Report of the Portfolio
Committee on Health on an oversight visit to
The
Portfolio Committee on Health having undertaken an oversight visit to
1.
INTRODUCTION
The Portfolio Committee on
Health has an oversight role over the Department of Health. The vision of the committee is to ensure an
accessible, affordable, equitable, quality, effective and efficient health
system for all the people of
2.
OBJECTIVES OF
THE VISIT
There had been an infection
outbreak at
3.
DELEGATION
4.
BACKGROUND
Dr Daynia
Balldt who was in charge of the neonatal ward briefed
the committee about the events that led to the death of the 6 neonates at
Dr Balldt
stated that the babies were admitted to 3 different wards but were sick at the
same time. They were then admitted to 1 ward. She told the committee that the
hospital had never had an outbreak like that before and further indicated that
the hospital was once rated a world class hospital. She stated that she was
very concerned over the bad reports by the media. She indicated that staff has
to be acknowledged for the good job they did during the outbreak instead of
blaming them. She also admitted that there were challenges like overcrowding in
the ward and staff shortages and that most of the staff did not want to work at
the neonatal ward because of the heavy workload.
She mentioned that there
were forty five neonates in the ward while the capacity of the ward was thirty
five. She told the committee that there was no way they could have avoided
overcrowding or they would have been in breach of the Constitution of South
Africa which states that everybody has the right to access to health care
services and because most of the neonates were born at the hospital there was
no way they could have chased them away after birth. She also told the
committee that they were faced with financial constraints but that they were
doing their best with what they had.
Dr Balldt
further informed the Committee that they had initially suspected that the
outbreak and deaths were due to pre-Nan Feeds. The majority of the babies were
premature varying from low to very low birth weights. The hospital then called
the National Health Laboratory Services to conduct an investigation on what
might have been the cause of the deaths of the babies.
5.
INVESTIGATIONS
BY THE NATIONAL HEALTH LABORATORY SERVICES (NHLS)
Dr Balldt stated that on Sunday, 16 May 2010
Professor AG Duse who worked for the National Health
Laboratory Services and the
Sixteen faecal samples were
submitted for virology investigations and fifteen of these tested positive for Norovirus. She indicated that Noroviruses
have been documented as causes of neonatal diarrhoea that can become complicated
to more serious and potentially life-threatening conditions such as extensive
inflammation and damage and death of cells in the gastrointestinal tract (necrotising enterocolitis). In
premature neonates, severe inflammation of the gastrointestinal tract can lead
to both resident and hospital-acquired gut bacteria migrating into the
bloodstream causing severe sepsis and even death of the infant.
Dr Balldt
stated that line-listing was done with all affected neonates. An audit with
on-site infection prevention and control, training and education was carried
out in wards 177 and 184. Nineteen
empty, used milk-fed bottles with evidence of residual milk were collected and
sent to the National Health Laboratory Services Infection Prevention and Control
Laboratory for culture. She further stated that twelve of these bottles grew klebsiella pneumonia but they were still awaiting the antibiogram which would be available by Thursday, 20 May
2010. A further 6 grew a gram-negative bacillus morphologically resembling klebsiella but they were awaiting final confirmatory
identification and antibiogram results. One bottle
grew a gram-negative bacillus to be further identified.
Four reconstituted milk-fed
bottles were collected and sent to the NHLS Infection Prevention and Control
Laboratory for culture. One of these bottles grew a gram-negative bacillus
morphologically resembling klebsiella but they were
also awaiting the final confirmatory identification and antibiogram
results which would be available by Thursday, 20 May 2010.
Thirteen rectal swabs and 4
stool samples were collected in duplicate (a total of 4 specimens) from
symptomatic neonates for bacteriology and virology investigations. Of the
seventeen sent for microbiology, fifteen grew a gram-negative vacillus morphologically resembling klebsiella
but the hospital was still awaiting final confirmatory identification. Of the sixteen received by the National Institute for Communicable
Disease (NICD) for virology, fifteen tested positive for the norovirus.
