In their recent review, Spach and associates [1] imply that infection risk is appreciable and that published reports "probably represent a minority of all infections transmitted by endoscopy". The American Society for Gastrointestinal Endoscopy (ASGE) has been aware of the potential for endoscopic transmission of infection since the advent of fiberoptic flexible endoscopy, when more complicated instruments replaced rigid endoscopes. The ASGE, with other societies concerned with endoscopy, developed recommendations for the appropriate handling and care of endoscopes [2]. We are involved with the Food and Drug Administration and the Centers for Disease Control and Prevention in trying to standardize the method for disinfecting instruments.

The article failed to consider several important issues. First, there are absolutely no data to suggest under-reporting of endoscopic infection transmission. Our view is that given that more than 9 million procedures were done in the United States in 1991, the incidence of infection is extraordinarily low. Second, a large percentage of their references were published before the universal use of effective disinfection. Indeed, the recognition of these problems led to today's routine use of endoscopic disinfection. Third, many current problems are related to noncompliance with recommendations for endoscopic disinfection. Fourth, the implication about the risk for transmission of the acquired immunodeficiency syndrome (AIDS) is misleading. No such transmission has been documented, and only one case of transmission of hepatitis B virus has been reported. Hepatitis B and human immunodeficiency viruses are easily destroyed by simple mechanical cleansing with detergent or the currently recommended disinfectant solution of 2% glutaraldehyde [3]. Fifth, surveys, never a satisfactory substitute for actual data about compliance with recommended disinfection procedures, should not be used to suggest that the process of disinfection itself is inadequate, although they may point to occasional lack of compliance with available disinfection procedures.

The authors state that "new" types of endoscopes must be tested to address this "problem". The disclosure by one of the authors that he has an interest in a company that is developing a "new type" of sheathed endoscope raises a concern about objectivity [4].