Journal of Gastroenterology and Hepatology (2000) 15, G78–G81

minimal guidelines for the region surveyed. Thus, weundertook a postal and email survey to characterizeendoscopic disinfection and accessory reprocessingpractices in the Asia–Pacific region.

METHODS

This postal survey preceded the formulation of guide-lines on endoscope disinfection for the Asia–Pacificregion. A complete cross-section from most of the coun-tries and territories in this region were surveyed. A threepage multiple-choice questionnaire seeking informationon the procedures for the disinfection of endoscopesand accessories was used.This questionnaire focused ondetails regarding the endoscopy facility where the pro-cedures were performed, the number of personnelemployed, the standard disinfection process used, theimmersion time in disinfectant, the processing of endo-scopes after use in patients with known infections, useof automated disinfectors, the reprocessing of duo-

INTRODUCTION

A worldwide concern has emerged with regard to endo-scope disinfection and hence many gastrointestinalendoscopy associations have come up with guidelinesfor proper disinfection of endoscopes and endoscopicaccessories. They are not much different from eachother and include mechanical cleaning as the first andmost important step, followed by immersion in 2% glu-taraldehyde, a disinfectant, for periods ranging from 5to 20 min. Lack of compliance with these guidelineshas, however, been noted in 20–70% of centres inEurope. UK, Australia and Asia.1–13

There is a paucity of information on the currentreprocessing practices of the gastrointestinal (GI)endoscopy centres. This information is vital, because ithelps in knowing the level of awareness among theendoscopists regarding disinfection practices. Regularsurveys of this kind are indirectly audits of the state ofdisinfection practices and help in forming future per-spectives. This also provides information on the infra-structure and consequently helps in formulating

WORKING PARTY REPORT: CARE OF ENDOSCOPES

Survey of gastrointestinal endoscope disinfection and accessoryreprocessing practices in the Asia–Pacific region

VINEET AHUJA AND RAKESH K TANDON

Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India

Abstract Concern has been raised about the possibility of transmission of infection by gastrointesti-nal endoscope. This vexation may be related to reliability of the disinfecting techniques or to the com-pliance with the guidelines laid down for disinfection.There have been very few recent surveys examiningthe disinfection practices for gastrointestinal endoscopes and their accessories. This survey was under-taken to understand such practices in the Asia–Pacific region. A questionnaire was sent by post or electronic mail to 356 randomly selected endoscopy centres in the Asia–Pacific region. Responses werereceived from 38.7% of the centres. The survey showed that there were significant aberrations in theapplication of disinfection procedures. One-third of the respondents did not practise disinfection at thestart of the day’s session, 2.9% of the centres were not using a high-level disinfectant and 34.7% of the centres used a soak time in 2% glutaraldehyde of less than 10 min. At 40% of the centres, at theend of the day’s session, forced air or alcohol was not used to dry the endoscopes. Reuse of accessoriesmeant for single use was widely practised.© 2000 Blackwell Science Asia Pty Ltd

Key words: endoscope disinfection, reprocessing, survey.

Correspondence: Prof. RK Tandon, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi110029, India. Email: rtandon@medinst.ernet.in

Survey of endoscope disinfection practices G79

denoscopes and any cases of cross-infection due toinadequate endoscope disinfection. In 1999, randomlyselected endoscopists from countries in the Asia–Pacificwere asked by mail (postal or email) to complete thequestionnaire. If members did not respond, a reminderwas sent after 2 months.

Responses were tabulated and presented as a per-centage of those respondents answering a particularquestion. Results were compared with other nationalguidelines.

