The inquest into last year's deaths
from a Clostridium difficile outbreak at the
Honor�-Mercier Hospital in Saint-Hyacinthe, Qu�bec,
has been underway for a month, but little testimony
has emerged to reassure victims' families that everything
was done to safeguard their loved ones.
The hospital's new director, Mario
Lariviere, provided the most electrifying testimony
of all, when, within days of the inquest's opening he
revealed that the hospital was battling a new outbreak.
No deaths have occurred this time, but the outbreak
in five patients was enough to activate the hospital's
"crisis cell," which now oversees emergency measures,
he said.
"LOST
CONTROL"
The hospital's former director Denis Blanchard blamed
subordinates and contractors for failing to implement
hygiene standards during last year's outbreak. While
the sixteen deaths at the hospital occurred between
May and November, Mr Blanchard told the coroner Catherine
Rudel-Tessier that he only learned of the problem in
October. He acknowledged he "took it for granted" that
the correct disinfection procedures had been enacted.
Reports from microbiologist Dr
Anne Vibien, head of the hospital's infection prevention
committee, flagging the infection and recommending procedures
to counter it, went unread, it was revealed.
Those same reports reached the
Monteregie public health department in September, but
they only intervened a month later. The department's
head, Dr Jocelyne Sauv�, explained to the inquest: "We
couldn't reach anyone at the hospital until October
20." By then, she said, the hospital had "lost control"
and the outbreak had become a serious public menace.
Dr Vibien attributed the failures
in cleaning to staff shortages. The hospital hired 10
new housekeeping staff in December. It is now running
$1 million over budget for this year, which is against
Quebec law. The hospital's new director says $800,000
of that extra spending is directly attributable to C diff infection control.
Despite the alarming facts of the
St-Hyacinthe outbreak, infection control experts in
Quebec believe the superbug is temporarily in retreat.
Such an outbreak would have been business as usual in
most Quebec hospitals three years ago. But new cases
have fallen about 40% in Quebec since the peak of 2002-2005,
when an estimated 2,000 people succumbed to C diff infection
in the province.
ONTARIO'S
PROBLEM
In Ontario, however, the trend appears to be moving
in the other direction. A number of new outbreaks have
been reported this year, though they received less attention
than St-Hyacinthe.
Mississauga's Trillium Health Centre
reported 17 cases at the beginning of March. Four patients
who died at Trillium in the past two months have tested
positive for the bug, including one who carried the
feared NAP1 strain, responsible for almost all C diff
fatalities.
The Hotel-Dieu Grace Hospital in
Windsor announced two deaths from C diff in February,
while the Royal Victoria Hospital in Barrie reported
28 infections in January and 15 additional cases in
February, considerably more than usual. The Scarborough
Hospital also reported "a number" of cases, though officials
said these were sporadic cases, within the rate deemed
acceptable at this time of year.
It's almost impossible to get a
clear picture of the distribution of C diff infection
in Canada, according to Denise Gravel, manager of the
Nosocomial and Occupational Infections section of the
Public Health Agency of Canada (PHAC), because only
Quebec and Manitoba have compulsory reporting systems.
Manitoba, along with PEI and New Brunswick, has thus
far been spared C diff infection.
But Quebec's reputation as the
most stricken province appears deserved from the data
we do have. The province has both the highest incidence
and the worst mortality. Quebec sees about 13 cases
per 1,000 admissions. This compares to seven per 1,000
in Ontario, six per 1,000 in the Atlantic provinces,
and three per 1,000 in Western Canada, according to
PHAC figures.
Quebec also has a case-fatality
rate of nearly 8%, which is about three times worse
than in Ontario, four times worse than in the West,
and six times worse than in the Atlantic.
DEADLY
STRAIN
Quebec's scary death rate is largely due to the exceptionally
high proportion of cases that involve the deadly NAP1
strain, first isolated and identified in Quebec. Dr
Gravel says that patients with the NAP are "more than
twice as likely to suffer a serious adverse outcome,"
such as death, colectomy, or ICU admission, than those
infected with lesser strains.
Dr Jacques P�pin, a University
of Sherbrooke epidemiologist who was among the first
to notice the scale of Quebec's C diff problem, has
tested infected patients in his region who first acquired
C diff outside a hospital, and found that a third of
them carried the NAP1 strain. With its fecal transmission
route, and spores that can persist for days on a dirty
surface, he believes it's inevitable that such a widespread
infection should put down roots outside the hospital
environment.
Given the prevalence of NAP1 in
Quebec, infection control specialists are not sure why
the rate of serious infection has fallen since 2005.
McGill infectious diseases expert Dr Vivian Loo led
the research team that first hypothesized, in a seminal
New England Journal of Medicine article, that
Quebec's extraordinary C diff death rate was
the work of a virulent new strain. She says population
immunity can't be ruled out as a cause of the 40% province-wide
decline in infections. "But it's impossible to say,
as we have no system to measure it. What certainly has
made a difference is the $20 million injection the Quebec
government gave to hospitals for infection control.
At our hospital (the Montreal General) we spent it on
dedicated equipment, which we badly needed, and housekeeping.
There's also the decline in antibiotic use."
But the bug is far from beaten.
It has become much more deadly in recent years, says
Dr Gravel. "As far as we can tell from the data available,
incidence has remained steady since our last study in
1997, but deaths have risen fourfold, from 1.5% to 5.8%.
That is mainly due to the spread of the NAP1 strain."
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