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

Infect Control Hosp Epidemiol. 2012 Jul;33(7):649-56. doi: 10.1086/666345. Epub 2012 May 7.


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.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Cross Infection / epidemiology
  • Cross Infection / etiology*
  • Cross Infection / transmission
  • Cross Infection / virology*
  • Electronic Health Records
  • Endoscopes / microbiology*
  • Epidemiologic Studies
  • Equipment Contamination*
  • Equipment Reuse / standards
  • Female
  • HIV / isolation & purification*
  • HIV Seroprevalence
  • Hepacivirus / isolation & purification*
  • Hepatitis B virus / isolation & purification*
  • Humans
  • Male
  • Medical Audit
  • Middle Aged
  • Viremia / epidemiology