Failure to institute infection control measures is found to have caused the bacterial infection outbreak at the Neonatal Intensive Care Unit (NICU) of the national referral hospital in Thimphu that led to the deaths of 11 babies.

The infection was reported on July 22. The last case was reported on August 9.

An official with the health ministry said the recent infection outbreak at the NICU is called hospital-acquired infection (HAI). “It occurs when infection control measures are not taken properly.”

HAI originates in a hospital that has evolved resistance to antibiotics. He said HAI was a rising concern globally.

The ministry sent a team including their infection control programme officer and officials with the quality assurance and standard division to the hospital soon after the ministry knew about the infection outbreak in July.

The infection control team at the hospital and the team from the ministry has compiled a report.

As per the report, besides water contamination, it was found that many infection control measures were not employed including poor hand hygiene. The hospital claimed that they were not able to carry out the infection control measures because of shortages of human resources and many staff at the NICU were new and not very experienced in neonatal care.

According to the report, the hospital also had shortages of infection control resources like chlorine for disinfection and hand sanitisers for sometime.

Kuensel learnt that hypochlorite solution used in the hospital was found to contain only five percent of active chlorine against the required 30 percent of active chlorine.

Both the water sources of the hospital were found not contaminated which means contamination was in the distribution of the water and the hospital’s tank.

The official said the contaminated water and poor infection control measure could have resulted in the outbreak of the infection. “The hospital has since taken proactive measures and infection control measures were put in place.”

“We focused on immediately stopping the spread of the infection. To ensure that such things don’t happen again by recommending them to put infection control measures and other measures in place,” he said.

He said functionally JDWNRH was autonomous and the ministry makes policies, standards and guidelines that are to be followed by all health centres in the country.

“Even in terms of infection control and waste management, we have set guidelines and standards which are distributed to all health centres and the health workers are also trained to prevent infection.”

He said all the technical experts are with the hospital. The hospitals should have active surveillance for them to be aware of the potential problem and address it before it arises.

As per the report, the hospital was not able to do it regularly because of staff shortage. “They have now put additional staff at the unit and also put in place all intervention control measures,” he said.

He said the guidelines were prepared in consultation with the stakeholders including JDWNRH. “I think the weakness was in implementation of the infection control measures.”

As per the report, he said all babies who died were  preterm births. “Preterm babies have less resistance to infection so they are more prone to get an infection.”

Infection control programme officer with the ministry is in the districts visiting hospitals to advocate health centres on the practice especially infection control, the official said. “It is important to continuously look at the measures to prevent possible future infections in all health facilities, not only JDWNRH.”

The ministry has sent a notification to all district hospitals to make sure all infection control resources are available at all times and strengthen hand hygiene among staff including mothers.

“The ministry will provide any support required to the hospitals to prevent such incidents,” he said.


Dechen Tshomo