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On July 24, 2008, Southern Nevada Health District official announced that genetic testing has traced seven hepatitis C infections to two patients who underwent procedures at the Endoscopy Center of Southern Nevada last year.

Brian Labus, Health District Senior Epidemiologist, said one of the sources underwent a procedure July 25 and the other Sept. 21. The Sept. 21 patient was a known carrier of hepatitis C, meaning both the health care provider and patient knew the virus was in the patient’s bloodstream at the time of the procedure.

It was unclear if the source from July 25 was a known carrier, Labus said at Thursday’s meeting. “We know when it started and where it went,” Labus said, referring to the transmission of hepatitis C to seven former patients of the facility at 700 Shadow Lane on those two dates.

Six people have tested positive who underwent procedures at the clinic on Sept. 21. One tested positive following a July 25 visit. An eighth hepatitis C case has been linked to the clinic based on a procedure in 2005.

Health officials now will concentrate on determining how many more of the Shadow Lane facility’s 50,000 patients may have been exposed during procedures between March 2004 and Jan. 11. That is the time frame in which health officials believe it was common practice among nurse anesthetists at the Shadow Lane facility to reuse single-dose vials of medication and syringes.

The number of acute hepatitis C cases linked to the clinic probably will remain at seven, unless the health district receives a report by the end of the month, Labus said.

Acute hepatitis C occurs when someone becomes ill within six months of exposure. July 11 marked the last date a former patient of the endoscopy center would have developed acute hepatitis C, based on a Jan. 11 exposure date.

“Within the next week or so, we should be done with getting acute cases,” Labus said.

Chronic hepatitis C cases are a different story. In such cases, a patient won’t become symptomatic within the incubation period, and the disease usually isn’t identified until years after exposure.

Seven of the eight cases linked to the Shadow Lane facility are acute. The eighth case, which was announced is a chronic case.

“This person had no symptoms,” Labus said. “They wouldn’t have known they had it unless they had been tested.”

The remaining case is linked to an affiliated clinic on Burnham Avenue.

Dr. Dipak Desai, a Las Vegas gastroenterologist, is majority owner of both clinics, which were closed shortly after the outbreak was announced.

County prosecutors will fold the new hepatitis case into the ongoing criminal investigation, Deputy District Attorney Scott Mitchell said.

The investigation was hindered by a wall of silence by the clinic’s nurse anesthetists, who will be key witnesses in any prosecution, Mitchell said.

The lack of cooperation changed in recent weeks when prosecutors subpoenaed the nurses to testify before an investigative grand jury, he said.

“We have broken through that wall,” Mitchell said, adding that some nurse anesthetists now are cooperating with investigators.

The grand jury also helped separate potential witnesses from potential defendants, allowing investigators to “whittle down the case against core people who we have good evidence against,” he said.

The investigation will probably continue for a couple of months before any charges are filed, Mitchell said.

Desai and one of his partners, Dr. Eladio Carrera, have had their licenses suspended pending an investigation by the Nevada Board of Medical Examiners. The board has scheduled hearings for Desai and Carrera in September and October.

Both performed procedures at the Shadow Lane facility on July 25 and Sept. 21, dates when CDC and health district investigators believe nurse anesthetists contaminated single-dose anesthesia vials with syringes that were reused.

One nurse anesthetist told CDC investigators that the clinic’s staff had instructed him to reuse syringes and single-dose vials of propofol, a fast-acting sedative.

Debra Scott, executive director of the Nevada State Board of Nursing, said 36 complaints have been filed against nurses affiliated with the endoscopy center.

Hearings have been scheduled for Oct. 22 and 23. However, Scott said, the regulatory board has not filed any charges against nurses.

She said complaints or charges brought by the nursing board could be filed 30 days in advance of the hearing.

“We have evidence at this point that there are witnesses willing to come forward saying some of the CRNAs used single-dose vials for more than one patient,” she said.

The nursing board still needs some reports from law enforcement to complete its investigation, Scott said.

Six nurse anesthetists with ties to the Shadow Lane facility have voluntarily surrendered their licenses.

