Epidemiologist Brian Labus last month bemoaned that local attorneys were telling their patients not to cooperate with Southern Nevada Health District surveys intended to gauge the extent of a hepatitis C outbreak.
Nevertheless, Labus will present to the health district's board this morning the best numbers he has, ones that will define the known scope of the outbreak traced to two affiliated endoscopy centers.
The number of cases that can be definitively linked to the Endoscopy Center of Southern Nevada on Shadow Lane and the Desert Shadow Endoscopy Center on Burnham Avenue remains at nine -- eight from the Shadow Lane facility and one from the Burnham facility.
Health officials now say that 105 cases are "possibly associated" with those facilities. That number is up from the 77 that were reported over the summer.
Thirty-five patients have been classified as "indeterminate," meaning they had other risk factors for the disease. "We can't say they got it at the clinic, we can't say they didn't," Labus said.
And 136 were found to have contracted hepatitis C elsewhere. They "were easy to rule out," Labus said, because they had hepatitis C prior to any procedures at the endoscopy centers.
The problem, Labus said, is only 7,331 out of 53,000 people who were notified to enroll in the health district's Hepatitis C Exposure Registry actually did so -- a response rate of just under 14 percent.
Now comes the challenging part: determining exactly what these figures mean.
"It's not a nice sample size," Labus said.
"What this means for the larger clinic population, we really can't say.''
Four of the 105 patients whose disease is considered "possibly associated" to their treatment went to Desert Shadow. The remaining 101 were patients of the Shadow Lane facility.
Both facilities are closed.
Attorneys representing former endoscopy center patients who believe they acquired hepatitis C at the clinics say these figures are too low, and will rise in upcoming months.
The attorneys also agree with Labus that not enough people responded to the registry. But they lay the blame on the health district, saying the questions asked could be misleading.
"Just because you have one or more of the risk factors doesn't mean you didn't get hepatitis C at the clinic,'' said Billie-Marie Morrison, an attorney with Craig P. Kenny & Associates in Las Vegas. "I think the health district has done a good job, but there is still more work to be done.''
Morrison's firm represents hundreds of former endoscopy center patients who have tested positive, and negative, for hepatitis C.
Nia Killebrew, an attorney representing 40 to 45 people who have tested positive for hepatitis B or C and were treated at one of the endoscopy centers, made similar comments.
Both said they directed their clients not to respond to the health district's registry because some questions were inappropriate.
Patients were asked about the location and dates of procedures, and whether propofol, a form of anesthesia, was administered.
They were also asked whether they'd had any blood transfusions or organ transplants prior to 1992, or whether they have been on long-term hemodialysis.
They were also asked if they have had sexual contact with a known hepatitis C carrier.
The health district and the federal Centers for Disease Control and Prevention decided on the questions, Labus said. They are based on known risk factors for hepatitis C, he said.
Killebrew said some of the risk factors for hepatitis C could be ruled out if a patient's full medical records were examined. For example, she said a person with one or more risk factors may have tested negative for hepatitis C prior to their procedures at the endoscopy center, making the likelihood pretty high that they were exposed at a clinic.
She said that person shouldn't be ruled out, or placed in the "indeterminate" classification, because of their risk factors.
Morrison said she doesn't necessarily have a problem with her clients discussing risk factors with the health district; she would just like to be present.
In addition, she said before her clients become part of the health district's registry she wants some assurances that attorneys for Dr. Dipak Desai, the majority owner of the clinics, and the endoscopy centers don't have access to that information.
"We notified the health district officials about our patients and told them that we would gladly go over the information with them. But we are not about to allow our clients to sign an open-ended release, and that's what the health district wants.''
Morrison and Killebrew also said they believe the health district is overwhelmed, which could lead to some positive hepatitis cases falling through the cracks.
Killebrew said several of her clients fall into that category.
Labus said the health district is not in the business of contacting attorneys.
He said endoscopy center patients were notified twice, and the second time they were told to call the health district to enroll in the registry regardless of whether they tested positive.
He said the attorneys' refusal to allow their clients to speak would impact the agency's investigation.
"If the attorney is telling their client not to enroll in the registry, it doesn't give us the information we need to describe what happened. The people we want to find out the most about, we find out the least about,'' Labus said. "By not allowing their clients to speak to us, the attorneys essentially took out all of the positives and left us with the negatives. That really doesn't help our investigation.''
Morrison said her office is dropping clients if they've determined their infections likely came from a different source.
"This week, our office will be getting rid of a lot of cases based on our expert opinions and prior blood work,'' Morrison said. "What we've found is that there were an awful lot of people in Las Vegas with hepatitis C but didn't know it.''
Contact reporter Annette Wells at firstname.lastname@example.org or 702-383-0283.