The hunt for a deadly superbug that sickened 22 patients at a Dutch hospital began just before noon on a spring day in 2012.

Inside a lab in the tiny hamlet of Zoeterwoude, a technician carefully peeled back the tip of a state-of-the art medical scope. Watching him intently was a small group of hospital officials and executives from Olympus Corp., the maker of the device.

A 2012 inspection by Olympus and Dutch hospital officials revealed a brown film inside a duodenoscope. (Arjo Loeve / Delft University of Technology)

The Olympus technician found trouble right away. He spotted a brown, grimy film inside parts of the flexible, snake-like scope — parts that were supposed to be sealed. A rubber ring designed to keep bacteria out was cracked and worn. The same bacteria that had sickened the patients were found on the scope.

An investigator hired by Olympus and the hospital concluded that the scope’s design could allow blood and tissue to become trapped, spreading bacteria from one patient to another. In his report, he called on Olympus to conduct a worldwide investigation and recall all its scopes if similar problems turned up.

Over the next three years, 21 people died and at least two dozen more became ill from infections related to scopes in Pittsburgh, Seattle and Los Angeles. An unknown number of other patients have been infected. The Food and Drug Administration has identified 10 outbreaks, seven of which involve Olympus scopes.

Even as patients died and others were put at risk, Olympus continued to sell the device and failed to warn U.S. hospitals that the scopes were tied to dangerous infections, according to interviews with dozens of hospital officials, doctors, regulators and former Olympus employees.

After each outbreak, Olympus contended that its scopes did not cause the infections and blamed the hospitals for not cleaning them properly. The company treated each case as an isolated incident, not telling the U.S. hospitals that they weren’t alone.

“Olympus’ silence on this important issue was unethical, irresponsible and dangerous,” said Dr. Andrew Ross, chief of gastroenterology at Virginia Mason Medical Center in Seattle, where 18 patients sickened by tainted scopes died and 21 more were infected.

“ Olympus’ silence on this important issue was unethical, irresponsible and dangerous. ” — Dr. Andrew Ross, chief of gastroenterology at Virginia Mason Medical Center in Seattle Share this quote

Olympus controls 85% of the U.S. market for gastrointestinal scopes. U.S. prosecutors and congressional investigators are looking into how Olympus and two smaller scope manufacturers responded to the superbug outbreaks.

The investigations were launched after the Los Angeles Times reported in February about an outbreak that claimed three lives at UCLA Ronald Reagan Medical Center.

The day after the article, regulators issued a warning to all U.S. hospitals that an increasing number of infections across the country might be related to the design of the scopes.

Olympus declined to answer specific questions from The Times about the scope’s role in patient infections and its handling of the outbreaks.

“We have expressed our sympathy to patients and families who have experienced or have been affected by infections,” the company said. “We continue to work closely with the Food and Drug Administration in an effort to understand and address potential root causes.”

A robust business

Many people think of cameras when they hear the name Olympus. Doctors know it as a medical device giant, one with a reputation for engineering expertise and a close working relationship with healthcare professionals.

Olympus medical sales by fiscal year and percentage by region

Medical devices today account for nearly 75% of the Tokyo company’s $7 billion in annual revenue. Sales of its scopes surged 18% to $1.4 billion for the six months ending in September, and overall company profit jumped 60% to $294 million.

Olympus worked with doctors to invent the device called a duodenoscope more than four decades ago. It is used in a procedure known as ERCP, or endoscopic retrograde cholangiopancreatography. Doctors thread the flexible scope down a patient's throat and into the digestive tract, where cancers, gallstones and other conditions can be diagnosed and treated, without the complications of more invasive surgery.

Physicians perform nearly 700,000 of those procedures annually in the U.S., and 2 million worldwide, Olympus said. Many of those patients have serious illnesses, making them more vulnerable to infection.

By 2010, two Olympus rivals, Pentax and Fujifilm, were selling a redesigned scope that they said was easier to clean because a crucial section of the device was sealed to keep bacteria out.

Olympus introduced a similar model, known as the TJF-Q180V. The company touted the $40,000 scope as a technical triumph designed to give doctors the ability to perform more complex procedures.

