More people than ever are living with weak immunity: premature infants, the elderly, and people with cancer, HIV and other illnesses that were once fatal but are now often chronic conditions. That's also why superbugs most often occur in hospitals, nursing homes and other healthcare facilities—places where susceptible populations are concentrated.
In 2001, a task force led by the CDC, the Food and Drug Administration and the National Institutes of Health declared antibiotic-resistant infections to be a grave public health threat and issued an action plan to tame the problem. The group's recommendations included creating a national surveillance plan and speeding development of new antibiotics.
Yet not a single new class of antibiotics has been approved for medical use since 1987. Despite years of efforts to educate healthcare workers about infection control, multiple studies show that many still routinely flout even basic preventive measures, like hand-washing.
While the types of bacteria showing drug resistance have multiplied, the federal government requires hospitals to report infections for only two of them, MRSA bacteremia, or blood infection, and C. difficile. It requires limited reports on the others and relies on the states to fill in the gaps.
In 2014, the administration of President Barack Obama issued a new national action plan to combat antibiotic-resistant bacteria. Congress followed last year with a $160 million increase in the CDC's budget to bolster research, drug development and surveillance of superbugs by the states.
But as Reuters found, surveillance carried out by the states can come up against strong institutional resistance and laws that shield the healthcare industry.
Under Virginia law, Chippenham Hospital should have reported its 2010 MRSA outbreak to the state Department of Health when the third baby in the neonatal intensive care unit tested positive for the bug, health department officials said. That was four days before newborn Josiah Cooper-Pope fell ill.
Instead, according to Virginia Health Department records and interviews with department officials, the hospital didn't notify public health officials until nearly every baby in the unit had been infected—and then only by mail.
By that time, Josiah had been dead two weeks and another baby was in critical condition with a MRSA infection.
After persuading the hospital to temporarily close the unit and bringing the outbreak under control, Health Department investigators found that Chippenham hadn't taken basic steps to prevent MRSA's spread, such as training staff, scrubbing furniture and computers, and testing all infants in the nursery when the infection first surfaced.
Jennifer Stanley, a spokesperson for Hospital Corp of America, which owns Chippenham, said that since the outbreak, the hospital has put in place "aggressive infection prevention measures" and "intensive education and training."
Virginia took no action against the hospital for the lethal outbreak.
'How the Sausage Is Made'
The state can fine hospitals for violating regulations, but "this is not the approach [the Department of Health] typically follows," said Maribeth Brewster, department spokesperson. Officials prefer "working closely" with hospitals to correct patient safety problems, she said, and a follow-up inspection at Chippenham Hospital found no regulatory violations, so no action was warranted.
In response to a Reuters public records request on the outbreak, the Health Department sent a copy of its investigation report in which the name and address of the hospital were blacked out.
The same was true for 22 more superbug outbreaks in Virginia healthcare facilities since 2007 that involved more than 130 patients, including 15 who died. State law prohibits the agency from identifying the location of outbreaks. At least 27 other states have similar laws or policies in place.
Disclosing the names of healthcare providers "would serve as a significant disincentive to the timely reporting of disease outbreaks," said Brewster, the Virginia Health Department spokesperson.
Tarant, the doctor who signed Josiah's death certificate, put it this way: "Things like this, if dealt with appropriately, are best if kept internally. I don't think people want to see how the sausage is made."
At a conference last year, hospital infection-control specialists told CDC officials that medical staff and internal review boards sometimes blocked them from reporting infections as required by state law or by the Centers for Medicare & Medicaid Services (CMS), which reduces payments to hospitals for preventable infections and high infection rates.
The specialists said medical staff sometimes were discouraged from testing patients with clear signs of infection—one of several tactics they said staff used to get around reporting rules.
Those complaints were detailed in a notice the CDC and CMS sent late last year to hospitals nationwide, warning them that offenders could be fined and cut off from federal funds for covering up infections they are legally required to disclose.
Officials said that due to database limitations, they did not know whether any facilities had been cited for underreporting infections since the notice was issued.
Acknowledging any infection caught in a hospital or other healthcare setting carries another risk: The paper trail can support a subsequent lawsuit.
Emma Grace Breaux and her twin brother, Talon, fell ill from infections shortly after they were born 12 weeks premature at Lafayette General Medical Center in Lafayette, Louisiana, in 2005. Talon died at 15 days old after becoming infected by a virulent strain of Pseudomonas aeruginosa, a ubiquitous bacteria that easily contaminates hospital equipment.
"The day we buried him, we found out about Emma's infection," said Kelly Breaux, their mother.
Emma had a MRSA infection. She survived, but with permanent damage to her heart, lungs and one leg.
Three and a half years later, Emma was in Florida to have her leg repaired when she came down with swine flu. It was too much for her heart and lungs. After a six-week battle, she died at Miami Children's Hospital just shy of her fourth birthday. Her death certificate blamed flu-related pneumonia. Including MRSA as a cause of death "was not considered," said Dr Sharon Skaletzky, who was at Miami Children's at the time and signed the death certificate.
Talon's case was clear-cut; his death certificate cited septic shock due to his hospital-acquired Pseudomonas infection as the cause of death.
