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State slow to fight deadly 'bug'

Sunday, December 18, 2005

By Harlan Spector

Plain Dealer Reporters

Ohio health officials have failed to act on a statewide investigation

into a deadly intestinal bacteria in hospitals, despite urging from

government health experts and growing evidence of outbreaks.

Since as early as May, reports of increasing infection rates at

hospitals and nursing homes from a virulent strain of Clostridium

difficile, or C. diff, have poured in to the Ohio Department of

Health, according to e-mails obtained through a public-records request.

The e-mails and interviews reveal a department reluctant to take on an

investigation that federal health officials tried to launch as early

as last spring. They also reveal that ODH has been reluctant to

publicly acknowledge evidence of outbreaks or possible outbreaks.

Investigating infections would help stem the spread of C. diff by

arming authorities with information on infection patterns and the

prevalence of the superstrain, which has triggered outbreaks in most

hospitals where it has been found. The study proposed in Ohio did not

get past the design stage.

Hospital outbreaks have occurred over the past year in the Cleveland

area and elsewhere in Ohio, records and interviews show.

No hospitals have reported outbreaks to Cuyahoga County or state

public health agencies, as the law requires. As late as November, as

evidence of a growing threat mounted, the state's top infectious

disease official said she had no knowledge of outbreaks.

In at least one case, the state agency was told in May of an outbreak

at Licking Memorial Hospital in Newark. The Newark health commissioner

said ODH has yet to answer a June request for an investigation,

following confirmation that the superstrain had infiltrated the Newark

hospital and three area nursing homes.

C. diff is a common cause of diarrhea in hospitals and nursing homes.

But the superstrain, called the " epidemic strain, " is far more

serious. It is blamed for thousands of deaths in Canada and Britain

and has been verified at three Cleveland hospitals and elsewhere in Ohio.

Increasingly, the infections cause recurrent bouts of diarrhea and

colitis and require surgeries to remove colons destroyed by potent

bacterial toxins. In some cases, the infections spread to the

bloodstream, leading to organ failure and death.

The Plain Dealer has confirmed 21 deaths related to C. diff in the

Cleveland area, most in 2005. The number is based on coroner records,

which capture only some C. diff deaths, and other cases brought to the

newspaper's attention and confirmed through death certificates.

Doctors said that despite a hospital's best efforts, C. diff is

difficult to control because the bug can be picked up anywhere and

live in the colon for a long time. It usually doesn't become

infectious until a patient takes antibiotics, which wipe out natural

bacterial defenses.

The prevalence of C. diff is not known because hospitals are not

required to report infections acquired by patients, as they are with

many other infectious diseases.

Getting a grip on the C. diff threat took on new urgency this month

when the Centers for Disease Control and Prevention reported fresh

evidence that the infections are striking healthy people outside

health-care settings and women just before or just after giving birth.

The bug has been known to infect, almost exclusively, patients who are

taking antibiotics in hospitals and nursing homes. The CDC report was

based on cases from four states, including Ohio. ODH learned about

those cases in May, the same time it learned about the outbreak in Newark.

Around the same time, federal health officers employed by an arm of

the CDC who are assigned to Ohio were pushing for a statewide

initiative that would involve a study of hospital cases. Officials

reviewed case reporting forms for hospitals and discussed lab work costs.

Barbara Bradley, chief of infectious diseases at ODH, said the

investigation didn't happen because the CDC backed off its plans to do

research and one of the federal health officers got busy with other

matters. The ODH instead is concentrating on an initiative started by

Cleveland hospitals and local health officials to track C. diff cases

locally, which Bradley called a pilot project.

" It's not a reportable disease and we're pretty swamped with

reportable diseases in Ohio, day to day, " she said.

Dr. Clifford Mc, an authority on C. diff at the CDC who has

consulted extensively with ODH, said he believed Ohio was still

weighing whether to test bacterial cultures from select hospitals to

further study the superstrain.

Ohio public health officials, who hold news conferences during

community disease threats such as Legionnaire's and bacterial

meningitis, generally have little visibility on the subject of

infectious diseases on hospital grounds.

But in Cuyahoga County, Health Commissioner Terry Allan began framing

C. diff as a community problem last summer, after hearing reports that

patients moving between hospitals and nursing homes were spreading the

infections.

Hospitals in Cleveland say they have taken aggressive steps to control

C. diff. But infectious-disease doctors are reluctant to divulge

infection rates. They said there is no standard way to measure

hospital-acquired infections and that changes in testing practices and

antibiotic use affect rates.

The Cleveland Clinic, University Hospitals of Cleveland and

MetroHealth Medical Center nevertheless began collaborating with local

health officials to set up a voluntary reporting system for C. diff

cases to begin in January. The participation of smaller hospitals

remains unclear.

