NIH should have notified it of superbug outbreak, Montgomery County official says


A MacConkey agar culture plate that cultivated anaerobic Klebsiella pneumoniae bacteria.They are commonly found in the human gastrointestinal tract, and are often the cause of hospital acquired, or nosocomial infections involving the urinary and pulmonary systems. (Courtesy CDC)
August 23, 2012

In the wake of the disclosure of a deadly superbug outbreak at the National Institutes of Health’s Clinical Center, Montgomery County Council President Roger Berliner said Thursday that the NIH should be required to notify the county in such cases.

“I do think there should be an obligation to share this information with the local jurisdiction,” said Berliner (D-Potomac-Bethesda). “We deserve to be notified. This is our community. If there is a problem, it’s going to manifest itself first here.”

Berliner said he did not have enough details to know whether it would have been appropriate for the county to inform the public about the outbreak, which began last August and continued through January. He wants to change an existing agreement between the county and NIH on how they work together during emergencies to require the notification.

The NIH disclosed the outbreak Wednesday in a scientific publication. For some public officials and consumer advocates, the incident raised questions about whether and how the public should be notified of hospital-borne infections, which the Centers for Disease Control and Prevention says kill 99,000 people annually while racking up $45 billion in health-care costs.

The top staffers at the 234-bed research hospital were so concerned about the outbreak that they began turning away surgery patients to protect them against infection.

“There were patients we advised not to come into the hospital,” said Henry Masur, chief of the hospital’s Critical Care Medicine Department. “We decided not to do elective surgery for a period of time if the patient might have to come into the intensive care unit,” the epicenter of the outbreak.

The antibiotic-resistant bacterium Klebsiella pneumoniae spread from one patient to 17 others, killing six. Two patients testing positive for the bacterium remain at the hospital.

As the outbreak progressed, the hospital “became more and more stringent about who should come in and who should not,” Masur said. “I don’t think it was ever an all-or-none” situation.

Defending the way the hospital handled the situation, Masur said hospital physicians were encouraged to inform their patients about the risk of infection. “Our approach was to make sure all providers had this information, and all providers could discuss with their patients how it might affect their decision whether to get care.”

Patient advocate Lisa McGiffert said the hospital did not go far enough in informing the public.

“If you ask any person going into a hospital if they want to know they’re having an outbreak with a deadly superbug, every person would want to know that,” said McGiffert, manager of the Safe Patient Project at Consumers Union, which advocates for more disclosure of hospital-based infections. “These outbreaks should be made public like notices of health problems with a restaurant.”

But Ezekial Emanuel, a bioethicist at the University of Pennsylvania who worked at NIH for 15 years and helped shape the 2010 federal health-care law, said it can be difficult to weigh the costs and benefits of public disclosure — especially during a fast-moving outbreak.

“The issue is, you want to be honest about the situation, but you don’t want to alarm people when you don’t have all the facts,” he said. “In the midst of an event, you might provide false information, you might scare away people who need treatment.”

NIH’s Masur said that few patients were at risk. “For many patients going into the hospital, this organism was irrelevant,” he said. “If you come in for mental health, if you come in for an outpatient provider, if you’re not terribly sick, this organism posed no risk to you.”

As a federal facility, the NIH hospital is not licensed by Maryland and is not required to report hospital-borne infections to the state.

State epidemiologist David Blythe said NIH officials contacted the health department in December — four months after the outbreak began — to ask for advice on stopping the superbug.

The NIH’s Clinical Center is unique. Every patient is enrolled in a government study, there is no emergency room, and no one goes there to have a baby or get an appendix removed. The patients tend to be the sickest of the sick — those with no other options. Those were the patients — those with weakened immune systems — who were at highest risk for contracting the superbug.

Since 2003, 26 states, including Maryland, have passed laws requiring that hospitals report hospital-borne infections. The federal health-care law requires such reporting nationwide, although that provision is still being put into effect. Facilities that show rates of hospital-acquired infection higher than the national average stand to lose 1 percent of their Medicare and Medicaid funding.

The CDC has long pushed hospitals to disclose such infections, said Mike Bell, deputy director of the center’s division of health-care quality promotion. “Transparency drives change,” he said. “When people can see where infections are occurring, it helps them make good decisions.”

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