An Olympus sales brochure touting the design of its duodenoscope in 2010. See the full document

The Olympus sales force also pitched its new scope as being easier to clean. That appealed to hospitals where nurses and staff were under pressure to quickly disinfect the devices, a process that could take as long as an hour.

But the redesign had created a new problem.

A ‘nightmare’ bacteria

The 2012 outbreak in the Netherlands, at Erasmus University Medical Center in Rotterdam, was the first sign of trouble.

“You only need one bacteria to get inside and multiply,” said the Dutch investigator, Arjo Loeve, a mechanical engineer at Delft University of Technology. “You shouldn’t find anything on the inside.”

After Loeve’s report linked the bacterial outbreak to its scope, Olympus alerted European hospitals about potential contamination. But it didn’t issue a similar warning in the United States, its biggest market.

Federal reports of duodenoscope-related infections and contamination *Through Feb. 17, 2015. Note: One report can involve numerous patients.

Just a few months later, patients at the University of Pittsburgh Medical Center began testing positive for a superbug known as CRE. That superbug is so resistant to antibiotics that health officials call it the “nightmare bacteria.” As many as half of infected patients die.

The Pittsburgh hospital discovered that many patients infected with the superbug had been treated with an Olympus scope. The hospital quickly pulled its Olympus devices out of service, alerted the company and tested them for the bacteria.

Five of the hospital’s 31 scopes came back positive for bacteria — even after being scrubbed by hand and machine-washed with a powerful disinfectant, the hospital said. One device contaminated with CRE was originally linked to 18 sick patients. The hospital later said it could definitively tie only one case to the Olympus scope because some patients underwent procedures at other hospitals.

An Olympus representative who reviewed the test results told doctors that the scopes might not be getting completely cleaned because the hospital was using the wrong type of automatic washer, the hospital said. The representative persuaded the hospital to replace its cleaning machine with an Olympus model, which can cost about $25,000.

But another scope tested positive for bacteria even after it was cleaned in the new machine. The medical center began sterilizing scopes with a toxic gas, a costly, more time-consuming method. Because of the longer cleaning time, Pittsburgh ordered more scopes from Olympus, doubling its supply.

Another scope, similar infection worries Long before the recent superbug outbreaks, Olympus Corp. drew national attention for a faulty device tied to patient infections. In 2001, the Japanese company recalled thousands of bronchoscopes from U.S. hospitals after reports of contamination and patient infections. The episode — and the company’s response to it — mirrors its current troubles with gastrointestinal scopes. Bacteria were trapped unexpectedly inside a loose biopsy port on the bronchoscope, and potentially dangerous bugs could be passed to the next patient. More recently, a similar pattern emerged with duodenoscopes harboring life-threatening superbugs even though hospitals followed Olympus’ cleaning instructions, federal regulators said. Even after the 2001 recall, patients continued to get sick from tainted bronchoscopes because Olympus didn’t reach all of its customers in a timely manner, according to regulators and hospitals. The bronchoscopes are used to examine the throat, trachea and lungs in about 500,000 procedures a year in the U.S. “The whole response by Olympus was slow and defensive,” said William Schaffner, professor of preventive medicine and an infectious disease expert at Vanderbilt University in Nashville. He helped lead the outbreak investigation for the Tennessee Department of Health when some hospital patients in the state fell ill. “Contaminated bronchoscopes were going into the bronchial tree of already sick patients. Olympus knows where each and every bronchoscope is, and they did not send the sales force out in an aggressive nature to contact each of the owners,” Schaffner said. At the time, Olympus defended its recall notification to customers. The company said that it cooperated with health officials and hospitals, and that the recall was issued as soon as the biopsy port problem was identified. Officials at Johns Hopkins Hospital in Baltimore said Olympus’ delayed response enabled continued outbreaks. Dr. Trish Perl helped lead John Hopkins’ investigation, which determined that the loose biopsy port on the bronchoscopes had spread the bacteria to patients. In a 2002 letter to Olympus, an FDA official said there was “no information to indicate any irregularity” in the cleaning done by hospitals. Doctors at Johns Hopkins published a 2003 study in the New England Journal of Medicine that called on device makers and regulators to make cleaning a priority when designing reusable instruments. More than a decade later, some experts say, the recent outbreaks show that the warning wasn’t heeded. “It’s clear the industry really hasn’t felt the need to respond,” said Perl, a senior epidemiologist. “Olympus didn’t agree with us, and it was extremely ugly.” Cecil Young, a Memphis, Tenn., property appraiser, died in June 2001 after being treated with an Olympus bronchoscope that would be recalled later that year. His widow, Julia Young, sued Olympus, alleging wrongful death and negligence. She said she rejected a six-figure settlement from Olympus because it included a nondisclosure agreement. Ultimately, a judge dismissed Young’s lawsuit in 2012, in part because she had sued the U.S. unit of Olympus, which, the company successfully argued, handled sales and not scope design and manufacturing. Laura Storms, vice president of regulatory and clinical affairs in the U.S. for Olympus, has said that hospitals are frequently at fault because they let scopes fall into disrepair, they don’t maintain their cleaning machines or staff members don’t follow proper procedures. Young said Olympus’ response during the latest outbreaks reminds her of what happened during the bronchoscope infections. “Blaming hospital staff has been Olympus’ mantra a long time — and it still works,” Young said. Concerns about bronchoscopes haven’t gone away. The FDA issued an alert in September, citing more than 100 reports since 2010 concerning bronchoscope-related infections or tainted devices. A year ago, Olympus notified the FDA that one of its bronchoscopes had potentially infected 14 patients. The medical facility wasn’t named, and Olympus declined to comment on the report. Read more x

