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Public Notice: Infection Prevention and Control lapse at Walk-In Clinic in Burlington. More info →

IPAC Lapse Disclosure

IPAC Lapse Disclosure

Public health notice: Infection Prevention and Control lapse at Burlington walk-in clinic

UPDATED September 18, 2025: As a result of an investigation, Halton Region Public Health has identified an Infection Prevention and Control lapse at the Halton Family Health Centre Walk-In Clinic in Burlington (2951 Walkers Line, Burlington (Google Maps link), corner of Walkers Line and Dundas Street). Improper infection prevention and control practices involved the use of unsterile needles with multidose vials of local anesthetic medication (freezing) between January 1, 2019, and July 17, 2025.

It is important to note that the same needle was not used continuously throughout the period, rather appropriate infection prevention and control measures were not followed when using multidose vials over the time period. This practice may pose a risk of cross-contamination and transmission of infections. Immediate corrective action was taken, there is no current risk to patient safety, and the clinic is open. Halton Region Public Health continues to monitor the situation to ensure ongoing compliance.

Although the risk of infection from this lapse is low, if you are a patient who received a procedure requiring local anesthetic (freezing) by injection (needle) at the Halton Family Health Centre Walk-in Clinic between January 1, 2019, and July 17, 2025 we are recommending you:

  • speak with your healthcare provider or visit a walk-in clinic to discuss testing for hepatitis B, hepatitis C, and HIV
  • download and print a copy of the laboratory requisition (PDF file) and physician letter (PDF file) to bring to the healthcare provider
  • not visit a hospital emergency department, as it is not necessary

Examples of procedures that may require local anesthetics include but are not limited to:

  • laceration repairs (stitches for cuts or tears of the skin)
  • intrauterine Device (IUD) insertions
  • endometrial biopsies 
  • skin biopsies
  • removal of lumps and bumps
  • partial or complete nail removal
  • joint injections or aspirations

If you are a patient, and have specific questions about the lapse, please call Halton Region Public Health at 311 , 905-825-6000 or toll-free 1-866-442-5866 . Otherwise, please speak with your healthcare provider.

Resources

For patients:

For physicians:

More information: Read the IPAC Lapse Disclosure for the Halton Family Health Centre Walk-In Clinic below.

Questions and answers: Infection Prevention and Control lapse at Burlington walk-in clinic

Halton Region Public Health Department became aware of the lapse on July 10, 2025, and immediately initiated an investigation.
An infection prevention and control lapse is when proper infection prevention and control standards and best practices are not followed, putting patient/clients at potential risk of infection.

Staff did not follow proper infection control practices when using multidose vials for administering local anesthesic medication by injection (freezing) for pain relief during procedures.

As a result, the anaesthetic medication in multidose vials may have been contaminated with blood, and blood-borne infections such as hepatitis B, hepatitis C, and HIV, potentially infecting another person when the multidose vials were used again.

A multidose vial is a bottle of medicine that has more than one dose inside. It can be used several times, but each time, a sterile needle and syringe must be used to take the medicine out safely.
Individuals who had a medical procedure that required local anesthetic medication by injection (freezing) between January 1, 2019 and July 17, 2025 are considered at risk.
No. The Health Department is currently not aware of an outbreak of disease in relation to the infection prevention and control lapse at this medical office.
If the procedure you had required that you get a local anaesthetic medication by injection you may be at risk. Examples of these procedures include putting in stitches to repair skin tears,intrauterine device (IUD) insertions, endometrial biopsies, skin biopsies, removal of lumps and bumps, partial or complete nail removals and joint injections or aspirations.
Halton Region Public Health recommends that affected patients speak with their healthcare provider to discuss getting tested for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). Patients should download the laboratory requisition (PDF file) and physician letter (PDF file) and bring them to their appointment.
No, this notification only applies to patients who underwent procedures that required local anesthetic medication by injection.
These viruses can be transmitted from person to person through blood or other body fluids. Improper infection control practices when handling multidose vials carries a low risk of transmitting hepatitis B, hepatitis C and HIV to patients.
Yes. The Health Department recommends that all patients see their healthcare provider, even if previously vaccinated for HBV. HBV vaccine does not protect against Hepatitis C and HIV. The recommendation remains to discuss testing with your healthcare provider.
Please visit the <a href="/For-Residents/Immunizations-Preventable-Disease/Diseases-Infections/Prevent-Communicable-Diseases-A-Z-Index#accidental-exposures-to-blood-or-body-fluids">Preventing Communicable Diseases: A-Z Index page</a> for more information.
Go to a walk-in clinic with the laboratory requisition (PDF file) and physician letter (PDF file). It is not necessary to visit an emergency department. 

