Old Codger
2008-03-23 08:22:06 UTC
On Sun, 23 Mar 2008 07:55:26 -0000, "Pat Gardiner"
kick up the arse British Politicians need to stop covering this up.
Pat's Note: The Sunday Times is hot on the trail as you can see. They will
finish up at the door of Defra asking why they have not tested the pigs or
pork and the relevance of PMWS in 1999.
Does anyone in the Politburo feel slightly uneasy about the way they treated
Jonathon Miller, their columnist, back in 2001?
They should. It was a very serious mistake. He has colleagues, and the
Politburo have plenty to hide. UKBA is the place to come for all the leads.
You can find them by following the trail of abuse.
http://www.timesonline.co.uk/tol/news/uk/health/article3582299.ece
From The Sunday Times
March 23, 2008
Superbugs and NHS failings
Superbugs kill at least 10,000 people in Britain each year - 20 times the
number who die of Aids. Why isn't the government spending more on finding
out why?
Lois Rogers
Like many, Brian Clinch was under the impression that, despite the failures
of the past, the British health service was tackling the frightening
epidemic of antibiotic-resistant superbugs. That was before a visit to
Norway made him realise that this record-breaking tide of resistant
infections is far from under control and is also a problem of our own
making.
Clinch, a former RAF pilot from Dorset, has kidney failure and needs
dialysis three times a week. It was only when he went for dialysis treatment
in the Norwegian city of Stavanger three months ago that he discovered he
was one of the tens of thousands of Britons unwittingly infected with the
deadly superbug methicillin-resistant Staphylococcus aureus (MRSA).
The day after arriving in the oil-refining port on Norway's Atlantic coast,
he went to the city's university hospital. Dialysis had been arranged on the
understanding that he had been tested for MRSA in the UK. But a routine
throat swab in Stavanger showed Clinch was carrying MRSA. "All hell broke
loose," he says. "The results of the MRSA tests arrived after they'd given
me one session of dialysis. They were angry and deeply unimpressed with the
dialysis centre in England.
I hope Norway have complained to the EU. Maybe a huge fine will be thefinish up at the door of Defra asking why they have not tested the pigs or
pork and the relevance of PMWS in 1999.
Does anyone in the Politburo feel slightly uneasy about the way they treated
Jonathon Miller, their columnist, back in 2001?
They should. It was a very serious mistake. He has colleagues, and the
Politburo have plenty to hide. UKBA is the place to come for all the leads.
You can find them by following the trail of abuse.
http://www.timesonline.co.uk/tol/news/uk/health/article3582299.ece
From The Sunday Times
March 23, 2008
Superbugs and NHS failings
Superbugs kill at least 10,000 people in Britain each year - 20 times the
number who die of Aids. Why isn't the government spending more on finding
out why?
Lois Rogers
Like many, Brian Clinch was under the impression that, despite the failures
of the past, the British health service was tackling the frightening
epidemic of antibiotic-resistant superbugs. That was before a visit to
Norway made him realise that this record-breaking tide of resistant
infections is far from under control and is also a problem of our own
making.
Clinch, a former RAF pilot from Dorset, has kidney failure and needs
dialysis three times a week. It was only when he went for dialysis treatment
in the Norwegian city of Stavanger three months ago that he discovered he
was one of the tens of thousands of Britons unwittingly infected with the
deadly superbug methicillin-resistant Staphylococcus aureus (MRSA).
The day after arriving in the oil-refining port on Norway's Atlantic coast,
he went to the city's university hospital. Dialysis had been arranged on the
understanding that he had been tested for MRSA in the UK. But a routine
throat swab in Stavanger showed Clinch was carrying MRSA. "All hell broke
loose," he says. "The results of the MRSA tests arrived after they'd given
me one session of dialysis. They were angry and deeply unimpressed with the
dialysis centre in England.
kick up the arse British Politicians need to stop covering this up.
"I felt like a complete pariah. I was taken into an isolation room and
everyone put on gowns, masks and bootees before they came anywhere near me.
It's obvious they are frightened to death of getting these infections in
Norway, and are doing everything they can to keep them out."
He is right. Norway, with its population of 4.7m, had only 332 cases of MRSA
in 2006, and has the lowest rate of antibiotic-resistant bacteria in Europe.
About 1 in 200 of the infections found in patients' bloodstreams in Norway
is caused by a treatment-resistant "superbug", while in Britain, getting on
for half of all infected patients have been colonised by strains of bacteria
that normal antibiotics cannot treat.
Norway, which, like Britain, runs a publicly funded health service free at
the point of delivery, prides itself on its "search and destroy" policy for
killer infections. But the contrast between its health services and our
chaotic hospital system is a stark reflection of a difference in approach
that has much more to do with attitude than money.
The public area of Stavanger's 950-bed hospital resembles nothing so much as
an up-market hotel. Leather armchairs are arranged around a virtual log
fire; seemingly relaxed visitors sip coffee and nibble pastries. The town is
comparable to Ipswich in size and affluence, but first impressions of the
hospital suggest it is wealthier. But beyond the reception, the 1970s-built
wards tell a different story. Norway's cash-limited national health service
is suffering exactly the same colossal pressure as our own NHS.
In the infectious-diseases unit there are 19 people on trolleys in the
corridor. At least 11 more lie in the corridors of other departments. The
wait may be long, and patients may end up temporarily in the wrong
department as staff struggle to allocate beds. It is a sight familiar to
anyone who has observed the treatment lottery of the British NHS, and the
enormous battle between restricted supply and limitless demand for
healthcare. But even under the pressure of winter infections, Stavanger's
problems with capacity are not reflected in infection rates.
The atmosphere is busy but calm. The gleaming corridors are populated with
cheery cleaners; there is a sense of belonging among the workforce that is
often absent among the clock-watching agency workers who increasingly
maintain large chunks of our own hospitals.
