Mayo Clinic Proceedings Home

Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel

  • Melissa K. Schaefer
    Correspondence: Address to Melissa K. Schaefer, MD, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-31, Atlanta, GA 30333.
    Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
    Search for articles by this author
  • Joseph F. Perz
    Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
    Search for articles by this author



      To summarize available information about outbreaks of infections stemming from drug diversion in US health care settings and describe recommended protocols and public health actions.

      Patients and Methods

      We reviewed records at the Centers for Disease Control and Prevention related to outbreaks of infections from drug diversion by health care personnel in US health care settings from January 1, 2000, through December 31, 2013. Searches of the medical literature published during the same period were also conducted using PubMed. Information compiled included health care setting(s), infection type(s), specialty of the implicated health care professional, implicated medication(s), mechanism(s) of diversion, number of infected patients, number of patients with potential exposure to blood-borne pathogens, and resolution of the investigation.


      We identified 6 outbreaks over a 10-year period beginning in 2004; all occurred in hospital settings. Implicated health care professionals included 3 technicians and 3 nurses, one of whom was a nurse anesthetist. The mechanism by which infections were spread was tampering with injectable controlled substances. Two outbreaks involved tampering with opioids administered via patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining 4 outbreaks involved tampering with syringes or vials containing fentanyl; hepatitis C virus infection was transmitted to 84 patients. In each of these outbreaks, the implicated health care professional was infected with hepatitis C virus and served as the source; nearly 30,000 patients were potentially exposed to blood-borne pathogens and targeted for notification advising testing.


      These outbreaks revealed gaps in prevention, detection, and response to drug diversion in US health care facilities. Drug diversion is best prevented by health care facilities having strong narcotics security measures and active monitoring systems. Appropriate response includes assessment of harm to patients, consultation with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies.

      Abbreviations and Acronyms:

      CDC (Centers for Disease Control and Prevention), CDPHE (Colorado Department of Public Health and Environment), CRNA (certified registered nurse anesthetist), DEA (Drug Enforcement Administration), HCV (hepatitis C virus), PCA (patient-controlled analgesia pump)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. New Hampshire Department of Health and Human Services, Division of Public Health Services. State of New Hampshire Hepatitis C Outbreak Investigation Exeter Hospital Public Report. Published June 2013. Accessed December 10, 2013.

      2. United States Attorney’s Office, District of New Hampshire. Former employee of Exeter Hospital pleads guilty to charges related to multi-state hepatitis C outbreak [press release]. Published August 13, 2013. Accessed December 10, 2013.

      3. Claffey J. Trial dates scheduled for Exeter hepatitis C lawsuits. ExeterPatch website. Published March 29, 2013. Accessed December 10, 2013.

      4. Maryland Department of Health and Mental Hygiene. Public Health Vulnerability Review: Drug Diversion, Infection Risk, and David Kwiatkowski’s Employment as a Healthcare Worker in Maryland. Published March 2013. Accessed December 10, 2013.

      5. Caruso DB, Ramer H. Hepatitis C outbreak: arrest of medical technician David Kwiatkowski shows flaws in system. Huffpost Healthy Living website. Published August 14, 2012. Accessed December 10, 2013.

        • Finn P.
        Inaccurate resume hid felon’s tracks.
        Fort Worth Star-Telegram. January 30, 1995; (News, p 1)
      6. National Association of Drug Diversion Investigators. What exactly is drug diversion? National Association of Drug Diversion Investigators website. Published May 12, 2011. Accessed December 10, 2013.

