That's because it's unclear how many of these unsafe practices have been noticed or reported. When they are, the process of notifying patients does not always find them. If the patients are found, not all seek testing and if they do seek testing, they may choose not to get back to the notifying health provider whether they were infected.
"I honestly don't know," says Guh, principal author of the report. "There is a part of me that wonders if this is the tip of the iceberg."
Healthcare workers "are not waking up and saying, you know, I'm going to go and intentionally, deliberately re-inject a syringe," Guh says. "A lot of it comes down to providers or clinicians doing what they observed others doing or what they had been taught. We find that people say, 'Well, this is how I was taught to do it,' and so they continue doing it that way."
Guh's study looked at events that resulted in communicating to groups of patients about the possibility they were infected with a bloodborne pathogen stemming from an unsafe injection practice between 2001 and 2011.
The researchers said they identified 35 patient notification events in at least 17 states and the District of Columbia. And nearly three in four occurred since 2007, including all four of the events involving more than 5,000 patients.