HIV in the Endoscopy Suite

Safe Healthcare for the Sickest

The mere mention of HIV (human immunodeficiency virus) in public may still draw suspicious glances. Although HIV has been part of the communicable disease landscape for 20 years, it still engenders universal fear. Endoscopy team members play a significant role in healthcare for HIV-infected patients; each day, they may be exposed to a number of pathogens, but HIV remains one of the most feared.

Anthrax, West Nile and Ebola are all topics of discussion for communicable disease experts, but HIV affects overwhelmingly more people and is prevalent in all pockets of the world, unlike the other four diseases, which may be found only in small geographic pockets.

Of all the symptoms that accompany HIV when it progresses to later stages of disease -- AIDS (acquired immunodeficiency virus) -- gastroenterological complaints are the most common, according to a report presented at the 2002 SGNA (Society of Gastroenterology Nurses and Associates) by Amber Wilson, MSN, RN-CS, FNP.¹

Because of the delicate immune system, evaluation should progress from less-invasive to more-invasive procedures and should be based on the severity and acuity of the symptoms, says Wilson.

Alternatives to Traditional Endoscopy

Because endoscopy is by nature an invasive technique, and because many HIV-positive patients would do well to avoid invasive procedures, alternatives have recently been a subject of study. One study held in Düsseldorf, Germany, tested the Given^® Video Capsule System in HIV-infected patients and healthy volunteers. Each of the 28 patients (8 C-defined HIV-infected patients who had gastrointestinal symptoms and a CD4 count below 200; 9 HIV-infected patients without gastrointestinal symptoms and a CD4 count below 200; and 11 healthy volunteers) ingested the Given capsule after at least a 12-hour fast.³

Results of the pilot study indicated that the procedure was well-tolerated and was able to reveal additional diagnostic information of the small intestine that had not been available by conventional endoscopy. Diagnoses were made of jejunal lesions of Kaposi's sarcoma, antrum gastritis, suspected jejunal angiodysplasias, brunneromas and pseudodiverticulum, among others. The authors concluded that, particularly in the small bowel, capsule endoscopy is safe for discerning gastrointestinal lesions in HIV patients.

Eradicating HIV

Despite HIV's devastation to the immune system, it is vulnerable to high-level disinfectants. "The HIV virus is well-known to be a lipophilic (soluble in lipids due to its lipid- containing envelope) virus quickly killed by high-level disinfectants," says Norman Miner, PhD, director of research at MicroChem Laboratory. "At this time, that would be 2 percent alkaline glutaraldehyde, peracetic acid and hypochlorous acid at 650 ppm free available chlorine, all as approved for use with flexible endoscopes by the FDA."

If HIV does become a problem in the endoscopy suite, it is not so much a concern of its susceptibility to disinfectants, but more a matter of the cleaning process and the high-level disinfection of the endoscope. What is crucial, Miner emphasizes, is that "every surface of the endoscope that could be contaminated by the virus is cleaned, contacted by the high-level disinfectant for its label claim exposure and thoroughly rinsed."

Miner has more than a professional stake in the cleanliness of endoscopy equipment. "As a virologist that understands the virology of this situation, and as one experienced with the potential for some inadvertent flaws and mistakes in the cleaning, disinfecting and rinsing process for endoscopes, and as a patient with acid reflux-associated problems wherein I occasionally am on the receiving end of a gastroscope, I would feel much better about the condition of endoscopes to know that standard practice involved processing the endoscope, and repeating the endoscope re-processing a second time in cases where HIV was known or even suspected," says Miner.

Certainly the patient's desire for HIV-free medical facilities is understandable, all the more so if the patient has a medical background and knows exactly what pathogens can lurk in improperly-cleaned instruments. "You can imagine my misgivings, born of too much knowledge, when I personally encounter the gastroscope," Miner explains. "However, I know through direct communication and personal observation that my health caregivers are very careful as they properly reprocess endoscopes. Unfortunately, that is probably not universally true."

Not all disinfectants are equal. "I understand that there are problems with gases (ethylene oxide) and vapors (hydrogen peroxide) when used with endoscopes due to the difficulties of these gases and vapors penetrating into the long internal channels of the flexible endoscopes," says Miner. "Professionally, I prefer the knowledge that fluids (high-level disinfectants) are being pumped through the internal channels of an endoscope. I can see the fluids flowing through all of the open channels of the endoscopes, and I am not so sure that vapors get into these channels. I know that at one time the FDA restricted the use of vapors to relatively short length channels," he adds.

Several papers have been published regarding this problem; Miner references an article by Michelle Alfa of St. Boniface Hospital and Research Centre at the University of Manitoba, Winnipeg, Manitoba, Canada (Alfa, M.J., et. al. New Low Temperature Sterilization Technologies., pub. in Disinfection, Sterilization, and Antisepsis in Health Care, Edit. Wm A. Rutala, 1998, Polyscience Publications, Inc.). "You should read this publication to understand the details, and avoid market hype by gas and vapor manufacturers," Miner suggests.

"From a patient safety point of view, there is virtually no difference between an endoscope that has been high-level disinfected by an FDA-approved product/process, and a sterilized endoscope," Miner clarifies. "The difference is the AOAC (Association of Official Analytical Chemists) Sporicidal Test using high numbers of bacterial spores dried in their culture medium onto silk suture loop and unglazed porcelain cylinder carriers. The AOAC Sporicidal Test is a laboratory tool, and can be useful in the right hands, but has little or no impact on the microbiological and patient-safe condition of a properly, promptly cleaned, disinfected and thoroughly rinsed flexible endoscope. I know this is a difficult concept to understand if you're not familiar with laboratory tests for disinfectants, and the potential for certain microbes to be on or to be a problem for endoscopes, but it is true. As a microbiologist, and as a sometimes patient, I would rather have a promptly, properly cleaned, high-level disinfected by an FDA-approved high-level disinfectant, and thoroughly rinsed and properly dried and stored endoscope used than an endoscope exposed to a supposedly sterilizing vapor or gas. I trust the fluids more than the vapors."

Asked if he has always been this outspoken about the cleaning of endoscopic instrumentation, Miner replies, "As for when I came to these conclusions, it is amazing how focused and conservative your views become when it's your turn to use an endoscope!"

Safety As the Hallmark of Good Patient Care

Miner's views are understandable; sterilization is only as good as the sterilizer itself. Regular maintenance recommended by the manufacturer should be provided when it is suggested. If the manufacturer suggests regular check-ups of the sterilizer's effectiveness, those checks should also be performed without delay.

Protection of the staff is just as important as protection of the patient. Healthcare workers and the patients they serve should be safe not only from viruses and other pathogens but also from the disinfectants and sterilizers used to eliminate such microorganisms from medical equipment.

Endoscopy staff should be educated regarding hazards associated with performing or assisting with endoscopies and with reprocessing. They should be trained regarding the Occupational Safety and Health Administration (OSHA)'s hazardous communications standard, and should have access to a spill containment plan pertinent to the sterilant or disinfectant being used when reprocessing occurs.²

Cleaning Endoscopy Equipment

A Web site offered by the Queensland, Australia Health Electronic Publishing Service discusses the possibility that HIV may not be deactivated by some disinfectants if it has the protection of a dried protein coagulum. "Some chemical disinfectants including 1 percent glutaraldehyde will fail to inactivate the virus within five minutes," the site cautions. However, another series of studies that investigated the removal of high-titer HIV serum from the surface and internal channels of endoscopes demonstrated that "simple manual cleaning removed HIV activity from all except a single endoscope." The remaining endoscope was cleansed after an additional 10 minutes or less in 2 percent glutaraldehyde.

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