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VA Colonoscopy Health Scare

http://www.cnn.com/2009/POLITICS/03/24/florida.va.facilities/index.html?eref=rss_topstories

From Jennifer Pifer Bixler, Elizabeth Cohen and Sabriya Rice

(CNN) -- Thousands of veterans in South Florida may have been exposed to hepatitis and HIV because of contaminated equipment after getting colonoscopies at the Miami Veterans Affairs Healthcare System, officials announced Monday.

Two Florida lawmakers are asking for an inspector general's inquiry.

"The VA is a model of the type of health care we provide our veterans, and when mistakes like this occur, it undermines the efficacy of the entire system," said Rep. Kendrick B. Meek, D-Florida, in a news release. Meek, along with Sen. Bill Nelson, D-Florida, is requesting an official inquiry by the inspector general of the VA.

In a letter to retired Gen. Eric Shinseki, the secretary of Veterans Affairs, Nelson said he is also concerned about possible contaminated equipment at facilities in Murfreesboro, Tennessee, and Augusta, Georgia.

"I am requesting that the VA Office of Inspector General begin an investigation into the potential problems of contamination; whether any patient has contracted an infection from unsterilized equipment; and, most importantly, how we can prevent such problems from happening again," Nelson wrote.

"Finally, I urge the VA to commit to providing ongoing medical care in cases where it is responsible for exposing someone to a disease."

On Monday, the VA sent letters to 3,260 people who may have had colonoscopies between May 2004 and March 12, 2009. Hospital officials said a review of safety procedures found that tubing used in endoscope procedures was rinsed but not disinfected.

In the first 24 hours after the letters were released, the Miami VA got more than 2,600 calls and checked out more than 350 patients. Nearly 600 more are scheduled for examinations over the next two weeks, officials at the facility said.

Officials say the risk of infection is minimal.

"What happened should not have happened. We are taking steps to change it right now," said John Vara, the Miami VA's chief of staff.

The problem at the Miami VA facility comes on the heels of similar problems with endoscopies at the VA clinic in Murfreesboro. In December 2008, an investigation found that clinic workers were not following manufacturer's directions and switched out parts they weren't supposed to switch out, according to investigators. About 6,000 people who underwent colonoscopies at the clinic were notified and offered free testing for infections.

The Charlie Norwood VA Medica Center in Augusta, Georgia, also said it had "recently notified 1,200 veterans they may have been exposed to infection when undergoing ear, nose and throat (ENT) procedures between January and November of 2008."

In Miami, the VA has opened "special care clinics" to test veterans who received the notice and to provide information.

"Screening is strictly precautionary and does not indicate that any patients have contracted a virus," Mary D. Berrocal, director of the Miami VA, said in a statement on the VA's Web site.

The special care clinics opened Tuesday morning, and officials say response from patients has been good. "They are being proactive, and we are glad. We want them to get tested," said Susan Warren, a spokeswoman for the Miami VA facility
5 Responses
Avatar universal
VA coloscopy powerball

Here's the lastest sad news on the news tonight;

http://news.aol.com/article/va-3-patients-hiv-positive-after-clinic/416642?cid=14

VA: 3 patients HIV-positive after clinic mistakes
By BILL POOVEY      AP


CHATTANOOGA, Tenn. -Three patients exposed to contaminated medical equipment at Veterans Affairs hospitals have tested positive for HIV, the agency said Friday.
Initial tests show one patient each from VA medical facilities in Murfreesboro, Tenn.; Augusta, Ga.; and Miami has the virus that causes AIDS, according to a VA statement.
The three cases included one positive HIV test reported earlier this month, but the VA didn't identify the facility involved at the time.

The patients are among more than 10,000 getting tested because they were treated with endoscopic equipment that wasn't properly sterilized and exposed them to other people's body fluids.

Vietnam veteran Samuel Mendes, 60, said he was surprised to learn of an HIV case linked to the Miami facility, where he had a colonoscopy. He was told he wasn't among those at risk.
"I was hoping and expecting to not get anyone contaminated like that," he said. "It's probably a little worse than we thought."
***************
The VA also said there have been six positive tests for the hepatitis B virus and 19 positive tests for hepatitis C at the three locations.
***************
There's no way to prove patients were exposed to the viruses at its facilities, the agency said.  (see my note below- Willy)
"These are not necessarily linked to any endoscopy issues and the evaluation continues," the statement said.
The VA has said it does not yet know if veterans treated with the same kind of equipment at its other 150 hospitals may have been exposed to the same mistake before the department had a nationwide safety training campaign.