Deflecting blame

A few months later, in October 2013, patients undergoing operations with Olympus scopes at Virginia Mason Medical Center in Seattle began to develop serious infections. Eighteen of those infected eventually died.

Hospital officials summoned Olympus.

A sample is taken from inside an Olympus scope during a Netherlands outbreak investigation in 2012. (Arjo Loeve / Delft University of Technology)

A company service representative watched hospital employees wash the scopes and raised no concerns, said Dr. Andrew Ross, the hospital’s chief of gastroenterology. Over the next several weeks, Virginia Mason sent its eight scopes back to Olympus, one by one, for inspections. Olympus never told the hospital about the Rotterdam and Pittsburgh infections, he said.

In 2014, nearly a year later, Olympus told the FDA that no Virginia Mason devices were returned for evaluation. The company also said that it had offered an on-site visit but that the hospital declined.

That account was at odds with that of the hospital, and Virginia Mason is suing Olympus for fraud, arguing that it “deceptively concealed … the risks and flaws of the scopes.” Olympus denies the allegation, contending that the hospital failed to follow the instructions for cleaning the scope.

An investigation by federal, state and county officials concluded this year that the hospital followed proper cleaning procedures and that the Olympus cleaning instructions were insufficient. In a report, the health officials called that “disturbing.”

Salesman’s denials

When doctors at UCLA’s Ronald Reagan Medical Center began to suspect that they were using tainted scopes in December 2014, they called their Olympus salesman, Vincent Hernandez.

Hernandez was one of the company’s top salesmen; he boasted on LinkedIn about securing $14.6 million in new business during 2014. He had spent much of that summer with UCLA doctors and administrators, wrapping up a major sale of Olympus scopes.

Hernandez and Olympus technicians visited the hospital. Company representatives watched UCLA employees clean the scopes. None of them raised concerns about the cleaning or mentioned the previous outbreaks, according to UCLA officials involved in the investigation.

Olympus told the FDA, though, that one of its employees had noted “inconsistencies” in the hospital’s cleaning practices. In court filings, Hernandez and two other employees said they couldn’t have warned UCLA about outbreaks linked to the scopes in the Netherlands, Pittsburgh or Seattle because they weren’t aware of them.

By late January of this year, the relationship between Olympus and UCLA had grown testy. University doctors had taken two scopes linked to patient infections out of service and asked Olympus to lend them two more. Olympus asked for the scopes to be returned before replacements would be sent. UCLA declined.

