Hospital tools put kids in HIV risk

Clara Pirani, Medical reporter
The Australian
Feb. 10, 2007

ALMOST 100 children may have been infected with HIV or hepatitis as a result of being treated at Canberra Hospital with surgical instruments that had not been sterilised.
Health authorities are searching for patients who had a colon biopsy at the hospital between 1987 and mid-October last year.

The patients, all under the age of three at the time, would have had the biopsy to diagnose Hirschsprung's disease, which affects the colon and can cause severe constipation.

Health officials became aware of the problem in October when a staff member noticed some of the biopsy equipment was not sterilised properly.

"The hospital and ACT Health are dismayed that this has happened," acting ACT chief health officer Charles Guest told The Australian.

"This is an isolated rare event in healthcare. It's very unfortunate that it has occurred but occasionally things like this will happen in hospitals."

An investigation by hospital staff found two biopsy forceps used to take tissue samples were routinely washed but not sterilised as required by national standards.

A tracking system records the sterilisation of all hospital equipment. However, there was no record that the two forceps had been sterilised during the past 20 years.

The hospital has contacted and tested half the patients involved.

Dr Guest said the Health Department would not make public information about the outcomes of the tests.

"These results are highly confidential," he said.

"We are very concerned for the privacy of people who have had the biopsies and are now undergoing counselling for the possibility of infection through these blood-borne viruses."

He denied that more than 100 patients may have been exposed.

"Our records go back to 1987. It's very unlikely that biopsies of this kind would have been done before this time, because that was when these instruments began to be used.

"Theoretically, there may be a few more patients, but it's very unlikely."

Dr Guest defended the Health Department's delay in contacting the patients. "It has taken quite some time to assemble all the records on people's possible exposure to these biopsy forceps," he said.

"Then we got into the Christmas season and it was decided that it was better to do the notification of them all at the one time, rather than staggering it out over some weeks and missing people over the holiday period.

"We didn't want some people to hear about it first through the media."

Dr Guest said the risk of patient-to-patient transmission of Hepatitis B or C was about one in 100,000 and one in 16 million for HIV.

Australian Patient Safety Foundation president Bill Runciman said the case highlighted the need for hospitals to improve monitoring systems.

"One of the biggest categories of problems, with respect to patients being harmed, is infections that occur in hospital, including surgical site infections," said Professor Runciman.

"It's essential with surgical equipment, especially forceps that grab and bite, to get the matter out of the jaws andhinges, and then to makesure that they are properly sterilised.

"There can also be systematic technical failures in the machines that are supposed to maintain a certain temperature and pressure for a certain time."

Professor Runciman said some cases of infection were hard todetect.

"In this case, with only 100 patients seen over 20 years, it would have been difficult to identify if there was a pattern of problems," he said.

"However, I think the whole health system needs a bit more regulation."