Stavanger has a policy of not moving infected patients around; if they have
several conditions, doctors from different specialities come to them, not
the other way round. And isolation rooms are available, complete with
negative air pressure to prevent infections from being wafted outside.
Barrier nursing methods involving gloves, aprons and scrupulous hand-washing
are strictly applied with infectious patients.
Jon Sundal, the head of infectious diseases at Stavanger, complains of a
relentless battle to keep his unit under control. "There is a shortage of
nurses - the five new single rooms cannot be staffed," he says.
Nevertheless, even with bed occupancy running at over 100%, conditions in
his hospital offered a stark contrast to the grime of most of Britain's
healthcare facilities.
"We saw the writing on the wall early on with antibiotic resistance," says
Olav Nataas, head of medical microbiology at Stavanger. "We had one serious
outbreak in the 1980s, and since then we just haven't allowed it to happen,
except when we sent some waiting-list patients to Britain for hip
replacements and they came back infected.
"I don't think hospital cleaning has much to do with it. What works is
screening. You test everyone, and you isolate and treat everyone you find
with it. In England you can't do that now because you have too many cases."
It is legitimate to ask if Britain's NHS has lurched into a ruinously
expensive crisis that may yet see the entire service implode. It is also
legitimate to ask how our microbial surveillance system, let alone our
hospital cleaning services, has failed us so badly: why did scientists not
warn us of this disaster in the making, and is it too late to do anything
about it?
The global use of antibiotics since the 1940s has achieved a simple
Darwinian consequence: the fittest bacteria survive. Antibiotics work by
disrupting the production of components needed to create new bacterial
cells. Penicillin, for example, selectively interferes with the construction
of bacterial cell walls, which have a different structure to the cell tissue
of humans and other mammals. By the end of the 1940s, about half of the
Staphylococcus aureus strains tested in hospitals had adapted to produce an
anti-penicillin toxin called penicillinase. Within months of the launch of
the antibiotic methicillin in 1960, the first resistant strains of
Staphylococcus aureus were emerging. Shortly after that, bacteriologists
began finding strains impervious to up to four common antibiotics.
Warnings about the dangers of antibiotic overuse started to emerge from
laboratories, but because relatively few patients were affected and nobody
knew what to do about it, the situation was ignored. Antibiotics continued
to be consumed in ever-growing quantities by sick humans and farm animals
alike.
The problem took off in 1991, when Britain contributed its own supercharged
strain to the world lexicon of multi-drug-resistant superbugs. MRSA-16 first
appeared in Northamptonshire, rapidly infecting 400 patients and 27 staff in
three hospitals. Within 18 months it had been reported in 135 more
hospitals. Nobody knows how it spread. Along with another British strain,
MRSA-15, it went on to infect patients around the world, a pattern that
continues. A meticulous Health Protection Agency study, mapping how the new
strains popped up unexpectedly in new hospitals, was published in the
Journal of Clinical Microbiology in 2004. But it was too long after the
event to shed any light on how the infection had carried. Now research
funding is focused on firefighting - casting around for ways to damp down
the effects of the pathogens.
It is not just MRSA that is sweeping across Britain like a plague.
Streptococcus, enterococcus and Escherichia coli (E coli) are among a host
of bugs emerging in resistant forms and causing everything from pneumonia to
tuberculosis, bone destruction and lethal damage to the heart. In addition,
we are facing "hyper-virulent" new strains of the bacteria Clostridium
difficile (C diff), which have colonised the sites left free by the effect
of antibiotics, which kill off many harmless bacterial colonies in their
path.
Although C diff is not resistant to treatment, its spores linger
indefinitely and, until recently, NHS staff were largely unaware of how to
kill them. Consequently, it is the biggest killer of the current superbugs.
In 2006 it was mentioned on the death certificates of 6,480 people, against
1,652 deaths officially attributed to MRSA. However, these figures are
recognised to be underestimates, as many superbug deaths are never
identified. Mandatory surveillance of MRSA bloodstream infections is a
recent innovation, the number of people carrying it with no symptoms is not
recorded, and the formal collection of figures for death and disease
associated with C diff (which causes unstoppable diarrhoea or gut
perforation) only began in April 2007. The government estimates the annual
cost of treatment for such cases to be over £1 billion.
Officially, the total number of MRSA infections is 7,000-8,000 a year, while
C diff is running at an annual 55,600 cases. Many experts believe the real
total for all superbug infections is nearer 300,000 - how many are fatal is
believed to be vastly higher than the official figures suggest. There is no
way of knowing the true figure, as relatively few people are tested.
Meanwhile, a variety of new resistant pathogens are waiting in the wings. In
September 2006, a variation of Staphylococcus aureus that produces a toxin
called Panton-Valentine leukocidin (PVL) claimed its first British victims.
Since then, anxiety over this threat has escalated. The pathogen selectively
attacks the young rather than the old; it gets into bones and joints,
causing crippling damage.
A multi-drug-resistant version of a common food-poisoning bug, ESBL
(extended-spectrum beta-lactamase) E coli, is also causing anxiety. First
identified in the 1980s, it has spread steadily to cause an average of
30,000 cases of blood poisoning and urinary-tract infections a year.
Although it has officially been blamed for 57 deaths so far, the true total
is believed to be many thousands. Government scientists think the source is
meat and milk, colonised by superbugs as a result of overuse of agricultural
antibiotics.
Jodi Lindsay, a senior expert at St George's hospital, London, and a world
authority on superbugs, says: "It is inevitable things will get much worse.
We don't know enough about how these bacteria behave, because not enough
research is being done. We have increasing numbers of surgical operations,
elderly people with long-term serious disease, and diabetics. All these
patients have compromised immune systems and are at risk. Not only that,
there is potential for new, really virulent strains of bacteria, capable of
attacking healthy people."
