Oral statement to the Assembly by Health Minister Edwin Poots
Update on Pseudomonas in the Neo-Natal Unit at the Royal Jubilee Maternity Hospital
~ Tuesday, 24 January 2012
Firstly, let me express my deepest condolences to the parents and families of those whose babies tragically died as a result of Pseudomonas infection. I also wish to extend my thoughts and prayers to all the families involved and I know there are many others who feel anxious in these very difficult circumstances.
I want to set the scene by looking at what we know about the pseudomonas bacterium. It is an organism that can be found in many natural environments, including soil and water. It can be found in sinks, taps and water systems and can be difficult to eradicate.
Pseudomonas bacteria can be present on the skin without causing infection. Some of us may even be carrying it now. This is known as colonisation. However, if the bacterium enters the body into the blood stream, lungs or urine it can cause infection. The infection can be treated by antibiotics.
Pseudomonas infections occur mainly in immunocompromised and debilitated patients. The bacterium rarely causes infection in otherwise healthy individuals. From 2008 to 2011, in Northern Ireland, we have seen on average between 80 and 90 cases of pseudomonas bacteraemias across all age groups. For children under 1, the numbers are in single figures.
Outbreaks of Pseudomonas have occurred in intensive care facilities around the world as patients in these facilities are frequently immunocompromised. For example, there were a number of outbreaks in English and Welsh hospitals in 2010. In response, my department issued guidance on best practice on the management of infection risks associated with water sources.
Unfortunately babies in neonatal units are already vulnerable due to clinical conditions and varying degrees of prematurity. Their immune systems are not fully developed, and this makes them less able to withstand infections including those that would not cause problems in healthy babies.
It is important to keep these facts in mind as we seek to understand how this outbreak could have happened and what we need to do in response.
If I could now turn the clock back to what has happened regarding pseudomonas over the past few months. An incident of pseudomonas infection occurred in Altnagelvin hospital NICU in December 2011 and was reported in the local media at the time. The Western Trust worked closely with the PHA and kept the parents of babies in their unit fully informed. There were three cases of pseudomonas bacteraemia. One baby sadly died and I would offer my condolences to this family also. One baby recovered, and one was transferred to the Royal Jubilee Maternity Hospital with appropriate infection control procedures being implemented. It is important to note that the strain of pseudomonas bacteria in the two units is different.
In response to the situation in Altnagelvin, the Chief Medical Officer and the Departmental Estates Officer jointly issued a letter to Trusts on 22 December reminding them of the potential infection risks posed by water systems in healthcare facilities and reinforcing important messages regarding the use of sinks and general hygiene.
This brings me now to the current outbreak in RJMH. On 6 January, a baby died in the RJMH from pseudomonas bacteraemia. Then a further baby died of pseudomonas bacteraemia on 13 January. There are many different types of pseudomonas bacteria and detailed typing is performed in the Reference Lab in England. These tests take time to conduct and results are not available immediately.
However, on 16 January typing confirmed two babies with the same strain of pseudomonas in the same unit within a short period of time. The Trust met on Tuesday 17 January to discuss these results and declared an outbreak. This information was relayed to the PHA and onward to the HSCB and the Department late on Tuesday. My officials provided me with all available details on Wednesday 18 January.
You will appreciate that circumstances such as these are complex evolving situations which require considerable detective work to piece together what is happening. I was in a position to issue a press statement on Thursday 19 January.
Unfortunately later that day, a third baby died and a further press release was issued. This has been followed by further updates as the situation has unfolded.
I want to focus now on the hunt for the source of infection. As I said earlier, pseudomonas is present in many natural environments, including soil and water. It can be found in sinks, taps and water systems and can be difficult to eradicate. For this reason, sinks, taps and water supplies are obvious places to start looking. However, this is a micro-organism which can be difficult to eradicate completely and permanently.
I can report that investigations so far have shown that pseudomonas bacteria have been found in a number of taps in the intensive care area of the neonatal unit in the RJMH. The Trust Health Estates team are in the process of removing and replacing all taps and related pipework in the affected area. There is no evidence of pseudomonas in the water system. This indicates that it is likely to be a localised problem.
