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CDC HIV/AIDS/Viral Hepatitis/STD/TB Prevention News Update

PENNSYLVANIA: Jefferson Hospital Warns of Possible Infections


Philadelphia Inquirer (04.16.13)

Thomas Jefferson University Hospital in Philadelphia has sent letters warning 51 patients who underwent gastrointestinal procedures at the hospital. The letters warned of potential exposure to blood-borne viruses that cause hepatitis B, hepatitis C, and HIV. The possible contamination occurred during four weeks in February and March of 2013 because of a lapse in the hospital’s infection-control measures. Hospital spokeswoman Jacqueline Kozloski said that later review of patients' records found no known cases of HIV infection. Jefferson University Hospital offered the patients free blood tests to check for infection and in a statement said, “As of last week, 48 patients had received their free baseline testing and there was no evidence of infection.” The hospital recommended that all patients get additional follow-up testing. In gastrointestinal endoscopic procedures, a flexible fiber-optic scope is threaded into the digestive tract to view the intestines, stomach, or esophagus; surgical instruments may also be inserted to remove samples of biopsy tissue. Jefferson Hospital explained in the letter to patients that during a biopsy, "sterile, single-use" forceps are rinsed in a cup of water that is supposed to be discarded after the procedure; however, "some rinse water was reused for a small number of patients." The hospital said it was waiving the fee of the patients’ GI procedures, and "in the highly unlikely event that an infection has been transmitted," the hospital will provide free follow-up treatment. As a corrective measure, Jefferson Hospital has reviewed infection-control practices and required retraining of all GI unit employees. Jefferson's website indicates that it performs more than 13,000 endoscopic procedures a year. Expert medical groups have created strict guidelines for disinfecting GI endoscopy equipment. Consequently, transmission of infection is very rare, with an estimated frequency of one in 1.8 million procedures.


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