Infection prevention and control lapse involving medical equipment reprocessing at a family medicine clinic in Ottawa, Ontario, 2018

Background: In April 2018, Ottawa Public Health identified a large-scale infection prevention and control (IPAC) lapse spanning 15 years related to inadequate reprocessing of reusable critical medical equipment used in a family medicine clinic. Objectives: To describe the public health response to, and estimate the risk of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission from, this IPAC lapse. Methods: Patients who underwent a procedure of concern (during which reusable equipment may have been used) at this clinic were identified using Ontario Health Insurance Plan data and individually notified. Testing for HBV, HCV and HIV at the Public Health Ontario Laboratory was recommended, and the odds of infection were estimated. Results: Of 4,495 patients possibly exposed to improperly reprocessed equipment, 1,496 (33.3%) underwent testing within six months of notification. The prevalence of HBV, HCV and HIV infection in this group was lower than in the general Canadian population. Among patients first diagnosed with HBV after a procedure of concern, the odds of HBV transmission were not increased when the procedure occurred within seven or 28 days of another patient with a positive HBV test result (OR7 days, age-adjusted=0.59, 95% CI: 0.14-2.51; OR28 days, age-adjusted=1.35, 95% CI: 0.62-2.93). The odds of HCV and HIV transmission could not be estimated because no patient was diagnosed with HCV or HIV after having a procedure of concern within 28 days of another patient with a positive HCV or HIV test result. Conclusion: We found no evidence of HBV, HCV or HIV transmission associated with this IPAC lapse. However, transmission cannot be ruled out conclusively because only a third of possibly exposed patients underwent testing.