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

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 ...