reuse of insulin pens 1125


figure 1b. Hepatitis C virus (HCV) genetic fingerprinting results for genotype 1b from site A. Phylogenetic tree of genotype 1b HCV E1/E2 sequences from 1 case patient (B12, shaded), 7 proximal patients (B11, B13-14, and B16-19), and 2 non-related patients (ENR3-4) from site A. Single genome sequences (average of 22 sequences per sample, range 21–24 sequences) were aligned with MUSCLE, and a neighbor-joining tree was created using Geneious, employing a Jukes-Cantor distance model with 1000 bootstrap replications. Scale bar represents percent nucleotide variability.


administration serologic test result(s) for 1 or more viruses available or who were known to be chronically infected with HBV, HCV, or HIV and received insulin via an insulin pen while an inpatient during the defined period. Case patients were not temporally matched with specificpotential proximatepatients since it was unclear howlong unlabeled insulin pens had been in medication carts or which patients were exposed to which pens. Viral serologic testing was performed at each facility and in


some cases additional testing was conducted at VA’s Public Health Reference Laboratory in Palo Alto, California. HBV testing included HbsAg, HbcAb, hepatitis B surface antibody, and when indicated, HBV viral load testing. HCV testing included HCV Ab, and when initial screen was positive, a confirmatory antibody test with an alternative antibody assay, HCV viral load, and genotype testing. HIV testing included HIV 1/2 Ab, and when indicated, HIV-1 confirmatory Western blot and HIV-1 viral load (Online Table 1). Background inpatient and outpatient seroprevalence for


HIV, HBV, and HCV infection at each facility from January 1, 2010, through May 28, 2014, was obtained from the VA Healthcare Associated Infection and Influenza Surveillance System, which contains national VA patient infectious diseases–related laboratory results. Unique patients were used


for calculation purposes and exposed cohort patients were included within the total number of unique patients tested. Fisher exact statistics comparing cohort and facility background seroprevalence were calculated under the null hypothesis that standardized morbidity ratios of observed (cohort) versus expected (based on facility) counts were 1 if there was no sig- nificant difference. Calculations were conducted using OpenEpi, version 3, and were considered significantly different at P<.05.14 For patients with sufficient HCV viral load present, single-


genome sequencing of the HCV envelope E1-E2 gene region (300 base pairs) was performed to assess relatedness of viral strains from patients with chronic and incident HCV infec- tion.15,16 Briefly, all laboratory investigations were performed using established methods and rigorous quality control pro- cedures, as described previously.17–21 Extracted plasma HCV RNA was reverse transcribed with random primers, diluted, and amplified by nested polymerase chain reaction. Following capillary electrophoresis analysis, only amplicons generated at cDNA dilutions where only 1 of every 3 reactions was positive (thus considered to arise from a single genome) were subse- quently sequenced bidirectionally. During sequence assembly, any reactions showing evidence of mixtures at any nucleotide position were discarded. Pairwise analysis of nucleotide


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