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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 ([email protected])
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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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References

1. Seoane-Vazquez, E, Rodriguez-Monguio, R. Endoscopy-related infection: relic of the past? Curr Opin Infect Dis 2008;21(4): 362–366.CrossRefGoogle ScholarPubMed
2. Srinivasan, A. Epidemiology and prevention of infections related to endoscopy. Curr Infect Dis Rep 2003;5(6):467–472.Google Scholar
3. Rutala, WA, Weber, DJ. Reprocessing endoscopes: United States perspective. J Hosp Infect 2004;56(suppl 2):S27–S39.Google Scholar
4. Spach, DH, Silverstein, FE, Stamm, WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993;118(2):117–128.CrossRefGoogle ScholarPubMed
5. Rutala, W, Weber, D, Committee THICPA. Guideline for Disinfection and Sterilization in Healthcare Faciliríes. Atlanta: Centers for Disease Control and Prevention, 2008.Google Scholar
6. Seoane-Vazquez, E, Rodriguez-Monguio, R, Visaria, J, Carlson, A. Endoscopy-related infections and toxic reactions: an international comparison. Endoscopy 2007;39(8):742–778.Google Scholar
7. Morris, J, Duckworth, GJ, Ridgway, GL. Gastrointestinal endoscopy decontamination failure and the risk of transmission of blood-borne viruses: a review. J Hosp Infect 2006;63(1):1–13.CrossRefGoogle ScholarPubMed
8. Alvarado, CJ, Reichelderfer, M; Association for Professionals in Infection Control. APIC guideline for infection prevention and control in flexible endoscopy. Am J Infect Control 2000;28(2): 138–155.Google Scholar
9. Banerjee, S, Shen, B, Nelson, D, et al. Infection control during GI endoscopy. Gastrointest Endose 2008;67(6):781–790.Google Scholar
10. Ishino, Y, Ido, K, Koiwai, H, Sugano, K. Pitfalls in endoscope reprocessing: brushing of air and water channels is mandatory for high-level disinfection. Gastrointest Endose 2001;53(2): 165–168.Google Scholar
11. Cleaning and disinfection of equipment for gastrointestinal flexible endoscopy: interim recommendations of a Working Party of the British Society of Gastroenterology. Gut 1988;29(8): 1134–1151.Google Scholar
12. Cleaning and disinfection of equipment for gastrointestinal endoscopy: report of a Working Party of the British Society of Gastroenterology Endoscopy Committee. Gut 1998;42(4): 585–593.Google Scholar
13. Nelson, D, Jarvis, W, Rutala, W, et al. Multi-society guideline for reprocessing flexible gastrointestinal endoscopes. Infect Control Hosp Epidemiol 2003;24(7):532–537.Google Scholar
14. Ayliffe, G. Decontamination of minimally invasive surgical endoscopes and accessories. J Hosp Infect 2000;45(4):263–277.Google Scholar
15. Banerjee, S, Nelson, D, Dominitz, J, et al. Reprocessing failure. Gastrointest Endose 2007;66(5):869–871.Google Scholar
16. Foweraker, JE. The laryngoscope as a potential source of cross-infection. J Hosp Infect 1995;29(4):315–316.Google Scholar
17. Yee, KF. Decontamination issues and perceived reliability of the laryngoscope—a clinician's perspective. Anaesth Intensive Care 2003;31(6):658–662.Google Scholar
18. Lübbe, D, Fagan, J. South African survey on disinfection techniques for the flexible nasopharyngoscope. J Laryngol Otol 2003; 117(10):811–814.Google Scholar
19. Muscarella, L. Prevention of disease transmission during flexible laryngoscopy. Am J Infect Control 2007;35(8):536–544.Google Scholar
20. Sooy, CD, Gerberding, JL, Kaplan, MJ. The risk for otolaryngologists who treat patients with AIDS and AIDS virus infection: report of an in-process study. Laryngoscope 1987;97(4):430–434.Google Scholar
