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Results from a Large-Scale Epidemiologic Look-Back Investigation of Improperly Reprocessed Endoscopy Equipment

Published online by Cambridge University Press:  02 January 2015

Mark Holodniy ,
Gina Oda ,
Patricia L. Schirmer ,
Cynthia A. Lucero ,
Yury E. Khudyakov ,
Guoliang Xia ,
Yulin Lin ,
Ronald Valdiserri ,
William E. Duncan  and
Victoria J. Davey
...Show all authors
Mark Holodniy*
Affiliation:
Office of Public Health, Department of Veterans Affairs, Washington, DC Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California
Gina Oda
Affiliation:
Office of Public Health, Department of Veterans Affairs, Washington, DC
Patricia L. Schirmer
Affiliation:
Office of Public Health, Department of Veterans Affairs, Washington, DC
Cynthia A. Lucero
Affiliation:
Office of Public Health, Department of Veterans Affairs, Washington, DC
Yury E. Khudyakov
Affiliation:
Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
Guoliang Xia
Affiliation:
Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
Yulin Lin
Affiliation:
Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
Ronald Valdiserri
Affiliation:
Office of HIV/AIDS Policy, Department of Health and Human Services, Washington, DC
William E. Duncan
Affiliation:
Office of Quality and Safety, Department of Veterans Affairs, Washington, DC
Victoria J. Davey
Affiliation:
Office of Public Health, Department of Veterans Affairs, Washington, DC
Gerald M. Cross
Affiliation:
Office of Patient Care Services, Department of Veterans Affairs, Washington, DC
*
Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA 94304 (mark.holodniy@va.gov)
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Abstract

Objective.

To determine whether improper high-level disinfection practices during endoscopy procedures resulted in bloodborne viral infection transmission.

Design.

Retrospective cohort study.

Setting.

Four Veterans Affairs medical centers (VAMCs).

Patients.

Veterans who underwent colonoscopy and laryngoscopy (ear, nose, and throat [ENT]) procedures from 2003 to 2009.

Methods.

Patients were identified through electronic health record searches and serotested for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Newly discovered case patients were linked to a potential source with known identical infection, whose procedure occurred no more than 1 day prior to the case patient's procedure. Viral genetic testing was performed for case/proximate pairs to determine relatedness.

Results.

Of 10,737 veterans who underwent endoscopy at 4 VAMCs, 9,879 patients agreed to viral testing. Of these, 90 patients were newly diagnosed with 1 or more viral bloodborne pathogens (BBPs). There were no case/proximate pairings found for patients with either HIV or HBV; 24 HCV case/proximate pairings were found, of which 7 case patients and 8 proximate patients had sufficient viral load for further genetic testing. Only 2 of these cases, both of whom underwent laryngoscopy, and their 4 proximates agreed to further testing. None of the 4 remaining proximate patients who underwent colonoscopy agreed to further testing. Mean genetic distance between the 2 case patients and 4 proximate patients ranged from 13.5% to 19.1%.

Conclusions.

Our investigation revealed that exposure to improperly reprocessed ENT endoscopes did not result in viral transmission in those patients who had viral genetic analysis performed. Any potential transmission of BBPs from colonoscopy remains unknown.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 33 , Issue 7 , July 2012 , pp. 649 - 656
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

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