Abstract & Commentary
Pertussis Outbreak in a Newborn ICU costs $100,000 to Contain
By Philip R Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent, Medicine, Mayo Clinic, Rochester, MN.
Dr. Fischer reports no financial relationships in this field of study.
SYNOPSIS: In a neonatal intensive care unit in Arizona, five infants and ten health care providers were found to have pertussis during a two month period. The outbreak cost the involved hospital nearly $100,000 in expenses and could likely have been prevented by careful implementation of staff vaccination policies, limitation of symptomatic staff and family members from contact with neonatal patients, and application of established environmental management policies.
SOURCE: Yasmin S et al. Healthcare-Associated Pertussis Outbreak in Arizona: Challenges and Economic Impact, 2011. J Pediatr Infect Dis Soc 3:81-84, 2014.
The index case, a four-week-old girl born prematurely after a 28 week gestation, was hospitalized at an unnamed neonatal intensive care unit. She developed apnea that was attributed to gastro-esophageal reflux and then developed a cough that lasted 26 days. Only after being transferred to a different facility was pertussis testing done; both PCR and culture were positive.
The index case shared two nurses with the premature newborns in the adjoining beds. The space between beds was 16 inches. Those two adjacent babies also developed pertussis. Ten health care providers in the neonatal intensive care unit had, it was retrospectively determined, coughing illnesses that fulfilled a case definition of pertussis; each kept working through the illness. A fourth infant case was visited by an older sibling with symptomatic pertussis at the time of the visit.
The intensive care unit was evaluated by an outbreak investigation team. Of eight sinks in the area, access to two was obstructed by carts and trash cans. Hospital policies required health care providers with acute respiratory illnesses to take personal leave, but those policies were not enforced. Visitors to the neonatal intensive care unit were not screened for respiratory symptoms, and no signage warned ill visitors to postpone their visits.
After identification of the outbreak, costs were evaluated. More than half of costs were due to missed work after a diagnosis of pertussis, but there were also costs of testing and treatment of symptomatic individuals as well as for vaccination of incompletely immunized employees. The total cost of the outbreak came to approximately $100,000 (separate from patient care costs).
Since the era of Semmelweis, astute clinicians have recognized an increased risk of infection in some inpatient settings. Fortunately, there have been significant improvements in the quality and safety of healthcare offered in hospitals since then. Nonetheless, there are still risks of getting sick in healthcare facilities.
The Arizona NICU pertussis outbreak documents the risk of staff spreading infection to the smallest and most vulnerable of patients. More importantly, it also provides clear guidance toward the prevention of such tragedies. As noted in the paper by Yasmin and colleagues, "standard" policies might have been effective if they had been implemented. Health care providers should refrain from working when they are ill with acute respiratory infections (as was the policy at the involved hospital; unfortunately, the policy had not been followed). Visitors should be warned not to visit when they are symptomatic with respiratory illnesses. And, clinicians should suspect pertussis in infants with cough, especially chronic cough. (Of the five infected babies in the Arizona outbreak, symptoms had persisted from seven to 51 days before testing was done.)
Aware of the specific need to prevent children from becoming sick in hospitals, the Society for Healthcare Epidemiology of America Pediatric Leadership Council has been working for four years to reduce the burden of infection in residential healthcare facilities, of central line-associated bloodstream infection, and of Clostridium difficile infection.1 Opportunities, however, remain; there is still a need to better study infection prevention implementation strategies.
Infection control is particularly challenging in resource-limited settings where even hand hygiene is relatively costly and where isolation rooms and materials are incompletely available. This is seen in newsworthy outbreaks such as Ebola (reported in May 2014 in Infectious Disease Alert) as well as in the more common outbreaks of measles and meningitis.
Despite the challenges, the Arizona outbreak reminds us that infection is often more expensive than prevention. Careful attention to and implementation of hospital infection control measures are still needed.
- Sandora TJ. Hospital Epidemiology and Infection Control for Children: Report from the Society for healthcare Epidemiology of America Pediatric Leadership Council. J Pediatr Infect Dis Soc 3:4-6, 2014.