Lives Are Shattered by Needle Sharing at Cancer Clinic
Squinting through the red chemo fog clouding her vision, breast cancer patient Jill Watson couldn’t be sure that she was seeing this right.
A nurse had just used a needle and syringe to flush the catheter implanted in Watson’s chest with saline solution. Watson was sure of that much. She had felt the needle’s pinch.
As the nurse moved on to repeat the procedure on the next patient in the small clinic, Watson craned her neck to watch. Was the nurse using the same syringe and the same saline bag? Could that possibly be right?
Watson tried to think about that, but she was so very tired.
More than a year later, Watson’s cancer was in remission. But she got something in the mail that took her back to the cancer clinic and had her replaying that scene in her mind again and again.
It was a letter from the state health department. Several people in the Fremont area had been infected with hepatitis C, the letter said. And all of them had been treated at the same clinic as Watson. In all, 612 patients of Dr. Tahir Javed would have to be tested for the virus.
After the testing, 81 of the clinic’s patients got devastating news. Because the clinic had failed to use the most basic sanitary precautions, they had contracted a disease that can be fatal and often requires a liver transplant.
To public health workers, it was shocking -- all the more so because it was not the first time that this had happened. Less than two months before the September outbreak in Fremont, it was discovered that 80 people were infected with hepatitis C in Norman, Okla., when a nurse there reused needles and syringes.
“We’re very concerned about this,” said Beth Bell, chief epidemiologist in the Centers for Disease Control and Prevention’s viral hepatitis division. “Two outbreaks of the magnitude of Nebraska and Oklahoma so close in time are unprecedented.”
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Today, Javed’s oncology clinic, in a space rented from the Fremont Area Medical Center, sits padlocked.
He and his wife and children returned to Pakistan in July. He has not contacted his patients since.
His disappearance is a stinging slap to a community whose slogan is “Fremont: We’re What You’ve Been Looking For!”
People thought that Javed had found it when he agreed to direct the new Fremont Cancer Clinic. Part of the deal: a three-story, $5.2-million oncology center now under construction to rival cancer clinics in Omaha and Lincoln.
Embracing both biotechnology and a foreign-born doctor seemed like a bold plan for this town of 24,000.
Fremont is a 19th-century rail hub surrounded by flat horizons of cornfield stubble and rich black earth. Family-owned stores still crowd Main Street like a diorama of a past America -- Lou’s Sporting Goods next to Sampter’s Clothiers & Tuxedo Rentals, across from Abe Krasne Home Furnishings. Outside the hardware store, gleaming rototillers and snow blowers line up on the sidewalk like spiffy soldiers for inspection.
Men here aren’t likely to drive very far in their pickup trucks without wearing a ball cap and chewing a toothpick.
In contrast, nobody recalls seeing Javed -- a trim man with rectangular eyeglasses and a shock of coal-black hair -- wearing anything but a suit and tie. His credentials include postgraduate work at three U.S. universities.
Around Fremont, the whispers are deafening.
Local real estate agents combing through property records learned that Javed sold his home over the summer.
He told townspeople that his busy practice supported a free clinic and school in a remote corner of his native Punjab province near the border with India. An Internet Web site soliciting contributions describes the Javed Welfare Foundation as a “very small foundation being started by our family and friends ... to provide services to the needy, sick and poor.”
In October, Javed, 37, was elected to the Punjab provincial assembly. His family is politically active; his father was mayor of their village.
His attorney, Michael Jones of Omaha, says Javed has not decided whether to return to the United States.
“It would be easy to turn this into a witch hunt,” Jones said. “He is a very caring physician. He did not know what happened in the clinic or how it happened.”
Many patients still praise Javed for his gentle bedside manner, noting that he would drive patients home and answer their midnight telephone calls.
“I can’t believe he hasn’t come back,” Jill Watson said.
Other patients apparently never noticed that something was amiss at Javed’s clinic. But Watson worked as a clerk at the hospital, including the infection control office.
She applied to be Javed’s receptionist when he moved to Fremont in 1998 from the Medical University of South Carolina in Charleston.
She didn’t get the job. But she helped the hospital foundation raise money to buy the recliners used in the chemotherapy clinic.
During one of her groggy chemo sessions, Watson screwed up her courage and asked the nurse why she wasn’t wearing protective gloves.
“Latex allergy,” the nurse replied, offering her red, scaly claws for inspection.
Shouldn’t she be using more than one syringe?
“Everything’s fine,” Watson was assured. “Now lie back before you start clotting.”
Watson rewinds the memory over and over.
“Why didn’t she know better?”
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Dr. Tom Safranek asks that question too.
As Nebraska’s state epidemiologist, he has grown accustomed to rapid-fire updates on West Nile virus.
And bioterrorism. With hoofed animals outnumbering humans 5-to-1 here, Homeland Security officials are pumping $9.7 million into Nebraska for anthrax surveillance.
But the call he got in late September about two hepatitis C carriers jolted him.
Both patients had genotype 3A. That strain accounts for fewer than 10% of all viral hepatitis C cases in the United States. And both patients received chemotherapy at the Fremont clinic beginning in 2000.