21. Bond, WW, Favero, MS, Petersen, NJ, Ebert, JW. Inactivation of hepatitis B virus by intermediate-to-high-level disinfectant chemicals. J Clin Microbiol 1983;18(3):535–538.Google Scholar
22. Hanson, PJ, Gor, D, Jeffries, DJ, Collins, JV. Elimination of high titre HIV from fibreoptic endoscopes. Gut 1990;31(6):657–659.Google Scholar
23. Hanson, PJ, Gor, D, Clarke, JR, et al. Contamination of endoscopes used in AIDS patients. Lancet 1989;2(8654):86–88.CrossRefGoogle ScholarPubMed
24. Classen, M, Dancygier, H, Grtler, L, Deinhardt, F. Risk of transmitting HIV by endoscopes. Endoscopy 1988;20(3):128.Google Scholar
25. Chanzy, B, Due-Bin, DL, Rousset, B, et al. Effectiveness of a manual disinfection procedure in eliminating hepatitis C virus from experimentally contaminated endoscopes. Gastrointest Endose 1999;50(2):147–151.Google Scholar
26. Nelson, D. Effectiveness of manual cleaning and disinfection for the elimination of hepatitis C virus from GI endoscopes. Am J Gastroenterol 2002;97(1):204–206.CrossRefGoogle ScholarPubMed
27. Ramachandran, S, Xia, G-L, Ganova-Raeva, L, Nainan, O, Khu-dyakov, Y. End-point limiting-dilution real-time PCR assay for evaluation of hepatitis C virus quasispecies in serum: performance under optimal and suboptimal conditions. J Virol Methods 2008;151(2):217–224.Google Scholar
28. Nainan, O, Alter, M, Kruszon-Moran, D, et al. Hepatitis C virus genotypes and viral concentrations in participants of a general population survey in the United States. Gastroenterology 2006; 131(2):478–484.Google Scholar
29. Patel, P, Larson, AK, Castel, A, et al. Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies. JAMA 2006;296(16):2005–2011.Google Scholar
30. Cody, S, Nainan, O, Garfein, R, et al. Hepatitis C virus transmission from an anesthesiologist to a patient. Arch Intern Med 2002;162(3):345–350.Google Scholar
31. Thompson, ND, Hellinger, WC, Kay, RS, et al. Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center. Transpl Infect Dis 2009; 11 (4): 324–329.Google Scholar
32. Rutala, W, Weber, D. How to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Infect Control Hosp Epidemiol 2007;28(2):146–155.Google Scholar
33. Backus, L, Gavrilov, S, Loomis, T, et al. Clinical case registries: simultaneous local and national disease registries for population quality management. J Am Med Inform Assoc 2009;16(6): 775–783.Google Scholar
34. Schembre, DB. Infectious complications associated with gastrointestinal endoscopy. Gastrointest Endose Clin N Am 2000;10(2): 215–232.CrossRefGoogle ScholarPubMed
35. Cheung, RJ, Ortiz, D, DiMarino, AJ. GI endoscopic reprocessing practices in the United States. Gastrointest Endose 1999;50(3): 362–368.Google Scholar
36. Kaczmarek, RG, Moore, RM, McCrohan, J, et al. Multi-state investigation of the actual disinfection/sterilization of endoscopes in health care facilities. Am J Med 1992;92(3):257–261.CrossRefGoogle ScholarPubMed
37. Gorse, GJ, Messner, RL. Infection control practices in gastrointestinal endoscopy in the United States: a national survey. Infect Control Hosp Epidemiol 1991;12(5):289–296.Google Scholar
38. Rutala, WA, Clontz, EP, Weber, DJ, Hoffmann, KK. Disinfection practices for endoscopes and other semicritical items. Infect Control Hosp Epidemiol 1991;12(5):282–288.Google Scholar
39. Lessa, F, Tak, S, Devader, S, et al. Risk of infections associated with improperly reprocessed transrectal ultrasound-guided prostate biopsy equipment. Infect Control Hosp Epidemiol 2008; 29(4):289–293.Google Scholar