No, only patients who received local anesthetic medication by injection during a procedure at Halton Family Health Centre Walk- in Clinic between January 1, 2019 and July 17, 2025, are considered at risk and recommended to see a healthcare provider to discuss testing.

The risk of disease from this situation is very low. Discussing testing with a healthcare provider is recommended as a precaution.

Blood samples are collected and sent to a laboratory for analysis.
The Ontario Health Insurance Plan (OHIP) covers the cost of the tests. There may be a cost associated with the assessment and testing if you are not covered by OHIP or private insurance.
The healthcare provider that ordered the testing will receive the results and provide them to you. The time to receive results varies. Please contact the healthcare provider who ordered the test for results.
Your healthcare provider will review your results and offer guidance. Since hepatitis B, hepatitis C, and HIV are reportable diseases, your results will also be shared with Halton Region Public Health, and a public health nurse will follow up with you.
Discuss with your healthcare provider about how your results will be provided to you.
Since this issue is related to the use of multidose vials becoming contaminated, even healthcare providers who were following the proper infection control measures when using these vials may have unknowingly exposed patients.
No. This IPAC Lapse only includes the walk-in clinic during the specified time period and does not include procedures or care received at the Halton Family Health Centre family practice physician offices.
Halton Region Public Health has conducted follow-up visits to the clinic and confirmed that the recommended practices for using multidose vials have been implemented and are being followed. Any implicated multidose vials have been removed from the clinic.
No. The Health Department does not routinely inspect medical offices or offices of other regulated health professionals. Inspections are completed in response to a complaint or as part of a reportable disease investigation.
Updates will be considered as required, based on whether new information is obtained. 
Contact your healthcare provider if you have questions about your health.
For more information about the investigation, please contact the Health Department at 905-825-6000 or call 311.

Information about IPAC lapse disclosure

This page contains reports on premises where an infection prevention and control lapse was identified through the assessment of a complaint or referral, or through communicable disease surveillance. It does not include reports of premises that were investigated after a complaint or referral where no infection prevention and control lapse was identified.

These reports are not exhaustive, and do not guarantee that those premises listed and not listed are free of infection prevention and control lapses. Identification of lapses is based on assessment and investigation of a premises at a point in time. These assessments and investigations are triggered when potential infection prevention and control lapses are brought to the attention of the local medical officer of health.

Reports are posted on the website of the board of health in which the premises is located. Reports are posted on a premises-by-premises basis (they will correspond with one site only). If you wish to view a full investigation report for any posted lapse, please call 311 and ask for the Communicable Disease Reporting Line.

Summary of establishments in Halton Region that have had a lapse in IPAC

Initial report

  • Premise/facility under investigation: Halton Family Health Centre Walk-in Clinic, 2951 Walker's Line, Burlington ON L7M 4Y1
  • Type of premise/facility: Walk-in Medical Clinic
  • Date Board of Health became aware of IPAC Lapse: 2025-07-10
  • Date of Initial Report posting: 2025-09-17
  • Date of Initial Report update(s): N/A
  • How the IPAC lapse was identified: Complaint
  • Summary description of the IPAC Lapse: Failure to follow PIDAC Best Practices regarding use of multidose vials.
  • Initial report comments: N/A

IPAC lapse investigation

  • Did the IPAC Lapse involve a member of a regulatory college: Yes
  • If yes, was the issue referred to the regulatory college: Yes
  • Were any corrective measures recommended and/or implemented: Yes
  • Please provide further details/steps:
    • Immediately stop re-entering multidose vials with a used needle or syringe.
    • Immediately follow Best Practices for multidose vials as outlined in Ontario Agency for Health Protection and Promotion (Public Health Ontario) Infection Prevention and Control for Clinical Office Practice; 2015.
  • Date any order(s) or directive(s) were issued to the owners/operators:
    • July 15, 2025: directive provided to Clinic
    • July 17, 2025: verbal Section 13 Order
    • July 19, 2025: written Section 13 Order

Final report

  • Date of final report posting: 2025-09-17
  • Date of any order(s) or directive(s) were issued to the owner/operator:
    • July 15, 2025: directive provided to Clinic
    • July 17, 2025: verbal Section 13 Order
    • July 19, 2025: written Section 13 Order
  • Brief description of corrective measures taken: Reinspection was conducted, and all corrective measures were confirmed to have been implemented on July 24, 2025.
  • Date all corrective measures were confirmed to have been completed: 2025-07-24
  • Final report comments: N/A
If you have any further questions, please contact Halton Region Public Health at 905-825-6000 or by email at healthprotection@halton.ca.