Mark Enright, professor of molecular epidemiology at Imperial College
London, says the real number of deaths in the UK from MRSA and C diff is
"easily more than 10,000". He shares the concern that reservoirs of superbug
infection in hospitals will increasingly spill out to attack otherwise
healthy people: "You could be carrying a resistant form of MRSA and it could
then get in through a superficial injury."
There is evidence that such a problem is already occurring in other parts of
the world. A new form of MRSA, USA300, has emerged not in hospitals but in
the wider community in America. It is killing 18,000 a year - considerably
more than the number killed by HIV/Aids, and, most worryingly, the victims
include a number of otherwise healthy children. The latest flurry of anxiety
was in Brooklyn, New York, in October, when Omar Rivera, a previously fit
12-year-old, suffered the telltale crop of pus-filled spots associated with
USA300. Within days he was dead. In other parts of America, three other
children, aged 4, 11 and 17, died the same month.
A team at the University of California in San Francisco has been tracking
the infection. Last month they published a study showing that a variant of
USA300 was spreading in gay communities on the East and West Coasts. And a
new "community" strain of C diff in the US has targeted children, pregnant
women and new mothers, with fatal results. There has been at least one
similar death in the UK, but testing was not available to confirm if it was
the same pathogen.
Europe also has a "community" MRSA: ST80. Officially it is considered less
of a threat because, it is argued, levels of poverty in western Europe are
not as severe as in the US. Without the immune-system damage caused by
malnutrition, the infection is less likely to cause an epidemic.
All that is known about USA300, and other virulent community-acquired
strains of staphylococcus, is that they generally include Panton-Valentine
leukocidin, and that this lethal toxin can jump between different types of
bacteria. If a PVL-carrying bacterium infects someone already carrying a
cold virus, it can spur the onset of a deadly form of necrotising or
tissue-killing pneumonia, which kills 60% of those who develop it. Although
guidelines for GPs to alert them to this new threat to public health are
being issued later this spring, Lindsay and other scientists complain that
Britain persists in spending too little on basic research to tell us more
about the nature of these brand-new infectious agents.
Many scientists have also attacked our slow and patchy response to the
problem of antibiotic resistance. "In the early 1990s, microbiologists were
divided," says Hugh Pennington, emeritus professor of bacteriology at
Aberdeen University. "For everyone who argued the case for containment,
there'd be many more who maintained that Staph aureus had been with us for
ever, and it did not make much difference if strains were
methicillin-resistant or not."
As a result, investigating how microbes developed their resistance, how
infections spread, why particular resistant strains appeared in some areas
but not in others, did not seem that important to healthcare planners.
Microbiology began to feature less and less in medical training. According
to the Royal College of Pathologists, there are now only 645 fully qualified
hospital microbiologists in Britain, of whom only 387 are working in the NHS
in England. Up to 10% of hospital microbiology posts are unfilled because of
a shortage of qualified applicants.
At the same time that the superbugs were taking hold, those with the
expertise to tackle them were keen to work instead in Aids research, with
its support from glamorous figures such as Princess Diana and Elizabeth
Taylor. The pattern inexplicably continues. According to the Department of
Health, £3.8m has been spent by the government since 2002 under the umbrella
of "clinical microbial research", while £14m a year is spent on Aids, which
kills fewer than 500 here annually. And it has become clear that a recently
allocated £16.5m that microbiologists believed was for research into
antibiotic resistance will be shared with research projects on sexually
transmitted diseases and hepatitis.
"Asking why we put so much money into Aids research is a very good
question," said Brian Duerden, government inspector of microbiology and
infection control. "Medical research is highly political and highly
fashion-driven."
Dr Peter Dukes, programme manager of the Infections and Immunity Research
Board at the Medical Research Council (MRC), blamed the paucity of research
proposals and the shortage of researchers in the field of antibiotic
resistance: "When the MRC offered to fund a research project six years ago,
20 proposals were received and only one was good enough to sponsor." Given
America's sinister new USA300 infection, our persistent preoccupation with
Aids may soon look very misguided indeed.
Microbiologists who have remained in the NHS are dismayed that their
warnings of disaster from antibiotic resistance have been ignored by
hospital managers focused on performance indicators and productivity
targets, which concentrated on waiting times. "We needed to do more
screening, but there were never the resources. Even now they are cutting
back," said a consultant intensive-care specialist at a large provincial
hospital. "There used to be two consultant microbiologists here, but one
left and was not replaced. So we had no expert on intensive-care ward rounds
to advise on appropriate antibiotics and infection control."
New government directives require hospitals to carry out MRSA screening on
patients being admitted - though not those having outpatient or day-surgery
procedures. The consultant said the extra testing burden, without any extra
staff to do it, had meant that vital surveillance for other new infections
was not happening.
In addition, as pressure has been ratcheted up to channel funds into meeting
a range of "patient episode" productivity targets, basic hospital cleaning
has been scaled back and contracted out. Those working in healthcare seem
increasingly ignorant of the basics of hygiene. Healthcare workers
increasingly fail to wash their hands as they race between beds, which are
meant to be kept 100% occupied. Increasing numbers of patients are
unnecessarily admitted to wards from accident-and-emergency departments,
simply to avoid breaking the maximum four-hour permitted A&E wait. In
December it was reported that the hotel costs of caring for extra patients
who were not actually sick enough to need treatment had wasted £2 billion
over the past five years.
Many microbiologists point to the decline of attention to hygiene as a basic
function of healthcare as nurse training has become increasingly academic
and classroom-based. "The only infection-control procedure proven to work is
scrupulous hand-washing, a basic approach explained by Florence Nightingale
during the Crimean war and seemingly lost in the intervening 150 years,"
said Richard Wise, former chairman of the government's specialist advisory
committee on antimicrobial resistance, and adviser to the Health Protection
Agency Board. "Not washing the hands between patients should be made a
disciplinary offence."
