RENO, Nev. – The staff at a Las Vegas clinic at the center of a large hepatitis C outbreak likely caused the transmission of the bloodborne pathogen by “routinely mishandling injection equipment and single-use medication vials,” the Centers for Disease Control and Prevention said in a report released Friday.

The CDC's report bolsters earlier conclusions by county and state health officials about the outbreak that led to the biggest public health notification operation in U.S. history. Officials have linked 84 cases of the potentially deadly liver disease to the clinic and have notified 50,000 patients that they may be at risk.

“The practice of reusing syringes during a procedure to access shared propofol (a sedative) was observed, and interviews suggested it was a common practice” at the now-closed Endoscopy Center of Southern Nevada, the CDC doctors said in a report to the Nevada State Health Division.

“This was considered the most likely mode of transmission,” the report said.

Steve George, public information officer for the Nevada Department of Health and Human Services, said the report confirmed that the reuse of syringes likely caused the outbreak.

“Essentially, this is what we've been saying all along,” George said.

“People were saying this didn't happen, that there wasn't any reuse of vials. But the CDC is saying here 'we saw that happen and we made them stop immediately,” he said.

Based on a CDC investigative team's observations, the report said the staff was told to “never reuse needles or syringes when draining medications; never pool medications from individual vials; never use single-use vials for multiple patients; never recap needles; and immediately dispose of sharps in appropriate containers.”

They also were told to wash their hands before providing injections and to wear gloves for procedures that might involve contact with blood.

The report follows recent word from public health administrators that 84 people treated at the clinic tested positive for the potentially deadly virus and had no risk factors other than their treatments. Another case was linked to a sister clinic.

The 85 are among about 400 former patients of the center who tested positive. Officials have determined the other patients could have contracted the virus through other means, including intravenous drug use, blood transfusions, organ transplants or kidney dialysis, receiving blood clotting agents before 1987, or sexual contact with a person with hepatitis C.

Hepatitis C results in the swelling of the liver and can cause stomach pain, fatigue and jaundice. It may eventually result in liver failure. Even when no symptoms occur, the virus can slowly damage the liver.

State health officials contacted the CDC on Jan. 2 after two persons treated at the clinic were diagnosed with acute hepatitis C. The center sent officers from its Division of Viral Hepatitis and Division of Heathcare Quality Promotion to investigate Jan. 9.

The investigators said that while most staff generally wore gloves, one certified registered nurse anesthetist was observed not to do so and one was seen “moving around the room with an uncapped needle.”

The techniques at the clinic “varied, particularly in regard to the manner in which propofol was administered to patients who required additional sedation during an endoscopy procedure,” the report said.

One nurse placed a needle on the same syringe that had been used to administer initial sedation to a patient.

When questioned, the nurse “indicated that reuse of syringes in the manner for an individual patient was his routine practice and reflected what clinic staff had instructed him to do,” the report said.

Another nurse reported having been instructed to reuse syringes to administer multiple doses of propofol to an individual patient, but did not do so.

Nurses also were observed pre-filling multiple 10cc syringes with 1 cc of lidocaine, recapping the needles and storing them in a drawer.

“The syringes were neither labeled with their contents nor dated,” the report said.

The Endoscopy Center and several other clinics were headed by doctors Dipak Desai and Eladio Carrera, whose Nevada medical licenses have been suspended pending state Board of Medical Examiners hearings.

Las Vegas police have seized medical records from the clinics, and the FBI, the Nevada state attorney general and the Clark County district attorney are involved in a criminal investigation. The owners of the clinics have surrendered business licenses and paid $500,000 in fines.

Former patients at the Endoscopy Center are being tested for hepatitis strains C, B, and HIV, the virus that causes AIDS. No cases of hepatitis strain B or HIV have been linked to the outbreak.

Since 1999, the CDC counts 14 hepatitis outbreaks in the U.S. linked to bad injection practices.

The largest outbreak occurred in Fremont, Neb., where 99 cancer patients were infected at an oncology center from 2001 to 2002. At least one died.

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