Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment

Mark Holodniy, Gina Oda, Patricia L. Schirmer, Cynthia A. Lucero, Yury E. Khudyakov, Guoliang Xia, Yulin Lin, Ronald Valdiserri, William E. Duncan, Victoria J. Davey, Gerald M. Cross

Research output: Contribution to journalArticle

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.

Original languageEnglish (US)
Pages (from-to)649-656
Number of pages8
JournalInfection Control and Hospital Epidemiology
Volume33
Issue number7
DOIs
StatePublished - Jul 2012
Externally publishedYes

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Endoscopy
Equipment and Supplies
Veterans
Colonoscopy
Blood-Borne Pathogens
Laryngoscopy
Genetic Testing
Pharynx
Nose
Hepatitis B virus
Hepacivirus
Ear
HIV
Infectious Disease Transmission
Electronic Health Records
Endoscopes
Disinfection
Virus Diseases
Viral Load
Cohort Studies

ASJC Scopus subject areas

  • Microbiology (medical)
  • Epidemiology
  • Infectious Diseases

Cite this

Holodniy, M., Oda, G., Schirmer, P. L., Lucero, C. A., Khudyakov, Y. E., Xia, G., ... Cross, G. M. (2012). Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment. Infection Control and Hospital Epidemiology, 33(7), 649-656. https://doi.org/10.1086/666345

Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment. / Holodniy, Mark; Oda, Gina; Schirmer, Patricia L.; Lucero, Cynthia A.; Khudyakov, Yury E.; Xia, Guoliang; Lin, Yulin; Valdiserri, Ronald; Duncan, William E.; Davey, Victoria J.; Cross, Gerald M.

In: Infection Control and Hospital Epidemiology, Vol. 33, No. 7, 07.2012, p. 649-656.

Research output: Contribution to journalArticle

Holodniy, M, Oda, G, Schirmer, PL, Lucero, CA, Khudyakov, YE, Xia, G, Lin, Y, Valdiserri, R, Duncan, WE, Davey, VJ & Cross, GM 2012, 'Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment', Infection Control and Hospital Epidemiology, vol. 33, no. 7, pp. 649-656. https://doi.org/10.1086/666345
Holodniy, Mark ; Oda, Gina ; Schirmer, Patricia L. ; Lucero, Cynthia A. ; Khudyakov, Yury E. ; Xia, Guoliang ; Lin, Yulin ; Valdiserri, Ronald ; Duncan, William E. ; Davey, Victoria J. ; Cross, Gerald M. / Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment. In: Infection Control and Hospital Epidemiology. 2012 ; Vol. 33, No. 7. pp. 649-656.
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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.",
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N2 - 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.

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