Emma's was more complicated. Her medical expenses alone eventually exceeded $4 million for repeated hospitalizations due to complications from her MRSA infection. The family sold their home, truck and other possessions to stay afloat while she underwent multiple operations.
A Louisiana appeals court ultimately ruled that MRSA was responsible for her death and in 2013 upheld a jury award of more than $6 million in damages and medical expenses for the twins.
Lafayette General Medical Center spokesperson Daryl Cetnar said no one with knowledge of the case was available.
Lack of a unified national surveillance system makes it next to impossible to count the number of drug-resistant infections, fatal or otherwise. Theoretically, deaths could be counted through the nation's vital statistics.
Those numbers, compiled by the National Center for Health Statistics (NCHS), include births, marriages, divorces and, using data culled from death certificates, information on what is killing whom. The numbers are critical in determining how money is distributed for research and public health campaigns.
As examples in this article show, superbug infections are often omitted from death certificates. But even when they are recorded, NCHS can't feed that information into vital statistics: The World Health Organization (WHO) classification system the agency uses lacks mortality codes for most drug-resistant infections, though it has codes for more than 8,000 other possible causes of death.
The CDC added codes for use in the United States for terrorism-related deaths a year after the Sept. 11, 2001, attacks. It could do the same for deaths from drug-resistant infections. Officials told Reuters the CDC is instead working to incorporate the codes into the WHO's next revision of the international classification system. The revised system is expected to be completed in 2018 but not fully in use until the 2020s.
There are other ways to count deaths, such as searching the text of death certificates as Reuters did in its analysis with help from the NCHS. CDC officials told Reuters they now are exploring "how we might be able use literal text capture to get additional information on resistant infection deaths which could be useful for annual tracking."
As it stands, the CDC has the National Healthcare Safety Network. Under this surveillance program, about 5,000 hospitals and in-patient rehabilitation facilities file quarterly reports on several types of healthcare-related infections as a condition of receiving Medicare and Medicaid payments.
But only two superbug infections are on the reportable list, MRSA bacteremia and C. difficile. The others are reported under only limited circumstances, such as when related to a hysterectomy or a catheter-associated urinary tract infection.
The reports are typically five to seven months old by the time they are logged, and thus aren't useful for real-time surveillance. And the CDC doesn't require facilities to report deaths. Determining cause of death is difficult and would entail extra training for hospital staff who fill out the forms and oversight, which the agency can't afford, according to Dr Daniel Pollock, surveillance branch chief for the CDC's Division of Healthcare Quality Promotion.
CDC Director Frieden, noting that there is "no simple way to code for drug-resistant infections" on death certificates, said the CDC "is supporting states' efforts to respond to antibiotic resistance and help protect Americans from this threat."
Just 16 state health departments told Reuters that they tally deaths from reportable antibiotic-resistant infections. Eight others track deaths only when they are part of an outbreak. (Pennsylvania and Georgia declined to answer the survey questions.)
Among states that don't track deaths is Texas, where Natalie Silva contracted MRSA in November 2012 at Hospital Corp of America's Del Sol Medical Center in El Paso. Two days after giving birth to a healthy boy by cesarean section, her incision began gushing blood, said her sister, Crystal Silva. Back at the hospital, Natalie Silva tested positive for MRSA.
Hospital staff assured Silva it was safe to continue holding and breastfeeding her week-old son, according to Crystal Silva and her other sister, Stephanie Hall. One month later, her son was in the neonatal intensive care unit battling his own MRSA infection, they said.
He survived. For Silva, the next few months brought a cascade of medical complications, records show. Multiple infections led to multiple surgeries that left her paralyzed. Hall recalled spending a Friday night in September 2013 at her sister's bedside, painting Silva's fingernails metallic blue and her toenails metallic purple, optimistic that her sister would return home.
Three days later, Silva died.
Silva's doctors wanted to blame cardiac arrest on the death certificate, Silva's sisters said.
Del Sol Medical Center declined to comment.
Silva's family paid $3,000 for an autopsy that confirmed that the MRSA infection contributed to her death. Her death certificate lists cardiopulmonary arrest as the immediate cause of death, due to complications from a MRSA infection.
"She was 23 years old and healthy. We knew that MRSA played a huge role," said Crystal Silva. "We had to fight for them to include it."
In September last year, Hall filed a medical malpractice and wrongful death lawsuit against Del Sol in El Paso County District Court, alleging that the hospital was responsible for Silva's MRSA infection and the fatal complications that followed. The lawsuit is seeking payment to Silva's two children for the loss of their mother, loss of her wages while she was sick, medical costs and funeral expenses.
Christine Mann, spokeswoman for the Texas health department, said counting superbug deaths would require a formal statute or rule change in the state. "We prioritize our resources and attention toward taking public health action where it is most needed," she said.
Natalie Silva's was among about 10,000 deaths linked to antibiotic-resistant infections in Texas from 2003 to 2014, according to the Reuters analysis. Though her sisters succeeded in getting an honest reckoning on Silva's death certificate, her death by superbug was never counted.
© 2016 Thomson Reuters. All rights reserved.
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