The Buffalo Veterans Affairs Medical Center contacted all but three of the 526 patients who underwent colonoscopies with equipment that may have been inadequately cleaned and most of them have agreed to testing for possible infection.
To date, more than 360 veterans have been screened for hepatitis B, hepatitis C and HIV, the virus that causes AIDS, hospital officials said. The VA has said the risk of infection is "very low," and notification of the screening does not mean a patient is infected. The VA made multiple attempts to reach the three patients, officials said.
Asked whether any patients developed infections, officials said in a statement test results will be communicated directly to patients and treatment, if needed, provided. The Veterans Health Administration, through the office of Public Health Surveillance and Research, will publish the outcomes after completion of an investigation, officials said in a statement.
VA officials have declined repeated requests for interviews about the case, reporting in statements only that a recent review of the disinfection process found that repetitive steps in the manufacturer's instructions for cleaning the reusable endoscopes may not have been followed in some cases by an employee between April 19, 2015, and June 23, 2017.
"Each scope used in these colonoscopies was disinfected. However, this letter is to inform you that one technician may not have followed a part of the established disinfection procedure when cleaning scopes," according to a letter sent to patients.
Despite assurances from the medical center about the low risk of infection, the incident prompted concern.
"It's upsetting," said Ronald Stevenson, a Vietnam War veteran.
Stevenson, of Jamestown, said he underwent a colonoscopy at the medical center in October 2015 and, the day after, developed a bacterial infection that required treatment with antibiotics. He said he received a letter about the free screening, was tested and is awaiting results.
"You have to wonder if there are people who were infected from a scope and never realized it," Stevenson said.
VA officials said the employee, a sterile processing technician, was removed from his cleaning responsibilities and issued a notice of proposed removal from federal service in accordance with recent legislation that gives the VA secretary greater authority in disciplinary cases, including shortening the time employees have to respond to disciplinary action.
In a conference call last week that included a staff member representing Rep. Brian Higgins, D-Buffalo, hospital medical and administrative officials described the technician's error as brushing a part of the equipment once instead of three times before placing it in a device for sterilization, according to a person familiar with the discussion. The time period of concern coincided with the technician's employment, according to a fact sheet the VA provided at the time of the call.
"We are deeply sorry this situation occurred and are committed to the safety and well-being of all the patients we serve. Please be advised that when this issue was identified, we took immediate action to ensure our patients’ safety," the VA wrote in its letter to patients.
For years, there has been increasing concern about infections linked to endoscopes, the flexible tubes that doctors use to peer inside patients’ bodies. Certain parts of the devices can be difficult to clean, with steps prone to human error, and require strict adherence to manufacturers' instructions to remove tissue and body fluids, as well as to prepare for reuse in another patient. Technicians also must know which disinfectants and reprocessing machines are compatible with a particular endoscope.
Outbreaks have been associated with a number of different medical scopes, including duodenoscopes threaded into the top of the small intestine, gastroscopes passed into the stomach, bronchoscopes to view airways and colonoscopes inserted into the rectum to view the large intestine.