Salem, MA – Salem Hospital in Massachusetts has notified nearly 450 patients that they may have been exposed to HIV, hepatitis B and hepatitis C due to a lapse in infection control in the hospital’s endoscopy unit.
The exposures occurred between June 2021 and April 2023 and were related to the administration of IV medications during endoscopic procedures. Endoscopy involves the insertion of a thin, flexible tube with a light and camera on the end to examine the gastrointestinal tract.
Hospital Says Risk of Infection is Low
In a statement on November 15, Salem Hospital said the manner in which the IV medications were given was “not consistent with our best practice” but provided no further details about the lapse in protocol.
The hospital stressed that the risk of infection is “extremely small” and there have been no cases connected to the exposures so far.
“There is no evidence to date of any infections resulting from this incident,” the hospital said. “The safety of our patients is our highest priority, and we have undertaken multiple corrective actions in response to this event. We sincerely apologize to those who have been impacted, and we remain committed to delivering high-quality, compassionate health care to our community.”
Patients Notified, Offered Free Testing
The 449 patients potentially affected have been notified by letter and are being offered free blood tests for HIV, hepatitis B and hepatitis C. The hospital has also set up a hotline to answer patients’ questions.
The exposures were discovered earlier this year and the lapse has since been corrected, according to the hospital.
State Health Department Investigating
The Massachusetts Department of Public Health (DPH) has been investigating the incident and advised the hospital to notify patients and provide follow-up testing.
“DPH advised the hospital to notify all impacted patients in writing about the potential exposure to bloodborne pathogens and to offer free-of-charge follow-up care, including testing,” the department said in a statement.
Hepatitis and HIV: Transmission and Treatment
Hepatitis B, hepatitis C and HIV are bloodborne pathogens that can be transmitted through contact with infected blood and bodily fluids.
Hepatitis B and C are viral infections that cause inflammation of the liver. Both are treatable with antiviral medications, especially when caught early, but they can lead to serious liver damage if left untreated.
HIV weakens the immune system by attacking CD4 cells that fight infection. While there is no cure, antiretroviral therapy (ART) can keep the virus under control and prevent its progression to AIDS. When treated early, people with HIV can live long and healthy lives.
For the Salem Hospital patients, health experts say the risk of contracting these viruses from the potential exposure is low. Endoscopic procedures are considered relatively safe with a low infection transmission rate when proper sterilization protocols are followed.
Hospital Implements Corrective Measures
Following the discovery of the lapse earlier this year, Salem Hospital said it “immediately investigated the situation, implemented corrective actions, and have taken steps to prevent this from happening again.”
The statement did not elaborate on the corrective measures but said the hospital reported the exposures to the DPH and has been working closely with the agency during its investigation.
Hospital endoscopy units follow strict protocols to avoid spreading infection between patients, including fully sterilizing scopes after every procedure. It is unclear exactly where the lapse occurred in this case.
The DPH will monitor the hospital to ensure proper procedures are now in place. Meanwhile, Salem Hospital reminded patients they can still safely undergo endoscopy procedures at their facility.
Response Praised as Responsible, Transparent
Healthcare experts are praising Salem Hospital’s handling of the potential exposures, calling it a responsible and transparent response.
“They investigated it, fixed it, notified patients promptly and offered free testing – that’s exactly what should happen when a lapse occurs,” said Dr. Neil Calman, president of the Institute for Family Health in New York.
“The risk of actually acquiring HIV or hepatitis from this kind of exposure is small. But providing patients with information and resources shows the hospital’s commitment to safety and restoring trust,” Calman said.
While concerning, such potential exposures from lapses in protocol are not uncommon and often go unnoticed. Salem Hospital’s acknowledgement of the incident and swift action to notify and care for patients are considered exemplary.
“Hospitals around the country can look to Salem’s response as a model for how to handle such a situation ethically,” said bioethicist Arthur Caplan. “The transparency will go a long way toward maintaining patients’ faith in the institution.”
