Improperly Cleaned Endoscopes Raise Infection Risk in VA Facilities

The Miami Veterans Administration Health Care System is notifying 3,260 veterans of a potential health risk from endoscopies performed between May 2004 and March 12, 2009.  While the endoscopes themselves were cleaned and disinfected, an attached section of tubing was rinsed but not disinfected between procedures.

According to the Miami VA, this creates a small risk of infection with viruses Hepatitis B, Hepatitis C, or HIV (Human Immunodeficiency Virus).  Therefore, they are:

• Notifying patients who had endoscopies between May 2005 and March 12, 2009 of the risk for infection.
• Establishing a Special Care Call Center at (305) 575-7256 or 1-877-575-7256
  where patients can call with questions or to schedule an appointment for hepatitis or HIV blood testing.
• Opening Special Care Clinics for follow-up care and testing for potentially affected patients Miami VA Medical Center, the Broward County VA Clinic, the Homestead VA Clinic and the Key West VA Clinic.

The Miami VA Healthcare System emphasizes that follow-up testing is only a precaution and that they know of no patients who have acquired an infection after endoscopy performed during the targeted dates.  There is no cost or co-pay for testing, and patients are eligible for transportation assistance.

Tubing is attached to the endoscope to carry water to clean the scope lens so that doctors can see the inside of the colon more clearly.  There is a small risk that infected material might splash back into the tubing and contaminate it.  The manufacturer recommends both rinsing and disinfecting the tubing after each procedure.

Miami VA Healthcare Systems Director Mary D. Berrocal says,

Miami VA emphasizes that screening is strictly precautionary and does not indicate that any patients have contracted a virus.  Although there is minimal risk, we feel that even a slight risk is unacceptable to the Veterans we care for.

If you are a veteran who had a colonoscopy or endoscopy performed in the Miami VA Healthcare System, you can get more answers to your questions online or you can call the Special Care Call Center at (305) 575-7256 or 1-877-575-7256.

Another 6,000 patients in the Tennesee Valley VA Healthcare System were notified of risk of infection due to a colonoscope valve connected incorrectly at a VA facility in Murfreesboro, TN.  Patients who had colonoscopies at the Alvin C. York campus between April 23, 2003 and December 1, 2008 were told to schedule blood testing as a precaution.

The Society of Gastroenterology Nurses and Associates has developed very precise and detailed guidelines for cleaning and disinfecting endoscopy equipment to prevent infection.

The American Society for Gastrointestinal Oncology estimates that there is no more than one infection in every one million, three hundred thousand endoscopy procedures.  Since their guidelines for high-level disinfection (HLD) went into effect in 2003, there have been no reports of infection when the guideline HLD procedures were followed.

Additional coverage of the situations in Miami and Mursfreesboro is available from MedPage Today, March 26, 2009.