In 1846, Ignaz Philipp Semmelweis, a sad-eyed, mustachioed young medical graduate, became chief resident of obstetrics at the Vienna General Hospital. Over the next two decades of his brief career, he became the “savior of mothers” and an enemy of the medical establishment, driven mad by his quest for the truth about hospital-acquired infections.
In the 1840s, teaching hospitals operated by trading free medical care in exchange for the opportunity to practice on poor people. At Semmelweis’s hospital, two clinics ran side-by-side. One clinic trained midwives, and operated with a maternal mortality rate of about one in 25. But in the other clinic, which taught medical students, one in ten women admitted would die before she left the hospital. In some months, nearly a third of the women at this clinic died. The leading cause of death was childbed (or puerperal) fever, and both clinics were referred to in official papers as “houses of death.” But, Semmelweis noted, mortality rates were perplexingly lower among women who insisted on giving birth in the streets and fields of Vienna rather than risk setting foot in the maternity clinics:
To me, it appeared logical that patients who experienced street births would become ill at least as frequently as those who delivered in the clinic. What protected those who delivered outside the clinic from these destructive unknown endemic influences?
Despondent, Semmelweis left for Venice:
I hoped the Venetian art treasures would revive my mind and spirit, which had been so seriously affected by my experiences in the maternity hospital.
But while the art treasures of Venice may have temporarily soothed his spirit, upon his return Semmelweis learned that his close friend, another doctor, had been pricked with a clumsy students’ scalpel in the middle of an autopsy. The doctor quickly became ill and died. Semmelweis wrote:
Day and night I was haunted by the image of [his] disease and was forced to recognize, ever more decisively, that the disease from which [he] died was identical to that from which so many maternity patients died.
In these pre-Louis Pasteur days, the medical establishment didn’t yet know about bacteria. The main preoccupation of the time was with humours and miasmas, and ‘treatment’ for childbed fever involved inducing vomiting, bloodletting, blistering agents applied to the women’s inner thighs, enemas, and liberal use of leeches with the aim of purging the fever heat from the body.
His friend’s death—so similar to the deaths in the medical student clinic—led Semmelweis to hypothesize that the trainee doctors were exposed to ‘cadaverous particles’ in the course of the autopsies they conducted, which they then transferred to the new mothers. The midwives in the neighboring clinic, who concerned themselves only with births, weren’t exposed to these cadaverous vapors. Semmelweis proposed, for the first time in medical history, a connection between touching cadavers and a risk of infection.
Semmelweis decided to act on his hunch. He instituted a clinic-wide policy of mandatory hand washing between cutting up a body and assisting in a birth. “[Hospital staff] had frequent opportunity to contact cadavers. Ordinary washing with soap is not sufficient to remove all adhering cadaverous particles. This is proven by the cadaverous smell the hands retain,” Semmelweis wrote, introducing a chlorinated lime solution to the hospital. It removed the smell of death and would, hopefully, remove the particles too.
In the first three months, death rates plummeted from one in ten to one in a hundred. Semmelweis had shown that he could conquer childbed fever with handwashing.
Or so you’d think. In fact, Semmelweis’ arguments were completely rejected by the medical establishment at the time. Coming decades before Pasteur’s germ theory of disease, and without a strong theoretical explanation, his actions seemed to be a reversion to the “speculative theories of earlier decades that were so repugnant to his positivist contemporaries.”
Danish physician Carl Edvard Marius Levy wrote a vitriolic attack of Semmelweis’s findings. First, he deferred to the statistics, blaming the success of Semmelweis’s hypothesis on normal fluctuations of mortality rates in maternity clinics. Next, he argued against the assertion that anything so small as to be invisible could cause death, saying that, “With due respect for the cleanliness of the Viennese students, it seems improbable that enough infective matter or vapor could be secluded around the fingernails to kill a patient.” Lastly, he questioned Semmelweis’s methods altogether: why didn’t he run a simpler experiment, by fully separating those working with cadavers from those aiding in births?
To be fair, Semmelweis did have major faults in his reasoning—he thought that only cadaverous particles caused the fever, and couldn’t explain why some women still contracted fever in the midwife clinic. But, perhaps most importantly, his theories presented a behavioral conundrum for his fellow physicians: testing his hypothesis further could implicate them as dealers of death. Accusing doctors of haplessly causing disease was a slur on the gentlemanly art of medical practice.
Such resistance within the medical community was short-lived. In the later part of the 19th century, a rising tide of empiricism—in particular the work of Joseph Lister and Louis Pasteur—lifted the lonely little ship of hygiene, and the benefits of hand washing would become universally accepted.
But while medical knowledge has radically shifted in the last 170 years, the reluctance to wash hands has persisted. The figures are striking. One large studyfound that hand washing rates were at just 26% in intensive care units, and 36% in the other wards (after monitoring systems were put in place, they jumped to about 50%). Another found doctors self-reported hand washing 73% o the time, but actually only did it 10% of the times they should have. The results are clear: doctors in hospitals not washing their hands kills roughly 100,000 Americans every year and sickens 1.7 million more.
So after 150 years, why is this still a problem? Excuses from doctors range from being too busy, to the washing solution and alcohol rubs drying out their hands, to constantly having to carry equipment which makes it difficult to wash, to hand washing facilities being inconveniently located. Others simply say they forget.
Today, a whole industry of high-tech ways to remind doctors to wash their hands has sprung up, selling hospitals vibrating sensors to remind doctors to lather up, intensive video-monitoring, and incentive schemes for good hygienic practices. One hospital introduced waist-high monitoring that buzzed when doctors walked past without washing their hands. But doctors got down on their knees and crawled under the sensors, just to avoid washing their hands. While busy doctors may occasionally be absent-minded, such reports seem to indicate that sometimes they knowingly avoid it.
Several studies have shown that nurses wash their hands more than doctors. Ironically, part of this may go back to the resistance among Semmelweis’s 19th century peers: It’s speculated that doctors develop a complex of invulnerability—that, as medical professionals, they can’t be harmed or harm others. “The ego can kick in after you have been in practice a while,” one emergency department physician told the New York Times. “You say: ‘Hey, I couldn’t be carrying the bad bugs. It’s the other hospital personnel.’”
Doctors are pretty much universally regarded as empirically-minded. But knowledge doesn’t always translate to universal shifts in behavior—regardless of how easy, necessary, or cheap the solution. The clean, elegant answers produced by biomedical science can’t be found in equal measure in the dirty world of human actions and motivation.
And what about our hero, Dr. Semmelweis? Increasingly obsessive over the years, Semmelweis took his colleagues’ reluctance to accept his theories as a personal affront. Rather than launch a charm offensive to win his fellow obstetricians over, he wrote them abusive public letters: “I declare before God that you are a murderer and [history] would not be too unfair if it remembers you as a medical Nero,” he told one. Increasingly driven mad by the world’s failure to appreciate the importance of hand washing, likely exacerbated by a a touch of syphilis or Alzheimer’s, his colleagues eventually had enough: three obstetricians signed referrals committing him to a mental asylum. One day, while on vacation with his wife and child, he was met at a train station by an old friend who wanted to show him his sanitarium.
Under this pretext, the 47-year old Semmelweis was driven straight to a large, public asylum. He was severely beaten by the guards and died—of an infection—two weeks later.
