Tag Archives: hepatitis outbreak

It Takes Courage to Speak the Truth

September 29, 2014

Evelyn McKnight and Lauren Lollini

Lauren is the survivor of the 2009 Hepatitis C Outbreak in Colorado who chose to take a first step to passing legislation to make patients safer.

Lauren is the survivor of the 2009 Hepatitis C Outbreak in Colorado who chose to take a first step to passing legislation to make patients safer.

As a therapist, I often find myself congratulating clients for taking the first step as that is usually the most difficult. That first step might be making a phone call and asking about what resources are available for help or quite literally taking that first step into my office. So, too, do I congratulate the past contributors to our blog who have gone above and beyond to take that first step to share their stories. By speaking their truth, they have risked much, but were still undeterred.

You simply need to scroll back through the last few months and you will find many heroes who could no longer stay silent. Most recently, Anita Betrand shared her journey from addiction as a CRNA to that of an advocate speaking out so others can learn from her. Her struggle in and of itself was an arduous one, yet Anita chose to take that one next step to help educate so other healthcare workers finding themselves in a similar circumstance know there is a light at the end of the tunnel.
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When will we learn from past mistakes?

July 21, 2014

Evelyn McKnight and Lauren Lollini

Lauren is one of many Coloradans infected with Hepatitis C from a hospital outbreak in 2009.

Lauren is one of many Coloradans infected with Hepatitis C from a hospital outbreak in 2009.

On July 12th, the New York Post printed an article about some very disturbing issues at a VA facility in Albany. The article illustrates just how bad things can get in a hospital setting. These reports are atrocious.


But what continues to replay in my mind is the section which outlines a nurse diverting morphine. Apparently, this nurse was withdrawing the pain medication from vials and replacing it with a clear unknown substance. Could have be water or saline. The article states that over the past year this could have occurred more than 5,000 times.

Some 5000 opportunities for patients to go without their pain medication. Some 5000 opportunities to recognize this nurse’s actions and put a stop to it. And countless other patients and hospital employees put at risk. read more »

“I tell everyone I know” – Karen Morrow’s Story

June 23, 2014

Evelyn McKnight and Lauren Lollini

Karen Morrow is a survivor of the 2007 Las Vegas Outbreak and a member of the board of directors of HONOReform

Karen Morrow is a survivor of the 2007 Nevada Outbreak

Karen Morrow is a survivor of the 2007 Las Vegas Outbreak

Karen Morrow studies the Safe Injection Practices Weekly Digest and informs her friends and family about outbreaks that happen throughout the country.  Because the outbreak that took place in Las Vegas in 2008 was so large and touched every segment of society, people there tend to think similar outbreaks cannot happen anywhere else.
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Lauren Lollini Salutes Joe Perz and the CDC DHQP

Joseph Perz, DrPH, MA Quality Standards and Safety Team Leader for the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention

Joseph Perz, DrPH, MA
Quality Standards and Safety Team Leader
for the Division of Healthcare Quality Promotion,
Centers for Disease Control and Prevention

I have held a special place in my heart for Dr. Joe Perz of the CDC for the last 5 years. Even though we have not met in person, we were introduced in a very peculiar way. You see, Joe was one of the first on the scene to investigate a potential outbreak in Colorado in the spring of 2009. The CDC was called in when it was determined there were two reported cases of hepatitis C from individuals who had surgeries at the same hospital just a day or two apart.

I was one of those two patients. I am eternally grateful to Joe and his colleagues for not only getting to the heart of the outbreak and allowing a broken system to be mended but for offering me a sense of understanding about how I had gotten infected. Along the way, several other healthcare professionals with whom I was in contact scoffed at my insistence that I had been infected during my healthcare procedure—and that many other patients had, too. Ever since this first unusual “meeting,” I have followed the tremendous work of Joe Perz and the CDC’s extraordinary Division of Healthcare Quality Promotion (DHQP). I’m a fan!
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The North Dakota Outbreak: The Daughters of a Victim Speak Out, Call for Action

May 5, 2014

Evelyn McKnight and Lauren Lollini

Tam Black and Jan Laudenschlager tell the heartbreaking story of how their father was infected with  Hepatitis C while a resident at a long-term care facility in North Dakota.

