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Improper Infection-Control Practices During Employee Vaccination Programs -- District of Columbia and Pennsylvania, 1993

MMWR 42(50);969-971

Publication date: 12/24/1993

Table of Contents


Reported by

Editorial Note




The improper use of needles and syringes and contamination of multidose medication vials can result in transmission of bloodborne pathogens (e.g., hepatitis B virus {HBV} and human immunodeficiency virus {HIV}) and other infectious agents from patient to patient (1-6). Since September 1993, CDC has received reports from health-care providers and public health departments in two U.S. cities regarding improper infection-control practices during vaccination of employees at worksite vaccination programs. These practices could potentially have exposed vaccine recipients to infectious agents. This report summarizes the preliminary findings of an ongoing investigation of these reports.(*)

(*) Single copies of this report will be available free until December 17, 1994, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231.

District of Columbia. A company occupational health officer reported that a physician retained to administer influenza vaccine to employees had been observed reusing needles to subsequently vaccinate other employees. Investigation by the local health department confirmed that the physician vaccinated a series of employees by using the following routine: the physician first aspirated several doses of vaccine from a multidose vial into a syringe, inoculated an employee, and then, after wiping the needle with an alcohol swab, used the same needle and syringe to subsequently inoculate another employee.

Pennsylvania. A supervisor at a worksite reported that a physician retained to administer influenza and pneumococcal vaccines to employees had been observed puncturing multidose vials of vaccine with needles that had been used previously to inoculate patients. Investigation by the local health department confirmed that the physician first aspirated a dose of influenza vaccine into a syringe and inoculated an employee; then, using the same syringe and needle, aspirated pneumococcal vaccine from a multidose vial of that vaccine and inoculated the same person. Although a new syringe and needle were used for each employee, the physician repeatedly punctured the multidose vials containing pneumococcal vaccine with used needles.

Follow-up. Persons who received vaccinations at these worksites have been counseled and offered serotesting for bloodborne pathogens (e.g., HBV and HIV). Further investigation and follow-up of the vaccine recipients are ongoing.

Reported by

M Levy, MD, District of Columbia Commission of Public Health. M Moll, MD, BR Jones, DVM, Pennsylvania Dept of Health. HIV Infections Br, Hospital Infections Program, and Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; National Immunization Program; National Institute for Occupational Safety and Health, CDC.

Editorial Note

This report describes examples of improper use of needles, syringes, and multidose vials that could potentially result in patient-to-patient transmission of infectious agents. For example, bacteria can survive in and have been transmitted to patients through contaminated multidose vials and syringes (1,2,7). HBV has been transmitted by contaminated multidose medication vials and reuse of contaminated needles and syringes (3,4). In addition, nosocomial patient-to-patient transmission of HIV has occurred when needles and syringes were reused without being properly sterilized (5) or were inadvertently reused between patients (6). Finally, in a laboratory simulation of improper clinical use, syringes and multidose vials became contaminated with viruses (8).

Reports of transmission of infectious agents by a single injection with a contaminated needle and syringe or from a multidose vial have been limited. However, the frequency with which injections are administered in health-care settings increases the likelihood of infection transmission if proper infection-control practices are not followed when medications, vaccines, and other parenteral substances are injected. The following infection-control principles are consistent with previous CDC recommendations and should be adhered to by health-care providers and all other persons who administer parenteral substances by injection (9,10):


  1. Stetler HC, Garbe PL, Dwyer DM. Outbreaks of group A streptococcal abscesses following diphtheria-tetanus toxoid-pertussis vaccination. Pediatrics 1985;75:299-303.

  2. CDC. Postsurgical infections associated with an extrinsically contaminated intravenous anesthetic agent -- California, Illinois, Maine, and Michigan, 1990. MMWR 1990;39:426-7,433.

  3. Alter MJ, Ahtone J, Maynard JE. Hepatitis B transmission associated with a multiple-dose vial in a hemodialysis unit. Ann Intern Med 1983;99:330-3.

  4. Oren I, Hershow RC, Ben-Porath E, et al. A common-source outbreak of fulminant hepatitis B in a hospital. Ann Intern Med 1989;110:691-8.

  5. Hersh BS, Popovici F, Apetrei RC, et al. Acquired immunodeficiency syndrome in Romania. Lancet 1991;338:645-9.

  6. CDC. Patient exposures to HIV during nuclear medicine procedures. MMWR 1992;41:575-8.

  7. Highsmith AK, Greenhood GP, Allen JR. Growth of nosocomial pathogens in multidose parenteral medication vials. J Clin Microbiol 1982;15:1024-8.

  8. Plott RT, Wagner RF, Tyring SK. Iatrogenic contamination of multidose vials in simulated use: a reassessment of current patient injection technique. Arch Dermatol 1990;126:1441-4.

  9. Garner JS, Favero MS. Guidelines for handwashing and hospital environmental control. Am J Infect Control 1986;14:110-26.

  10. CDC. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(no. 2S).


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