        • Berge K.H.
        • Dillon K.R.
        • Sikkink K.M.
        • Taylor T.K.
        • Lanier W.L.
        Diversion of drugs within health care facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection, and prevention.
        Mayo Clin Proc. 2012; 87: 674-682
        • Guh A.Y.
        • Thompson N.D.
        • Schaefer M.K.
        • Patel P.R.
        • Perz J.F.
        Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001-2011.
        Med Care. 2012; 50: 785-791
        • Behrens-Muller B.
        • Conway J.
        • Yoder J.
        • Conover C.S.
        Investigation and control of an outbreak of Achromobacter xylosoxidans bacteremia.
        Infect Control Hosp Epidemiol. 2012; 33: 180-184
      7. United States of America v Kristen Parker. United States Court of Appeals, 10th Circuit. No. 10-1072 (D.C. No. 1:09-CR-00332-REB-01) (D. Colo.). Filed February 18, 2011.

      8. Minnesota Department of Health, Infectious Disease Epidemiology, Prevention and Control Division. Outbreak of Gram-Negative Bacteremia at St. Cloud Hospital: Investigation Summary, Minnesota Department of Health, 2011. Published September 14, 2012. Accessed December 10, 2013.

      9. United States Attorney’s Office, Minnesota. Kimball nurse sentenced for fraudulently obtaining a controlled substance [press release]. Published March 20, 2013. Accessed December 10, 2013.

      10. Lee KC, Scoville S, Taylor R, et al. Outbreak of acute hepatitis C virus (HCV) infections of two different genotypes associated with an HCV-infected anesthetist [abstract]. Poster presented at: 43rd Annual Infectious Diseases Society of America Annual Conference; October 8, 2005; San Francisco, CA.

      11. Meritz, D. Former nurse at Beaumont Army Medical Center given 3½ years. El Paso Times. Published December 2, 2009. Accessed December 10, 2013

      12. United States of America v Jon Dale Jones. US District Court Western District of Texas El Paso Division Plea Agreement. Case 3:08-cr-00595-FM. Filed April 6, 2009.

        • Perz J.F.
        • Thompson N.D.
        • Schaefer M.K.
        • Patel P.R.
        US outbreak investigations highlight the need for safe injection practices and basic infection control.
        Clin Liver Dis. 2010; 14: 137-151
        • Vogt T.M.
        • Perz J.F.
        • Van Houten Jr., C.K.
        • et al.
        An outbreak of hepatitis B virus infection among methamphetamine injectors: the role of sharing injection drug equipment.
        Addiction. 2006; 101: 726-730
        • Hellinger W.C.
        • Bacalis L.P.
        • Kay R.S.
        • et al.
        Health care-associated hepatitis C virus infections attributed to narcotic diversion.
        Ann Intern Med. 2012; 156: 477-482
      13. United States Attorney’s Office, Middle District of Florida. Radiology technician sentenced to 30 years for product tampering [press release]. Published September 11, 2012. Accessed December 10, 2013.

      14. United States Attorney’s Office, District of New Hampshire. Former employee of Exeter Hospital sentenced in connection with widespread hepatitis C outbreak [press release]. Published December 2, 2013. Accessed December 10, 2013.

      15. New York State Department of Health. Westchester Co. hospital notifies patients of possible hep C exposure [press release]. Published July 15, 2009. Accessed December 10, 2013.

      16. Ramer H. Hepatitis C tests continue after medical tech David Kwiatkowski’s arrest. Huffpost Healthy Living website. Published December 22, 2012. Accessed December 10, 2013.

      17. Kansas Department of Health and Environment. State health officials provide update in the case of potential hepatitis C exposures at Hays Medical Center [press release]. Published August 10, 2012. Accessed December 10, 2013.

      18. Walker AK. 1,750 Had possible contact with technician with hepatitis C. Baltimore Sun. Published August 12, 2012. Accessed December 10, 2013.