Most hospitals have bottles of alcohol-based hand disinfectant by their
doors, but Duerden says that until recently their inefficacy against C diff
spores was "not common knowledge" outside microbiology circles - an
unacceptable level of ignorance, insists Wise, who said it had been known
about "for donkey's years".
Olav Nataas, however, insists the search-and-destroy process is key: "We
know hand-washing is never 100%," he says. "This preoccupation with cleaning
is not the main issue. It is identifying the infection as rapidly as
possible and treating it in a way that does not risk others."
It is this uncertainty among Britain's scientists, healthcare administrators
and politicians that has led to the latest disagreement about hospital
cleaning. This month, every hospital in Britain is meant to have completed a
special "deep clean", for which an extra £57m has been allocated. How
exactly a deep clean is performed is less clear. There are no prescriptions
for cleaning materials, training for cleaners, or methods of checking
whether things are actually clean.
A helpful list of Department of Health ideas has been published, including
suggestions such as washing curtains, walls and beds. Many will be dismayed
to discover these are not already part of routine procedures. A government
rapid-review panel has also been established to examine the efficacy of
cleaning products, but it is down to individual hospital trusts to decide
what they need to do, and which wards to deep-clean. While, for example, the
West Midlands region is spending almost £10m on the exercise, only £3m is
being spent in the northeast. Some hospitals are emptying entire wards to
allow hydrogen peroxide "fogging", which uses a vapour to destroy the cell
walls of all organisms, or ultrasound vibration, to produce a similar
effect.
Nobody is keen to define what "clean" means in hospital terms and, according
to Andrew Large, the director-general of the Cleaning and Support Services
Association, some hospitals are doing nothing at all. "There is no
specification about whether hospitals are clean or not, but there is plenty
of academic evidence that a greater presence of people doing routine
cleaning on wards is what makes a difference," he says. "After all, you
could do a deep clean, but if the person inspecting it goes in and sneezes
when they happen to be carrying one of these infections, you are back to
square one."
Annual spot checks for cleanliness are being introduced by the Healthcare
Commission from next month. Those not complying may be issued with lists of
improvement needed, and if, for example, they still leave bedpans lying
around, "special measures" will be imposed. It is not possible to find out
what these special measures might be; according to a Department of Health
spokesman, "it will be decided at a local level".
Many patients have paid a high price for our confused health policies. In
Britain's worst outbreak of superbug infection, there were 90 deaths and
1,170 C diff infections across three hospital sites in Maidstone, Kent,
between April 2004 and September 2006. A report on the disaster by the
Healthcare Commission in October described patients being left to lie in
their own infection-laden excrement, a shortage of nurses and an ignorance
of the risks of moving infected patients between wards.
There were a further 33 avoidable deaths from C diff between 2003 and 2005
at Stoke Mandeville hospital in Buckinghamshire. An inquiry found that
managers ignored advice to isolate those infected and instead concentrated
on shutting down more beds to cut costs.
The cost of compensating superbug victims is also soaring. The NHS
Litigation Authority has paid out £12.5m for 287 cases, plus a
record-breaking £5m in January to the actress Leslie Ash, 49, whose career
has been ruined. An anticipated £1m will go to Shaun Franks, 39, who
underwent surgery for a broken ankle. His leg was taken over by an immovable
colony of MRSA, which could only be eradicated from his body by amputation
of the leg. During his treatment, staff at Northampton general hospital
unwittingly used an antibiotic that accelerated the growth of the MRSA. "It
has been a nightmare," said Franks. "I lost my job, my relationship -
everything. Every time I thought I was getting better, it would come back
again."
There is no question that ignorance of good practice has played a
significant part in the spread of superbugs in Britain. A study in the late
1990s by Otto Cars, an expert in infectious diseases at Uppsala University,
Sweden, compared antibiotic use across Europe. British doctors were
administering over 18 daily doses per 1,000 people, compared with 13 in
Germany and Sweden and 11 in Denmark. Most of the prescriptions were for
coughs and colds - 90% of which are caused by viruses, not bacteria.
Duerden admits that the first comprehensive campaign to educate GPs and the
public about the overuse of antibiotics only got off the ground eight years
ago with the launch of a cartoon character, Andybiotic. But a survey of
almost 11,000 adults published in the British Medical Journal last year
indicated that most people still did not understand the risks.
Hajo Grundmann, now a senior infection-control adviser to the Dutch
government, worked for seven years in Britain's NHS before returning home in
2001. He runs the Eurosurveillance database, monitoring levels of
antibiotic-resistant infections in 31 countries. Britain has the highest
rate in western Europe. "It is connected with the high workload," he says.
"I worked in Nottingham. We were able to isolate MRSA cases at first, but
when the waiting-list initiative came in, there was huge pressure on beds.
As soon as the pressure goes up, hand-washing goes down. But the British
problem is also due to people's attitudes. It just has not been taken
seriously enough."
So where do we go from here? Plans remain vague to introduce the sort of
routine pre-treatment screening for superbugs that exists in Norway, but
there is hope. Lewisham hospital in south London has seized the initiative
and, since 2005, has been screening all patients admitted through A&E. They
take swabs from mouths, noses, armpits and groins of everyone, and swirl
them around in a proprietary bacteriological "broth" that is cooked
overnight. If the broth changes colour, MRSA is definitely not there. If it
does not, the patient might be infected. Precautions are taken for "might
be" cases while they receive further testing. Dr Gopal Rao, the consultant
microbiologist leading this blindingly obvious initiative, which has halved
the rate of MRSA from 12% to 6% in the hospital, says: "If you know someone
is infected, you treat them differently, even if you don't have the
facilities to isolate them."
