Hospital 'Breach' May Have Exposed Patients to HIV, Hepatitis: What Went Wrong?

Surgical instruments
(Image credit: Shutterstock)

Some patients at a Colorado hospital may be at risk for HIV or hepatitis infection after the hospital discovered an issue with the way it cleaned certain surgical instruments. But what, exactly, went wrong?

On Wednesday (April 4), the Colorado Department of Public Health and Environment (CDPHE) announced that it was investigating a sterilization "breach" at Porter Adventist Hospital in Denver. The breach may have affected patients who had orthopedic or spine surgery at the hospital between July 21, 2016, and Feb. 20, 2018, according to a statement from CDPHE.

"The process for cleaning surgical instruments following orthopedic and spine surgeries was found to be inadequate," and this may put patients at risk for infections of their surgical site, or for HIV, hepatitis B or hepatitis C infections, the statement said. Still, this risk is of contracting HIV or hepatitis is "very low," CDPHE said.

Specifically, Porter Adventist Hospital said the issue involved the "precleaning" process, which occurs before the instruments go through heat sterilization and other cleaning steps.

The precleaning process is the first step in cleaning after the instruments have been used. The process essentially involves manually cleaning off debris from the instruments after surgery, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, who is not involved with Porter Adventist Hospital or the investigation. [27 Devastating Infectious Diseases]

This step needs to take place so that there is nowhere for pathogens to "hide" during the sterilization process that follows. "If you’ve got debris in there, it might shield the viruses from being deactivated" by the sterilization process, Adalja told Live Science.

Adalja likened the precleaning process to rinsing off a plate before you put it in the dishwasher — if you've got food stuck to the plate when you put it in the dishwasher, it's not going to be fully cleaned when it comes out.

"You want to get the debris off so the cleaning process is more effective," Adalja said.

Even with this lapse, Porter Adventist Hospital said that the chance of getting an infection from a blood-borne pathogen, such as HIV or hepatitis, is "extremely low." But the hospital said it was notifying patients for transparency's sake, and to "ensure the safety and confidence" of their patients.

Patients who may have been affected by the breach are being given the option to get tested for blood-borne pathogens. So far, no infections related to the breach have been found, CDPHE said.

Original article on Live Science.

Rachael Rettner

Rachael is a Live Science contributor, and was a former channel editor and senior writer for Live Science between 2010 and 2022. She has a master's degree in journalism from New York University's Science, Health and Environmental Reporting Program. She also holds a B.S. in molecular biology and an M.S. in biology from the University of California, San Diego. Her work has appeared in Scienceline, The Washington Post and Scientific American.