More than 1,800 veterans at risk for HIV due to VA hospital cleaning gaffe

Improperly washed dental equipment may have led more than 1,800 veterans being exposed to the hepatitis B and C viruses, as well as the human immunodeficiency virus (HIV) infection at the John Cochran Veterans Administration Hospital in St. Louis, according to a letter sent by the Department of Veterans Affairs to the vets on June 28.

Techs at the hospital washed the dental equipment by hand prior to putting the tools through a sterilization process, but protocol requires the equipment to go directly to the hospital's sanitizing and sterilizing department for specialized cleaning, reports Dr. Stephen Streed, system director for epidemiology and infection prevention at HealthPark Medical Center in Fort Myers, Fla., and a member of the board of directors for the Association for Professionals in Infection Control (APIC), told FierceHealthcare that while the techs may have thought they were doing the right thing, cleaning and sterilization can be a much more complex process. 

"Hand washing [equipment] may or may not remove all of the protein material, blood, serum and debris that's left on the instruments," Streed said. "Normally, you take instruments once they're used, and you send them through a series of enzymatic cleaning processes that sometimes use ultrasound and enzymes combined together; that both shakes the debris off and dissolves it off." 

In its letter, the hospital urges veterans to get a free blood test as soon as possible, despite a "low risk of exposure." 

"We deeply regret that this situation occurred," the letter reads, "and we assure you that we are taking all the necessary steps to make certain that testing is offered quickly and results communicated timely." 

Rep. Russ Carnahan (D-St. Louis) called the situation "absolutely unacceptable" in a letter sent to Secretary of Veterans Affairs Eric Shinseki, and called for those responsible to be disciplined. 

"No veteran who has served and risked their life for this great Nation should have to worry about their personal safety when receiving much needed healthcare services from a Veterans Administration hospital," Carnahan writes. "The men and women who have served this nation deserve the very best healthcare available--anything less is intolerable." 

This is not the first time the VA has had to deal with an issue of this magnitude. Just last year, three patients who were patients at VA hospitals in Tennessee, Georgia and Florida respectively, all tested positive for HIV after exposure to contaminated equipment, with thousands more requiring testing. What's more, this is not the first time that this specific hospital has been cited for poor infection control: In 2008, the VA determined in a review of the St. Louis hospital that storage areas at the facility contained both clean linens and dirty patient care equipment, and that medications were stored at temperatures warmer than recommended. The review also noted that employees at the hospital failed to "consistently document actions when refrigerator temperatures were out of range." 

"I think one of the most important things is to make sure that each organization, such as a hospital, has a sufficient number of infection preventionists who are specially trained experts in this area," Streed said. "[They need to be] both resourced and given the appropriate authority to make sure they can implement change when necessary." 

For more information:
- here's the article
- read the letter from the VA to the veterans
- here's a statement and the letter written by Rep. Carnahan
- check out the 2008 VA review of the St. Louis hospital