In honor of Semmelweis’s legacy to medicine, several medical schools, hospitals, womens’ clinics, and museums now stand proudly bearing his name. But, perhaps most appropriately, his name graces the so-called “Semmelweis reflex”: the kneejerk reflex to reject new evidence contradicting established norms.
Leah Ginnivan is a public policy researcher and campaigner with an appreciation for arcane Wikipedia. Twitter: @leahginnivan.
CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions.
The Nursing Home Compare Web site features a quality rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average. There is one Overall 5-star rating for each nursing home, and a separate rating for each of the following three sources of information:
Health Inspections – The health inspection rating contains information from the last 3 years of onsite inspections, including both standard surveys and any complaint surveys. This information is gathered by trained, objective inspectors who go onsite to the nursing home and follow a specific process to determine the extent to which a nursing home has met Medicaid and Medicare’s minimum quality requirements. The most recent survey findings are weighted more than the prior two years. More than 180,000 onsite reviews are used in the health inspection scoring nationally.
Staffing – The staffing rating has information about the number of hours of care provided on average to each resident each day by nursing staff. This rating considers differences in the levels of residents’ care need in each nursing home. For example, a nursing home with residents who had more severe needs would be expected to have more nursing staff than a nursing home where the resident needs were not as high.
Quality Measures (QMs) – The quality measure rating has information on 11 different physical and clinical measures for nursing home residents. The rating now includes information about nursing homes’ use of antipsychotic medications in both long-stay and short-stay residents. This information is collected by the nursing home for all residents. The QMs offer information about how well nursing homes are caring for their residents’ physical and clinical needs. More than 12 million assessments of the conditions of nursing home residents are used in the Five-Star rating system.
Caution: No rating system can address all of the important consideration that go into a decision about which nursing home may be best for a particular person. Examples include the extent to which specialty care is provided (such as specialized rehabilitation or dementia care) or how easy it will be for family members to visit the nursing home resident. As such visits can improve both the residents’ quality of life and quality of care, it may often be better to select a nursing home that is very close over one that may be, compared to a higher rated nursing home that would be far away. Consumers should therefore use the Web site only together with other sources of information for the nursing homes (including a visit to the nursing home) and State or local organizations (such as local advocacy groups and the State Ombudsman program).
In the Downloads section below, the Five-Star Quality Rating System Technical Users’ Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Beginning with the March 2009 version, the Technical Users’ Guide consists of two documents: the Five-Star Quality Rating System Technical Users’ Guide and the Five Star Quality Rating System State-Level Cut Point Tables. In addition, beginning with March 2009 we have posted a data file that contains reported, expected, and adjusted staffing time values for all nursing homes on Nursing Home Compare – Updated October 2016.
The analysis, published in the BMJ, shows that medical errors claim 251,000 lives every year, more than causes such as respiratory disease, accidents, stroke, or Alzheimer’s. People are dying from the care they receive, rather than the disease for which they are seeking care. Why is the quality of medical care in the United States so bad? In a world where medical professionals are held accountable for their actions, you would think that the costs of providing poor quality care would provide adequate incentives to ensure high quality care. The thing is, as a result of heavy lobbying from the cash-cows in the medical and pharmaceutical industry, “tort reform” has limited the penalties medical professionals may face for destroying lives by providing negligent medical care.
Caps on damages in medical malpractice are one of the hallmarks of the “tort reform.” The idea is that when a patient sues a physician or other medical provider for screwing up, there is a limit on the amount of damages the patient can claim. In Missouri the cap for wrongful death damages in a medical malpractice case is just $350,000, a cap that was upheld by the Missouri Supreme Court just a few weeks ago in Dodson v. Ferrara.
Tort “reformers” argue that there is an “epidemic” of medical negligence liability that drives up costs for everyone (but especially for doctors purchasing medical liability insurance). Moreover, they argue, doctors facing the possibility of full liability for their actions will practice “defensive medicine,” by ordering unnecessary tests and conducting unnecessary procedures. There is no evidence of this—in fact, in places where “tort reform” has taken hold, costs have risen, not fallen. And this makes sense—holding doctors accountable for their actions should improve the quality of care, lowering costs, including malpractice claims. And why would doctors fearing liability for errors order tests that fail to increase the quality of care? Indeed, empirical evidence shows that this argument is smoke and mirrors—malpractice liability does not increase the use of irrelevant treatment.
You would think that a nationwide epidemic of medical malpractice would have been noticed by now. The problem is, the Centers for Disease Control and Prevention does not even measure medical negligence in its annual list reporting the top causes of death. When the CDC records causes of death, it does so based on death certificate data, but this system does not take into account things like communications breakdowns, diagnostic errors and poor judgment. Far too often, according to the Johns Hopkins study authors, these factors lead to mistakes that cost lives.
Dr. Martin Makary, one of the authors of the study, points out that ignorance of the true costs of medical negligence leads to an overestimate of cardiovascular and other diseases, and an underappreciation of medical care as a cause of death. “That informs all out national health priorities and our research grants,” he said.
The CDC denies that its coding procedures are to blame for this lack of data regarding the cost of medical errors. Bob Anderson, chief the Mortality Statistics Branch at the Nation Center for Health Statistics, with responsibility for overseeing the CDC’s mortality data collection efforts, said that the CDC’s codes are adequate and follow international guidelines. But the CDC’s mortality statistics only count the underlying cause of death, which is defined as the condition that led a person to seek treatment. So even if a doctor does list “medical error” as a cause of death, that fact does not end up on the CDC’s official tally.
Anderson believes that there is no “compelling reason” to change this methodology, because it allows the statistics in the U.S. to compared with the causes of death in other nations. By following international guidelines, researchers can do an apples-to-apples comparison—but if the true impact of medical errors was included, this would skew the comparative numbers for other causes of death. As the Johns Hopkins study authors point out, “no method of investigating and documenting preventable harm is perfect.” But completely ignoring a leading cause of death means that our decisions about health care policy, including damages caps on medical negligence actions, will be based on incorrect information.
The tort “reformers” might argue that free-market forces, rather than tort suits, can ensure quality medical care. But in the health care system in the United States there is no market pressure on doctors to succeed at providing quality care, because health insurance costs and outcomes are not publicly available. Do you ever look up the cost of a doctor before undergoing treatment? Probably not. The way our the healthcare system works in the United States is not free-market at all. You can’t have a competitive market when costs and outcomes are concealed from consumers. If you call your doctor’s office and ask what a procedure costs they probably can’t give you an answer.
And if the CDC doesn’t even know how often medical negligence causes death, you as a consumer are not going to be able to unearth that information. We have a system where there is no cost or quality pressure—so free-market economics can’t be what put pressure on doctors to succeed and avoid bad patient outcomes.
Some institutions have internal quality controls that may put pressure on doctors when their death rates are too high. But do you trust companies to internally make sure that the quality of their products? Probably not in any other setting besides in the medical field. We tend to place absolute trust in our medical providers because they are providing life-giving care. So those that are most in need of medical care, like the elderly, are the least able to self-advocate.