The hospital soon faced a shortage of scopes because new cleaning methods were taking longer. When the university asked about buying more scopes, Olympus said the price had increased since the hospital had purchased scopes a few months earlier, according to hospital officials. The company also said it couldn’t promise when the devices would arrive because the outbreaks had increased demand.

Dr. Raman Muthusamy, UCLA’s director of endoscopy, said he hadn’t been aware of the Netherlands case while his hospital was investigating the infections. When he read the Dutch investigator’s report, he was struck by the similarities.

Jeffrey Hughes, 11, at UCLA Medical Center in November 2014. (Hughes family photo) The Hughes family pictured at their home in Santa Monica. (Robert Gauthier / Los Angeles Times)

“Pittsburgh was established. We had Virginia Mason. We had Rotterdam,” he said. “You wonder, why didn’t they get on this earlier? I had no inkling this was an issue.”

The family of 11-year-old Jeffrey Hughes, from Santa Monica, says they deserved to know about the potential risks. Jeffrey, who had been fighting cancer for three years, was treated with an Olympus scope at UCLA during the outbreak and developed an infection. The sixth-grader died a month later.

His parents have sued Olympus in federal court in Los Angeles, blaming the scope.

“To put something in him that could risk his life — yeah, I would have wanted to know that,” said his mother, Annie Hughes. “Olympus knew about this in 2012. At least tell us.”

Olympus has denied liability in the boy’s death, saying it could have been caused by preexisting conditions.

Late reports

Although Olympus did not alert U.S. hospitals to previous outbreaks, it was required to file reports to federal regulators. Most of those reports suggested culprits other than its scope, including poor cleaning procedures.

The company’s reports didn’t suggest a link among the cases; instead, they were each reported as separate, unconnected incidents.

The FDA issued no warnings based on those reports. Following federal rules, it didn’t publicly identify the hospitals.

Olympus waited until 2015 to file a detailed report on the 2012 Netherlands outbreak. In it, the company again contended that the hospital may have not cleaned the scope properly.

“The cause of the patient infection could not be conclusively determined,” Olympus concluded.

Hard questions

In February 2015, immediately after the UCLA outbreak was reported, Olympus sent an alert to customers. It disclosed, for the first time, that it was aware of 95 complaints tying its scope to patient infections.

A former top Olympus executive familiar with the inner workings of the company said the previous scope models logged far fewer complaints.

“This rash of incidents couldn’t be explained away,” this former official said, asking not to be named out of fear it would damage career prospects in the medical industry. “They should have pulled the scope.”

In May, the FDA convened a panel of medical experts at its headquarters outside Washington to examine the scope-related infections.

Doctors from Rotterdam, Seattle and Los Angeles gathered in a large, wood-paneled auditorium during the two-day hearing. One by one, they described how their outbreaks unfolded.

“ A solution must be found in changing the design. I think many transmissions will occur ... This is the tip of the iceberg. ” — Dr. Margreet Vos, Erasmus University Medical Center in Rotterdam Share this quote

Dr. Margreet Vos, an infectious diseases doctor at the Rotterdam medical center, showed regulators and medical experts the photos taken inside the Olympus lab after the Dutch outbreak three years earlier.

She pointed to the brownish debris that Olympus employees had found behind the glass cover of the scope’s camera — an area closed off from cleaning.

She put an image of the rubber seal on a giant screen. It was worn down with rough edges and a tear on the bottom left side.

Carla and Bill Warner. (Photo courtesy of Carla Warner)

“A solution must be found in changing the design,” Vos told the audience. “I think many transmissions will occur.… This is the tip of the iceberg.”

Then FDA officials invited the public to speak. Carla Warner stepped out of her seat on the aisle and walked to the microphone to share her family’s story.

The North Carolina widow said her 55-year-old husband, Bill, was treated with an Olympus scope at Carolinas Medical Center in Charlotte. He died of an infection in November 2013.

His family sued Olympus, alleging wrongful death, in federal court last month in Philadelphia.

“Olympus knew of the risk and hid the infections,” Warner said, sobbing. “My husband should be alive today.”

Olympus executives sat silently in the back of the room. None of them rose to speak.

Contact the reporters

Times researcher Scott Wilson contributed to this report.