RESULTS

Of the 356 endoscopy centres selected for survey invarious countries, 138 (38.7%) answered the question-naire.The countries from which responses were elicitedincluded Australia, Bangladesh, China (including HongKong), India, Indonesia, Israel, Korea, Japan, Malaysia,Nepal, New Zealand, Philippines, Saudi Arabia, Singa-pore, Sri Lanka, Taiwan, Thailand and United ArabEmirates. High response rates (more than 55%) werefrom Australia, New Zealand, Japan, Hong Kong, Israeland India. The demographic characteristics are shownin Table 1. Among the 138 replies, 55% were from met-ropolitan public teaching hospitals and 21% were frommetropolitan private hospitals. Most of the centres hada heavy endoscopy load, with 47.1% performing morethan 100 endoscopies per week and 38.4% doing50–100 endoscopies per week. Only 20.5% had onenursing staff member available at each endoscopysession, while the rest had more than one staff member.More than two-thirds (76.9%) alternated two or morescopes during a daily list of endoscopic procedures toallow for more time for decontamination.

Endoscope damage was not a frequent problemfaced. Air/water channel blockage was the mostcommon problem, but that was also seen infrequently.Regarding the disinfection protocol (Table 2), beforecommencing a day’s session, only 66.3% disinfected theendoscopes. Among the respondents practising preses-sion disinfection, the time used for disinfection with 2%glutaraldehyde prior to the start of the day’s list was 5min (11.4%), 10 min (27.1%), 20 min (50%) or greaterthan 20 min (8.5%). In between cases, 100% of therespondents disinfected the endoscopes but 7.2% didnot clean the endoscopes before disinfection. Inbetween cases, 65.1% used an immersion time in glu-taraldehyde of 10 min or more. At the end of day’ssession, 79.8% immersed the scope in glutaraldehyde

Table 1 Demographic characteristics of endoscopy centressurveyed

Percentage of Characteristic respondents

Number of procedures per week< 10 3.6%10–50 14.4%50–100 38.4%> 100 47.1%

Number of units performing ERCP 84.1%Nursing staff available in each endoscopy

session1 20.5%2 45.2%3 21.9%

WorkplaceMetropolitan public teaching hospital 55.0%District public hospital 17.0%Metropolitan private hospital 21.0%District private hospital 5.0%Freestanding private centre 2.0%

ERCP, endoscopic retrograde cholangiopancreatography.

Table 2 Disinfection practices at various centres

Percentage of Practice respondents

Presession disinfection timeNot done 33.7%5 min 8.7%10 min 18.1%20 min 33.3%> 20 min 6.2%

Cleaning between casesYes 92.8%No 7.2%

Disinfectant immersion time between cases< 5 min 16.3%5 min 18.4%10 min 28.2%20 min 26.1%> 20 min 10.8%

Disinfectant immersion time at end of session

< 5 min 6.7%5 min 13.5%10 min 33.7%20 min 33.7%> 20 min 12.4%

Forced air dryingYes 59.4%No 40.6%

Use of automated disinfectorsYes 51.0%No 49.0%

Immersion time in glutaraldehyde after use in a known HBV/HIV-positive patient

10 min 7.4%15 min 33.3%20 min 40.7%30 min 12.9%60 min 5.5%

HBV, hepatitis B virus; HIV, human immunodeficiencyvirus.

G80 V Ahuja and RK Tandon

for 10 min or more. Forced air drying at the end of theday’s session does not seem to be a popular practice,because only 59.4% of respondents claimed to have followed this procedure. Automated disinfectors aregaining acceptability, with 51% of endoscopy centresusing them. Glutaraldehyde remains the most com-monly used disinfectant, with 87.9% preferring it.Other alternative disinfectants used by a minority wereperacetic acid and acid electrolyte water.

At 68% of centres, a distinction between known HIV-positive and routine patients was made and at 47.2% ofthe centres, a distinction between patients with knownhepatitis B virus (HBV)/hepatitis C virus (HCV) infec-tions and routine patients was made. Approximately40.7% of the respondents used more than 20 min soaktime after endoscopy in a known HBV-positive patient.Glutaraldehyde remained the choice of disinfectant atmost centres (87.9%; Table 3). Only 9.1% of centreshad resorted to a change of disinfectant because ofproblems related to glutaraldehyde sensitivity. Endo-scopic retrograde cholangiopancreatography (ERCP) isa more invasive procedure, yet 32.8% of respondentsdid not disinfect the duodenoscopes prior to procedureand approximately the same number did not disinfectthe scopes in between cases. Ninety-five per cent ofrespondents reused disposable accessories after steril-ization (Table 4).Surprisingly, more than three-quartersof respondents would reuse accessories given a choice(Table 5).