  • Establishment: Neo Nail Studio
  • Address: 4150 Fairview St, Burlington, ON L7L 0G7
  • IPAC Lapse Summary:
    • Failure to store and handle reusable instruments in a sanitary manner.
    • Failure to dispose of single use instruments immediately after client use.
    • Failure to clean and disinfect reusable instruments properly after client use.
  • Date of Lapse: July 29, 2025
  • Report: Neo Nail Studio - Final Report (PDF file)

  • Establishment: Xu Zhang Acupuncture and Herbs
  • Address: 466 Speers Road, Unit 210 Oakville, ON L6K 3W9
  • IPAC Lapse Summary:
    • Concerns with reprocessing of equipment/devices that come into contact with blood and/or body fluids.
    • Concerns with hand hygiene.
    • Concerns with disposal of sharps.
  • Date of Lapse: July 18, 2025
  • Report: Xu Zhang Acupuncture and Herbs - Final Report (PDF file)

  • Establishment: Nail Boutique and Spa
  • Address: 478 Dundas St. West Unit #3, Oakville, ON, I6H 6S2
  • IPAC Lapse Summary:
    • Failure to store and handle reusable and disposable instruments in a sanitary manner
    • Failure to dispose of single-use instruments immediately after use
    • Failure to clean and disinfect reusable equipment properly after use
  • Date of Lapse: July 23, 2025
  • Report: Nail Boutique and Spa - Final Report (PDF file)

  • Establishment: Ryna's Nails
  • Address: 1505 Guelph Line, Unit 2, Burilngton, ON, L7P 3B6
  • IPAC Lapse Summary: 
    • Failure to store and handle reusable instruments in a sanitary manner.
    • Failure to dispose of single-use instruments immediately after use.
    • Failure to properly clean and disinfect reusable equipment after use.
  • Date of Lapse: July 14, 2025
  • Report: Ryna's Nails - Final Report

  • Establishment: Hair in Style
  • Address: 280 Guelph St, Georgetown, ON, L7G 4B1
  • IPAC Lapse Summary: Failure to properly clean and disinfect reusable instruments after use. Failure to dispose of single use instruments immediately after use.
  • Date of Lapse: April 21, 2025
  • Report: Hair in Style - Initial Report (PDF file)

  • Establishment: Central Park Medical Centre
  • Address: 101-216 Oak Park Blvd Oakville, ON L6H 7S8
  • IPAC Lapse Summary: Failure to reprocess medical instruments as per the Provincial Infectious Diseases Advisory Committee (PIDAC) Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices In All Health Care Settings (as current).
  • Date of Lapse: November 6, 2024
  • Report: Central Park Medical Centre - Initial Report (PDF file)

  • Establishment: Helen 21 Nails and Spa
  • Address: 2544 Speers Rd. Oakville, ON, L6H5W8
  • IPAC Lapse Summary:
    • Failure to store and handle reusable instruments in a sanitary manner
    • Failure to dispose of single-use instruments immediately after use
    • Failure to clean and disinfect reusable equipment properly after use
  • Date of Lapse: October 29, 2024
  • Report: Helen 21 Nails and Spa - Final Report (PDF file)

  • Establishment: CC's Nail and Beauty
  • Address: 5327 Upper Middle Rd., Unit 8, Burlington, Ontario L7L 0E9
  • IPAC Lapse Summary: Single-use equipment/tools were not being discarded after use.
  • Date of Lapse: September 17, 2024
  • Report: CC's Nail and Beauty - Final Report (PDF file)

  • Establishment: Pedi N Nails
  • Address: 2508 Winston Park Drive, Unit C 50, Oakville, ON, L6H 7E5
  • IPAC Lapse Summary: Issues related to disinfection of reusable instruments.
  • Date of Lapse: February 7, 2024
  • Report: Pedi N Nails - Final Report (PDF file)

  • Establishment: Nice One Nails
  • Address: 2501 Third Line Unit 27, Oakville, ON L6M 5A9
  • IPAC Lapse Summary: Failure to dispose of single-use instruments immediately after use; failure to clean and disinfect reusable instruments after use; failure to keep records of accidental exposures to blood and/or body fluids
  • Date of Lapse: October 4, 2023.
  • Report: Nice One Nails - Final Report
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