HIV risk at Miami VA Medical Center

Procedure at Miami VA Medical Center may have been HIV risk
By Mike Clary and Bob LaMendola South Florida Sun-Sentinel
March 24, 2009
MIAMI - More than 3,200 patients who had colonoscopies at the Miami VA Medical Center in the past five years may be at risk of contracting hepatitis B, hepatitis C or the virus that causes AIDS because of failure to disinfect a piece of equipment.While insisting the risk of infection is "minimal," hospital officials said Monday they had begun sending out letters to patients, most residents of South Florida, advising them to come in to a VA facility in Broward, Miami-Dade or Monroe counties to be tested.The VA announced special care clinics had been set up in the Miami VA, the Broward County VA Clinic, the Homestead VA Clinic and the Key West VA Clinic to handle screening of patients who may be infected. Officials also established a special care 24-hour hot line at 305-575-7256, or toll free, 1-877-575-7256.
John Vara, chief of staff of the Miami VA Health Care System, said a manufacturer's safety alert sparked an internal review of procedures for cleaning a length of tubing used with a certain kind of endoscope. Endoscopy uses a fiber optic camera on the end of a flexible tube to examine the body's interior.Although the endoscope itself was properly cleaned and disinfected, an attached section of tubing "was not processed in accordance with manufacturer's recommendations," said Vara.There is no evidence that any of the 3,260 patients being notified has been infected, Vara said. Of those patients, 549 have since moved out of the Miami VA system area, he said.Vara said he could not explain why the manufacturer's recommendations for cleaning the tubing were not followed. He said no disciplinary actions have been taken."I am deeply sorry for the situation, and I want to assure you that we are taking all the necessary steps to ensure your health," said Miami VA director Mary Berrocal in a letter to patients dated Monday.The chairman of the nonprofit Florida Patient Safety Corp. agreed that the VA's mistake may pose little risk to its patients, and said most were exposed long ago and therefore are likely out of danger.Even so, the mistake is serious and needs to be studied in order to prevent future incidents, said Dr. Anthony Silvagni, chairman of the safety group and a dean at the Nova Southeastern University health sciences division."You don't want people unnecessarily alarmed, but you do want to know what's wrong and fix it," Silvagni said."It's hard to imagine five years going by and they never noticed they were doing it wrong," Silvagni said.U.S. Rep. Kendrick Meek, D-Miami, on Monday asked Eric K. Shinseki, Secretary of the Department of Veterans Affairs, to order an investigation of the procedure failure. He urged a door-to-door campaign to alert veterans of the error.Meek made the same request to VA inspector general George Opfer."This information is shocking," he wrote Opfer. "The very notion that veterans have to contemplate this new reality now before them and visit Special Care Clinics to undergo blood testing is stomach-turning."Mike Clary can be reached at mclary@sunsentinel.com or at 305-810-5007.