Tam Black & Jan Laudenschlager are advocates for their dad in the North Dakota outbreak

Tam Black & Jan Laudenschlager are advocates for their dad in the North Dakota outbreak

Our Dad is one of the 44 victims of the Hepatitis C outbreak in North Dakota. The outbreak occurred at ManorCare, a long-term care/rehab facility in Minot. Dad spent six days at ManorCare in November of 2012 for physical therapy following a minor stroke. During his short stay, he had two blood draws and a tuberculosis test. After he returned home, he never got back the energy and strength levels he had prior to the stroke. We now attribute this to the Hepatitis C infection he caught just days after his stroke.

In July of 2013, he tested positive for Hepatitis C. It was a complete shock, and it still hasn’t really sunk in. The stigma of the infection was hard for both of our parents. They didn’t want anyone to know and were worried about having anyone over to their home, especially their grandchildren. We can’t begin to imagine the stress our Dad was living with then and now, not knowing what is to come.

The State Health Department was in charge of investigating the outbreak, and we waited patiently for their findings. In December of 2013, they concluded that the exact method of transmission was not identifiable and suggested that it could be associated with phlebotomy, podiatry, or nail care. We found this unacceptable!

One night, Jan was searching the internet for information on Hepatitis C and came across the HONOReform website. She emailed a short message explaining the situation and within 20 minutes received a phone call from Steve Langan.

No one in our community was paying attention to what happened at ManorCare, so with guidance from HONOReform, we decided to let the public know about the outbreak. It took great courage for both of our parents to let us take their story to the media in hopes of getting some answers. With Steve and Evelyn’s help, we were able to get our local news to televise a series of short features about the outbreak.

We wish Dad could start the oral medications he needs to combat the infection, hoping that it would help with his fatigue and weakness. He was denied coverage of the medications by the Veterans Administration and cannot afford them otherwise. For the 12-week regime of two pills a day, the cost is $160,000.

Mom and Dad are still taking things day-by-day. A support group for the victims and their family members has slowly been forming, which will hopefully make the task ahead easier – because we will continue to fight for answers. Our parents, along with other victims and their families, are owed at least that much.

Simply put, these 44 victims deserve an explanation. They should not be forgotten.

Meeting with patients in North Dakota

April 21, 2014

Evelyn McKnight and Lauren Lollini

Steve Langan, director of HONOReform, is meeting with people affected by the North Dakota outbreak today

Steve Langan, director of HONOReform, is meeting with people affected by the North Dakota outbreak today

We send our best wishes in a special way today to our friends in Minot, North Dakota. Minot is the location of a healthcare-assoicated outbreak of Hepatitis C in which 44 residents of a nursing home were infected. Public health officials continue to investigate, but the exact cause is a mystery at this time. We send our best wishes for the good health and comfort for all the victims and their families.

I well remember those days of questions and confusion. When I found out I had Hepatitis C in early 2002, my husband and I were so stigmatized by the diagnosis that we told no one. We were alone in our worry and puzzlement. It wasn’t until several years later, after the public health investigation and discovery of facts through litigation, that we understood the cause and magnitude of the Nebraska Hepatitis C outbreak. The community was shocked that 99 people had been infected through re-use of syringes during chemotherapy at our local oncology clinic.

Once I learned that we had contracted this deadly disease through healthcare services, I let go of my feelings of stigma. Having Hepatitis C caused many difficult emotions, but shame was not one of them. I was frightened, confused and angry. I mourned the loss of good health, peace of mind and confidence in our healthcare system. I was overwhelmed with the amount of new information I had to process and the decisions I had to make regarding my health, my family’s welfare, my finances, and possible legal recourse.

Members of our community hosted several information sessions to address these questions. Some of us formed an informal support group. We learned to cope in the years following the Nebraska outbreak. I believe that the people of the North Dakota outbreak will as well. And we want to help you learn to cope.

At HONOReform, our primary aim is the elimination of outbreaks caused by lack of adherence to national injection safety standards. But, despite robust national awareness and advocacy for injection safety, outbreaks continue to occur. We offer our support to the people who are affected by outbreaks. We are glad for the opportunity—which is a privilege and at the center of our mission—to help support patients and communities as they learn to cope with the many consequences of an outbreak.