“We have to test everyone who’s been at the clinic,” Safranek said. “We don’t know how big the risk is.”
How did it happen? Safranek called the chemo nurse. Quickly, his suspicions matched Watson’s fears.
His summary: The nurse used a sterile needle to pierce each patient’s chest valve. But when she flushed their ports, she would uncouple the syringe and fill it from a jumbo saline bag.
In mid-2000, one of the patients at the clinic was already unknowingly infected with HCV. Once that patient’s syringe touched the saline, as many as 49 additional patients whose chest valves also were flushed with saline from the same bag were exposed to the virus.
The nurse repeated the dirty practice, bag after bag, for more than a year. In all, 621 patients were exposed.
“You always have a bag of saline going, so, in effect, you are continuously contaminated,” Safranek said.
State health officials will decide whether to suspend or revoke the nurse’s license. The nurse has not been officially identified. She has not responded to repeated calls by the Associated Press at her home in Fremont.
She left Javed’s clinic in June 2001. Now she works at an Omaha hospital; her supervisors told Safranek that she works under tighter controls than at the small Fremont clinic.
Safranek doesn’t excuse the nurse’s apparent ignorance. “You’re supposed to learn this stuff in nursing school,” he said.
But he wondered: “Why wasn’t there sufficient supervision or education or training in the back of that clinic?”
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Hospital-acquired infections kill 90,000 Americans annually. Most are infected by antibiotic-resistant superbugs that defy the most aggressive controls.
Hepatitis C is different. Outbreaks can be traced to ignorance of basic sterile practices, rules that are, in the words of the Centers for Disease Control and Prevention, “well established and long-standing.”
Yet in Brooklyn, N.Y., 19 patients were infected at a neighborhood clinic in 2001 when an anesthesiologist reused needles and a vial of medication.
And earlier this year, 52 people were infected with HCV by nurse anesthetist James C. Hill in Norman, Okla. He admitted that he reused needles and syringes up to 25 times a day when he injected back pain medication through intravenous tubes.
Health authorities say his mistake was not intentional.
After that incident, the American Assn. of Nurse Anesthetists sent out more than 30,000 letters warning hospitals and nurses not to reuse needles.
“After discussion with infection-control experts, we have concerns there may be a widespread misunderstanding by health care practitioners of the dangers associated with the reuse of needles and syringes,” the letter said.
Viral hepatitis C is perhaps the most common blood-borne infection in the United States with 4 million carriers. HCV slowly attacks the liver. Symptoms might not appear for 20 years.
It kills up to 10,000 Americans each year. Federal health officials expect the rate of infection to quadruple in the next 10 years.
The virus is rampant among IV drug addicts and prison inmates who share tattoo needles. But it also spreads among chronically ill patients who regularly receive infusions and injections -- especially those on dialysis.
If the immune system doesn’t clear the virus naturally, physicians turn to a combination drug therapy that lasts 12 to 48 weeks. Among the strains of hepatitis C, genotype 3A is among those that respond better to the drugs, officials said.
Among the drugs’ side effects are multiple neuropsychiatric symptoms, including severe depression, psychosis, even suicide.
The alternative is a $350,000 liver transplant and a lifetime on powerful anti-rejection drugs. Fourteen thousand Americans are on waiting lists for liver transplants.
Those were the prospects facing Watson, already struggling to beat cancer.
During the three-week wait for her test results, she focused on her three children and the routines of any young mother. Laundry. Homework. Halloween costumes. Christmas shopping.
On a Tuesday morning, the letter came.
She gasped for joy.
“I am happy to inform you that your blood has tested NEGATIVE,” the form letter read.
“Based on this information we are confident that you ARE NOT infected. No further testing or medical care is necessary.”
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Grandmothers. Farmers. Teachers. Grain loaders. Even a paramedic.
Fremont attorney Jim Davis finds worried people by the dozen sitting on his cold office steps in the morning. They’re waiting for him after lunch. They keep him working late into the evening.
They are Javed’s patients and the survivors of patients who died.
“We try to schedule them one every hour, but they just walk in,” said Davis, who previously won class-action lawsuits against failed vaccines and defective orthopedic bone screws. “In their mental state, I’m not going to tell them to make an appointment.”
In Dodge County, at least three patients have filed lawsuits against Javed and the hospital. The largest claim is for $1.25 million, filed by Thomas W. Stover and his wife, Lois. Stover was infected with hepatitis.
The Stovers probably won’t get rich. Nebraska is one of the few states that does not allow victims to collect punitive damages. Survivor payouts in wrongful death judgments are limited too.
“There will be no windfalls,” Davis said.
Who will pay? Hospital officials say they just rented clinic space to Javed.
State health officials describe the clinic as a “gray area.” They say the health care industry is relying more on outpatient clinics because they generate profits with less regulatory oversight -- including infection control.
Davis, who grew up in Fremont and once worked as a road manager for country singer Willie Nelson, wants to establish a multimillion-dollar trust to finance drug therapy and extended patient care. But first he must establish whether Javed still has malpractice insurance.
“It’s probably a given that some of these people are going to need liver transplants down the road,” he said.
