Dáil Éireann Debate, Wednesday - 7 April 2004
4 Caoimhghín Ó Caoláin asked the Minister for Health and Children if the number of patients in hospitals here infected with MRSA has been recorded; if he will provide the figures; the way in which this compares with the rates of MRSA infection in other States; the strategies in place to deal with this so-called hospital superbug which is causing much concern for the hospital system; and if he will make a statement on the matter. [11057/04]
Amharc ar fhreagraThis is a lengthy reply. There are a number of tongue twisters in this reply and I ask the Deputy to bear with me. The National Disease Surveillance Centre collects data from hospitals on methicillin resistant staphylococcus aureus, MRSA, bacteraemia, otherwise known as bloodstream infection or blood poisoning, as part of the European antimicrobial resistance surveillance system, EARSS. This is a voluntary system and, as such, not all hospitals participate. Nevertheless, the participating hospitals in Ireland represent at least 95% of the population, the highest level of participation of any country involved in EARSS.
The EARSS data for Ireland approximates the true total number of cases of MRSA bacteraemia in Ireland. In 2003, 477 cases of MRSA bacteraemia were reported in Ireland. MRSA is a resistant form of a common bacteria known as staphylococcus aureus. The proportion of staphylococcus aureus bacteraemia caused by MRSA in Ireland in 2002 was 42.7%, while the proportion for the last quarter of 2003 was41.7%. While there does not appear to have been a significant increase in the overall proportion of infections caused by MRSA in recent years, the proportion is one of the highest among European countries participating in the EARSS.
The level of antibiotic resistance in Ireland in terms of MRSA is one of the highest in Europe, second only to the United Kingdom and Malta. Two of the reasons for this, and the responses to date, are as follows. One of the common strains of MRSA in Ireland is highly contagious and it is particularly difficult to control its spread. This strain is also observed in the United Kingdom and partially explains the reason both the UK and Ireland have such high MRSA rates. The national MRSA reference laboratory at St. James's Hospital can now identify individual strains of MRSA and reports this back to each hospital. Having this information helps each hospital to identify whether it has a problem with a particular strain of MRSA and to decide on appropriate control measures.
The overuse of antibiotics in hospitals is the second key issue. The hospital antibiotic sub-committee formed as a result of the strategy for the control of antimicrobial resistance in Ireland, SARI, has completed draft guidelines for hospitals on promoting prudent use of antibiotics. Many of the regional SARI committees have also appointed clinical pharmacists to individual hospitals to improve antibiotic prescribing habits. A pilot project on promoting more rational use of antibiotics has been funded by my Department, through the SARI national committee and recently commenced in the Midland Health Board region.
Additional Information not given on the floor of the House
In 1999, my Department asked the National Disease Surveillance Centre to evaluate the problem of antimicrobial resistance in Ireland and formulate a strategy for the future. The NDSC gave detailed consideration to these issues and drew up the strategy for the control of antimicrobial resistance in Ireland, which I launched on 19 June 2001. This report contains a wide range of detailed recommendations to address the issue of antimicrobial resistance, including a strategy to control the inappropriate use of antibiotics.
The SARI recommendations can be grouped into five main categories: surveillance of antimicrobial resistance; monitoring of the supply and use of antimicrobials; development of guidance on the appropriate use of antimicrobials; education of health care workers, patients and the general public; and development of principles regarding infection control in the hospital and community setting.
The strategy for the control of antimicrobial resistance in Ireland recommended that a national SARI committee be established to develop guidelines, protocols and strategies on antimicrobial resistance. This committee was established in late 2002 and as part of its remit provides advice to the regional SARI committees in each health board area, established as a result of the strategy's recommendations. The national SARI committee is comprised of a wide range of experts in the field.
Tackling the problem of antimicrobial resistance is a multifaceted issue which will require action on a number of fronts. Implementation of the strategy is taking place on a phased basis and will take a number of years to complete. To date, approximately €12 million has been allocated by my Department to health boards to enable them to implement measures to control antimicrobial resistance. It is ultimately a matter for each health board chief executive officer to determine the priorities in each region. These priorities should take account of the recommendations in the SARI report and the relevant regional SARI committee.
Much of the funding is designated for improving hospital infrastructure for control of infection and appointing additional microbiologists, infection control nurses and other health care professionals involved in the control of infection. There is still some progress to be made to meet the numbers of such professionals required, as outlined in the SARI report, but significant progress in making additional appointments has been made in the past two years.