It also remains to be seen whether the reporting system will yield

useful information to the public about C. diff rates at hospitals they

visit. In several C. diff cases, patients and families said in

interviews they had never heard of the bug before encountering it in

hospitals and nursing homes.

" We were just so blindsided, " said Arthurs of Brunswick. Her

husband, , died in July after a C. diff infection destroyed his

colon and spilled into his bloodstream. Arthurs, 68, had been

hospitalized for heart surgery.

Ohio health officials have been slow to acknowledge the sense of

growing worry indicated in correspondence from colleagues and Ohio

communities.

Bradley said in a November interview that she had no reason to suspect

outbreaks have occurred in Ohio. No hospitals have reported outbreaks

to the Ohio's disease reporting system, she said.

Records show that a week earlier, Bradley acknowledged a problem in

Cleveland-area hospitals. " The fact that they suspect a `problem' (in

Cleveland) indicates that this may be an outbreak, " she said in a Nov.

14 e-mail to an ODH colleague.

Around that time, Bradley had warned Cuyahoga Health Commissioner

Allan that the plan to track cases would cause infection reports to

become a public record. She didn't think C. diff should be reportable

like dozens of other infectious diseases, she said in an e-mail.

Hospitals are required to alert authorities only to outbreaks or

unusual incidences of infections. Reporting outbreaks allows health

officials to mobilize expertise and prepare for a communitywide problem.

An outbreak boils down to an abnormal spike in infection rates.

C. diff outbreaks have been measured in Britain and Quebec, Canada.

The CDC examined millions of hospital discharge records to determine

that C. diff rates doubled between 2000 and 2003, according to

Mc. The epidemic strain has been verified in 16 states, more

than double the number a year ago, the CDC found.

Tracking cases early is a key lesson from a devastating C. diff

outbreak in Quebec, said Dr. Jacques Pepin of the University of

Sherbrooke. Public health officials were slow to act in Quebec, where

Pepin estimated in a study that C. diff had killed 2,000 people from

2003 to 2004.

" If you want to respond to an epidemic, the first step is to know

what's going on, where the problems are, " Pepin said. " That allows the

authority to track down the epidemic, and it also allows hospitals to

compare themselves. "

Several hospitals have notified ODH about increases in C. diff cases,

and numerous local health officials sought ODH's guidance on how to

address it, e-mails show.

In July, after a federal health officer requested data on Ohio nursing

home C. diff cases, the department reported that cases had jumped from

2,072 in 2002 to 3,550 in 2004.

A Wayne County health official notified Bradley in August about a C.

diff problem at a nursing home, noting that a doctor said " the problem

was pretty bad and spreading to other health facilities. "

In an interview Tuesday, Bradley said she was not aware of increases

in C. diff cases in Ohio hospitals, only that infections had become

more severe.

On the question of reporting outbreaks, hospital and health officials

seem to be stuck in a semantics trap.

The ODH hasn't defined " outbreak, " so hospitals can't report it, said

Bill , chief of the Center for Health Affairs, the Cleveland-area

hospital association and a former state health director. Bradley said

the dilemma is that hospitals don't have a benchmark for normal rates

of C. diff.

With little information to go on, patients have been alarmed by signs

of serious problems they encountered in hospitals.

Therese Pohorence of Cleveland said that when her 89-year-old

mother-in-law was admitted to Lakewood Hospital in June, she asked a

nurse why doors to several patient rooms had tags indicating the

patients were infectious.

" She said the tags were for C. diff, " Pohorence said. " She said it's a

problem. It's all over the hospital. "

Lakewood Hospital officials declined to comment about the incidence of

cases, and said the door tags are not unusual and may have been for

conditions other than C. diff. " Lakewood Hospital is aggressive at

assigning contact precautions to patients suspected of having, or

documented as having, Clostridium difficile disease, " the hospital's

director of infection surveillance said through a spokesman.

Lynn Krall of North Royalton had a similar experience when her father

was readmitted in November to Southwest General Health Center in

Middleburg Heights with a C. diff infection. She said a nurse told her

that 52 patients in the 340-bed hospital had the bug.

Hospital spokeswoman Van Dalen said the number is " highly

inaccurate " but declined to give a number. " We haven't had a

statistically significant increase, " she said.

Dr. Dale Gerding, a Loyola University epidemiologist who has studied

C. diff for 25 years, said he can't explain why the superstrain has

jumped to so many hospitals at the same time. But he offered this

advice to hospital patients:

" When your doctor says it's time to go home, you should jump out of

bed and run out the door. "

To reach this Plain Dealer reporter: hspector@...,