The germ arrived at the hospital in June 2011 with a New York woman who needed a lung transplant. It infected more patients by August 2011, eventually infecting a total of 18, 12 of whom died. Seven of the deaths were directly attributed to the superbug.
In December, as the situation worsened, NIH contacted Maryland’s state epidemiologist, seeking advice. But neither NIH nor the state shared any information with the county about the outbreak, which became public in August 2012, when NIH researchers published a scientific paper about it. At the time, Montgomery County Council President Roger Berliner (D-Potomac-Bethesda) complained that the county hadn’t been notified.
Carol Jordan, the county health department’s director of communicable diseases and epidemiology, said recent discussions about the new agreement have clarified all the parties’ public health responsibilities, including informing the public.
Under the pact, NIH will notify the county of rare or potentially high-profile diseases or outbreaks that might alarm the public, even if there is no public health risk, Jordan said.
“Nobody wanted a repeat of what happened during the Klebsiella outbreak over there,” she said.
Jordan said the outbreak “was probably not a risk to the public,” but added, “When a paper is published about it, it will certainly raise questions from the public. . . . And that kind of thing, the county needs to know about.”
NIH officials have said they did not alert the public earlier for several reasons. Experts at NIH and elsewhere said healthy people outside the hospital were at minimal risk. The infection was not among the infectious diseases required to be reported to the federal Centers for Disease Control and Prevention. And as a federal facility not licensed by Maryland, NIH is not required to report health-care-acquired infections or certain other diseases to the state.
When the outbreak erupted, the clinical center’s infection control staff scrambled, walling off infected patients, tearing out plumbing and swabbing equipment, walls, railings and patients to track and contain the bacterium. Despite these extreme efforts, the outbreak still ticked along for more than a year as the hardy superbug lingered on hard surfaces — and inside patients, among the sickest of the sick.
Residents who live and work near the sprawling NIH campus, as well as some employees exposed to the affected wards, grumbled that they had been put at risk because they hadn’t been told about the infection.