Other hospitals, including Guy's and St Thomas' in London, are trying out
similar initiatives, but it is expensive, and it is difficult to introduce
new practices in the NHS without producing years of evidence demonstrating
the cost benefit. Wolverhampton hospital estimates it has saved 212 lives
and £6.8m with better infection-control measures, such as giving consultants
targets for infection rates among patients. Why can't other hospitals do the
same?
The government says it can reduce MRSA to half its 2004 rate by the end of
the summer and cut levels of C diff by 30% within three years, though the
starting points for this claim are unclear. Health Protection Agency (HPA)
data for the latest quarter, during the summer of 2007, show MRSA
bloodstream-only infections have fallen from 1,304 to 1,072; C diff
infections were 10,334, compared with 13,669 for the previous quarter. The
HPA admits the data is unreliable owing to changes in collection methods.
Cynics might simply conclude there are fewer patients in hospital in summer.
There are, however, measures being launched by the government: to increase
the number of hospital matrons to 5,000 to oversee hygiene by May, and make
available £270m a year for hygiene campaigns, extra infection-control nurses
and pharmacists to tackle over-reliance on antibiotics.
But that does not explain why we continue to invest in areas such as Aids
research, or the hypothetical risk of pandemic flu, yet hope that drugs
developed in the middle of the last century will protect us against new
infections that are killing thousands each year.
Despite repeated requests, no minister was available to answer the questions
raised in this article. A written statement explained that investment in
Aids was vital as part of Britain's contribution to world public health. The
statement also referred to the (unsuccessful) infection-control policies
introduced up to a decade ago; offered guidance on the need to isolate
infectious patients in single rooms; and highlighted the aspiration to offer
more patients single rooms in several new hospitals currently being planned.
A Department of Health spokesman explained that despite the fact that Brian
Duerden had been unable to answer many of my questions, it was not
government policy to offer more than one spokesman on the same issue.
According to Richard Wise, it is impossible to avoid the conclusion that
until superbugs become - as they surely will - impossible to ignore, we can
expect to see our governments concentrate on headlines rather than detail.
everyone put on gowns, masks and bootees before they came anywhere near me.
It's obvious they are frightened to death of getting these infections in
Norway, and are doing everything they can to keep them out."
He is right. Norway, with its population of 4.7m, had only 332 cases of MRSA
in 2006, and has the lowest rate of antibiotic-resistant bacteria in Europe.
About 1 in 200 of the infections found in patients' bloodstreams in Norway
is caused by a treatment-resistant "superbug", while in Britain, getting on
for half of all infected patients have been colonised by strains of bacteria
that normal antibiotics cannot treat.
Norway, which, like Britain, runs a publicly funded health service free at
the point of delivery, prides itself on its "search and destroy" policy for
killer infections. But the contrast between its health services and our
chaotic hospital system is a stark reflection of a difference in approach
that has much more to do with attitude than money.
The public area of Stavanger's 950-bed hospital resembles nothing so much as
an up-market hotel. Leather armchairs are arranged around a virtual log
fire; seemingly relaxed visitors sip coffee and nibble pastries. The town is
comparable to Ipswich in size and affluence, but first impressions of the
hospital suggest it is wealthier. But beyond the reception, the 1970s-built
wards tell a different story. Norway's cash-limited national health service
is suffering exactly the same colossal pressure as our own NHS.
In the infectious-diseases unit there are 19 people on trolleys in the
corridor. At least 11 more lie in the corridors of other departments. The
wait may be long, and patients may end up temporarily in the wrong
department as staff struggle to allocate beds. It is a sight familiar to
anyone who has observed the treatment lottery of the British NHS, and the
enormous battle between restricted supply and limitless demand for
healthcare. But even under the pressure of winter infections, Stavanger's
problems with capacity are not reflected in infection rates.
The atmosphere is busy but calm. The gleaming corridors are populated with
cheery cleaners; there is a sense of belonging among the workforce that is
often absent among the clock-watching agency workers who increasingly
maintain large chunks of our own hospitals.
Stavanger has a policy of not moving infected patients around; if they have
several conditions, doctors from different specialities come to them, not
the other way round. And isolation rooms are available, complete with
negative air pressure to prevent infections from being wafted outside.
Barrier nursing methods involving gloves, aprons and scrupulous hand-washing
are strictly applied with infectious patients.
Jon Sundal, the head of infectious diseases at Stavanger, complains of a
relentless battle to keep his unit under control. "There is a shortage of
nurses - the five new single rooms cannot be staffed," he says.
Nevertheless, even with bed occupancy running at over 100%, conditions in
his hospital offered a stark contrast to the grime of most of Britain's
healthcare facilities.
"We saw the writing on the wall early on with antibiotic resistance," says
Olav Nataas, head of medical microbiology at Stavanger. "We had one serious
outbreak in the 1980s, and since then we just haven't allowed it to happen,
except when we sent some waiting-list patients to Britain for hip
replacements and they came back infected.
"I don't think hospital cleaning has much to do with it. What works is
screening. You test everyone, and you isolate and treat everyone you find
with it. In England you can't do that now because you have too many cases."
It is legitimate to ask if Britain's NHS has lurched into a ruinously
expensive crisis that may yet see the entire service implode. It is also
legitimate to ask how our microbial surveillance system, let alone our
hospital cleaning services, has failed us so badly: why did scientists not
warn us of this disaster in the making, and is it too late to do anything
about it?
The global use of antibiotics since the 1940s has achieved a simple
Darwinian consequence: the fittest bacteria survive. Antibiotics work by
disrupting the production of components needed to create new bacterial
cells. Penicillin, for example, selectively interferes with the construction
of bacterial cell walls, which have a different structure to the cell tissue
of humans and other mammals. By the end of the 1940s, about half of the
Staphylococcus aureus strains tested in hospitals had adapted to produce an
anti-penicillin toxin called penicillinase. Within months of the launch of
the antibiotic methicillin in 1960, the first resistant strains of
Staphylococcus aureus were emerging. Shortly after that, bacteriologists
began finding strains impervious to up to four common antibiotics.