At national level, MRSA bacteraemia is now included in the revised list of notifiable diseases, which means hospitals are legally required to report cases of serious MRSA infection to the departments of public health in the regional health boards and to the NDSC.
The SARI infection control sub-committee recently completed a consultation process on national guidelines for hand hygiene in health care settings. Hand hygiene is a key component in the control of MRSA and the final guidelines will be available in the next two to three months. The sub-committee is also updating national guidelines on the control of MRSA, which it is hoped will be available later this year. Each of the health boards has a regional SARI committee, which has been developing regional interventions to control hospital infection, including MRSA.
Methicillin resistant staphylococcus aureus or MRSA, a term both of us will find easier to accommodate, is the most significant antibiotic resistant bacteria found in our hospitals. This was acknowledged by the Minister and in the 1999 North-South study. Does the Minister accept that antimicrobial resistance is a serious and growing problem in many of our hospitals?
I noted the Minister highlighted that statistics are not available in every case. Is he aware that the death rate from MRSA in Britain increased from 13 in 1993 to 114 in 1998 and that it has also been acknowledged that MRSA was a factor in the deaths of many thousands of other patients? These are alarming statistics.
The Minister will recall stating in June 2001 and today that we have a high rate of MRSA infection by northern European standards. How is this rate being measured? Are deaths from MRSA being recorded as such? Can we compare current and past rates of infection? How accurate is the statistics gathering exercise on MRSA now and how accurate was it in the past? The answers to these questions will give us a clearer picture.
As the Minister will be aware, in January 2000 the intensive care unit at Belfast City Hospital was forced to close because of MRSA infection. MRSA and other hospital based infections are causing increased worry to patients, their families and the wider community and having a significant impact on health care delivery. Have all the recommendations of the 1999 North-South study on MRSA been implemented and, if not, why not?
I accept that this is a very serious issue. In June 2001, we launched the strategy for the control of antimicrobial resistance, the SARI document formulated by the National Disease Surveillance Centre, which records the incidence of MRSA. The NDSC publishes figures on its website, although these need to be updated. A national SARI committee, established to develop guidelines, protocols and strategies on antimicrobial resistance, resulted in the establishment of a regional committee in each health board area consisting of experts from a broad range of fields.
My Department has allocated €12 million to date to assist health boards in implementing measures to control antimicrobial resistance. Additional microbiologists, infection control nurses and other health care professionals involved in the control of infection have been appointed. MRSA has also been included in the revised list of notifiable diseases, which means hospitals are legally required to report cases of MRSA infection to the departments of public health in the regional health boards and the National Disease Surveillance Centre.
While hospitals must report the incidence of MRSA, this does not necessarily apply to deaths given that there may be multiple reasons involved in the death of a person. The Deputy is correct, however, that MRSA could be a factor in complicating an already serious condition, particularly for elderly patients who may suffer from a number of health problems. In such circumstances, contracting MRSA makes recovery difficult.
The SARI infection control sub-committee recently completed a consultation process on national guidelines for hand hygiene in health care settings. Hand hygiene is a key component in the control of MRSA and final updated national guidelines on the control of MRSA will be available in the next two months.
I do not understate the importance of antimicrobial resistance. The chief medical officer of the Department is leading the charge on the issue which is being taken seriously. All hospitals are aware of the problem and have protocols in place to try to reduce, minimise and contain outbreaks which may occur.
One of the recommendations of the North-South study of 1999 was that each hospital have a written antibiotic policy with appropriate audit of implementation. Has this essential recommendation been implemented? Is surveillance of MRSA ongoing North and South?
The Minister indicated that not all hospitals are attentive to this area. This is a matter of grave concern and a deficit that needs address. Will he ensure, if he is not already doing so, that the matter is pressed on all hospital managers and administrators?
What has been done to research and redress the significant regional variations in MRSA incidence identified in the 1999 study? Such research could shed light on administrative and managerial policies. Are the real statistics on MRSA emerging? As I stated, and the Minister agreed with my point, MRSA, as a contributory factor to death, is being understated. The reality is that its impact is much greater than indicated by the statistics.
Many people being subjected to catheter and other invasive procedures are very anxious. I am not overstating this matter as I have spoken to people who have major concerns about family members facing such an operation.
To be fair to all concerned, the national SARI committee has communicated with all hospitals. As I indicated, Ireland has the highest participation rate of any country involved in the European antimicrobial resistance surveillance system, with participating hospitals covering 95% of our population. I accept, however, that we must ensure that all hospitals are involved. I cannot state definitively that all hospitals are participating in the system but I will pursue the matter and revert to the Deputy with details.
