Improper Sterilization at Veterans Affairs Hospital Could Have Exposed Thousands to HIV, Hepatitis


A letter has been sent to more than 4500 veterans stating that reusable instruments used in medical procedures may not have been sterilized properly at a Georgia hospital.

(Adobe Stock)

(Adobe Stock)

More than 4500 veterans may have been exposed to HIV, hepatitis B, and hepatitis C at the Carl Vinson Veterans Affairs Medical Center (CVVAMC) in Dublin, Georgia, after an internal review found that proper sterile processing protocols are not always being followed, according to Officials say, though, that while patients should consider getting tested for possible infection, the risk of infection is “very low.”

The hospital warned the thousands of patients involved by e-mail or letter that they may have been exposed to blood-borne pathogens. The potential exposures stemmed from incomplete reprocessing of reusable medical equipment. The affected patients underwent dentistry, endoscopy, urology, podiatry, optometry, or surgical procedures in 2021. The hospital’s website includes no information about this situation.

The possible exposure came to light when a member of the veteran’s hospital reported that not all steps for cleaning all medical instruments were being taken. The hospital conducted an internal review and determined discrepancies in preprocessing reusable equipment. The hospital then halted all procedures between January 12 and January 14, and the veterans affected were notified they needed to be tested.

“We learned during an internal hospital review that there may have been times when all the steps necessary for complete and safe cleaning or sterilization were not followed,” the letter to the affected veterans read. “We sincerely apologize and accept responsibility for this mistake and are taking steps to prevent it from happening in the future.”

Cleaning reusable medical equipment is one of the main transmission methods of infectious diseases. Other methods include needles, syringes, sexual contact, and certain bodily fluids.

Even though the letter says the hospital is “confident that the risk of infectious diseases is very low,” administrators recommend “[f]or your own reassurance, however, you may wish to be tested for infections like hepatitis B, hepatitis C, and HIV.” The testing is not required, but is being offered free of charge. No mention was made of testing for spouses or caregivers of the patients.

“We’re committed to providing world-class health care for America’s veterans in a safe and healthy environment,” Manuel Davila, CEO and medical director of CVVAMC, said in a statement on Facebook on February 11, 2022. “When these issues come to light, we stop the line and confront them directly, and we use this opportunity to retrain and create best practices to improve patient safety. Accountability remains at the forefront of caring for veterans, and it is our goal to correct this issue moving forward.”

“We will make it right. We do own it. We are transparent about it,” Davila continued. However, he said he did not know how many patients have been tested or the results. “We are also working closely with experts to make sure our methods of cleaning equipment and training staff are the best they can be.”

CVVAMC brought in another sterilization team from Augusta Veterans Association Hospital to sterilize equipment while the CVVAMC workers were retrained by Veterans Affair Medical Centers in Atlanta, Georgia, Columbia, South Carolina, and Birmingham, Alabama.

The CVVAMC leadership noted in the Facebook statement that veterans who have questions or are seeking more information are encouraged to call (478) 274-5400.

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