And caps on medical negligence damages are fundamentally an anti-free-market idea. The free market philosophy is that costs are most efficiently allocated when market participants are allowed to set prices based on supply and demand. The free market works best when costs are borne by the market participants responsible for incurring them, rather than externalized by a policy imposed by the government. Negligence caps remove the ability of the marketplace to allocate costs against participants responsible for incurring them, and instead transform damages that are in excess of the caps into external costs to be borne by society as a whole.
Given the fact that our system of medical services does not and probably never will function as a truly free marketplace, it’s up to practitioners of tort liability to hold doctors accountable. The only way the doctors are going to be held to task for screwing up as if they’re sued for medical malpractice. And so those who are in favor of “tort reform” are really working on behalf of doctors only, and not on behalf of patients. “Tort reform” and quote doesn’t actually protect medical costs. All it does is remove the one feature of our legal system that serves as a check against physician error.
Given the recent success of “tort reform” it shouldn’t come as any shock to any of us that medical errors are one of the leading causes of death in the United States. When there’s no way to call doctors accountable except through negligence actions, and negligence actions are strictly curtailed by the action of politicians and lobbyists protecting well-heeled industry donors, we should expect a system where medical errors are rampant.
We should reject the arguments of those who contend that civil liability increases insurance premiums and instead except the much simpler and more likely possibility that civil liability decreases mistakes, because it incentives quality care. If you know you are going to face a potentially ruinous civil judgment, as a physician you have motivation to refrain from making medical errors.
The case against “tort reform” has taken on a much more urgency given the Johns Hopkins study. We have reached the point that now medical negligence is starting to show up as one of the leading causes of death in America. We should not be willing to accept this as collateral damage of a battle between special interests. We should take a stand against so-called “tort reform” and realize that in our system for better or for worse, liability for medical negligence is the only aspect of our legal system keeping doctors motivated to provide high-quality services.
We should not have to live in a world where medical error is one of the leading causes of death. The Purpose of medicine is to treat people, not to kill them. It’s a premise so obvious it should go without saying. And yet our policies bely this basic premise. We have set up a system which basically ensures that medical negligence will occur. And now, lo and behold, it has.
It seems that every time researchers estimate how often a medical mistake contributes to a hospital patient’s death, the numbers come out worse.
In 1999, the Institute of Medicine published the famous “To Err Is Human” report, which dropped a bombshell on the medical community by reporting that up to 98,000 people a year die because of mistakes in hospitals. The number was initially disputed, but is now widely accepted by doctors and hospital officials — and quoted ubiquitously in the media.
In 2010, the Office of Inspector General for Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year.
Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says.
The new estimates were developed by John T. James, a toxicologist at NASA’s space center in Houston who runs an advocacy organization called Patient Safety America. James has also written a book about the death of his 19-year-old son after what James maintains was negligent hospital care.
Asked about the higher estimates, a spokesman for the American Hospital Association said the group has more confidence in the IOM’s estimate of 98,000 deaths. ProPublica asked three prominent patient safety researchers to review James’ study, however, and all said his methods and findings were credible.
What’s the right number? Nobody knows for sure. There’s never been an actual count of how many patients experience preventable harm. So we’re left with approximations, which are imperfect in part because of inaccuracies in medical records and the reluctance of some providers to report mistakes.
Patient safety experts say measuring the problem is nonetheless important because estimates bring awareness and research dollars to a major public health problem that persists despite decades of improvement efforts.
“We need to get a sense of the magnitude of this,” James said in an interview.
James based his estimates on the findings of four recent studies that identified preventable harm suffered by patients – known as “adverse events” in the medical vernacular – using use a screening method called the Global Trigger Tool, which guides reviewers through medical records, searching for signs of infection, injury or error. Medical records flagged during the initial screening are reviewed by a doctor, who determines the extent of the harm.
In the four studies, which examined records of more than 4,200 patients hospitalized between 2002 and 2008, researchers found serious adverse events in as many as 21 percent of cases reviewed and rates of lethal adverse events as high as 1.4 percent of cases.
By combining the findings and extrapolating across 34 million hospitalizations in 2007, James concluded that preventable errors contribute to the deaths of 210,000 hospital patients annually.
That is the baseline. The actual number more than doubles, James reasoned, because the trigger tool doesn’t catch errors in which treatment should have been provided but wasn’t, because it’s known that medical records are missing some evidence of harm, and because diagnostic errors aren’t captured.
An estimate of 440,000 deaths from care in hospitals “is roughly one-sixth of all deaths that occur in the United States each year,” James wrote in his study. He also cited other research that’s shown hospital reporting systems and peer-review capture only a fraction of patient harm or negligent care.
“Perhaps it is time for a national patient bill of rights for hospitalized patients,” James wrote. “All evidence points to the need for much more patient involvement in identifying harmful events and participating in rigorous follow-up investigations to identify root causes.”
Dr. Lucian Leape, a Harvard pediatrician who is referred to the “father of patient safety,”was on the committee that wrote the “To Err Is Human” report. He told ProPublica that he has confidence in the four studies and the estimate by James.
Members of the Institute of Medicine committee knew at the time that their estimate of medical errors was low, he said. “It was based on a rather crude method compared to what we do now,” Leape said. Plus, medicine has become much more complex in recent decades, which leads to more mistakes, he said.
Dr. David Classen, one of the leading developers of the Global Trigger Tool, said the James study is a sound use of the tool and a “great contribution.” He said it’s important to update the numbers from the “To Err Is Human” report because in addition to the obvious suffering, preventable harm leads to enormous financial costs.
Dr. Marty Makary, a surgeon at The Johns Hopkins Hospital whose book “Unaccountable” calls for greater transparency in health care, said the James estimate shows that eliminating medical errors must become a national priority. He said it’s also important to increase the awareness of the potential of unintended consequences when doctors perform procedure and tests. The risk of harm needs to be factored into conversations with patients, he said.
Leape, Classen and Makary all said it’s time to stop citing the 98,000 number.
Still, hospital association spokesman Akin Demehin said the group is sticking with the Institute of Medicine’s estimate. Demehin said the IOM figure is based on a larger sampling of medical charts and that there’s no consensus the Global Trigger Tool can be used to make a nationwide estimate. He said the tool is better suited for use in individual hospitals.
The AHA is not attempting to come up with its own estimate, Demehin said.
Dr. David Mayer, the vice president of quality and safety at Maryland-based MedStar Health, said people can make arguments about how many patient deaths are hastened by poor hospital care, but that’s not really the point. All the estimates, even on the low end, expose a crisis, he said.
“Way too many people are being harmed by unintentional medical error,” Mayer said, “and it needs to be corrected.”
Brown is Reintroducing the Strategies to Address Antibiotic Resistance (STAAR) Act to Help Address Growing Health Crisis. During News Conference Call, Brown Joined an Expert in Infectious Disease and Antibiotic Resistance to Discuss Threat Posed by Antibiotic Resistance.
WASHINGTON, D.C. – Today, U.S. Sen. Sherrod Brown (D-OH) outlined his plan to protect Ohioans from deadly “super bugs” by combatting antibiotic resistance. Antibiotic resistance and the growing shortage of effective antibiotic drugs impacts more than two million Americans each year – with an estimated 23,000 dying as a result – according to the Centers for Disease Control and Prevention (CDC). To address this increasing public health crisis, Brown is reintroducing the Strategies to Address Antibiotic Resistance(STAAR) Act, legislation that would strengthen the federal response by increasing antibiotic resistance data collection and monitoring, prevention and control, and research efforts.