Warnings about the dangers of antibiotic overuse started to emerge from
laboratories, but because relatively few patients were affected and nobody
knew what to do about it, the situation was ignored. Antibiotics continued
to be consumed in ever-growing quantities by sick humans and farm animals
alike.
The problem took off in 1991, when Britain contributed its own supercharged
strain to the world lexicon of multi-drug-resistant superbugs. MRSA-16 first
appeared in Northamptonshire, rapidly infecting 400 patients and 27 staff in
three hospitals. Within 18 months it had been reported in 135 more
hospitals. Nobody knows how it spread. Along with another British strain,
MRSA-15, it went on to infect patients around the world, a pattern that
continues. A meticulous Health Protection Agency study, mapping how the new
strains popped up unexpectedly in new hospitals, was published in the
Journal of Clinical Microbiology in 2004. But it was too long after the
event to shed any light on how the infection had carried. Now research
funding is focused on firefighting - casting around for ways to damp down
the effects of the pathogens.
It is not just MRSA that is sweeping across Britain like a plague.
Streptococcus, enterococcus and Escherichia coli (E coli) are among a host
of bugs emerging in resistant forms and causing everything from pneumonia to
tuberculosis, bone destruction and lethal damage to the heart. In addition,
we are facing "hyper-virulent" new strains of the bacteria Clostridium
difficile (C diff), which have colonised the sites left free by the effect
of antibiotics, which kill off many harmless bacterial colonies in their
path.
Although C diff is not resistant to treatment, its spores linger
indefinitely and, until recently, NHS staff were largely unaware of how to
kill them. Consequently, it is the biggest killer of the current superbugs.
In 2006 it was mentioned on the death certificates of 6,480 people, against
1,652 deaths officially attributed to MRSA. However, these figures are
recognised to be underestimates, as many superbug deaths are never
identified. Mandatory surveillance of MRSA bloodstream infections is a
recent innovation, the number of people carrying it with no symptoms is not
recorded, and the formal collection of figures for death and disease
associated with C diff (which causes unstoppable diarrhoea or gut
perforation) only began in April 2007. The government estimates the annual
cost of treatment for such cases to be over £1 billion.
Officially, the total number of MRSA infections is 7,000-8,000 a year, while
C diff is running at an annual 55,600 cases. Many experts believe the real
total for all superbug infections is nearer 300,000 - how many are fatal is
believed to be vastly higher than the official figures suggest. There is no
way of knowing the true figure, as relatively few people are tested.
Meanwhile, a variety of new resistant pathogens are waiting in the wings. In
September 2006, a variation of Staphylococcus aureus that produces a toxin
called Panton-Valentine leukocidin (PVL) claimed its first British victims.
Since then, anxiety over this threat has escalated. The pathogen selectively
attacks the young rather than the old; it gets into bones and joints,
causing crippling damage.
A multi-drug-resistant version of a common food-poisoning bug, ESBL
(extended-spectrum beta-lactamase) E coli, is also causing anxiety. First
identified in the 1980s, it has spread steadily to cause an average of
30,000 cases of blood poisoning and urinary-tract infections a year.
Although it has officially been blamed for 57 deaths so far, the true total
is believed to be many thousands. Government scientists think the source is
meat and milk, colonised by superbugs as a result of overuse of agricultural
antibiotics.
Jodi Lindsay, a senior expert at St George's hospital, London, and a world
authority on superbugs, says: "It is inevitable things will get much worse.
We don't know enough about how these bacteria behave, because not enough
research is being done. We have increasing numbers of surgical operations,
elderly people with long-term serious disease, and diabetics. All these
patients have compromised immune systems and are at risk. Not only that,
there is potential for new, really virulent strains of bacteria, capable of
attacking healthy people."
Mark Enright, professor of molecular epidemiology at Imperial College
London, says the real number of deaths in the UK from MRSA and C diff is
"easily more than 10,000". He shares the concern that reservoirs of superbug
infection in hospitals will increasingly spill out to attack otherwise
healthy people: "You could be carrying a resistant form of MRSA and it could
then get in through a superficial injury."
There is evidence that such a problem is already occurring in other parts of
the world. A new form of MRSA, USA300, has emerged not in hospitals but in
the wider community in America. It is killing 18,000 a year - considerably
more than the number killed by HIV/Aids, and, most worryingly, the victims
include a number of otherwise healthy children. The latest flurry of anxiety
was in Brooklyn, New York, in October, when Omar Rivera, a previously fit
12-year-old, suffered the telltale crop of pus-filled spots associated with
USA300. Within days he was dead. In other parts of America, three other
children, aged 4, 11 and 17, died the same month.
A team at the University of California in San Francisco has been tracking
the infection. Last month they published a study showing that a variant of
USA300 was spreading in gay communities on the East and West Coasts. And a
new "community" strain of C diff in the US has targeted children, pregnant
women and new mothers, with fatal results. There has been at least one
similar death in the UK, but testing was not available to confirm if it was
the same pathogen.
Europe also has a "community" MRSA: ST80. Officially it is considered less
of a threat because, it is argued, levels of poverty in western Europe are
not as severe as in the US. Without the immune-system damage caused by
malnutrition, the infection is less likely to cause an epidemic.
All that is known about USA300, and other virulent community-acquired
strains of staphylococcus, is that they generally include Panton-Valentine
leukocidin, and that this lethal toxin can jump between different types of
bacteria. If a PVL-carrying bacterium infects someone already carrying a
cold virus, it can spur the onset of a deadly form of necrotising or
tissue-killing pneumonia, which kills 60% of those who develop it. Although
guidelines for GPs to alert them to this new threat to public health are
being issued later this spring, Lindsay and other scientists complain that
Britain persists in spending too little on basic research to tell us more
about the nature of these brand-new infectious agents.
