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"Times-Herald
More than 3,000 Kaiser patients are at risk for hepatitis Females alerted
to unsanitized equipment that hospitals used
By MATTHIAS GAFNI
Times-Herald staff writer
Friday, April 08, 2005 - About 3,200 female patients from four Northern California Kaiser facilities, including Vallejo and Vacaville, have been notified that they may face a hepatitis infection due to improperly sanitized equipment during operations dating back four years.
In Vallejo and Vacaville, about 400 patients were notified, in Redwood City and Sacramento facilities, about 1,500 and 1,300 respectively.
Although Kaiser Permanente is calling the risk for hepatitis B and C "extremely low," officials have mailed letters asking those patients to take blood tests within two weeks.
"Kaiser Permanente's infection control experts have advised us that our patients are at an extremely low risk for infection, but should be contacted and offered a free screening as a precaution," the hospital said in a prepared statement.
The women all received hysteroscopy procedures in which doctors examine the interior of the uterus for diagnostic purposes.
In all the red-flagged cases, doctors used instruments called flexible hysteroscopes, which weren't sterilized properly, Kaiser officials said. The hospitals halted all those procedures in December 2004, and began to review the equipment, said Kaiser Vallejo spokeswoman Valerie Roberts Gray.
"All our equipment went through the sterilization process, but we've been advised that our pre-cleaning procedure may have been incomplete," Roberts Gray said. "It was brought to our attention and we immediately scrutinized our practices."
Roberts Gray said the hospitals have done an extensive records search for all patients possibly affected.
"We've done a complete and thorough check of all the records from when the equipment came in," she said. "We've identified our members who had this procedure and they've been contacted, or are being contacted."
Kaiser officials checked records from when the instrument was placed in service Feb. 25, 2002 in Vallejo and May 17, 2001 in Vacaville. Dates for the Sacramento and Redwood City facilities were not available late Thursday.
A 49-year-old Sacramento woman, who wished to remain anonymous, had the procedure performed in November 2002, at the Vacaville facility and hadn't heard from Kaiser since. In her procedure, a doctor used a hysteroscope to shoot hot water into the uterus, burning it to stop bleeding, she said. The procedure was done to prevent a hysterectomy, a procedure in which doctors remove all or part of a woman's uterus.
Three years later, on March 29, she said the physician who performed the procedure called, saying it was a non-emergency call, but asking her to contact him.
She said she spoke to Dr. Jonathan M. Snook, of Vacaville's women's health department, later that day and she said he told her of the problem and potential infection.
"I was just hysterical," the woman said.
Calls from the Times-Herald to Dr. Snook on Thursday were forwarded to Kaiser's area spokeswoman.
The last week has been difficult for the former Vacaville patient.
"I was very, very shocked and very, very scared," she said. "I've been a Kaiser patient since I've been married 30 years ago and they've always given me good care. It's really, really upsetting to hear something like this, especially on the phone.
"They act very blas about it and that's why it's so offensive," she said. "They didn't have this procedure done. It's already tough as a woman to have to go through this procedure."
The former patient went to get tested Sunday at the Sacramento Kaiser facility, crying the whole time. She hasn't received her test results yet, she said.
Roberts Gray said there's been no infections yet.
"It's too soon to tell. It's an extremely low risk," she said. "The test results are still being evaluated."
Kaiser waived all co-payments for the tests and any follow-up visits, to which the former Vacaville patient laid on some thick, angry sarcasm to her doctor.
"I was just like, Oh, that's really nice of you.' I told him that, Oh, thank you,'" she said.
In response to the problem, each patient's physician who performed the hysteroscopy notified them by phone and letter of the problem, Kaiser officials said.
"We're taking it very seriously. We're scrutinizing our practices and making sure we follow stringent cleaning practices to make sure this won't happen again," Roberts Gray said. "We apologize for any inconvenience this has caused our members. We are taking it very seriously."
In a letter sent to the Vacaville patient, which the Times-Herald obtained, Dr. Snook explained how the hospital became aware of the problem.
"We made this discovery during a review of our sterilization procedure. We have thoroughly reviewed our sterilization process with medical and infection control experts. We are making changes in our procedures to do our best to prevent this from happening again," he wrote.
The Vacaville patient said her doctor recommended she get an HIV test as well.
Hospital officials said they consulted with infection control experts who said the sexually transmitted disease could not be transmitted through a hysteroscope.
"But if they request a HIV test we would honor that for them," Roberts Gray said.