Gathering of Nation’s glucose testing flawed

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ALBUQUERQUE, N.M. – People who received free blood glucose testing at the Indian Pueblo Cultural Center April 24 may have been exposed to blood borne diseases and are being urged by public health officials to contact the University of New Mexico for follow up risk assessment and care.

Officials from the cultural center and the UNM Health Science Center issued the alert in a press conference and on the university’s Web site about the diabetes testing incident that took place during the weekend of the Gathering of Nations powwow and the cultural center’s American Indian Week “Pueblo Days.”

A group of student volunteers from the university’s Physician Assistant program held a free diabetes screening clinic at the Indian Pueblo Cultural Center that week, but they did the tests incorrectly, using the same needle on multiple people and potentially exposing them to diseases spread by blood contact, according to Dr. Bob Bailey, associate dean of the university’s Health Science Center and incident commander.

“We estimate that 51 to 55 individuals were tested, potentially exposing these people to others’ blood. The diseases of greatest concern are Hepatitis B and C although theoretically HIV is also possible. Our best current assessment of the risk of infection is less than a 0.5 percent risk. Even though the risk is small it is something we are very concerned about and are taking it seriously,” Bailey said.

Bailey said the UNM School of Medicine deeply regrets the error and apologized to all those who may have been exposed, and to the Indian Pueblo Cultural Center.

“We are asking that those who were tested come forward so we can better assess any risk from this episode and assure that exposed persons receive appropriate follow-up testing and care. If you know someone who was tested please contact us.”

The University of New Mexico will cover the costs of the follow up services.

Not all of the individuals were tested with the same lancet, Bailey said.

“Many of the tests were done correctly and safely. While it is likely that others tested were tested by the same lancet to draw blood, it is unlikely that a single lancet was used and shared by all of those who were incorrectly tested.”

The error was discovered by the students, Bailey said.

“To their credit, the students were talking to one another afterward and some of them realized from the way people were talking about it that they hadn’t used the device in the way that others had. They were concerned enough to go to their faculty member and he was concerned enough to bring it forward, and we sat down with the students and asked them to demonstrate the use of the device and clarified that in fact they had misused it.

“The students are feeling pretty bad right now.”

So are some of the individuals who were tested. Indian Country Today received an e-mail from an individual whose mother and niece were among those tested.

“Our family is angry, concerned and upset for this negligence,” he said.

“I don’t blame people for being angry,” Bailey said, but added that he is concerned the incident is being seen as a Native American event.

“Clearly, it was at the Indian Pueblo Cultural Center, and most of the folks were Native American, but it really was a public event and I’m concerned that some people are seeing this as poor care provided to Native Americans. It wasn’t the quality of care we want to provide, but unfortunately we did it and we provided to everybody there,” Bailey said. A number of non-Native people were among those tested.

Although it took a couple of weeks to sort through the information and determine a process to deal with the incident, the delay is not likely to increase the potential risk of disease.

“There are some things you can do in the first 72 hours or so that might reduce the risk of acquiring infection somewhat, but there’s nothing that you can really do so it’s not likely at this point that the people who immediately got in touch with us will be at some greater advantage than those who might call in a week or two,” Bailey said.

As soon as the university discovered the test could have exposed individuals to a variety of blood borne diseases, the Health Services Center collected all of the devices used, including all of the lancet devices, the lancets, and the test strips and secured them with the center’s forensic and lab experts.

A special team was formed to work jointly with the Indian Health Service, New Mexico Department of Health and the Center for Disease Control and Prevention on a continuing investigation of the incident and the follow up, which includes efforts to track down individuals who were tested.

Bailey said the incident can be attributed to three mistakes: The students used the wrong device; they were not all properly trained on the device; and they didn’t keep the names and contact information of the people who were tested, making it difficult to track them down. Policies and procedures have been put in place to prevent such an error from occurring again.

By May 18, the Health Services Center had identified as many as 25 or 26 of the 55 people tested.

“We just got a couple of calls this morning so thanks to the media for spreading the story we’re starting to hear from people and that’s good news,” Bailey said. “We very much want to hear from those who were tested so that we may assist them.”

Those who participated in the diabetes screening event should contact (888) 899-6092 for more information and referral for screening, or use this web form to make contact and can access more information on the following sites: