Rural Alaska

Bethel dental patients asked to take blood tests after sterilization breach

BETHEL – Dozens of dental patients in Southwestern Alaska are being asked to submit to blood tests as a result of unsterilized instruments being used over a nine-day period in September.

Within that group, at most 13 patients are believed to have been exposed to potential infection from tools that were cleaned but not sterilized, according to Yukon-Kuskokwim Health Corp., the region's biggest health provider. The chance of anyone becoming ill or infected "is extremely low," said Jim Sweeney, YKHC vice president of health services.

While 191 patients were seen in the dental clinic from Sept. 13 to Sept. 21, only 13 sets of unsterilized equipment were used, he said.

"Because we can't tie a specific set of equipment to a specific patient, we are looking at everybody who was treated in that time period," Sweeney said Friday.

That means many patients are being notified and offered free blood tests, he said. Relatives, partners and children of patients are not at risk and don't need to be tested, said Tiffany Zulkosky, YKHC vice president of communications.

The breach in sterilization is causing the Alaska Native-run health agency to examine its procedures hospital-wide, Dan Winkelman, YKHC president and chief executive, said in "a letter to our customers" posted Thursday on the YKHC website.

"On behalf of YKHC, I apologize," Winkelman said in the letter.

The hospital is bringing in an outside expert to help it analyze its procedures, Sweeney said.

"As we learn more from our detailed investigation we will continue to implement whatever changes are necessary to ensure we protect our customers," Winkelman said.

The suspect batch of dental instruments went through two steps of a three-step process and missed the last one: sterilization, the health corporation said. The instruments – hand tools, impression pans and the like – were wiped down, cleaned with detergent ultrasonically and then dried before being packaged in bags and placed in a sterilizer, Sweeney said.

On Sept. 21, a technician following normal procedure pulled packaged equipment that a dentist needed for a particular patient.

"When they were pulling equipment, they noticed that one of the bags was not sterilized," Sweeney said. "So that's how we discovered the issue."

The bags feature a heat-sensitive mark that changes from light blue to a darker color during sterilization. The instruments are supposed to be heated to about 250 degrees in a process that takes about an hour, Sweeney said.

The technician spotted a bag still marked light blue and reported the discrepancy. YKHC turned to its sterilization log and determined that one batch made up of 16 sets of instruments had been placed into the sterilization machine, then removed prematurely.

"Through human error it was taken out again without running the sterilization unit," Sweeney said.

Three sets weren't used on patients. More than one set could have been used on the same patient, so at most, 13 patients are at risk, he said.

YKHC has called all the patients with working telephone numbers on file, and also sent certified letters explaining what happened. The organization is offering free blood tests for any signs of infection from hepatitis B, hepatitis C or human immunodeficiency virus, which causes AIDS.

YKHC didn't have to alert any patients or offer testing, given the low risk, officials said.

The health organization figured out what had happened, developed a response and contacted the U.S. Centers for Disease Control and Prevention as well as state epidemiologists for guidance.

"Honestly, it's been very quick," Louisa Castrodale, a state epidemiologist, said of YKHC's response. "They weren't under any obligation to notify us" but wanted to ensure patients got the proper care and that the message was communicated accurately, she said.

For anyone to get ill, the tools would have first been used on an infected patient and the virus would have had to remain on the equipment during the two rounds of cleaning, Castrodale said. HIV in particular is so fragile that it likely would have already been killed, she said.

The CDC classifies breaches in infection control as either high risk or low risk.

"This definitely falls into the lower category, where there is not a direct exposure like with a needle stick or something like that," Castrodale said.

Though testing and notification was optional, the health agency wanted to be open with patients about what had happened and put their health first, Zulkosky said.

The hospital already has added steps in its dental clinic. Time is being built in for dentists to check that equipment was sterilized, Sweeney said. Two people instead of one now must inspect material coming off the sterilization unit and confirm the procedure was done, he said.

Some patients have already said they didn't want to get their blood tested. As of late Thursday, 50 or 60 or so had done so, he said.

The health agency won't publicly state whether any of the tests show hepatitis or HIV. YKHC doesn't want to violate patient privacy, and there's no way to know for sure how the person became infected, Zulkosky said.

Patients with questions can call 844-543-6361 to speak with a medical professional, though after hours they might have to leave a message. YKHC also is posting information on Facebook and its website.

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