VIHA warns 500 patients of possible blood-borne virus infection

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VIHA warns 500 patients of possible blood-borne virus infection

Patients at General Hospital at risk had procedures June 2008 to

January 2010

By Watts, Times ColonistApril 23, 2010

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, B.C. - Nearly 500 people are being warned to get tested for hepatitis

and HIV after contaminated medical gear used at General Hospital was

linked to an elderly man’s infection.

They all underwent a procedure at the hospital between June 2008 and January

2010 known as an endoscopic retrograde cholangiopancreatography, or ERCP. It’s

used to investigate possible liver, pancreas or gall-bladder problems.

Letters have been sentby registered mail, advising the patients to have blood

tests for viral infections such as hepatitis B, hepatitis C and HIV.

Medical officials with the Vancouver Island Health Authority emphasized the risk

of infection is low — about .0000003 per cent based on U.S. studies.

But “we are taking these extraordinary measures because we believe we have a

duty to our patients and their physicians to advise them of any problem we have

detected,” said Dr. Wale, executive medical director for quality, patient

safety and infection control.

Wale said one of the four endoscopes used for the ERCP procedures was found in

February to be contaminated with a small amount of what is now believed to have

been dried blood. When cultured, the material yielded a bacteria called

pseudomonas.

Around the same time as the bacteria was discovered on the endoscope, a

terminally ill patient who had undergone an endoscopy procedure three days

before came into hospital suffering from a bacterial infection.

The patient’s procedure turned out to have been carried out with the same

instrument that yielded the bacteria. The bacteria from the patient was found to

match the bacteria cultured from the endoscope.

The infection was treated with antibiotics. The man later died, but his death is

unrelated to the infection.

An endoscope is a tube with a tiny light and camera that is used to look inside

a patient’s body. It is usually inserted through a natural opening, such as the

mouth.

Since the contamination problem was discovered, no other bacterial infections

have been found.

Wale said the health authority believes other patients are not at risk from

bacteria, since an infection would have become apparent within days of exposure.

But viral diseases have a much longer incubation period.

Patients whose endoscopy procedures were recent may require up to three blood

tests over nine months. Others will likely require only one.

Investigators believe the contamination occurred because the instrument was

allowed to dry after a procedure. Fern Christensen, a nurse and co-ordinator for

medical-device reprocessing, said bacteria in dried material is more difficult

to dislodge from the endoscope.

Since the discovery, measures have been undertaken to ensure endoscopes are not

allowed to dry. After a procedure, they are immersed immediately in a cleaning

solution.

They are then disinfected, a procedure requiring over one hour.

In the legislature, New Democrat health critic Dix reiterated his party’s

call for something he called a “health quality council,” independent from the

Ministry of Health Services. Such a council would investigate and ensure high

standards in all procedures, such as cleanliness and infection control.

Dix said the province has seen a decline in the standard of cleaning in

hospitals. “The consequences of that can be very high.”

Falcon, minister of health services, said while all health authorities

have rigorous standards for sterilization, there’s never a perfect solution.

“What you always have to do is be constantly trying to improve performance, have

checks in place, and make sure you are as careful as you can possibly be,” said

Falcon. “But you will never eliminate the risk altogether.”

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