While Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) clarified that it has reported nine deaths related to HAI (hospital-acquired infection) between July 23 and August 9, it confirmed that there were 11 deaths at the Neonatal Intensive Care Unit (NICU) when Kuensel reported the story.

According to a top official at the JDWNRH, the hospital later confirmed through an analysis that of the 11 deaths, nine were because of Klebsiella pneumonia. One case was suspect and another probable. The two infants were later confirmed to have died from other causes.

Klebsiella is a superbug that causes a range of diseases depending on which part of the body it infects. Such infections are HAI, which means they originate in a hospital that has evolved resistance to antibiotics.

In a press release the hospital issued yesterday, it stated, “As caregivers, we are extremely sorry for the loss of the infants’ life and we are concerned as much as the parents of those infants and the public about the unfortunate loss of those nine infants.”

According to the press release, the first signs of the bacteria was observed on July 16 in the NICU when the blood report of few neonates showed presence of the bacteria. The matter was reported to the infection prevention and control focal person with the hospital.

“The focal person immediately enforced the infection prevention and control practices and the infected babies were segregated from the non-infected ones,” it states. “In NICU, generally, four to six babies die every month of which, one or two are related to HAI.”

JDWNRH president, Lhab Dorji told Kuensel that HAI is a rising issue in all hospitals, not just JDWNRH. “HAI prevalence in neonates in the South-East Asia region is as high as 75 percent,” he said.

He said that before declaring an outbreak, the hospital has to confirm through tests that it is an outbreak. Four babies died after the infection was observed and the hospital declared that there was an infection outbreak in the NICU after five more babies died of HAI in the third week of July.

Of the nine babies that died because of the infection, two were born prematurely at six months weighing about a kilogram (kg) at birth. While four babies were born at seven months and weighed a little over 1kg with predisposing conditions in the mother, three babies had congenital heart and blood-related diseases.

“All babies were born preterm with a mean delivery period of 7.3 months of pregnancy and with predisposing conditions. The rate of HAI increases with the degree of both prematurity and low birth weight,” the press release states.

It also states that six out of nine mothers had severe pregnancy-induced hypertension, which is a well-established risk factor for neonatal deaths.

Lhab Dorji said preterm babies are susceptible to all kinds of organisms because their immune system hasn’t developed properly. “Several life-saving measures were put in place soon after the outbreak was notified on July 26.”

He said the hospital took help of Royal Centre for Disease Control (RCDC), health ministry, thromde and KGUMSB to find ways to contain the infection.

About 24 babies were infected with the bacteria in the NICU from July 16 to August 9, of which 15 were treated and cured. The first death occurred on July 23 and the last on August 6.

Factors that led to the outbreak of the infection

Lhab Dorji said the main source of contamination was the water supply to the hospital.

According to a July 31 report from  RCDC, the hospital’s water showed a presence of high level of coliform bacteria. However, it was found that both the water sources of the hospital were not contaminated which means the contamination happened in the distribution of the water supply.

The hospital said that the health ministry claiming that the hospital lacked infection control measures is not true. “This had really been disheartening for the staff and the management and a big blow to the morale of the employees in JDWNRH.”

Lhab Dorji asked how could a hospital like JDWNRH function without any infection control measures. “Everyday we clean all the facilities, not only to ensure a shiny surface but to ensure that we don’t have infections.”

According to the hospital, shortages of doctors and nurses, limited facility to segregate patients, complacency of the parents in sterilising the feeding materials, poor hand hygiene, and uncontrollable patient visitors are other factors which contributed to the aggravation of the HAI.

Normally, for the preterm babies, milk is expressed in a cup and a syringe and a plastic feeding tube used to feed the babies.

Lhab Dorji said the feeding materials were also found to be contaminated. “It is not that the mothers did not clean it. What needs be to be done is after cleaning the feeding materials, it should be submerged in hot boiling water for about 10 minutes. It seems the mothers did not do that.”

Despite putting measures to control visitors and biometric facility in the hospital, which is all geared towards infection control, Lhab Dorji said controlling visitors to the hospital is a challenge. “If people become responsible visitors, then it is okay but what people do is, one visitor gets a card and about three to four people follow him. How do we deal with that?”

Regarding shortages of infection control resources like hand washing soap, hand sanitisers and chlorine, Lhab Dorji said the hospital has looked into how much of the resources were issued and how much used during the period. “It is not that the hospital did not have these items at all.”

These consumables, Lhab Dorji said are tendered by the Department of Medical Services and Health Infrastructure (DOMSHI).  The hospital’s resources are based on the consumption of the previous year with the addition of five percent. For instance, he said if the hospital has used 100 hand sanitisers last year, the proposal for this year would be 105.

“If the hospital runs out of the 105 hand sanitisers because of an increase in patients, we have to reorder and the supplier has to order from some company. It takes months to get the supply to the hospital.”

Lhab Dorji said when there is a shortage of supplies with the supplier and if a ward boy asks for 10 bottles of hand sanitisers, they give five. “These things are not straightforward. There are so many factors and it is complicated to resolve.”

Lhab Dorji said the problem is break in the supply chain, not in the hospital not providing it.

The standard requirement for nurses in the NICU and ICU is 1:1 which is one nurse for one patient while the current ration in the NICU at the hospital is 1:4. Besides doctor shortages, the hospital currently has shortages of 173 nurses, 80 ward boys or girls and 35 cleaners.

Lhab Dorji said if the hospital has 1:1 nurse to patient ratio then there would be no risk of cross-contamination. “We have only one neonatologist and that is also employed by the KGUMSB. We need at least three neonatologists for the NICU of 16 beds.”

In terms of chlorine (bleaching powder), Lhab Dorji said the requirement is 30 percent concentration of chlorine. While the packet of the powder states that it contains 30 percent of chlorine, a test by RCDC found that it contained only 5.4 percent of the chlorine. “How will the hospital know that the packet actually contains only 5.4 percent of chlorine when it is mentioned on the packet that it contains 30 percent?”

DOMSHI, which supplies medical supplies to hospitals across the country including JDWNRH, receives thousands of medical supplies and JDWNRH doesn’t have the facility to test all the items, the president said.

Measures taken to prevent/reduce such incidences in future

Lhab Dorji said the hospital’s water tank is flat and there are chances of rainwater leaking into the tank. The hospital has raised the opening of the tank to prevent any water from outside getting into the tank.

“While the thromde already chlorinate the water, we have started chlorinating our own tanks. We will also fence the water tanks,” he said.

All ICUs are regularly cleaned and disinfected and hand hygiene practice reinforced for all nurses.

Long term-plans to reduce infection outbreak

To ensure safe drinking water at the hospital, it has plans to install a water treatment plant, Lhab Dorji said. “We will institute a separate infection control unit.”

He said the hospital is also exploring procurement of medicinal pediatric formulations to ensure that children of all ages have access to safe and accurate dosage of medicines.

To ensure continuous supply of hospital consumables, the hospital is also exploring consignment based supply where the hospital will have to give a purchase order for the year with no quantity mentioned. The hospital pays every month based on how much they have used. “This not only takes care of regular supply but also prevents wastage.”

Dechen Tshomo