Lack of Evidence of Transmission of Bloodborne Viruses by Improperly Reprocessed Fiberoptic Endoscopes

Background: A sterile processing service (SPS) technician was found to inadequately clean fiberoptic endoscope channels during reprocessing prior to high-level disinfection. Channels were only brushed once and 7 of 30 audited scopes had measurable bioburden. Consistent with VA policy, a retrospective investigation, along with public disclosure, was performed. Methods: A potentially exposed case (PEC) was defined as any patient who had flexible fiberoptic endoscopy between April 19, 2015, and June 23, 2017, when the identified SPS technician worked in the endoscope reprocessing station. Using the internal log of the automated high–level disinfection equipment (Medivators/Cantel, Minneapolis, MN), device serial numbers were matched to patients in endoscopy suite procedure logs. Additionally, the VA Corporate Data Warehouse (CDW) was queried for CPT and International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 procedure codes to verify identified cases and to search for other PECs. All PECs were notified by telephone and mail, and serologic testing for human immunodeficiency virus (HIV-1), hepatitis C virus (HCV), and hepatitis B virus (HBV) was offered. Results were compared to prior bloodborne pathogen (BBP) testing results extracted from the CDW. Facility microbiology laboratory records of positive cultures/microscopy for enteric pathogens also were compared to the list of PECs; no active testing was performed. Results: Of the 565 PECs, 552 (98%) were successfully contacted. 8 declined testing or preferred non-VA testing, and 22 died before testing could be initiated. Repeat testing at 6 months was requested for PECs who had initial testing performed <6 months after exposure; 32 refused additional tests or did not respond to additional requests. In total, 522 PECs (92%) had testing performed for 1 or more BBPs: (1) 521 were anti–HIV negative with 1 previously known positive; (2) 481 were anti–HCV negative—43 were previously known positive and 1 PEC with an undetectable HCV viral load was newly identified; (3) 461 were negative for both HBV core or surface antibodies and surface antigen—32 were previously known positive and 17 were newly positive for one or both antibody tests with negative HBV surface antigen. Of 17 newly identified positive PECs, 16 had undetectable HBV DNA; 1 died prior to HBV DNA testing. Conclusions: There was no evidence of transmission of BBPs in this cohort of PECs who had procedures with potentially improperly cleaned fiberoptic endoscopes. Although not all patients completed all retrospective BBP testing, <10% were missing all or some tests. Local passive surveillance did not indicate enteric pathogen transmission. Additional education regarding and monitoring of reprocessing procedures have been instituted. Funding: None Disclosures: None