10 May 2000
Colonoscope/Endoscope Sterilising Equipment Under Investigation
THE Ministry of Health has contacted all hospitals within New Zealand, including 26 which use a type of colonoscopy
sterilising equipment for endoscopes and colonoscopes, after one hospital reported a potential fault with the equipment.
Colonoscopes are pieces of equipment inserted into the bowel for internal investigations which help doctors diagnose, or
to guide them when carrying out operations. Only some hospitals perform this procedure.
The cleaning and disinfection are complex procedures carried out routinely by all large hospitals with
endoscopy/colonoscopy units.
Chief Medical Advisor Dr Colin Feek said that concern about the colonoscopy sterilising equipment was raised by Lakeland
Health on March 29, after routine infection control procedures detected E.coli bacteria in one colonoscope. E.coli is a
common bacteria found in the human bowel.
Lakeland Health has stopped using the equipment, pending investigation. The New Zealand distributor of the sterilising
equipment has also ceased distribution while this issue is being investigated.
Dr Feek said the Ministry was still investigating the cause of the problem, and is expecting a report from Lakeland
Health within 10-14 days.
"All hospitals had been advised of the situation, and the Ministry has requested hospitals using the same equipment to
confirm that cleaning procedures for endoscopes/colonoscopes are appropriately monitored."
Dr Feek said that, "Theoretically the Lakeland Health patients who have been treated with this equipment between
mid-February and March 29, could have been exposed to a risk of infection. However international expert, Dr Alistair
Cowen, of Australia has advised that the risk is negligible."
"Even though the risk is low, the Ministry of Health supports the actions of Lakeland Health to inform the patients. It
is clear that patients have a right to know about procedures that affect them," Dr Feek said.
"Unfortunately problems can occur with even the best equipment from time to time, the important point is to ensure that
there are steps in place to detect problems and correct them quickly as has happened in this case," Dr Feek said.
END
For more information contact: Selina Gentry, Media Advisor, ph: 04-496-2483 or 025-277-5411 Internet address:
http://www.moh.govt.nz/media.html
Background Information
What is a colonoscope? Endoscopes are devices inserted into the body for internal investigations which help doctors
diagnose, or to guide them when carrying out operations. Colonoscopes are devices inserted into the bowel for internal
investigations. Only some hospitals perform this procedure. The cleaning and disinfection are complex procedures carried
out routinely by all large hospitals with colonoscopy units.
How did Lakeland Health become aware of the situation? A new colonoscope was purchased in December and was first used on
17 February 2000. All equipment is subject to complex cleaning and disinfection procedures, and routine infection
control measures. Mid-March routine bacteria culture samples were taken and on March 29 the samples confirmed the
presence of E.coli in the new colonoscopy despite it having been sterilised. E.coli is a common bacteria found in the
human bowel. Lakeland Health has stopped using the equipment, pending investigation.
Have any other hospitals reported similar problems? No. However, there was an incident in Christchurch in July last year
involving the sterilisation of endoscopes. At that time the risk of infection to patients was negligible, and subsequent
testing showed no infection attributed to the sterilisation failure.
Is the sterilising equipment used in any other hospital in New Zealand? Yes. A total of 26 hospitals use this
sterilising equipment. A letter has been sent to ALL hospitals advising them of the problem at Lakeland Health and
requesting them to advise the Ministry about routine bacteriological testing procedures they employ when using the
Steris System 1.
Have any other hospitals reported problems with the Steris System 1 Processor There have been no other reported
problems.
Is the problem a result of a design fault or is it operator-related? We don't have the answer to that at this stage but
the investigation is continuing. The New Zealand distributor has ceased distribution while this issue is being
investigated.
END