“Antibiotics have been one of the greatest public health achievements of all time but antibiotic-resistant “super bugs” are an increasingly dangerous threat to Ohioans,” Brown said. “It’s critical that we do everything possible to preserve antibiotics as one of our most effective tools to fight disease and that’s why I’m reintroducing the STAAR Act to strengthen the federal response to antibiotic resistant bacteria. We have to be proactive if we want to prevent a public health crisis, and stop the spread of these superbugs before they erase many of the health gains we’ve made over the past century.”
During a news conference call, Brown joined Dr. Robert Bonomo – director of Medical Services at the Louis Stokes Veterans Affairs Medical Center, a professor at Case Western Reserve School of Medicine, and an expert in infectious disease and antibiotic resistance – to discuss why the STAAR Act is needed to address the threat antibiotic resistance poses.
“Drug-resistant infections are already a hidden epidemic and unless we take vigorous and immediate steps to curtail them, the American people will face a public health crisis of tragic proportions,” Dr. Bonomo said. “If we are to avoid this grim prospect, we must build off of existing successful programs by continuing to reinforce surveillance and reporting, and support basic research to address this global threat.”
Drug-resistant infections – like Methicillin-resistant Staphylococcus aureus (MRSA) – are impacting more than just hospitals and are also infecting healthy adults and children. If left unaddressed, antibiotic resistance could result in a generation of antibiotics that are virtually ineffective, seriously jeopardizing patient safety and public health. It is estimated that the total economic cost of antibiotic resistance to the U.S. economy is more than $20 billion a year in excess health care costs, with additional costs to society for lost productivity as high as $35 billion a year.
Brown’s bill would provide a multi-pronged strategy to help limit the growing impact of antibiotic resistance, positively impacting the nation’s overall health and national security, and lowering the costs associated with antimicrobial-resistant. Specifically, the bill would:
Reauthorize the Interagency Antimicrobial Resistance Task Force and codify sections of the National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB), to promote prevention and track antibiotic use and resistance.
Enact key CDC recommendations to place greater emphasis on federal antimicrobial resistance surveillance, prevention and control, and research efforts.
Authorize the use of grants to healthcare facilities to study the development and implementation of antimicrobial stewardship programs aimed at expanding efforts to encourage appropriate use of antibiotics.
Allow the CDC to partner with state health departments to implement prevention collaboratives, and to expand public health partnerships through the CDC’s established Prevention Epi-Centers work.
Require annual reports to Congress on implementation.
MICROSCOPIC MENACE: Potentially deadly multidrug-resistant strains of Pseudomonas aeruginosa can infect hospital patients through ventilators and other devices. REUTERS/Courtesy of Centers for Disease Control and Prevention (CDC)
Fifteen years after the U.S. declared drug-resistant infections to be a grave threat, the crisis is only worsening, a Reuters investigation finds, as government agencies remain unwilling or unable to impose reporting requirements on a healthcare industry that often hides the problem.
RICHMOND, Va. – Josiah Cooper-Pope, born 15 weeks premature, did fine in the neonatal intensive care unit for the first 10 days of his life.
Then, suddenly, his tiny body started to swell. Overnight, he grew so distended that his skin split.
His mother, Shala Bowser, said nurses at Chippenham Hospital in Richmond, Virginia, told her that Josiah had an infection and that she should prepare for the worst. On Sept. 2, 2010, she was allowed to hold him for the first and last time as he took his final breath. He was 17 days old.
What no one at the hospital told Bowser was that her newborn was the fourth baby in the neonatal unit to catch the same infection, methicillin-resistant Staphylococcus aureus,better-known as MRSA. It would sicken eight more, records show – nearly every baby in the unit – before the outbreak had run its course.
The shock of her son’s death came back to her when, after being contacted by Reuters earlier this year about the outbreak, Bowser went to Virginia’s Division of Vital Records to get a copy of Josiah’s death certificate. The cause of death: “Sepsis due to (or as a consequence of): Prematurity.” Sepsis is a complication of infection, but there was no mention of MRSA.
“My heart hurts,” Bowser said, sobbing. “I saw what this did to him. And then they just threw a bunch of words on the death certificate.”
According to their death certificates, Emma Grace Breaux died at age 3 from complications of the flu; Joshua Nahum died at age 27 from complications related to a skydiving accident; and Dan Greulich succumbed to cardiac arrhythmia at age 64 after a combined kidney and liver transplant.
In each case – and in others Reuters found – death resulted from a drug-resistant bacterial infection contracted while the patients were receiving hospital care, medical records show. Their death certificates omit any mention of the infections.
Fifteen years after the U.S. government declared antibiotic-resistant infections to be a grave threat to public health, a Reuters investigation has found that infection-related deaths are going uncounted, hindering the nation’s ability to fight a scourge that exacts a significant human and financial toll.
Even when recorded, tens of thousands of deaths from drug-resistant infections – as well as many more infections that sicken but don’t kill people – go uncounted because federal and state agencies are doing a poor job of tracking them. The Centers for Disease Control and Prevention (CDC), the go-to national public health monitor, and state health departments lack the political, legal and financial wherewithal to impose rigorous surveillance.
As a result, they miss people like Natalie Silva of El Paso, Texas, who contracted a MRSA (pronounced MER-suh) infection after giving birth. She died from infection-related complications nearly a year later, at age 23.
Silva’s sisters fought a successful battle to get the hospital to cite MRSA on her death certificate. Still, her death went uncounted: The Texas health department doesn’t track deaths like hers from antibiotic-resistant infections, and neither does the CDC.
As America learned in the battle against HIV/AIDS, beating back a dangerous infectious disease requires an accurate count that shows where and when infections and deaths are occurring and who is most at risk. Doing so allows public health agencies to quickly allocate money and manpower where they are needed. But the United States hasn’t taken the basic steps needed to track drug-resistant infections.
“You need to know how many people are dying of a disease,” said Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy, a Washington-based health policy research organization. “For better or worse, that’s an indicator of how serious it is.”
Drug-resistant infections are left off death certificates for several reasons. Doctors and other clinicians get little training in how to fill out the forms. Some don’t want to wait the several days it can take for laboratory confirmation of an infection. And an infection’s role in a patient’s death may be obscured by other serious medical conditions.
There’s also a powerful incentive not to mention a hospital-acquired infection: Counting deaths is tantamount to documenting your own failures. By acknowledging such infections, hospitals and medical professionals risk potentially costly legal liability, loss of insurance reimbursements and public-relations damage.
A mother’s lament: ‘They robbed me of my child’
Doctors and other clinicians also may simply not understand the importance of recording the infections. Sandy Tarant, the doctor who signed Josiah Cooper-Pope’s death certificate, told Reuters that he thought “it didn’t matter” whether he cited a MRSA infection.
Legally, he’s right. Most states don’t require doctors to specify whether MRSA was a factor in a death. Washington and Illinois are exceptions.
State laws govern how death certificates are filled out. Most use a model law that mandates financial penalties for anyone who deliberately makes a false statement on the document, said Patricia Potrzebowski, director of the National Association for Public Health Statistics and Information Systems. The penalties are often small and rarely enforced, she said.