        • Maki D.G.
        • Klein B.S.
        • McCormick R.D.
        • et al.
        Nosocomial Pseudmonas pickettii bacteremias traced to narcotic tampering: a case for selective drug screening of health care personnel.
        JAMA. 1991; 265: 981-986
        • Ostrowsky B.E.
        • Whitener C.
        • Bredenberg H.K.
        • et al.
        Serratia marcescens bacteremia traced to an infused narcotic.
        N Engl J Med. 2002; 346: 1529-1537
        • Sehulster L.
        • Taylor J.
        • Hendricks K.
        • VanEgdom M.
        • Whitely S.
        • Manning S.
        Hepatitis C outbreak linked to narcotic tampering in an ambulatory surgical center [abstract].
        in: Program and Abstracts of the 37th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy. American Society for Microbiology, Washington, DC1997: 293
      19. US Department of Health & Human Services. Combating the Silent Epidemic of Viral Hepatitis: Action Plan for the Prevention, Care, & Treatment of Viral Hepatitis. Accessed December 20, 2013.

      20. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control. Practitioner’s Manual: An Informational Outline of the Controlled Substances Act. 2006 edition. Accessed December 20, 2013.

      21. Centers for Medicare and Medicaid Services. 42 CFR 482.25 Condition of participation: Pharmaceutical services, (b)(1)(ii). Updated April 25, 2014. Accessed December 10, 2013.

        • Patel P.R.
        • Srinivasan A.
        • Perz J.F.
        Developing a broader approach to management of infection control breaches in health care settings.
        Am J Infect Control. 2008; 36: 685-690
        • Gallagher T.H.
        • Levinson W.
        Disclosing harmful medical errors to patients: a time for professional action.
        Arch Intern Med. 2005; 165: 1819-1824
      22. US Department of Health & Human Services, Office of Inspector General. A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse. Accessed December 20, 2103.

      23. Missouri Bureau of Narcotics & Dangerous Drugs. Drug Diversion in Hospitals: A Guide to Preventing and Investigating Diversion Issues. Published March 2011. Accessed December 20, 2013.

      24. Joyner C. Nurse suspended 3 years after drug offense: case illustrates how far behind the state nursing board has fallen. Atlanta Journal-Constitution. Published November 23, 2013. Accessed December 10, 2013.

      25. Sanborn A. Exeter Hospital suing alleged hepatitis C infector. Seacoastonline website. Published November 22, 2013. Accessed December 10, 2013.

      26. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control. Title 21 Code of Federal Regulations. Part 1301—Registration of manufacturers, distributors, and dispensers of controlled substances. Security requirements. 1301.76 Other security controls for practitioners, (b). Accessed December 10, 2013.

      27. Farnsworth S. Doctor admits infecting patients with hepatitis C. ABC News website. Published November 9, 2012. Accessed December 10, 2013.

        • Shemer-Avni Y.
        • Cohen M.
        • Keren-Naus A.
        • et al.
        Iatrogenic transmission of hepatitis C virus (HCV) by an anesthesiologist: comparative molecular analysis of the HCV-E1 and HCV-E2 hypervariable regions.
        Clin Infect Dis. 2007; 45: e32-e38
        • Bosch X.
        Spanish anaesthetist infects patients with hepatitis C.
        BMJ. 1998; 316 (1625.5)
        • Cody S.H.
        • Nainan O.V.
        • Garfein R.S.
        • et al.
        Hepatitis C virus transmission from an anesthesiologist to a patient.
        Arch Intern Med. 2002; 162: 345-350
        • Perz J.F.
        • Grytdal S.
        • Beck S.
        • et al.
        Case-control study of hepatitis B and hepatitis C in older adults: do healthcare exposures contribute to burden of new infections?.
        Hepatology. 2013; 57: 917-924
      28. Ibata D. Driver in Gwinnett wrong-way crash jailed. website. Published August 29, 2012. Accessed March 24, 2014.

        • Warner D.O.
        • Berge K.
        • Sun H.
        • Harman A.
        • Hanson A.
        • Schroeder D.R.
        Substance use disorder among anesthesiology residents, 1975-2009.
        JAMA. 2013; 310: 2289-2296
      29. Minnesota Department of Health, Minnesota Hospital Association. Minnesota Controlled Substance Diversion Prevention Coalition Final Report. Published March 2012. Accessed December 10, 2013.