Steve Langan, executive director of HONOReform, is in Minot today, Monday, April 21. He would like to meet with Hepatitis C outbreak victims and family members to determine their needs and goals – and to see how HONOReform can help.

He will be meeting with victims/family members at the Hyatt House, which is located in north Minot at the junction of the 83 Bypass & 21st Avenue NW (2301 Landmark Drive). Steve will be available from 11-1 and 4-6 in the Hyatt’s gathering room (take a right after you enter the building and it is just a few steps down the hall). For those who cannot see Steve at Hyatt House, it is possible to schedule an appointment for him to come to them (between 1 and 4 pm and after 6 pm). Steve’s direct phone number is 402.659.6343 and his email address is steve@www.HONOReform.org. We encourage everyone to contact him anytime.

HONOReform Thanks Journalists for Helping Educate Communities on the Importance of Injection Safety

April 14, 2014

Evelyn McKnight and Lauren Lollini

Jim Olson of KXMC Minot, ND did a series of article on the Minot, ND investigation

Jim Olson of KXMC Minot, ND did a series of articles on the Minot, ND investigation

We salute and commend our colleagues in the media—journalists, bloggers, hosts of television and radio programs—for their thorough support over the years for the need for injection safety. The patient notifications and confirmed outbreaks that move HONOReform and our many partners to take action have, sadly, become fairly regular occurrences. For us.

But in communities that are affected by a patient notification or a tragic outbreak caused by unsafe injection practices, it is brand new territory. These incidents defy credulity. How could this happen? This couldn’t happen here! This is a developing countries problem!

These are some of the comments we regularly hear. We understand. We have been there ourselves.

Thanks to the excellent engaged Safe Injection Practices Coalition, which is led by the Centers for Disease Control and Prevention, a variety of excellent materials are in place. The One and Only Campaign is an excellent resource—and one that we share straightaway with members of the media, whenever we are involved in a discussion on injection safety.

We encourage you to review the One and Only Campaign Resources: http://www.oneandonlycampaign.org/campaign_resources
and, if you are a healthcare provider, put these valuable materials in place in your institution.

On December 2, 2013, our executive director, Steve Langan, wrote a blog piece titled “HONOResponse: Why the North Dakota investigation is Representative.” We had just learned of this incident; we were trying our best to gather all the facts…and determine how best we could take actions to support victims and the overall community.

Thanks in part to the journalists in the community, including Jim Olson of KXMC, more of the facts of this outbreak, from which 44 North Dakotans have been infected with viral hepatitis, have become known. And there was a recent community meeting, during which family and community members came together to support one another—and consider ways to work together going forward.

It is our pleasure to share links to the recent KXMC stories:

“I am grateful to the many journalists who have taken time to understand our mission, and embrace it,” said Evelyn McKnight. “I also want to commend patient and family advocates, including Jan Laudenschlager and Tam Black of North Dakota, who regularly share their story. These powerful stories need to be heard, and they drive policy makers, public health leaders and healthcare workers to make necessary changes.”
(On an upcoming HONOReform blog, Jan and Tam will tell their story.)

HONOReform will be present in Minot on Monday, April 21, to meet with patients, their family members and members of the community. For more information contact Steve Langan, 402.659.6343 or steve@www.HONOReform.org.

Thank you for doing all you can to prevent unsafe injection practices.

HAI Focus

March 31, 2014

Evelyn McKnight and Lauren Lollini

Julie Reagan is the editor of HAI Focus

Julie Reagan is the editor of HAI Focus

We were honored to have a comment published to HAI Focus last week. It is a website designed to help you find the information or news you need about healthcare-associated infections (HAIs) and infection control. The site is updated on a daily basis to reflect current news and events related to HAIs. Our comment was in response to a recent patient notification that is taking place on Long Island. Click on the link http://www.haifocus.com/lets-talk-lives-depend-on-you/ or read the comment below.