“AN IMPRESSIONIST PAINTING”
Not even the CDC has a good handle on the extent of the problem. The agency estimates that about 23,000 people die each year from 17 types of antibiotic-resistant infections and that an additional 15,000 die from Clostridium difficile, a pathogen linked to long-term antibiotic use.
The numbers are regularly cited in news reports and scholarly papers, but they are mostly guesswork. Reuters analyzed the agency’s math and found that the estimates are based on few actual reported deaths from a drug-resistant infection.
The agency leaned heavily on small samplings of infections and deaths collected from no more than 10 states in a single year, 2011. Most didn’t include populous areas such as Florida, Texas, New York City and Southern California.
From those small samples, the CDC then extrapolated most of its national estimates, introducing so much statistical uncertainty into the numbers as to render them useless for the purposes of fighting a persistent public health crisis.
Describing the estimates to Reuters, even CDC officials used words like “jerry-rig,” “ballpark figure” and “a searchlight in the dark attempt.”
Michael Craig, the CDC’s senior adviser for antibiotic resistance coordination and strategy, said the agency, pressured by Congress and the media to produce “the big number,” settled on “an impressionist painting rather than something that is much more technical.”
In a statement emailed to Reuters, CDC officials said they released the 2013 estimates report “despite its limitations because of our profound concern about the seriousness of the threat.” The agency said it is working on improving its estimates.
The numbers of uncounted deaths from drug-resistant infections “speak to what can happen when we don’t allocate the necessary resources to bolster … our public health safety network,” said Senator Sherrod Brown. “When we see discrepancies in reporting, are unable to finance a workforce to monitor infections, and can’t even soundly estimate the number of Americans that die from [antibiotic-resistant infections] each year, we know we have a problem.”
The Ohio Democrat recently introduced a bill that would require the CDC to collect more and better data on superbug infections and death rates.
In the absence of a unified national surveillance system, the onus of monitoring drug-resistant infections and related deaths falls on the states. A Reuters survey of the health departments of all 50 states and the District of Columbia found wide variations in how they track seven leading “superbug” infections – if they do so at all.
Only 17 states require notification of C. difficile infections, for example, while just 26 states and Washington, D.C., do the same for MRSA. Fewer than half require notification of infections bycarbapenem-resistant Enterobacteriaceae (CRE), a family of pathogens that the CDC has deemed an “urgent threat.” CRE gained notoriety when more than 200 people were sickened through contaminated medical scopes in hospitals from 2012 to 2015.
Twenty-four states and the District of Columbia – an area comprising 3 of every 5 Americans – said they do not regularly track deaths due to antibiotic-resistant infections. In contrast, all 50 states require reporting of AIDS-related deaths. Deaths from hepatitis C and tuberculosis are also closely tracked.
States that said they do track deaths generally do so for only a few types of drug-resistant infections and not consistently. In the survey, they reported a combined total of about 3,300 deaths from 2003 to 2014.
That’s a tiny fraction of the actual toll: A Reuters analysis of death certificates found that nationwide, drug-resistant infections were mentioned as contributing to or causing the deaths of more than 180,000 people during the same period. To conduct the analysis, Reuters worked with the CDC’s National Center for Health Statistics’ Division of Vital Statistics to search text descriptions on death certificates to identify relevant deaths.
The mismeasure of a grave threat to public health
Among the states that don’t require reporting of superbug deaths is California, the nation’s most populous state. The Reuters analysis identified more than 20,000 deaths linked to drug-resistant infections during the 12-year period, the most of any state. A health department spokeswoman said the state legislature authorized the department to be notified of infections, but not deaths.
Tennessee doesn’t require notification of deaths, either. The Reuters analysis found more than 5,500 deaths linked to superbugs there, more than half of them MRSA-related.
“We know we have a problem with MRSA in Tennessee,” said Marion Kainer, the state’s director of antimicrobial resistance programs. Requiring hospitals to report deaths is more than the department can take on right now, she said. “We have a significant problem getting clinicians to report just the disease,” she said. “It’s grossly under-reported.”
The totals from the Reuters analysis also indicate that the problem is getting worse nationwide, as the number of deaths from drug-resistant infections more than doubled from 8,600 in 2003 to about 16,700 in 2014. (Some of that increase could be the result of clinicians’ increased awareness of the infections.)
Death certificates aren’t a perfect measure. They can be wrong: Cause of death often is a judgment call by clinicians, who may blame a drug-resistant infection in error. More likely, they undercount drug-resistant deaths, as cases like that of Josiah Cooper-Pope show. Just how far under is impossible to know.
But there are clues: Connecticut, with a grant from the CDC, is the only state that closely monitors MRSA deaths. It logged 2,084 deaths from drug-resistant infections from 2003 to 2014, all but 10 from MRSA. That’s nearly twice the number of deaths from MRSA in the state that Reuters found in its death certificate analysis.
One reason for the disparity is that the state’s count includes anyone who died with MRSA, even if it wasn’t the cause of death, said Dr Matthew L. Cartter, Connecticut’s epidemiologist. He also said death certificates may undercount MRSA deaths because the physician may cite a general infection-related condition – death due to sepsis, for example – without mentioning the actual bacteria involved, or merely describe the mechanics of death, such as organ failure or cardiac arrest.
For many victims’ relatives interviewed by Reuters, the death certificate held special significance. They had watched an infection squeeze the life out of a loved one, often over several months and in gruesome ways. To find no official record of that on the death certificate came as a shock. It was as if the killer got away.
How counting helps: the HIV/AIDS model
The CDC documented the first AIDS cases in 1981. Within three years, most state health departments required hospitals and physicians to report and name each new diagnosis.
Surveillance systems soon evolved to capture each AIDS-related death. Health officials used that information to direct resources to the hardest-hit areas and study how the disease was spreading. Officials and the public watched deaths across the country climb at an alarming rate.
“AIDS was constantly increasing,” said Mervyn Silverman, San Francisco’s director of health from 1977 to 1985. “AIDS cases became a few thousand, then 20,000, and it scared the hell out of people.”
Activism swelled, helping to attract millions of dollars for public education campaigns and drug development. The number of infections peaked at about 78,000 in 1993 and then rapidly fell. In 1995, as new, effective drug treatments became available, the number of deaths peaked at about 53,000. In 2013, the latest year for which numbers are available, about 13,000 people died with AIDS.
So far, drug-resistant infections haven’t prompted anything like that sort of broad mobilization.
Consider that for the current year, Congress allocated $7.7 billion to fight AIDS, including $789 million to the CDC for prevention and research. For antibiotic-resistant infections, which kill tens of thousands of people a year, this year’s total allocation came to $1 billion. Of that, $160 million in new money goes to the CDC, which until last year didn’t even have a line item in its budget for fighting drug-resistant infections.
Dan Greulich’s medical records show that, after his transplant operation, he spent five months battling drug-resistant infections that left him so debilitated he asked to be taken off of life support. He died in June 2012. By the time of his death – due to “cardiac arrhythmia,” according to the death certificate – the cost of his care at UCLA Medical Center amounted to more than $5 million.
“When the doctor wouldn’t count him as one of the people who die from hospital-acquired infections, I was outraged,” said Rae Greulich, his widow. She considered suing the hospital but never did.
