher CAB, Hollak CEM, et al. Failure of zidovudine prophylaxis after accidental exposure to HIV-1. N Engl J Med 1990;19:1375-7.

2. Davis LE, Hjelle BL, Miller VE, et al. Early viral brain invasion in iatrogenic human immunodeficiency virus infection. Neurology (in press).

3. Polder JA, Bell DM, Rutherford GW, et al. Investigation of inadvertent injection of HIV-contaminated material during nuclear medicine procedures (Abstract). Vol 1. VII International Conference on AIDS. Florence, Italy, June 16-21, 1991:379.

4. US Nuclear Regulatory Commission. Office for Analysis and Evaluation of Operational Data, 1990 annual report. Washington, DC: US Nuclear Regulatory Commission, 1991.

5. Occupational Safety and Health Administration, US Department of Labor. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64004-182.

6. Office of the Federal Register. Code of federal regulations -- energy. Part 35. Washington, DC: Office of the Federal Register, National Archives and Records Administration, 1992.

7. CDC. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36 (no. 2S):3S-18S.

8. CDC. Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR 1990;39(no. RR-1).

9. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination -- recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-13):21-4.

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