In March 1997 the infection control committee chief of a Riyadh hospital consulted us about a 14 month old girl with an acute Plasmodium falciparum infection. The patient and her family had never left Riyadh (a non-malarious area) since her birth, but the patient had been hospitalized for asthma 2 weeks previously.
Methodology
We reviewed all other malaria cases reported during February and March 1997 and routine vector surveillance for leishmaniasis control for Riyadh. We reviewed the patient files of all malaria patients on the pediatric ward of the hospital. We compared times of intravenous access and nursing staff of the girl during her asthma admission. We reviewed our data with medical and nursing staff.
Results
Malaria surveillance reports for February and March revealed 62 other malaria cases in Riyadh. All were in persons with recent travel to malarious areas and none were from the neighborhood of the girl. No anophelines had been captured in the Riyadh area. The asthma admission of the girl, 11 to 17 days before onset of malarial fever, overlapped with hospitalization of 3 patients to the same ward with imported P. falciparum infections. The asthmatic girl had received no blood products. Nurses routinely used single-use one-ml syringes to administer heparin solution from a common container (50 ml) to flush intravenous lines (IVLs) and heparin locks of the asthma patient and two malaria patients. No single nurse had used this heparin on the malaria patients and the girl during the same shift. After we presented this incident to the ward staff, a pediatrician recalled that she observed that after filling a syringe a nurse detached the syringe from the needle leaving the needle in place through the rubber diaphragm of the heparin container. After using a heparin syringe to start an IVL the nurse reattached the used syringe to the original needle to withdraw more heparin. Blood was visible entering the heparin container. The hospital administration responded by providing point of use syringe disposal in all patient rooms and switching to single use heparin containers.
Conclusion
Malaria was probably transmitted by contamination of the heparin container with blood of a malaria patient. Leaving needles in place in multi-dose containers was noted to be a common practice in a recent study of post vaccination abscesses and needs to be eliminated.