UCLA Medical Center declined to comment.
Joshua Nahum’s recovery from a skydiving accident on Sept. 2, 2006, was going so well at Longmont United Hospital in Colorado that he was transferred to Northern Colorado Rehabilitation Hospital a month later in preparation for going home.
Within days, his temperature spiked, his condition deteriorated, and he was transferred back to Longmont. There, he was diagnosed with meningitis from Enterobacter aerogenes, a virulent drug-resistant pathogen spread almost exclusively in healthcare settings.
By the time he died on Oct. 22, the swelling in his brain had made him a quadriplegic, said his father, Armando Nahum. The infection was “the most immediate cause of his death,” his neurosurgeon, Dr E. Lee Nelson, told Reuters.
His death certificate said he died of “Delayed Complications of Craniocerebral Injuries” from the accident. “I remember being dumbfounded. ‘Are you serious?’” Nahum said. “All I asked was that they write the truth – that Josh died of an infection.”
Hospital records obtained by the family show he also contracted meningitis from a methicillin-resistant Staphylococcus epidermidis infection while at Longmont. Similar to MRSA, it is a potentially lethal drug-resistant bug.
In an email statement, Nancy Driscoll, chief nursing officer at Longmont United, said an independent review concluded that Nahum’s care “was appropriate.” She did not respond to questions about how he contracted the infections. Northern Colorado Chief Executive Officer Beth Bullard declined to discuss the case.
Because Nahum died nearly two months after the accident, the cause of death was certified by the Boulder County coroner’s office. Dr John E. Meyer, deputy coroner at the time, signed the death certificate. He told Reuters that he did not recall the case but would not have thought to specify that the complication was an infection.
“There’s certainly no rule that I know of,” he said.
Patient safety groups petitioned the CDC in 2011 to add a question about hospital-acquired infections to its standard death certificate, which is used by many states.
CDC Director Dr Thomas Frieden wrote that he would consider including patient advocates in discussions the next time the agency revises its death certificate, but there were no plans to make any changes “in the near future.”
In a statement emailed to Reuters, Frieden said: “While death certificates provide helpful information, the unfortunate reality is that they don’t provide in-depth clinical information.”
Antibiotic-resistant bacteria have been around nearly as long as antibiotics. Alexander Fleming discovered penicillin, the first modern antibiotic, in 1928, saving millions of lives from infections that just a few years earlier would have been fatal. By 1940, researchers were reporting that bacteria had already developed resistance to the drug.
Modern science became locked in a war of one-upmanship with the microbial world. Researchers would develop a class of drugs to replace those that were becoming ineffective, and soon enough, bacteria would begin showing resistance to the new drugs – a problem worsened by widespread overprescription of antibiotics and their overuse in farm animals.
By the 1990s, drug-resistant infections had reached crisis proportions. Advances in medicine have been, paradoxically, a big reason for the worsening epidemic.
More people than ever are living with weak immunity: premature infants, the elderly, and people with cancer, HIV and other illnesses that were once fatal but are now often chronic conditions. That’s also why superbugs most often occur in hospitals, nursing homes and other healthcare facilities – places where susceptible populations are concentrated.
In 2001, a task force led by the CDC, the Food and Drug Administration and the National Institutes of Health declared antibiotic-resistant infections to be a grave public health threat and issued an action plan to tame the problem. The group’s recommendations included creating a national surveillance plan and speeding development of new antibiotics.
Yet not a single new class of antibiotics has been approved for medical use since 1987. Despite years of efforts to educate healthcare workers about infection control, multiple studies show that many still routinely flout even basic preventive measures, like hand-washing.
While the types of bacteria showing drug resistance have multiplied, the federal government requires hospitals to report infections for only two of them, MRSA bacteremia, or blood infection, and C. difficile. It requires limited reports on the others and relies on the states to fill in the gaps.
In 2014, the administration of President Barack Obama issued a new national action plan to combat antibiotic-resistant bacteria. Congress followed last year with a $160 million increase in the CDC’s budget to bolster research, drug development and surveillance of superbugs by the states.
But as Reuters found, surveillance carried out by the states can come up against strong institutional resistance and laws that shield the healthcare industry.
Under Virginia law, Chippenham Hospital should have reported its 2010 MRSA outbreak to the state Department of Health when the third baby in the neonatal intensive care unit tested positive for the bug, health department officials said. That was four days before newborn Josiah Cooper-Pope fell ill.
Instead, according to Virginia Health Department records and interviews with department officials, the hospital didn’t notify public health officials until nearly every baby in the unit had been infected – and then only by mail.
By that time, Josiah had been dead two weeks and another baby was in critical condition with a MRSA infection.
After persuading the hospital to temporarily close the unit and bringing the outbreak under control, Health Department investigators found that Chippenham hadn’t taken basic steps to prevent MRSA’s spread, such as training staff, scrubbing furniture and computers, and testing all infants in the nursery when the infection first surfaced.
Jennifer Stanley, a spokesperson for Hospital Corp of America, which owns Chippenham, said that since the outbreak, the hospital has put in place “aggressive infection prevention measures” and “intensive education and training.”
Virginia took no action against the hospital for the lethal outbreak.
The state can fine hospitals for violating regulations, but “this is not the approach [the Department of Health] typically follows,” said Maribeth Brewster, department spokesperson. Officials prefer “working closely” with hospitals to correct patient safety problems, she said, and a follow-up inspection at Chippenham Hospital found no regulatory violations, so no action was warranted.
In response to a Reuters public records request on the outbreak, the Health Department sent a copy of its investigation report in which the name and address of the hospital were blacked out.
The same was true for 22 more superbug outbreaks in Virginia healthcare facilities since 2007 that involved more than 130 patients, including 15 who died. State law prohibits the agency from identifying the location of outbreaks. At least 27 other states have similar laws or policies in place.
Disclosing the names of healthcare providers “would serve as a significant disincentive to the timely reporting of disease outbreaks,” said Brewster, the Virginia Health Department spokesperson.
Tarant, the doctor who signed Josiah’s death certificate, put it this way: “Things like this, if dealt with appropriately, are best if kept internally. I don’t think people want to see how the sausage is made.”
At a conference last year, hospital infection-control specialists told CDC officials that medical staff and internal review boards sometimes blocked them from reporting infections as required by state law or by the Centers for Medicare & Medicaid Services (CMS), which reduces payments to hospitals for preventable infections and high infection rates.
The specialists said medical staff sometimes were discouraged from testing patients with clear signs of infection – one of several tactics they said staff used to get around reporting rules.
Those complaints were detailed in a notice the CDC and CMS sent late last year to hospitals nationwide, warning them that offenders could be fined and cut off from federal funds for covering up infections they are legally required to disclose.
Officials said that due to database limitations, they did not know whether any facilities had been cited for underreporting infections since the notice was issued.
Acknowledging any infection caught in a hospital or other healthcare setting carries another risk: The paper trail can support a subsequent lawsuit.
Emma Breaux’s medical expenses eventually exceeded $4 million for repeated hospitalizations due to complications from her MRSA infection.