Many scientists have also attacked our slow and patchy response to the
problem of antibiotic resistance. "In the early 1990s, microbiologists were
divided," says Hugh Pennington, emeritus professor of bacteriology at
Aberdeen University. "For everyone who argued the case for containment,
there'd be many more who maintained that Staph aureus had been with us for
ever, and it did not make much difference if strains were
methicillin-resistant or not."
As a result, investigating how microbes developed their resistance, how
infections spread, why particular resistant strains appeared in some areas
but not in others, did not seem that important to healthcare planners.
Microbiology began to feature less and less in medical training. According
to the Royal College of Pathologists, there are now only 645 fully qualified
hospital microbiologists in Britain, of whom only 387 are working in the NHS
in England. Up to 10% of hospital microbiology posts are unfilled because of
a shortage of qualified applicants.
At the same time that the superbugs were taking hold, those with the
expertise to tackle them were keen to work instead in Aids research, with
its support from glamorous figures such as Princess Diana and Elizabeth
Taylor. The pattern inexplicably continues. According to the Department of
Health, £3.8m has been spent by the government since 2002 under the umbrella
of "clinical microbial research", while £14m a year is spent on Aids, which
kills fewer than 500 here annually. And it has become clear that a recently
allocated £16.5m that microbiologists believed was for research into
antibiotic resistance will be shared with research projects on sexually
transmitted diseases and hepatitis.
"Asking why we put so much money into Aids research is a very good
question," said Brian Duerden, government inspector of microbiology and
infection control. "Medical research is highly political and highly
fashion-driven."
Dr Peter Dukes, programme manager of the Infections and Immunity Research
Board at the Medical Research Council (MRC), blamed the paucity of research
proposals and the shortage of researchers in the field of antibiotic
resistance: "When the MRC offered to fund a research project six years ago,
20 proposals were received and only one was good enough to sponsor." Given
America's sinister new USA300 infection, our persistent preoccupation with
Aids may soon look very misguided indeed.
Microbiologists who have remained in the NHS are dismayed that their
warnings of disaster from antibiotic resistance have been ignored by
hospital managers focused on performance indicators and productivity
targets, which concentrated on waiting times. "We needed to do more
screening, but there were never the resources. Even now they are cutting
back," said a consultant intensive-care specialist at a large provincial
hospital. "There used to be two consultant microbiologists here, but one
left and was not replaced. So we had no expert on intensive-care ward rounds
to advise on appropriate antibiotics and infection control."
New government directives require hospitals to carry out MRSA screening on
patients being admitted - though not those having outpatient or day-surgery
procedures. The consultant said the extra testing burden, without any extra
staff to do it, had meant that vital surveillance for other new infections
was not happening.
In addition, as pressure has been ratcheted up to channel funds into meeting
a range of "patient episode" productivity targets, basic hospital cleaning
has been scaled back and contracted out. Those working in healthcare seem
increasingly ignorant of the basics of hygiene. Healthcare workers
increasingly fail to wash their hands as they race between beds, which are
meant to be kept 100% occupied. Increasing numbers of patients are
unnecessarily admitted to wards from accident-and-emergency departments,
simply to avoid breaking the maximum four-hour permitted A&E wait. In
December it was reported that the hotel costs of caring for extra patients
who were not actually sick enough to need treatment had wasted £2 billion
over the past five years.
Many microbiologists point to the decline of attention to hygiene as a basic
function of healthcare as nurse training has become increasingly academic
and classroom-based. "The only infection-control procedure proven to work is
scrupulous hand-washing, a basic approach explained by Florence Nightingale
during the Crimean war and seemingly lost in the intervening 150 years,"
said Richard Wise, former chairman of the government's specialist advisory
committee on antimicrobial resistance, and adviser to the Health Protection
Agency Board. "Not washing the hands between patients should be made a
disciplinary offence."
Most hospitals have bottles of alcohol-based hand disinfectant by their
doors, but Duerden says that until recently their inefficacy against C diff
spores was "not common knowledge" outside microbiology circles - an
unacceptable level of ignorance, insists Wise, who said it had been known
about "for donkey's years".
Olav Nataas, however, insists the search-and-destroy process is key: "We
know hand-washing is never 100%," he says. "This preoccupation with cleaning
is not the main issue. It is identifying the infection as rapidly as
possible and treating it in a way that does not risk others."
It is this uncertainty among Britain's scientists, healthcare administrators
and politicians that has led to the latest disagreement about hospital
cleaning. This month, every hospital in Britain is meant to have completed a
special "deep clean", for which an extra £57m has been allocated. How
exactly a deep clean is performed is less clear. There are no prescriptions
for cleaning materials, training for cleaners, or methods of checking
whether things are actually clean.
A helpful list of Department of Health ideas has been published, including
suggestions such as washing curtains, walls and beds. Many will be dismayed
to discover these are not already part of routine procedures. A government
rapid-review panel has also been established to examine the efficacy of
cleaning products, but it is down to individual hospital trusts to decide
what they need to do, and which wards to deep-clean. While, for example, the
West Midlands region is spending almost £10m on the exercise, only £3m is
being spent in the northeast. Some hospitals are emptying entire wards to
allow hydrogen peroxide "fogging", which uses a vapour to destroy the cell
walls of all organisms, or ultrasound vibration, to produce a similar
effect.
Nobody is keen to define what "clean" means in hospital terms and, according
to Andrew Large, the director-general of the Cleaning and Support Services
Association, some hospitals are doing nothing at all. "There is no
specification about whether hospitals are clean or not, but there is plenty
of academic evidence that a greater presence of people doing routine
cleaning on wards is what makes a difference," he says. "After all, you
could do a deep clean, but if the person inspecting it goes in and sneezes
when they happen to be carrying one of these infections, you are back to
square one."
