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Published Sunday May 11, 2003 Doctor apparently suspected, but didn't warn of, hepatitis C BY JEREMY OLSON
COPYRIGHT ©2003 OMAHA WORLD-HERALD

FREMONT, Neb. - A Fremont doctor apparently suspected that a high number of his cancer patients were infected with hepatitis C, but he failed to inform individual patients or warn the state of a possible outbreak.

Dr. Tahir Javed

Seven patients have told The World-Herald that Dr. Tahir Javed, director of the Fremont cancer center, ordered hepatitis C tests in 2000 or 2001 but didn't tell them beforehand or disclose the results afterward.

Most didn't learn they were infected until mid-2002, when state health officials found out about the outbreak and determined that it was caused by poor infection control at the cancer center. The patients didn't learn of the earlier tests by the cancer center until they requested copies of their medical records and reviewed old bills and insurance statements.

Although it's far from certain, earlier warnings might have helped Javed's patients - one of whom died in March. More than 80 were infected.

Medical ethics call for doctors to keep patients informed and get their consent for any tests. Nebraska law requires doctors to notify state health authorities if they detect an outbreak of a communicable disease.

What Javed knew and when he knew it are key issues in multiple investigations.

Federal and state investigators want to determine whether any effort was made to conceal the outbreak and whether criminal charges or disciplinary actions are warranted. State epidemiologists are studying the life cycle of the outbreak. And infected patients and their relatives want to know why the doctor they trusted may have been harboring his concerns.

"It made you suspicious whether he knew what was going on or not," said Gary Strong, 47, of Fremont, who discovered his test when he reviewed his records. Four months of interferon treatments for hepatitis C have exhausted Strong, and he has two months to go.

It is possible that Javed made brief references to tests that the patients missed or that he kept quiet to spare the cancer patients any more anxiety. Javed, now an elected official in Pakistan, could not be reached for comment. His Omaha attorney would not discuss the issues.

More than 70 patients have sued the cancer center, which has closed.

State public health investigators believe the spread of hepatitis from one patient to another occurred because nurses reused syringes and other single-use medical equipment.

In addition to those tested at Javed's clinic, several patients recalled that blood tests showed that they had elevated liver enzymes, a common predictor for hepatitis C. However, they don't recall being tested for hepatitis or alerted to the possibility of infection.

"Hepatitis was not mentioned," said Pam Savio, who received chemotherapy at the clinic in late 2000.

Others recalled discussing hepatitis with Javed. One patient, who works in health care, said her hepatitis test in the summer of 2001 seemed odd, because she had not shown any signs of being infected.

State public health investigators were similarly perplexed because some patients' medical files lacked information that justified ordering hepatitis tests.

Patients aren't routinely checked for hepatitis, local oncologists said, unless other blood tests show a reason for concern.

The patients who were tested by Javed said that they either didn't know the results or that the results were negative. That is plausible. The most common hepatitis C test looks for the body's response to the virus, and not the virus itself. So it may have been fooled by these patients whose immune systems had been weakened by chemotherapy.

Obtaining consent from patients and discussing test results is "basic social policy," according to the American Medical Association. If Javed withheld information from his patients, he "violated standards that are fundamental and universally accepted in Western medicine," said Judith Kissell of Creighton University's Center for Health Policy and Ethics.

Javed, 38, graduated from medical school in Pakistan in 1988 and completed residencies in South Carolina and New York. He started the Fremont cancer center in 1997 and developed a reputation for his compassion.

Martha Ann Lee recalled how she was given a few weeks to live when Javed initiated her treatments for lung cancer: "He said, 'We're in this together, we'll fight it.' That was three years ago."

Lee, 65, has hepatitis C but hasn't needed treatment yet.

State authorities learned of the outbreak in mid-2002, when a physician told them that a handful of his hepatitis patients had all received treatment at the same cancer center. Authorities then tested more than 500 patients.

Chronic hepatitis C usually doesn't cause cirrhosis, or other types of liver damage, for 10 to 20 years. And one in four infections don't become chronic. But cancer and blood disorder patients may be more susceptible.

Cancer center patient Cheryl Gentry died March 7 while awaiting a liver transplant, and her autopsy lists the cause of death as "cirrhosis with complications, secondary to hepatitis C virus infection."

Earlier notice may have been difficult, given the testing problems, but could have helped Gentry and other infected patients, said Dr. Mark Mailliard, a hepatitis expert with the University of Nebraska Medical Center in Omaha. The latest research shows that early treatment of hepatitis C can prevent chronic infections.

State health officials have determined that the outbreak started in March 2000, when a patient with a rare form of hepatitis C received cancer treatment. It ended in June 2001, when a review by an outside organization discovered that nurses at the cancer center were using poor infection control.

That organization, the Missouri Valley Cancer Consortium, was considering adding the Fremont cancer center as a site for clinical research. Instead, it issued a warning letter and sent a copy to the Fremont Area Medical Center, the hospital owned by Dodge County where the cancer center was located.

Attorneys for the infected patients have filed claims against the county, and have pointed to the hospital's early notice of infection control problems. Hospital officials stress they only leased space to Javed.

While procedures were corrected, nobody reported the cancer consortium's findings to the state. It is required under Nebraska law to report evidence of substandard care.

The World-Herald contacted 33 of the infected patients, some of whom declined to discuss their conditions. It is a wide-ranging group that includes health care providers, truckers, factory workers and farmers. At least one patient is in his 20s, while others are in their 70s.

Leona Slawson had survived cervical cancer, but she could tell during her work at a Fremont packinghouse last summer that something was wrong. The state test simply put a name to it.

"The work I do usually builds muscle and makes me stronger," she said, "but I was getting weaker."

Treatments have drained her, but she is working as much light duty as possible in order to support her 15-year-old daughter and to pay medical bills that aren't covered by insurance.

Some patients are frustrated that the state hasn't restricted or revoked the licenses of Javed and his former nurses. They have launched a letter-writing campaign to hasten the attorney general's decision.

A criminal investigation by the U.S. Food and Drug Administration is also under way.

Whether Javed will return from Pakistan is unclear. He left initially to attend to his ailing mother, but recently won elected office and is now the minister of health for the Punjab region of more than 70 million people.

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