Emma Grace Breaux and her twin brother, Talon, fell ill from infections shortly after they were born 12 weeks premature at Lafayette General Medical Center in Lafayette, Louisiana, in 2005. Talon died at 15 days old after becoming infected by a virulent strain of Pseudomonas aeruginosa, a ubiquitous bacteria that easily contaminates hospital equipment.
“The day we buried him, we found out about Emma’s infection,” said Kelly Breaux, their mother.
Emma had a MRSA infection. She survived, but with permanent damage to her heart, lungs and one leg.
Three and a half years later, Emma was in Florida to have her leg repaired when she came down with swine flu. It was too much for her heart and lungs. After a six-week battle, she died at Miami Children’s Hospital just shy of her fourth birthday. Her death certificate blamed flu-related pneumonia. Including MRSA as a cause of death “was not considered,” said Dr Sharon Skaletzky, who was at Miami Children’s at the time and signed the death certificate.
Talon’s case was clear-cut; his death certificate cited septic shock due to his hospital-acquiredPseudomonas infection as the cause of death.
Emma’s was more complicated. Her medical expenses alone eventually exceeded $4 million for repeated hospitalizations due to complications from her MRSA infection. The family sold their home, truck and other possessions to stay afloat while she underwent multiple operations.
A Louisiana appeals court ultimately ruled that MRSA was responsible for her death and in 2013 upheld a jury award of more than $6 million in damages and medical expenses for the twins.
Lafayette General Medical Center spokesperson Daryl Cetnar said no one with knowledge of the case was available.
Lack of a unified national surveillance system makes it next to impossible to count the number of drug-resistant infections, fatal or otherwise. Theoretically, deaths could be counted through the nation’s vital statistics.
Those numbers, compiled by the National Center for Health Statistics (NCHS), include births, marriages, divorces and, using data culled from death certificates, information on what is killing whom. The numbers are critical in determining how money is distributed for research and public health campaigns.
As examples in this article show, superbug infections are often omitted from death certificates. But even when they are recorded, NCHS can’t feed that information into vital statistics: The World Health Organization (WHO) classification system the agency uses lacks mortality codes for most drug-resistant infections, though it has codes for more than 8,000 other possible causes of death.
“We knew that MRSA played a huge role. We had to fight for them to include it” on the death certificate.
The CDC added codes for use in the United States for terrorism-related deaths a year after the Sept. 11, 2001, attacks. It could do the same for deaths from drug-resistant infections. Officials told Reuters the CDC is instead working to incorporate the codes into the WHO’s next revision of the international classification system. The revised system is expected to be completed in 2018 but not fully in use until the 2020s.
There are other ways to count deaths, such as searching the text of death certificates as Reuters did in its analysis with help from the NCHS. CDC officials told Reuters they now are exploring “how we might be able use literal text capture to get additional information on resistant infection deaths which could be useful for annual tracking.”
As it stands, the CDC has the National Healthcare Safety Network. Under this surveillance program, about 5,000 hospitals and in-patient rehabilitation facilities file quarterly reports on several types of healthcare-related infections as a condition of receiving Medicare and Medicaid payments.
But only two superbug infections are on the reportable list, MRSA bacteremia and C. difficile.The others are reported under only limited circumstances, such as when related to a hysterectomy or a catheter-associated urinary tract infection.
The reports are typically five to seven months old by the time they are logged, and thus aren’t useful for real-time surveillance. And the CDC doesn’t require facilities to report deaths. Determining cause of death is difficult and would entail extra training for hospital staff who fill out the forms and oversight, which the agency can’t afford, according to Dr Daniel Pollock, surveillance branch chief for the CDC’s Division of Healthcare Quality Promotion.
CDC Director Frieden, noting that there is “no simple way to code for drug-resistant infections” on death certificates, said the CDC “is supporting states’ efforts to respond to antibiotic resistance and help protect Americans from this threat.”
Just 16 state health departments told Reuters that they tally deaths from reportable antibiotic-resistant infections. Eight others track deaths only when they are part of an outbreak. (Pennsylvania and Georgia declined to answer the survey questions.)
Among states that don’t track deaths is Texas, where Natalie Silva contracted MRSA in November 2012 at Hospital Corp of America’s Del Sol Medical Center in El Paso. Two days after giving birth to a healthy boy by cesarean section, her incision began gushing blood, said her sister, Crystal Silva. Back at the hospital, Natalie Silva tested positive for MRSA.
Hospital staff assured Silva it was safe to continue holding and breastfeeding her week-old son, according to Crystal Silva and her other sister, Stephanie Hall. One month later, her son was in the neonatal intensive care unit battling his own MRSA infection, they said.
He survived. For Silva, the next few months brought a cascade of medical complications, records show. Multiple infections led to multiple surgeries that left her paralyzed. Hall recalled spending a Friday night in September 2013 at her sister’s bedside, painting Silva’s fingernails metallic blue and her toenails metallic purple, optimistic that her sister would return home.
Three days later, Silva died.
Silva’s doctors wanted to blame cardiac arrest on the death certificate, Silva’s sisters said.
Del Sol Medical Center declined to comment.
Silva’s family paid $3,000 for an autopsy that confirmed that the MRSA infection contributed to her death. Her death certificate lists cardiopulmonary arrest as the immediate cause of death, due to complications from a MRSA infection.
“She was 23 years old and healthy. We knew that MRSA played a huge role,” said Crystal Silva. “We had to fight for them to include it.”
In September last year, Hall filed a medical malpractice and wrongful death lawsuit against Del Sol in El Paso County District Court, alleging that the hospital was responsible for Silva’s MRSA infection and the fatal complications that followed. The lawsuit is seeking payment to Silva’s two children for the loss of their mother, loss of her wages while she was sick, medical costs and funeral expenses.
Christine Mann, spokeswoman for the Texas health department, said counting superbug deaths would require a formal statute or rule change in the state. “We prioritize our resources and attention toward taking public health action where it is most needed,” she said.
Natalie Silva’s was among about 10,000 deaths linked to antibiotic-resistant infections in Texas from 2003 to 2014, according to the Reuters analysis. Though her sisters succeeded in getting an honest reckoning on Silva’s death certificate, her death by superbug was never counted.
As if the killer got away
By Deborah J. Nelson, Yasmeen Abutaleb and Ryan McNeillIn a more than yearlong investigation, Reuters used court records, news reports, patient advocacy organizations and Web searches to identify individuals who had died of antibiotic-resistant infections and then contacted relatives to obtain death certificates and medical records. In some cases, the death certificate did not mention the lethal infection. In many others, it did, but the death occurred in a state that doesn’t track the infections. Even in states that do track some superbug deaths, none are counted nationally, in real time, in any unified surveillance system. For relatives, the lack of full disclosure on the death certificate was particularly galling – an insult to the memory of the dead.
Here are some of their stories:
Emma Grace Breaux
Richard Armbruster, 78, of Missouri, a former minor-league pitcher in the Greater St. Louis Amateur Baseball Hall of Fame, contracted an Acinetobacter baumannii infection after hip-replacement surgery in 2009 at St. Anthony’s Medical Center in St. Louis, hospital records show. Dr David Morton, chief medical officer, told Reuters that the hospital had 26 cases of Acinetobacter from 2008 to 2011, before infection-control measures eradicated it. Armbruster died two days after testing positive for the superbug. His death certificate says he died of bile duct cancer, with no mention of infection. It was a judgment call, said Dr Richard Payne, an independent pathologist who discovered the cancer during an autopsy and filled out the death certificate. Three years after Armbruster’s death, his wife Donna, 83, broke her pelvis in a fall. While in rehab, she contracted Clostridium difficile and died. “With our mom, it was so eerily similar,” said Amy Fix. However, her mother’s death certificate cited the infection. “This is something that really consumed me,” Fix said. “I didn’t feel I got justice for my dad.”