Specialist advice has been received from experts in England and action is based on current best available evidence. This work should be completed within the next couple of weeks. The unit will only be opened once all remedial work is completed and tests show that it is safe to nurse babies in this environment.
This brings me to the latest position. I want to be completely clear about where we are now.
Clearly the situation can change from hour to hour but at this point today we believe there had been pseudomonas infections in a total of 7 babies associated with this outbreak in the Belfast NICU. Of these 7 babies:
- 3 of the babies died in RJMH neonatal unit
- 1 baby recovered from pseudomonas but died later from unrelated causes
- 2 babies had recovered from the infection and are still in RJMH neonatal unit
- 1 baby in RJMH neonatal unit has pneumonia and is being treated as potentially infected. Although laboratory results have yet to be confirmed, doctors have a high index of suspicion and are treating the baby on clinical grounds.
In addition, by the evening of 23 January, there were 6 babies which were colonised but have no signs of infection. It is important to note that colonisation means they are carrying the infection, for example on their skin, however colonisation in itself does not make the baby ill.
The breakdown of the six babies is as follows:
- 3 babies currently in RJMH have been shown to be colonised but have no signs of infection.
- 2 babies who had no pseudomonas on screening were transferred out of RJMH, one to Antrim and One to Craigavon. On screening after arrival, both were found to be colonised. One remains in isolation, while the other is well and has been discharged home.
- 1 baby which was previously treated in RJMH neonatal unit and transferred out to Daisy Hill hospital some weeks ago is colonised.
Finally, a number of babies in other neonatal units also have confirmed pseudomonas colonisation. The situation on the evening of 23 January showed:
- 2 babies in Altnagelvin
- 2 babies in Craigavon.
These babies do not have active infection, but have been detected through screening which was carried out as a precautionary measure. At this time it would seem that these babies are not directly related to the RJMH outbreak.
It is important to realise that in normal clinical practice in neonatal units it is not uncommon to detect this bacteria on the skin of babies.
These findings illustrate the complexity of the situation. Although the main focus to date has been on the neonatal unit in the RJMH, as the bacterium has been found in babies in some of the other neonatal units, management of this situation requires coordination and cooperation between all trusts. The Public Health Agency will therefore ensure that all public health aspects are managed, working closely with the Health and Social Care Board regarding the ongoing provision of neonatal services. All Trusts will be involved in taking appropriate action as advised.
I fully understand the anxiety of parents and the wider community across Northern Ireland; however, as I informed Assembly members yesterday, my department, the HSC Board, the Trusts, the Public Health Agency and the Ambulance Service have been and continue to work very closely together to ensure safe continuity of care for infants, support for their families, and ongoing management of this outbreak.
There are a few other points that I want to make.
Firstly, there have been some concerns about the impact of this outbreak on ability to maintain neonatal provision in Northern Ireland. I am pleased to report that at present the neonatal network is managing well, however, the number of babies requiring neonatal care can change from hour to hour. Well established arrangements are already in place to ensure that when babies require a neonatal cot they can be transferred to a unit in Northern Ireland or another part of the UK or Republic of Ireland.
Secondly, I want to reassure women that the delivery wards and all other services at the RJMH hospital are operating as normal. Expectant mothers should attend their appointments as scheduled.
I want to thank all staff across the health sector for their continued dedication and commitment in caring for babies at this difficult time. I know that all staff across the entire health sector work tirelessly to provide a safe and caring environment for patients and I would like to express my gratitude to them all. In addition I would pay tribute to the work of the Public Health Agency in providing expert health protection advice and to the Health and Social Care Board as they ensure that neonatal services remain available for babies.
My priority at present is to manage the outbreak, however it is vital to learn lessons from this situation so that we can reduce the risk of this happening again. In the longer term, RQIA is currently considering the most effective way to approach inspections in intensive care settings such as neonatal units.
The Trusts, PHA, HSCB and the Department are continuing to manage and monitor the situation and a teleconference is in progress at present. I want to stress that while the information which I have given is correct, based on information from yesterday’s teleconference, this is a complex and dynamic situation and the numbers quoted will change. Further updates will be issued.
Notes to editors:
1.Media enquiries about this press release to DHSSPS Press Office on 028 9052 2841, or out of hours contact the Duty Press Office via pager number 07699 715440 and your call will be returned.
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