Health officials also announced that a hepatitis C registry launched by the health district last month is making progress. So far, 6,000 patients have responded to the registry.

The registry was launched in an effort to reach more of the clinic’s population to identify those who may have been exposed.

During the July 24, 2008 meeting, Dr. Joe Hardy asked if any former patients of the Shadow Lane facility had tested positive for hepatitis B or HIV, the virus that leads to AIDS.

Labus said they had not.

“That would be called good news,” Hardy said.

On April 7, 2008, the city of Las Vegas revoked the Endoscopy Center of Southern Nevada license and fined the center $500,000. Some former patients, who were exposed to Hepatistis C and HIV think harsher penalties should have been applied.

“I want to thank you for taking away their business license,” said Stephanie Entel Thornton, who told the Las Vegas City Council that she tested positive for hepatitis C after undergoing a procedure at the clinic. “These people took an oath to do no harm. They’ve done a great deal of harm.”

Barbara Botts said she’s also glad to see the license gone, but she was still angry that her husband died from hepatitis C and that other people may be sick now because of the clinic’s practices. Health officials have linked no deaths to the clinic.

“These men should be held accountable,” Botts said. “I don’t understand why they’re not being indicted.”

There is a criminal investigation in progress of the Gastroenterology Center of Nevada’s clinics, one of which is the Endoscopy Center at 700 Shadow Lane.

The proceedings on April 7, 2008 were narrow, concerning only the business license of that facility. The license was suspended Feb. 29, two days after health investigators announced that unsafe practices meant that 40,000 patients should get tested for hepatitis and HIV, the virus that causes AIDS.

The other clinics are outside of the city of Las Vegas.

“All we have jurisdiction over is their city license,” said Mayor Oscar Goodman. “We’ve gone to the full extent of our jurisdiction.”

The city was prepared to have an extensive hearing on the clinic, complete with witnesses, testimony and cross-examination by a city attorney and lawyers representing the clinic.

Those lawyers met with Goodman last month, shortly after the hearing was scheduled, and offered to surrender the business license without a hearing, an offer he said he “was not inclined or disposed to accept.”

Later, he continued, the attorneys for the clinics “called me and wanted to know: What would it take to avoid a full and complete hearing on this? What did we want in addition to the license?”

Goodman said he would recommend a $500,000 fine to be paid when the license is surrendered. The fine was broken into two $250,000 payments from both the Endoscopy Center and the Gastroenterology Center was made during the council hearing with checks being handed over to the city.

The money will be spent to help people affected by the clinic’s action specifically, on free testing and for access to medical records seized by the police. City staff will make spending recommendations at the May 6 council meeting.

Councilman Steve Wolfson described the arrangement as “a bird in the hand.”

“Sometimes we fine people or fine entities, and that fine is paper with an amount on it and it’s still swirling in the air,” he said. “We don’t have that today. We have $500,000 in the pockets of the city.”

Goodman said he arrived at that amount because it was “realistic under the circumstances.”

“If it was more than that, they very well could’ve said they weren’t going to pay it. I didn’t want to get involved in a back-and-forth situation,” he said.

“Most people expected us just to get the business license, and we went beyond that.”

Michelle Baltz told the council that she hoped at least some of the money would be spent on reorganizing the medical records seized by law enforcement investigators. Police took the records to safeguard them, but patients have reported problems finding their records among the thousands in police custody.

“There’s already a shortage of gastro doctors, and before a doctor will even tell if he’ll take me as a patient, I have to get my records,” said Baltz, who suffers from a chronic bowel condition known as Crohn’s disease.

She requested her records but was told they’re filed by date, not name.

“I don’t know when my procedure was done,” she said. “I’m walking around with Crohn’s disease and I can’t even see a doctor.”

According to health investigators, clinic workers reused syringes when administering medication to a patient, which introduced the risk of transferring an infectious agent to the medicine vial.

The vials were supposed to be single-use, but staff reused the vials on multiple patients, which could lead to the infectious agent being spread.

Investigators have linked six acute hepatitis C cases to the Shadow Lane facility and strongly suspect that a seventh case is connected to the Desert Shadow Endoscopy Center, an affiliated clinic on Burnham Avenue.