The CDC estimates are undermined by small sample sizes, old data and information from a few geographic areas.
ATLANTA, Ga. – In 2013, the U.S. Centers for Disease Control and Prevention released estimates of how many people in the country die every year from antibiotic resistant infections: 23,000. The agency estimates that an additional 15,000 die annually fromClostridium difficile, an infection linked to long-term antibiotic use.
The estimates, the agency said at the time, provided the “first snapshot of the burden and threats posed by antibiotic-resistant germs having the most impact on human health.”
Since then, the estimates have been cited by untold numbers of media outlets and scholarly reports. A Google search for the estimates can yield nearly 100,000 hits. Reuters took a close look at how the agency arrived at its numbers and made a surprising discovery: They are based on so little hard data that they could be off by more than 30 percent – more than 10,000 people – in either direction.
The statistical uncertainty is a byproduct of the nation’s lack of a unified surveillance system. No one at the state or federal level knows how many people are dying from drug-resistant infections.
Absent hard numbers, the agency turned to studies that rely on statistical sampling, whereby a subset of the population is studied and the results are extrapolated to cover the entire country.
Statistical sampling is common. Precision depends on the size of the sample. The larger the sample, the greater the precision. Reuters found that the CDC estimates are undermined by small sample sizes, old data and information from a few geographic areas.
For example, the CDC estimate of 15,000 deaths annually from C. difficile was based on monitoring of 88 inpatient and 33 outpatient laboratories in 10 areas across the country in 2011.
The 10 areas, part of the agency’s Emerging Infections Program (EIP), represented about 3.6 percent of the nation’s population at the time. Under the EIP, a handful of states are given federal dollars to closely monitor infectious diseases, generally in a few counties. They do not include population centers like New York City, Southern California, Chicago or Boston, or any locations in Texas or Florida.
Infectious diseases can occur at substantially different rates in different areas. For example, the study on which the estimates are based, titled “Burden of Clostridium difficile Infection in the United States” and published last year in the New England Journal of Medicine, found that the incidence of hospital-acquired C. difficile was 47.3 per 100,000 people in Klamath County, Oregon, while it was 159.1 per 100,000 in New Haven, Connecticut.
Because of statistical uncertainty, the estimate of deaths from C. difficile could be anywhere from 7,600 to 20,000, Reuters found.
In many components of the CDC estimates, the agency relied on even less information. One example is the deadly carbapenem-resistant Enterobacteriaceae (CRE), which public health officials describe as a nightmare bug with high mortality.
Not a single actual CRE death went into the estimates.
Instead, for CRE and five other infections, the agency turned to a study in which researchers surveyed 183 hospitals within the EIP program. The survey identified 504 hospital-acquired infections during a single year, 2011.
Based on those 504 infections, researchers extrapolated that there were 721,800 such infections nationally. But because of the small sample size, the estimate could be anywhere from 214,700 to 1.4 million.
CDC researchers then used the study, “Multistate Point-Prevalence Survey of Health Care-Associated Infections,” published in the New England Journal of Medicine, to estimate how many of the 721,800 infections were Klebsiella species or Escherichia coli, two of the more common types of bacteria that can become resistant to the carbapenem class of antibiotics.
Then the CDC used data reported by about 2,000 hospitals to its National Hospital Safety Network during 2009-2010 to determine what percentage of the infections were drug-resistant.
The agency estimated 6.5 percent of people with those drug-resistant infections die, based on a single study of a Chicago teaching hospital in 2000 in which 34 people died. Applying that percentage, they came up with their estimate of 600 deaths annually from CRE. Reuters found that using the CDC’s methodology, it could be twice that – 1,200 – or as few as 180.
By Ryan McNeill, Deborah J. Nelson and Yasmeen Abutaleb
After more than a half century without recognized local dengue outbreaks in the continental United States, there were recent outbreaks of autochthonous dengue in the southern parts of Texas (2004-2005) and Florida (2009-2011). This dengue reemergence has provoked interest in the extent of the future threat posed by the yellow fever mosquito, Aedes (Stegomyia) aegypti (L.), the primary vector of dengue and yellow fever viruses in urban settings, to human health in the continental United States. Ae. aegypti is an intriguing example of a vector species that not only occurs in the southernmost portions of the eastern United States today but also is incriminated as the likely primary vector in historical outbreaks of yellow fever as far north as New York, Philadelphia, and Boston, from the 1690s to the 1820s. For vector species with geographic ranges limited, in part, by low temperature and cool range margins occurring in the southern part of the continental United States, as is currently the case for Ae. aegypti, it is tempting to speculate that climate warming may result in a northward range expansion (similar to that seen for Ixodes tick vectors of Lyme borreliosis spirochetes in Scandinavia and southern Canada in recent decades). Although there is no doubt that climate conditions directly impact many aspects of the life history of Ae. aegypti, this mosquito also is closely linked to the human environment and directly influenced by the availability of water-holding containers for oviposition and larval development. Competition with other container-inhabiting mosquito species, particularly Aedes (Stegomyia) albopictus (Skuse), also may impact the presence and local abundance of Ae. aegypti. Field-based studies that focus solely on the impact of weather or climate factors on the presence and abundance of Ae. aegypti, including assessments of the potential impact of climate warming on the mosquito’s future range and abundance, do not consider the potential confounding effects of socioeconomic factors or biological competitors for establishment and proliferation of Ae. aegypti. The results of such studies therefore should not be assumed to apply in areas with different socioeconomic conditions or composition of container-inhabiting mosquito species. For example, results from field-based studies at the high altitude cool margins for Ae. aegypti in Mexico’s central highlands or the Andes in South America cannot be assumed to be directly applicable to geographic areas in the United States with comparable climate conditions. Unfortunately, we have a very poor understanding of how climatic drivers interact with the human landscape and biological competitors to impact establishment and proliferation of Ae. aegypti at the cool margin of its range in the continental United States. A first step toward assessing the future threat this mosquito poses to human health in the continental United States is to design and conduct studies across strategic climatic and socioeconomic gradients in the United States (including the U.S.-Mexico border area) to determine the permissiveness of the coupled natural and human environment for Ae. aegypti at the present time. This approach will require experimental studies and field surveys that focus specifically on climate conditions relevant to the continental United States. These studies also must include assessments of how the human landscape, particularly the impact of availability of larval developmental sites and the permissiveness of homes for mosquito intrusion, and the presence of other container-inhabiting mosquitoes that may compete with Ae. aegypti for larval habitat affects the ability of Ae. aegypti to establish and proliferate. Until we are armed with such knowledge, it is not possible to meaningfully assess the potential for climate warming to impact the proliferation potential for Ae. aegypti in the United States outside of the geographic areas where the mosquito already is firmly established, and even less so for dengue virus transmission and dengue disease in humans.