Faecal samples collected
from the seventeen neonates that were sent for bacteriological investigation
yielded a growth in fifteen of the seventeen samples of a bacterium called klebsiella pneumonia, 6 of which were highly resistant to
antibiotics and called ESBL positive strains. Dr Balldt
further mentioned that it is important to note that both drug sensitive strains
of klebsiella pneumonia were present in the blood of
at least 4 of the 8 neonates from whom blood cultures were collected suggesting
possible migration (translocation) of gut organisms into the bloodstream.
Eighteen used milk bottles were processed and in all of these klebsiella pneumonia was found, thirteen strains of which
were highly drug-resistant.
Two patients discharged
from the neonatal wards on Friday, 14 May 2010 were readmitted with diarrhoea
to ward 285 where blood cultures were taken on 18 and 19 May 2010. One blood
culture grew a drug-sensitive klebsiella and the
other a bacterium that needed further identification. Furthermore, two blood
cultures from 2 new babies were collected on 18 May 2010 and tested positive
for bacteria growth (microbes needed to be identified further).
6.
FINDINGS BY THE
NATIONAL HEALTH LABORATORY SERVICES (NHLS)
Investigations conducted
suggested that more than one (probably all four) of the above contributed to
the outbreak.
The hospital believed that
it was most likely that the virus was introduced into the neonatal ward by
caregivers (mothers), siblings or healthcare personnel.
7.
INTERVENTIONS BY
THE HOSPITAL
8.
WALK ABOUT AT
THE HOSPITAL
a)
PREM-UNIT (HIGH
CARE UNIT)
The committee visited the prem-unit, where 6 neonates died. There were no neonates at
the ward because all were removed to the newly renovated ICU after the
outbreak. The committee observed that the infrastructure was very old. The CEO,
Dr Barney Selebano informed the committee that the
ward was going to be renovated, cleaned and de-germed.
b)
NEW ICU
The committee was informed
that Carte Blanche donated money for the renovation of the unit. The purpose of
the renovation was to extend the intensive care unit so that young and older
children were not admitted to the same ward. The unit was where all the
neonates were admitted from the prem-unit. The
committee observed that the unit was very clean and had disposable gowns and
gloves that were used by the staff and people visiting the unit. The committee
further noted that all children were in single cubicles.
c)
LABOUR WARD
The committee was shown
where the babies were delivered. There was a four bedded unit at the labour
ward that was called the transitional unit for neonates. Babies were screened
at the unit and if found sick they were referred to the ICU, otherwise they were
referred to the prem-unit. The committee was informed
that there were two nurses per shift.
d)
MILK ROOM
The committee observed that
the milk room was in a bad condition. The infrastructure was very old and
bottle brushes were used that were very old and rusty.
9.
FINDINGS BY THE
COMMITTEE
The committee concluded its
visit and noted that the hospital was short staffed. Another key finding was
that the hospital was under funded hence they were still operating on a very
old infrastructure.
10.
RECOMMENDATIONS
The Committee
recommended that:
a) Communities and
children should be immunised and fully vaccinated especially towards winter
season.
b) Community based
education and preventative measures be scaled up especially on the basics like
cleanliness and washing of hands.
c) Parents visiting
neonates should be monitored at all times.
d) Counselling be arranged for staff members that were working at the
neonatal ward when the incident happened.
e) Radical action be taken by the health sector to strengthen the quality of
child care.
f)
Milk rooms be moved to the
neonatal ward or closer so as to enable health professions staff to be
involved.
g) The issue of
staff shortages and inadequate funding of the hospitals be dealt with as a
matter of urgency by the National Department of Health.
h) The Department
needs to strengthen and promote Primary Health Care.
i)
Tertiary institutions be run and managed by the
National Department of Health as one of the strategies to manage the referral
system.