An agency spokeswoman has said the mistake with the equipment was corrected nationwide by the time the campaign ended March 14. The problems discovered in December date back more than five years at the Murfreesboro and Miami hospitals.

The VA's disclosure Friday was the department's first comment since April 3, when the VA reported the one positive HIV test.
VA spokeswoman Katie Roberts has declined to provide any details on how widespread the problems might have been other than saying a review of the situation continues.

She said in an e-mail Friday that "there is a very small risk of harm to patients from the procedures at each site." She said the HIV results "still need to be verified" in additional tests.

The VA statement shows the number of "potentially affected" patients totals 10,797, including 6,387 who had colonoscopies at Murfreesboro, 3,341 who had colonoscopies at Miami and 1,069 who were treated at the ear, nose and throat clinic at Augusta.
More than 5,400 patients, about half of those at risk, have been notified of their follow-up test results, the VA said.

The Friday statement said the VA is "continuing to notify individuals whose letters have been returned as undeliverable, and working with homeless coordinators to reach veterans with no known home address."
The statement also said the VA has assigned more than 100 employees at the three locations to "ensure that affected veterans receive prompt testing and appropriate counseling.
"
All three sites used endoscopic equipment made by Olympus American Inc., which has said in a statement it is helping the VA address problems with "inadvertently neglecting to appropriately reprocess a specific auxiliary water tube."

Charles Rollins, 62, who served three tours in Vietnam with the Navy from 1966 to 1969, said the news concerns him because he's used the Augusta ear, nose and throat clinic several times.
"That's terrible," he said by phone as he socialized at an American Legion post in Augusta.

Associated Press writers Lisa Orkin in Miami and Dorie Turner in Atlanta contributed to this report.
--------------------------------------------------------------------------------------------
(my note....)
My comment on the highlighted section.  To the best of my knowledge they have records of who used the machines and when.  HIV virus cannot last very long at all outside of the body and/or at room temps.  HCV is thought to only remain viable for around 4 days.  If the people who used the equipment before the infected did do not have HIV or HCV it would seem to suggest that the equipment was not the vector for transmission.  IF the people with the infection for instance had severe damage one might also reasonably conclude that they may have had the infection for years and possibly decades.

ON the other hand ....... if it were to turn out that the infected seemed to share the same quasi-species of HCV or HIV as a patient that recently preceded their colonoscopy one would have near proof that the equipment was the vector.  Flipside back..... if one was a geno-4 and another a geno 2 one would also have to conclude that the equipment was not the vector.

So I'm wondering.....why are they maintaining that there is "no way to tell".....?  Does this strike anyone else as more ignorance on top of the injury?  Am I missing something?

best,
Willy
691935 tn?1421030690
Potentially affected" patients totals 10,797 -- that is really sad.  

Your comment  - if one was a geno-4 and another a geno 2 one would also have to conclude that the equipment was not the vector.

Not necessarily, a person may have contracted both and cleared one of them.  Or a lot of variables in the mix, depending on "how," "from whom,"  or even the "time period," the tubing was infected,  

Just one more thing to worry about while getting medical procedures.

568322 tn?1370169040
"So I'm wondering.....why are they maintaining that there is "no way to tell".....?  Does this strike anyone else as more ignorance on top of the injury?  Am I missing something? "
----------------
It gets much worse.  Let me show you.....

According to the CDC's MMWR report of March 21, 2008, in almost half of the cases (392 of 788) of acute HCV reported in the past decade there was no risk factor data listed (which would have helped determine the modes of transmission and the number of health care related infections).

But according to this recent CDC article, they say that in the past decade there were "33 health care exposure outbreaks, 448 infected, and nearly 60,000 were put at risk".


"Nonhospital Health Care–Associated Hepatitis B and C Virus Transmission: United States, 1998–2008

Nicola D. Thompson, PhD, MS; Joseph F. Perz, DrPH, MA; Anne C. Moorman, BSN, MPH; and Scott D. Holmberg, MD, MPH

6 January 2009 | Volume 150 Issue 1 | Pages 33-39

In the United States, transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) from health care exposures has been considered uncommon. However, a review of outbreak information revealed 33 outbreaks in nonhospital health care settings in the past decade: 12 in outpatient clinics, 6 in hemodialysis centers, and 15 in long-term care facilities, resulting in 448 persons acquiring HBV or HCV infection. In each setting, the putative mechanism of infection was patient-to-patient transmission through failure of health care personnel to adhere to fundamental principles of infection control and aseptic technique (for example, reuse of syringes or lancing devices)In all the outbreaks, investigators uncovered significant breaches of the most basic IC principles -- for example, reuse of syringes or lancing devices, contamination of medication vials by using them for multiple patients, and lapses in hand hygiene. Nearly 60,000 people were put at risk because of these faulty or deficient practices. The authors deemed all the outbreaks to have been preventable."
------------------------

HOWEVER, the number of people put at risk is actually much higher....this is a partial list of exposures at VA centers (info comes from press releases and articles at HCVets).