DISCUSSION

This was a postal survey and all respondents identifiedthemselves. Hence, it suffers from certain inherentbiases, chiefly being: (i) a non-respondent cluster of61%, (ii) the honesty of replies is assumed and (iii) disinclination to report inadequate practices. Thereporting of cases also depends on the awareness of dis-infection practices and their rigid application in variouscountries.

A survey conducted in Britain in 1980 revealed thatfewer than half (42%) of endoscopy centres disinfectedsatisfactorily.1 In 1987, a questionnaire was sent to 276hospitals in Australia and 145 responded.2 Endoscopeswere used regularly in 123 hospitals and in 60%, endo-

scopes were cleaned properly, but only 45% were dis-infected satisfactorily at beginning of the session and38% in between sessions. Results for larger and busierhospitals were better than for smaller hospitals. Thesurvey was redone in 1991 to determine whether therehad been improvements in the manner in which endo-scopes were being cleaned and it revealed that the per-centage of centres using satisfactory practices had risento 75%.3

Table 3 Disinfectants

Percentage of Practice respondents

Choice of disinfectantGlutaraldehyde 87.9%Alternative 12.1%

Is glutaraldehyde sensitivity a problem?Yes 19.4%No 80.6%

Change of disinfectant due to glutaraldehyde sensitivity 9.1%

Table 4 Endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic accessories

Percentage of Practice positive replies

Disinfection of duodenoscopesPrior to ERCP list 67.2%Between cases on ERCP list 69.7%Following ERCP list 87%

Reuse of disposable accessories after 95%sterilization

Biopsy forceps 99%Sclerotherapy needle 68.7%ERCP cannula 81.3%Sphincterotomes 72.6%Dormia basket 90%Biliary guide wire 82%Balloon stone extractor 82%Mechanical lithotripter 95%

Mode of sterilization for non-metallic accessories

Autoclaving 25.2%Ethylene oxide 25.2%Glutaraldehyde 43%Other 6.6%

Infectious complications noted after reuse of accessories

Never 67%Rarely 32%Often 1%Frequently 0%

Table 5 View points on endoscopic accessories

Question Percentage of positive replies

Given the choice, would you reuse 72.7%accessories?

Is optimum technical efficacy achieved with 66.7%reuse?

Are you aware of problems with disposal of 86.4%single-use items?

Do the financial implications of reuse 52.2%outweigh potential risk?

Survey of endoscope disinfection practices G81

In 1988, a questionnaire was mailed to 120 gastro-intestinal endoscopy centres in six European countries(Belgium, France, Spain, Italy, the Netherlands andWest Germany) and 74 responded.4 Of the centres per-forming more than 1500 endoscopies per year, 94%used adequate procedures, in contrast to 76% of centresperforming fewer than 1500 endoscopies per year. Theadequacy criteria for the study were very stringent: aminimum of 20 min immersion of the endoscope in 2%glutaraldehyde or an equivalent disinfectant. Mostcentres used a prolonged period of disinfection after usein infected patients: 96% of centres in the case of HBV-or HIV-positive patients and those with cholangitis,76% of centres in the case of mycotic infection and 74%in the case of infectious colitis. Surprisingly, only 30%of centres performed disinfection of endoscopes afterERCP, even though it was widely recognized that thisprocedure carried a much higher risk of infectious com-plaints than other endoscopic procedures. In a Frenchstudy in 1990, Raymond et al. found that only 27% ofcentres fully complied with accepted protocols.5

