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BACKGROUND: On July 10, 2013, a rural hospital contacted the Kansas Department of Health and Environment (KDHE) to report an infection prevention breach in colonoscope reprocessing. On January 3, 2013, the hospital introduced a new model of colonoscope with an auxiliary water channel that was not present on previous models; this channel was neither cleaned nor disinfected. Patient notification was performed by the hospital, in coordination with KDHE. An investigation into the potential for bloodborne pathogen (BBP) transmission was initiated.
METHODS: Between January 3 and July 18, 277 patients received colonoscopies; patients were cross-matched with KDHE’s infectious disease surveillance system to identify BBP infections. Patients were notified via mail and testing for hepatitis C virus (HCV) (total antibody with reflex to HCV polymerase chain reaction), human immunodeficiency virus (HIV) (total antibody), and hepatitis B virus (HBV) (surface antigen (HBsAg) and core immunoglobulin M antibody (anti-HBc IgM)) was recommended. For patient procedures less than six months before their initial blood test, repeat testing six months post-procedure date was recommended. The KDHE laboratory and a contract reference laboratory performed testing. Due to the small patient population, HIV results will not presented.
RESULTS: Prior to testing, three patients were known to be infected with a BBP. As of January 1, 2014, 269 patients have been tested, two expired before notification, and six declined testing. Of those tested, 214 have completed their testing, 41 are eligible to receive their second blood test but have not returned, and 14 have not completed their testing because six months had not elapsed since their procedure. No acute infections have been identified; five patients were newly identified as having laboratory evidence of a cleared HCV infection, and one patient tested positive for anti-HBc IgM but negative for HBsAg.
CONCLUSIONS: Risk of BBP transmission following inadequate colonoscope disinfection is believed low. When new colonoscopes are introduced, hospitals must be vigilant in providing adequate training on cleaning and disinfection. Thus far, KDHE reports no evidence of transmission despite uninfected patients undergoing procedures on days as individuals infected with a BBP. State health department engagement is crucial when infection control breaches warrant large-scale patient notifications as they can uniquely provide technical assistance, coordinate testing, and determine risk of transmission.