Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
3.24 It transpired that technical and nursing staff felt that there was a conflict of
interest in THL’s own investigation into the re-use of syringe incidents being
carried out by the acting Medical Director and the Group Manager (Hospital).
3.25 As a result of the THL June 2000 inquiry, and advice received by THL, a
“look back” programme was put in place. Patients considered at risk were
contacted and advised to see their general practitioners.
3.26 The draft report from the acting Medical Director (I was not provided with a
final report) stated:
“There is no debate that syringes were re-used in the first two to three
weeks of Dr L’s locum. No written information allows a more precise
estimate of the critical time period. While trying not to re-use in the
period thereafter, Dr L acknowledges that a 20+ year habit does not go
overnight, and that he cannot exclude a further use thereafter.”
3.27 The report contained a section on the Relevant Infectious Diseases:
“The key infectious diseases to consider are hepatitis B and C and HIV
(human immuno-deficiency virus, the causative agent of AIDS –
acquired immuno-deficiency syndrome).
The three are all transmitted through blood products and other body
fluids. Hepatitis B is the most easily transmitted of the three diseases.
Viral load in an infectious person is high, and the infective dose (in
terms of amount of body fluid) is very small. While the other two are
infectious, their degree of infectivity from small inoculations of blood is
far less. The transmission of hepatitis B through needle-stick injury is
well recognised: indeed, it is an occupational hazard for health workers.
While there is evidence of spread of HIV through needle stick, the risks
are of an order of magnitude less.
The prevalence of hepatitis B is higher in Tairawhiti in general, in
particular Maori and Asian populations. While HIV is prevalent in New
Zealand, Tairawhiti is a low prevalence (though not zero) area. The
prevalence of hepatitis C is thought to be low.
Hepatitis B is, therefore, by far the most infectious of the diseases under
consideration. The local prevalence increases one aspect of the risk of
syringe re-use. To become infected there has to be the following chain.
Firstly, a preceding patient has to be infectious for the disease
concerned. Secondly, there has to be transfer of sufficient viral particles
for infection, thirdly, the host patient has to be receptive, that is, nonimmune.
Patients were possibly exposed to an infection risk through the transfer
of virus particles from one patient’s blood or serum to another’s through
the re-use of a contaminated syringe.
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