Outbreak was preventable

The largest health-care-related hepatitis C outbreak in U.S. history, which could cost as much as $21 million in investigative and medical expenses, could have been prevented, according to the Southern Nevada Health District's final investigative report.

The two-year investigation determined that unsafe injection practices at the Endoscopy Center of Southern Nevada and its sister clinic, Desert Shadow Endoscopy Center, probably led to the infections of as many as 115 clinic patients, the 266-page report said.

Nine of the cases were linked to the clinics, while the other 106 were possibly linked, the report said.

The unsafe injection practices prompted health officials to notify some 63,000 clinic patients that they might have been exposed to hepatitis, HIV and other blood-borne diseases -- the largest patient notification of its kind in the country's history.

On average, more than 9 percent of the county's households had a member who could have been exposed, and more than 14 percent of the county's residents ages 65 to 69 were at risk, said Brian Labus, the health district's senior epidemiologist.

"When you have nearly 10 percent of the population potentially involved, people are always going to be interested in what happens," he said. "This wasn't just a few people getting sick eating at a restaurant. ... Everybody knows somebody who got a letter to get tested."

Through interviews and observations, investigators identified a combination of unsafe injection practices at the clinics, including reusing syringes on a single patient and reusing vials of anesthetic between patients.

Although investigators cannot say with certainty that the unsafe injection practices led to the infections, they ruled out every other possible source, including transmission from unclean scopes and reusing bite blocks, according to the report.

"We can never prove that it was done that way, but we looked at every possible alternative," Labus said.

The health investigation prompted scores of civil lawsuits and pending criminal investigations centered on Dr. Dipak Desai, the clinics' principal owner.

Desai's criminal lawyer, Richard Wright, had no comment on the final report.

Some nurse anesthetists told investigators they were instructed to use the unsafe practices, according to the report.

Trial lawyers who are representing hundreds of former clinic patients with lawsuits, said they were pleased with the final report's findings.

"It's pretty clear from the report that there is only one way that this could have happened," lawyer Will Kemp said.

Attorney Gerald Gillock said some patients and their lawyers worried the health district would back off its initial findings about the unsafe injection practices.

"It was a general concern on behalf of the litigants," he said. "But I think the health department stood by its responsibilities. There was nothing that would exonerate the clinics."

The health district's investigation began Dec. 4, 2007, with the first report of a hepatitis C case from a former patient at the Endoscopy Center of Southern Nevada.

Investigators soon identified a cluster of hepatitis C cases linked to the clinic and contacted the U.S. Centers for Disease Control for help.

Federal, state and local health officials worked together on the investigation, which included interviews with clinic workers and observations of their practices.

The investigation genetically linked seven hepatitis C infections to the Endoscopy Center, including six on Sept. 21, 2007. Patients who went to the clinic that day were 31 million times more likely to develop an acute hepatitis C infection, the report said.

Another case was directly linked to the Endoscopy Center, and an additional case was linked to the Desert Shadow clinic. Health officials identified another 106 cases from both clinics that were possibly linked to the clinics. Other possible infection sources could not conclusively be ruled out.

After announcing the outbreak and patient notification in February 2008, health officials set up a hot line that took 35,391 calls through the end of October 2008. At one point the line took 510 calls in one hour, Labus said.

Costs for the health district investigation were $828,369. Add in the $13.8 million spent to test thousands of clinic patients and future medical costs for hepatitis treatment, and the final cost for the outbreak will range from $16 million to $21 million, the report estimated.

Labus said the report focused on details about what happened and how it happened, but not why.

"I imagine there will be people who wish we had the motive for what happened," he said. "But that's not what the health district does. We laid the groundwork to find out the why."

Contact reporter Brian Haynes at bhaynes@reviewjournal.com or 702-383-0281.