A survey conducted in India in 1990 obtainedresponses from 32 of 60 endoscopy centres.6 Mechan-ical cleaning of the endoscope with some sort of detergent followed by a 10 min exposure to 2% glutaraldehyde was considered adequate. Using thesecriteria, 12 (37.5%) centres performed adequate disin-fection at the beginning of the endoscopy session, butonly four (12.5%) centres did so in between cases. Theremaining 20 centres (62.5%) either did not use anydisinfection procedure or used inadequate disinfectionpractices. Four centres claimed to have followed uptheir patients for 2 weeks to 6 months during a 1–3-month period of follow up, but none noticed any caseof endoscopically acquired symptomatic infection. Aquestionnaire sent to 435 endoscopy centres in Indiarevealed that only two (1.5%) centres reported occur-rence of infections following upper gastrointestinalendoscopic examinations. Only eight (18%) of the 44centres performing endoscopic retrograde cholan-giopancreatography (ERCP) reported infections, pri-marily in cholangitis in patients with obstructivejaundice.7 The Italian National Survey in 1994, carriedout in 781 centres, has shown that most of the centrescomply with their national guidelines.8 In 1997, asurvey conducted among 294 members of the Ameri-can Society of Gastrointestinal Endoscopy showed thatapproximately 10% of centres still did not conform tothe guidelines.9 Similar surveys in the past have showndeviations from the accepted guidelines at that time.10–13

The present survey shows that there are still signifi-cant departures from the laid-down practice of repro-cessing. One-third of the respondents do not practisecleaning and disinfection at the start of the session. Inaddition, 2.9% of the centres still do not use a high-

level disinfectant. One-third practise a soak time of lessthan 10 min in 2% glutaraldehyde. Forty per cent of therespondents do not dry the scopes with alcohol at theend of the day’s session. This highlights a need forincreasing the awareness regarding disinfection proto-cols for endoscopes and accessories among endo-scopists of this region, laying down of minimalguidelines and rigid adherence to the recommendationsto ensure a ‘cleaner endoscopy’.

REFERENCES

1 Axon AT, Banks J, Cockel R, Deverill CE, Newmann C.Disinfection in upper-digestive-tract endoscopy in Britain.Lancet 1981; i: 1093–4.

2 Collignon P, Graham E. How well are endoscopes cleanedand disinfected between patients? Med. J.Aust. 1989; 151:269–72.

3 Collingnon P, Grahman E. Cleaning and disinfection ofendoscopes. Have there been recent improvements? Med.J. Aust. 1991; 154: 391–4.

4 Van Gossum A, Loriers M, Serruys E, Cremer M, CremerM. Methods of disinfecting endoscopic material: Resultsof an international survey. Endoscopy 1989; 21: 247–50.

5 Raymond JM, Labadie JC, Fajiou E et al. Evaluation desprocedures de decontamination utilisees dans les centresd’endosocpic digestive de Giroride. Gastroenterol. Clin.Biol. 1990; 14: 143–9 (in French).

6 Tandon RK. Endoscope disinfection: Practices and recommendations. J. Gastroenterol. Hepatol. 1991; 6:37–9.

7 Arora A, Seth S, Tandon RK. Gastrointestinal endoscopedisinfection practices in India: Results of a survey. IndianJ. Gastroenterol. 1992; 11: 62–4.

8 Orsi GB, Filocamo A, Di Stefano L, Tittobello A. Italiannational survey of digestive endoscopy disinfection proce-dure. Endoscopy 1997; 29: 732–40.

9 Cheung RJ, Ortiz D, DiMarino J. GI endoscopic repro-cessing practices in the United States. Gastrointest. Endosc.1999; 50: 362–8.

10 Gorse G, Messner RL. Infection control practices in gas-trointestinal endoscopy in the United States: A nationalsurvey. Infect. Control Hosp. Epidemiol. 1991; 12: 289–96.

11 Kaczmarek RG, Moore Jr RM, McCrohan J et al. Multi-state investigation of the actual disinfection/sterlization ofendoscopes in health care facilities. Am. J. Med. 1992; 3:257–61.

12 Rutala WA, Clontz EP, Weber DJ, Hoffman KK. Dis-infection practices for endoscopes and other semicriticalitems. Infect. Control Hosp. Epidemiol. 1991; 12: 282–8.

13 Reynolds CD, Rhinehart E, Dryer P, Goldmann DA.Vari-ability in reprocessing policies and procedures for flexiblefiberoptic endoscopies in Massachusetts hospital. Am. J.Infect. Control 1992; 6: 282–90.