San Francisco Chronicle - Friday, April 16, 1999
Sabin Russell, Chronicle Staff Writer

Health officials in San Mateo and Santa Clara counties were preparing to mail out the warnings as early as this weekend to patients of the SmithKline Beecham Clinical Laboratory at 1101 Welch Road in Palo Alto.

"We all feel that the risk is quite low," said Dr. Jon Rosenberg, a state Department of Health epidemiologist who has been in charge of the investigation since SmithKline disclosed the problem 10 days ago. "But we can't assure ourselves that there is no risk, so we think people need to have this information."

Rosenberg said that the unidentified technician -- known as a phlebotomist --freely acknowledged re- using certain needles to draw blood from patients with difficult-to-pierce veins. She would wash the needles with water and a dilute solution of hydrogen peroxide -- which might kill some but not all pathogens in infected blood.

Although the woman typically worked alone at the office, investigators say a co-worker saw her reuse a needle March 22. SmithKline officials interviewed the phlebotomist, fired her and notified the state Department of Health Services on April 6.

SmithKline spokeswoman Tobey Dichter said the lapse in standard safety precautions was "shocking," and that nothing like it had happened in 30 years. "Our first concern is for the health of the patients," she said. "We are working to determine the risk, if any, and will do whatever is medically appropriate to support them."

Patients who had their blood drawn at the laboratory while the woman was employed there will be offered free tests at an independent laboratory under a program being established by the Department of Health Services. SmithKline will not perform the tests but will pay all costs associated with the program.

The technician told investigators that she reused needles only occasionally and during a limited period of her tenure. While this is reassuring, said Rosenberg, "we are not going to take her word for it."

The woman worked mostly unsupervised in the tiny office since June 1997. The clinic typically drew blood from 15 patients a day.

She was trained as a phlebotomist in 1994 and has worked in as many as 10 other Bay Area labs since then. Investigators are tracking down her previous employers and are assessing whether the notifications need to be expanded beyond those patients who had blood drawn in Palo Alto.

Since the disclosure of hazardous practices, state and county health officials have been huddled with investigators from the federal Centers for Disease Control and Prevention to determine what happened and what to do next.

Reuse of disposable needles is a gross violation of accepted safety procedures. It presents a small but not insignificant risk that viral diseases such as AIDS and hepatitis B and C can be transmitted if they were present in the blood of patients on whom the needles were previously used.

Based on the employee's own recollection, investigators believe that she reused needles during a limited period. The technician was described as cooperative with investigators, who do not believe she acted maliciously.

Health authorities are reassured that the risk of viral transmission is low because the clientele using the lab does not have a high percentage of HIV and hepatitis. They also believe that the washing procedure may have killed most viral particles if they were present and that the risk of transmission is lower when needles are used to draw blood rather than inject medications.

Health officials worry that disclosure of the potential risk may cause more health problems than the sloppy blood-drawing technique ever could: unnecessary anxiety, anger and stress. "Our primary concern is that we don't harm people," said Rosenberg. "We're concerned about alarming people unnecessarily about risk they may not have had incurred."

State and county officials had planned to disclose the problem at a news conference next week, after doctors and patients had received the notification. The state Health Department issued a statement about the investigation after an inquiry by The Chronicle last night.

"We're not going to sit on this," said Health Department spokesman Ken August.

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