27,000 patients at 16 VA hospitals across the country, improperly cleaned equipment for prostate biopsies.
3,260 patients Miami VA...colonoscopies.
6,400 patients in Tennessee colonoscopies from 2003-2008....10 positive.
1,100 veterans ENT procedures, Augusta, Ga...6 positive.
50,000 Las Vegas...endoscopies...114 positive.
155...El Paso Texas...surgery...8 positive
>2,000 diabetics New Mexico, 9 VA clinics...insulin pens....16 positive.
170 dialysis Manhattan...9 positive.
1,200 North Carolina, stress tests...7 positive.
1 cosmetic surgery...Texas.
657 New York dialysis center.
10,000 PA...transplants with contaminated tissue from corpses.
11,000 Virginia gynecologist reused syringes.
1,880 Indiana surgery center.
24 New York anesthesiologist...4 positive.
10,000 Long Island doctor reused syringes.
>13,000 Michigan dermatologist...6 positive.
3 El Paso...infected by nurse.
300 Virgina...exposed to same nurse.
4 transplant patients infected with HIV...Chicago.
1 infected ...bone allograft/dental implants...Chicago
23 ..unsterile instruments used in delivery rooms, Fresno, CA.
Virginia VA center...pain injections, reused syringes...unknown number.

That's over 100,000 put at risk....and that's not even the whole list.

---------------------

That's a big disparity in the numbers....so we decided to ask one of the CDC article authors, Dr Nicola D. Thompson, why their report didn't seem to list exposures at VA centers, and here's what she said......


"Many thanks for your e-mail. Sorry for the delay in responding, I have been out of the office for the past two days on work related travel.  

Our manuscript focused on outbreaks of viral hepatitis B and C infections associated with the receipt of healthcare. In our methods section it states our inclusion criteria,  
"For the purposes of this review, we only counted outbreaks of HBV and HCV infection that involved 2 or more infected persons and that could be epidemiologically linked to a specific health care facility". In the investigation at the VA, no transmission of HBV or HCV infection was identified. And thus, it did not meet the requirements for inclusion in our review.  

Again, many thanks for your inquiry.
Best wishes,
Nicola D. Thompson, PhD
Epidemiologist
Epidemiology and Surveillance Branch, Division of Viral Hepatitis
Centers for Disease Control and Prevention"
--------------------------


They only counted the exposures that involved 2 or more cases "that could be epidemiologically linked to a specific health care facility".....and since the VA says "there's no way to prove patients were exposed to the viruses at its facilities" even though some of the exposed patients tested positive....the CDC doesn't count them.

Over 100,000 exposures didn't get counted.  It's alot easier to keep blaming HCV on drug use than to expose the truth about health care transmission.  

Dr Thompson also forgot to mention that the CDC doesn't include exposure cases that happen in federal institutions in their report (i.e. VA clinics, prisons, etc).  

Veterans have the highest rate of HCV infection (including transmission from jetguns used to vaccinate them) and the VA clinics/hospitals continue to expose them, yet the CDC refuses to list "military service" as a risk factor.

That is certainly "more ignorance on top of the injury".

Co
233616 tn?1312790796
holy carp....ok...this really means I won't be awake OR asleep for any more of these...

to heck with the video just let me and my polyps rest in peace!!

MB

you know this whole thing has been bugging me since I let them take a look see....like how do they get something that long and kinky sterile anyway...how do I know my molecules aren't being passed on or vise-versa.

And who wants to do that procedure for a living anyway.....
maybe it's like the good book says....
somethings are just best left in the dark.........(jk)

mb
233616 tn?1312790796
>>>>>>>Over 100,000 exposures didn't get counted.  It's alot easier to keep blaming HCV on drug use than to expose the truth about health care transmission.  

tell me about it....have you listened to the Egyptian and Pakistani members in here?

Their whole school's were innoculated using one needle....

I think medicine has probably had more to do with the spread of both these retrovirus's than anyone will ever admit to.

and since they know about the airguns WHY are they not shutting the tatoo parlors down? Why are they flourishing?  Surely you don't think every Biker Bob autoclaves between every client?  Could the CDC be that dense??  Yup.

mb
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