Martin Henry: Hospital infections - beyond the fury
Hospitals and clinics can be very dangerous places. Particularly for the weakest and most critically ill patients like the 42 unhealthy premature babies who contracted Klebsiella or Serratia bacteria at the University and Cornwall Regional hospitals, 23 of whom have survived.
Health-care facilities are dangerous too for the people who manage them. By the time this is published, there may be a pile of heads which have rolled from the guillotine of public fury, alongside those of Prof Trevor McCartney and Dr Cecil White, executives of the University Hospital and first executees.
There has been a new round of calls for the minister of health's head. This is now a recurring decimal, like pi. I got a media call which amounted to seeking my help in dragging Fenton to the guillotine by opinion without fact. I declined.
The trouble is, after the guillotining of Chief Magician Dr Fenton Ferguson (Medicine and Magic are twins grown apart), another human being will have to take his place as Jamaica's minister of health in a world where hospital- or health-care-acquired infections (HAIs) are a growing and deeply worrying trend. So much so that the US Centres for Disease Control and Prevention (CDC) has made HAIs a matter of dedicated special concern with its own monitoring and evaluation unit.
The health authorities here, including the board of the University Hospital, are playing a gullible public, which has been properly riled up by a set-on media, with a pack of promises and a battery of buzzing activities, including setting heads rolling, which we are to believe will appreciably reduce chances of a recurrence of these infant deaths from infections. No such thing is going to happen.
in the international scheme of things
The infant mortality number is a stubborn bit of medical statistics. It does not budge lightly or easily, even under the heavy weight of public outrage over particular cases of infant deaths. Infant mortality measures the number of children per thousand who die in the first year of life. The number is just around 14 for Jamaica in international stats. Minister claims it is 12.
Not bad in the international scheme of things. As for most other development data, our country is smack in the middle of the global infant mortality data, logged at 112 out of 224 countries in the CIA World Factbook listing.
The infant mortality rate is affected by a composite of factors: The state of the economy, quality of, and access to maternal health care and infant health care and the long-term allocation of resources for these. The age of the mother is a significant factor, with the highest risk being for teen mothers and those over 35. And so are the birth weight and the period of gestation before birth.
From the medical literature: Low birth weight makes up 60-80 per cent of the infant mortality rate in developing countries. The mortality rate rapidly increases with decreasing weight, and most of the infants weighing 1,000g (2.2lb) or less die. As compared with normal-birth-weight infants, those with low weight at birth are almost 40 times more likely to die in the neonatal period. For infants with very low weight at birth the relative risk of neonatal death is almost 200 times greater."
Along with birth weight, the period of gestation makes up the two most important predictors of an infant's chances of survival and their overall health.
Every child's life is precious, and families are grieving. Di country vex, but it is not likely that the deaths from klebsiella and serratia infections will materially affect the infant mortality rate. We still don't know if these infant deaths were on account of specific negligence, carelessness and breach of medical protocols or were a more natural result of the general state of the health-care system and the innate susceptibility of already sickly newborns. And even if we come down to general inadequacies in the health-care system, to lay it all at the feet of the present minister of health stretches credibility much too far.
Hospital-acquired infection (HAI) is more technically known as nosocomial infection.
facts of occurrence
Here are some CDC data on US HAIs: Based on a large
sample of US acute care hospitals, an HAI survey found that on any given day, about one in 25 hospital patients has at least one health-care-associated infection. There were an estimated 722,000 HAIs in US acute care hospitals in 2011. About 75,000 hospital patients with HAIs died during their hospitalisation. More than half of all HAIs occurred outside of the intensive care unit. The WHO has put out its own manual for the "Prevention of Hospital-Acquired Infections", which, despite its optimistic intention for prevention, can scare the content of the guts out of us with the facts of occurrence.
Despite progress in public health and hospital care, the UN health agency warns, infections continue to develop in hospitalised patients, and may also affect hospital staff. Many factors promote infection among hospitalised patients: decreased immunity among patients; the increasing variety of medical procedures and invasive techniques creating potential routes of infection; and the transmission of drug-resistant bacteria among crowded hospital populations, where poor infection-control practices may facilitate transmission.
A prevalence survey of HAIs conducted under the auspices of WHO in 55 hospitals of 14 countries representing four WHO regions (Europe, Eastern Mediterranean, South East Asia, and Western Pacific) showed an average of 8.7 per cent of hospital patients getting nosocomial infections.
The key factors influencing these in-hospital infections include an abundance of available microbial agents. Patients are exposed to a variety of microorganisms during hospitalisation. Exposure leading to infection depends partly on the characteristics of the microorganisms, including their resistance to antimicrobial agents, their virulence, and the amount of infective material.
Most infections acquired in hospital are caused by microorganisms which are common in the general population, in whom they cause no or milder disease than among hospital patients. Like klebsiella and serratia in the vulnerable premature babies.
Another critical factor is patient susceptibility, including weak immune status and underlying disease, as in the case of those poor preemies.
Environmental factors within the health-care facility constitute another level of risk. Health-care settings are an environment where both infected persons and persons at increased risk of infection congregate and staff move around among them and there is high risk of contamination of objects.
Another key factor is the dreaded bacterial resistance, which is growing. Many patients are treated with antimicrobial drugs. Through selection and exchange of genetic resistance elements, antibiotics promote the emergence of multi-drug-resistant strains of bacteria. Microorganisms in the normal human flora which are sensitive to the drug are suppressed, while resistant strains persist and may become endemic in the facility.
Antimicrobial agents are, in many cases, becoming less effective because of resistance. As an antimicrobial agent becomes widely used, bacteria resistant to this drug eventually emerge and may spread in the health-care setting. Many strains of pneumococci, staphylococci, enterococci, and tuberculosis are currently resistant to most or all antimicrobials which were once effective. Multi-resistant klebsiella and pseudomonas are prevalent in many hospitals, the WHO notifies. This problem is particularly critical in developing countries where more expensive second-line antibiotics may not be available or affordable. This is a raw economic issue.
Nosocomial infections are widespread, the WHO says. And they are important contributors to morbidity and mortality. Ominously, they will become even more important as a public-health problem with increasing economic and human impact, the WHO warns, because of: increasing numbers and crowding of people, more frequent impaired immunity, new microorganisms, and increasing bacterial resistance to antibiotics.
When your baby is among those who died, all this does not matter. But as the fury over the regrettable deaths of very vulnerable newborns abates, whether or not Minister Ferguson's head gets added to the pile of klebsiella management casualties, the rest of the 2.7 million of us should pause and soberly consider how to contain (we can't eliminate) health-care-acquired infections and to further nudge down that pretty respectable infant mortality figure, which is 14 now but was twice that, 29 per thousand, 30 years ago in 1985.
- Martin Henry is a university administrator. Email feedback to columns@
gleanerjm.com and email@example.com.