Annual spot checks for cleanliness are being introduced by the Healthcare
Commission from next month. Those not complying may be issued with lists of
improvement needed, and if, for example, they still leave bedpans lying
around, "special measures" will be imposed. It is not possible to find out
what these special measures might be; according to a Department of Health
spokesman, "it will be decided at a local level".
Many patients have paid a high price for our confused health policies. In
Britain's worst outbreak of superbug infection, there were 90 deaths and
1,170 C diff infections across three hospital sites in Maidstone, Kent,
between April 2004 and September 2006. A report on the disaster by the
Healthcare Commission in October described patients being left to lie in
their own infection-laden excrement, a shortage of nurses and an ignorance
of the risks of moving infected patients between wards.
There were a further 33 avoidable deaths from C diff between 2003 and 2005
at Stoke Mandeville hospital in Buckinghamshire. An inquiry found that
managers ignored advice to isolate those infected and instead concentrated
on shutting down more beds to cut costs.
The cost of compensating superbug victims is also soaring. The NHS
Litigation Authority has paid out £12.5m for 287 cases, plus a
record-breaking £5m in January to the actress Leslie Ash, 49, whose career
has been ruined. An anticipated £1m will go to Shaun Franks, 39, who
underwent surgery for a broken ankle. His leg was taken over by an immovable
colony of MRSA, which could only be eradicated from his body by amputation
of the leg. During his treatment, staff at Northampton general hospital
unwittingly used an antibiotic that accelerated the growth of the MRSA. "It
has been a nightmare," said Franks. "I lost my job, my relationship -
everything. Every time I thought I was getting better, it would come back
again."
There is no question that ignorance of good practice has played a
significant part in the spread of superbugs in Britain. A study in the late
1990s by Otto Cars, an expert in infectious diseases at Uppsala University,
Sweden, compared antibiotic use across Europe. British doctors were
administering over 18 daily doses per 1,000 people, compared with 13 in
Germany and Sweden and 11 in Denmark. Most of the prescriptions were for
coughs and colds - 90% of which are caused by viruses, not bacteria.
Duerden admits that the first comprehensive campaign to educate GPs and the
public about the overuse of antibiotics only got off the ground eight years
ago with the launch of a cartoon character, Andybiotic. But a survey of
almost 11,000 adults published in the British Medical Journal last year
indicated that most people still did not understand the risks.
Hajo Grundmann, now a senior infection-control adviser to the Dutch
government, worked for seven years in Britain's NHS before returning home in
2001. He runs the Eurosurveillance database, monitoring levels of
antibiotic-resistant infections in 31 countries. Britain has the highest
rate in western Europe. "It is connected with the high workload," he says.
"I worked in Nottingham. We were able to isolate MRSA cases at first, but
when the waiting-list initiative came in, there was huge pressure on beds.
As soon as the pressure goes up, hand-washing goes down. But the British
problem is also due to people's attitudes. It just has not been taken
seriously enough."
So where do we go from here? Plans remain vague to introduce the sort of
routine pre-treatment screening for superbugs that exists in Norway, but
there is hope. Lewisham hospital in south London has seized the initiative
and, since 2005, has been screening all patients admitted through A&E. They
take swabs from mouths, noses, armpits and groins of everyone, and swirl
them around in a proprietary bacteriological "broth" that is cooked
overnight. If the broth changes colour, MRSA is definitely not there. If it
does not, the patient might be infected. Precautions are taken for "might
be" cases while they receive further testing. Dr Gopal Rao, the consultant
microbiologist leading this blindingly obvious initiative, which has halved
the rate of MRSA from 12% to 6% in the hospital, says: "If you know someone
is infected, you treat them differently, even if you don't have the
facilities to isolate them."
Other hospitals, including Guy's and St Thomas' in London, are trying out
similar initiatives, but it is expensive, and it is difficult to introduce
new practices in the NHS without producing years of evidence demonstrating
the cost benefit. Wolverhampton hospital estimates it has saved 212 lives
and £6.8m with better infection-control measures, such as giving consultants
targets for infection rates among patients. Why can't other hospitals do the
same?
The government says it can reduce MRSA to half its 2004 rate by the end of
the summer and cut levels of C diff by 30% within three years, though the
starting points for this claim are unclear. Health Protection Agency (HPA)
data for the latest quarter, during the summer of 2007, show MRSA
bloodstream-only infections have fallen from 1,304 to 1,072; C diff
infections were 10,334, compared with 13,669 for the previous quarter. The
HPA admits the data is unreliable owing to changes in collection methods.
Cynics might simply conclude there are fewer patients in hospital in summer.
There are, however, measures being launched by the government: to increase
the number of hospital matrons to 5,000 to oversee hygiene by May, and make
available £270m a year for hygiene campaigns, extra infection-control nurses
and pharmacists to tackle over-reliance on antibiotics.
But that does not explain why we continue to invest in areas such as Aids
research, or the hypothetical risk of pandemic flu, yet hope that drugs
developed in the middle of the last century will protect us against new
infections that are killing thousands each year.
Despite repeated requests, no minister was available to answer the questions
raised in this article. A written statement explained that investment in
Aids was vital as part of Britain's contribution to world public health. The
statement also referred to the (unsuccessful) infection-control policies
introduced up to a decade ago; offered guidance on the need to isolate
infectious patients in single rooms; and highlighted the aspiration to offer
more patients single rooms in several new hospitals currently being planned.
A Department of Health spokesman explained that despite the fact that Brian
Duerden had been unable to answer many of my questions, it was not
government policy to offer more than one spokesman on the same issue.
According to Richard Wise, it is impossible to avoid the conclusion that
until superbugs become - as they surely will - impossible to ignore, we can
expect to see our governments concentrate on headlines rather than detail.