I remain troubled by the news that 4,277 patients on Long Island, because of improper use of an insulin pen, have been placed in harm’s way (“Nassau hospital’s call to test injected patients seen as opportunity,” March 15). These men and women are in my thoughts and prayers.

I joined the CDC and its partners in 2008 to launch the One and Only Campaign. Because of troubling patient notifications and devastating outbreaks that have occurred in the last six years, our work on the campaign has expanded. We developed extraordinary resources on proper use of the insulin pen, for instance. I encourage healthcare workers throughout New York and the area to take time to reeducate themselves on all injection safety fundamentals.

In addition to my encouragement to healthcare workers to always give a safe injection, I encourage them to be unafraid in addressing each other directly, anytime injection safety standards are violated—or seem to be.

I was one of 99 people in Fremont, Nebraska, who was infected with hepatitis C while receiving treatment for cancer at an outpatient clinic in 2002. Syringes were reused, and the saline flush was used improperly. Not only does an outbreak of hepatitis C affect patients, it affects an entire community. Notifications like the current one on Long Island chip away at a community’s confidence in its medical care.

Did anyone speak up, when my fellow patients and I, people who were fighting one fatal disease only to have to take on another, were being violated over a long time through unsafe injection practices? Sadly, the answer is no.

In the recent reports, it appears an unnamed healthcare worker did make a stand. He or she heard a colleague say it’s okay to reuse an insulin pen on more than one patient. As we know, blood can become trapped in the reservoir and, if it is reused, cause an infection. As it states in the One and Only Campaign materials, “Insulin pens that contain more than one dose of insulin are only meant for one person.”

To the healthcare worker who said to his or her colleague, No, that is not how it is done, we issue our thanks. I expect this person will not perceive him or herself as strong or brave. I expect he or she would say, if I had a chance to provide a commendation, I was just doing my job.

However, speaking up to a colleague, and especially to a person of higher rank, clearly does not occur as often as it should in healthcare. I am one of many people throughout the United States who have been deeply affected by ongoing, unchecked unsafe injection practices.

On behalf of my fellow patients, and with the patients from Long Island in our minds and hearts, I urge healthcare workers to be unafraid to say, “Stop.” To say, “No.” Lives depend on you.

“There isn’t any thing I can’t do – Melisa French’s Story

March 17, 2014

Evelyn McKnight and Lauren Lollini

Melisa French is a survivor of the Florida outbreak of 2010

Melisa French is a survivor of the Florida outbreak of 2010

Melisa French has conquered many challenges in her very full life. As a certified cave diver, she often dives in wells hundreds of feet below the surface in search of Mayan skulls and artifacts. But the biggest challenge of her life came when she found out she had contracted Hepatitis C.

Melisa was vibrantly healthy when she sought a second opinion on hormone replacement therapy from a holistic and alternative health clinic in Florida in 2009. During the single IV vitamin infusion she had there she grew concerned when the nurse did not wipe the tops of the many vials of injectables with alcohol and accessed each with the same needle and syringe before she capped it and put it in her pocket. When the nurse removed the IV tubing from Melisa’s arm, she let the bloody tubing dangle from the IV pole instead of disposing it in a hazardous waste receptacle. There was no hazardous waste container in the room, hand washing sink, or alcohol hand hygiene products. Melisa left the clinic vowing never to go back. read more »

Seeing for ourselves how safety is engineered into medical injections

January 20, 2014

Evelyn McKnight and Lauren Lollini

BD hosted HONOReform and reporter Matthew Hanson for a plant tour

BD hosted HONOReform and reporter Matthew Hansen for a plant tour

What a great way to end the week!

Steve Langan and Matthew Hansen, features writer for the Omaha World-Herald, picked me up at my house on Friday morning, and we drove to a meeting at the BD (Becton, Dickinson and Co.) plant in Columbus. It’s one of two BD plants in Columbus. There are two others in the state, one in Broken Bow and another in Holdrege.

Congressman Jeff Fortenberry, a longtime supporter of injection safety whose district now also includes the Columbus area, was at the meeting. He met with our BD colleagues and the HONOReform team, and then he led a town hall meeting for BD employees.

I value Congressman Fortenberry’s straightforward, genuine approach to governing. read more »