Mistake Prompts State to Test Dozens for HIV, Hepatitis | NBC Connecticut

Mistake Prompts State to Test Dozens for HIV, Hepatitis



    (Published Friday, Aug. 23, 2013)

    The NBC Connecticut Troubleshooters have learned that at least 74 people were put at risk of potentially contracting HIV and Hepatitis B and C through a standard medical procedure performed by a UConn Health Center nurse.

    "You could have signed your death sentence right there by giving somebody something like that,” said Loretta, the sister-in-law of one of the nurse’s patients. Loretta and her husband Paul asked us to conceal their identities to protect their relative’s medical privacy. But they wanted to speak out against what they call a careless mistake that has put his life on the line.

    "They screwed up,” said Loretta.

    The mistake happened at MacDougall-Walker state prison in Suffield. It first came to light when a letter was sent to dozens of diabetic inmates on May 28th, reading in part, “There is a possibility that a vial of insulin that you may have recently come into contact with was contaminated.”

    The letter asked inmates’ permission to be tested for three blood-borne diseases: Hepatitis B and C, and HIV. Loretta said her brother-in-law, who is serving a 10-year sentence for larceny, could barely cope with the news.

    "He was scared and he was upset and he was crying,” she recalled.

    Loretta and Paul said the prison was telling inmates and family very little, so they turned to the Troubleshooters. The Department of Correction and UConn, which manages inmate health care for all state prisons, confirmed to the Troubleshooters that contaminated insulin was given to inmates, but the agencies would not go into details about how it happened.

    So the Troubleshooters dug deeper and uncovered court documents in which the state clearly admits one of its nurses “…made a mistake…” as she made the rounds, administering life-saving insulin to diabetic inmates. But that insulin was contaminated. The records said the nurse stuck a Hepatitis C infected inmate with a needle before realizing she hadn’t filled it with insulin. She put the needle back into the insulin vial, then gave dozens of other inmates the same contaminated medicine. The details are laid out in the court filing because the DOC had to ask a judge to force the first inmate to take a blood test for HIV. The agency feared the other inmates could be infected.

    We asked the diabetes experts at Saint Francis Hospital and Medical Center to show us the best practices when it comes to standard care for insulin-dependent diabetics.

    “Once the vial is open, it’s good for 28 days,” said Nurse Sally Cooney, Education Program Coordinator for the Center for Diabetes and Metabolic Care at Saint Francis, “After they’ve injected the insulin, they need to dispose of the sharp.”

    The Center for Diabetes’ Medical Director, Dr. Latha Dulipsingh, said the basic and overarching principals are safety and prevention of infection.

    "Would you ever use a needle and then place it back into the vial of insulin?" asked our Troubleshooter.

    "No. That would lead to contamination because every time you use a needle, chunks of skin get caught in the little bevel of the needle, so you'd be contaminating the vial if you were to reuse the needle," said Dr. Dulipsingh.

    So how could such a basic practice go so wrong? UConn said it’s still investigating jointly with the DOC, and the nurse has been put on paid administrative leave. In a statement, UConn told the Troubleshooters, “On May 28, 74 inmates at the MacDougall-Walker Correctional Institution were notified of a possible exposure to a potentially contaminated vial of insulin and advised to consent to periodic testing and monitoring. All appropriate notifications have been made and protocols followed. This includes a pending Department of Correction and Correctional Managed Health Care joint investigation, which limits disclosure of additional details. The risk of an infectious disease contracted as a result of this is considered extremely low, and all tests so far have been negative.”

    In fact, a source close to the investigation told the Troubleshooters the inmate at the center of the scare has tested negative for HIV, prompting UConn to send a letter on June 20th that read in part, “The transmission of HIV or Hepatitis B is unlikely. There is still the concern for the transmission of Hepatitis C.”

    The state continues to test the exposed inmates. Loretta and Paul said it’s been an agonizing wait.

    “He's sitting in an 8 by 10 cell and saying, ‘hmm, I get to sit here and wait and think about all the things I've got to go through,’” described Loretta.

    The Department of Public Health is also investigating the incident, and would not comment for our story.