infection control & hospital epidemiology october 2015, vol. 36, no. 10 original article
Reuse of Insulin Pens Among Multiple Patients at 2 Veterans Affairs Medical Centers
Patricia Schirmer, MD;1 Carla A. Winston, PhD, MA;1 Cynthia Lucero-Obusan, MD;1 Mark Winters, MS;2 Alan Lesse, MD;3,4 Charles de Comarmond, MD;5 Gina Oda, MS;1 Richard A. Martinello, MD;1,6 Mark Holodniy, MD1,2,*
objective. To determine whether reuse of insulin pens among multiple patients resulted in transmission of bloodborne pathogens (BBP). design. Retrospective cohort study. setting. Two Veterans Affairs medical centers. patients. Veterans who received insulin via insulin pens from 2010 to 2013.
methods. Patients were identified through electronic health records, notified of possible exposure, and serotested for human immunode- ficiency virus, hepatitis C virus (HCV), and hepatitis B virus. Newly discovered case patients were assessed in relation to potential proximate patients to determine viral strain relatedness by HCV envelope (env) gene sequencing.
results. Of 1,791 hospitalized veterans who received insulin via insulin pen, 1,155 were tested for at least 1 viral infection after exposure. Of these, 67 patients were newly diagnosed with 1 or more viral BBPs. For human immunodeficiency virus and hepatitis B virus no additional strain testing of case or proximate patients was possible; 8 HCV cases and 45 proximates (40 unique patients; 5 patients were positive for 2 genotypes) were identified as needing strain testing. Only 3 cases and their 19 proximates had samples available for further testing. None of the 26 remaining proximate patients had blood available for further testing. Median genetic distance between the HCV env sequences of those available for additional testing ranged from 14% to 24%, indicating nonrelatedness.
conclusions. Our investigation revealed that exposure to insulin pen reuse did not result inHCV transmission among patients who had viral genetic analysis performed. Analysis for any additional potential transmission of blood-borne pathogens was limited by the available samples.
Infect. Control Hosp. Epidemiol. 2015;36(10):1121–1129
Insulin pens are a combined syringe and insulin system originally developed for outpatient use owing to portability and ease of use. Reusable and disposable pens are currently available and can be used multiple times, for a single person only, using a new needle with each injection.1,2 Given potential backflow of blood into pen cartridges
during injection, insulin pens should not be shared among patients. If pens are reused among multiple patients, there is risk for bloodborne pathogen (BBP) transmission, despite changing needles between uses. Biological material, including macrophages, epithelial cells, and red blood cells, has been found in needles and cartridges from diabetic patients.3–5 However, no BBP transmission associated with insulin pen reuse on multiple patients has been documented.1
Recently, advisories were issued by the Institute of Safe Medication Practices, US Food and Drug Administration, and Centers for Disease Control and Prevention against insulin pen reuse on multiple patients owing to the risk of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) transmission.6–10 Similarly, the Department of Veterans Affairs (VA) notified providers about inappropriate use of multidose pen injectors (including insulin pens) and on February 4, 2013, use was prohibited on all VA inpatient care units except in rare circumstances.1,11 Herein, we describe insulin pen reuse exposures at 2 VA
medical centers prior to prohibition of insulin pen use in VA inpatient units. Our objective was to determine whether reuse of insulin pens among multiple patients resulted in transmis- sion of bloodborne pathogens.
Affiliations: 1. Office of Public Health, Department of Veterans Affairs, Washington, DC; 2. Stanford University, Stanford, California; 3. Veterans Affairs
Western New York Healthcare System, Buffalo Medical Center, Buffalo, New York; 4. University at Buffalo, Buffalo, New York; 5. W. G. “Bill” Hefner Veterans AffairsMedical Center, Salisbury, North Carolina; 6. Yale School of Medicine, New Haven, Connecticut.
*Presented in part: IDWeek 2014; Philadelphia, Pennsylvania; October 11, 2014 (abstract 1730). The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3610-0001. DOI: 10.1017/ice.2015.165 Received March 26, 2015; accepted June 17, 2015; electronically published July 22, 2015
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