INVESTIGATION: UNHEALTHY
HOSPITALS
Virus attacked Chicago children in outbreak
kept under wraps
By Michael J. Berens
Tribune staff reporter
Published July 21, 2002
The germ raced through the Misericordia Home for
handicapped children in Chicago, masquerading as a cold-weather flu as
it moved from bed to bed.
Each child already was ill; most had been born with severe physical and
mental impairments. The rare strain of adenovirus pounced on their
weakened immune systems, enveloping victims with blistering fevers while
attacking the brain, lungs or heart.
Over several weeks starting in October 1998, 31
children contracted flulike infections and eight died as the microscopic
invader snaked through the 93-bed long-term care center, which is
operated by the Sisters of Mercy with the support of the Catholic
Church.
The outbreak on the Southwest Side was one of several nationally linked
to the rare virus. But these incidents went largely unreported in the
media, and in Chicago the Department of Public Health still is not
releasing public records on the outbreak--an example of how health-care
facilities and public agencies are able to keep damaging information
about infections under wraps.
Though the virus' origins remain a mystery, federal and city health-care
investigators believe they know how it was spread: The germ hitched
rides on health-care workers.
Doctors and nurses at Misericordia and Rush-Presbyterian-St. Luke's
Medical Center--one of the hospitals that later treated the
children--also were infected by the germ, but they continued to work
among the children. The lapse meant that every cough, sniffle and touch
could result in death to another child, health-care investigators
concluded.
The Chicago deaths highlight what many epidemiologists warn are
escalating rates of infections inside the nation's secondary tier of
health care--specialized long-term care centers like Misericordia,
nursing homes and outpatient clinics.
Though the federal surveillance of germ outbreaks is centered almost
exclusively on hospitals, unsanitary conditions inside the nation's
growing network of specialized facilities remain largely undocumented.
"There are a lot of infections that occur outside hospitals that we know
nothing about," said Dr. Donald Graham, a former infection-control
investigator for the federal Centers for Disease Control and Prevention
and professor at Southern Illinois University School of Medicine.
"If we don't count our infections, we won't know about them and we won't
be able to intervene."
The Chicago outbreak also reveals how the Chicago Department of Public
Health undermined its trust as public guardian to protect the private
interests of health-care facilities.
City officials decided not to alert the public about the lethal
outbreak. Even though health department officials acknowledge
investigating it, they say they can't locate a single record.
"I know how embarrassing this looks for us," health department spokesman
Tim Hadac said.
Sources connected to the investigation, however, provided the Tribune
with city files on the Misericordia outbreak.
City health commissioner John Wilhelm defended the secrecy. The city has
a fragile, voluntary relationship with health-care facilities, and if
the city warned the public about every outbreak, health-care facilities
might stop sharing information, he said.
During a recent tour of Misericordia, officials said that visitors are
now asked to wash their hands or stay home if they have symptoms of any
illness, such as the flu.
Though it is a medical facility, the home is run differently in many
ways from a hospital. Children are bused to special-education classes,
for instance, and visitors are welcomed at all hours, presenting
opportunities for children to be exposed to germs.
"We give these children a quality of life. This is not a lockdown
facility. The parents know that infection is an everyday risk, but an
acceptable one," said Betty Flynn, a registered nurse and home
administrator at Misericordia.
The deadliest strain
At the time of the outbreak, Misericordia and hospital officials were
unaware that they were dealing with the most deadly strain of
adenovirus.
Drawing upon a biological archive of germ samples collected worldwide,
CDC scientists determined that the Chicago outbreak involved a strain
known as Ad7d2.
As a result, the CDC launched a national hunt for the Ad7d2 germ, first
documented by medical investigators in Beijing in 1981.
As word spread in the medical community about the deadly germ, a New
Orleans doctor filed a report detailing a previously undisclosed June
1996 outbreak in a Houma, La., pediatric facility for long-term care
that killed seven children and infected six others, according to CDC
records.
In October 1999, seven patients were killed and 26 others infected by
adenovirus that swept through a New York City chronic-care facility for
the mentally ill, those records show.
A year later, four children died and 16 other patients were infected
after the germ invaded a pediatric long-term care facility in Des
Moines.
Iowa public health epidemiologist Dr. Patricia Quinlisk said
investigators could not determine how the adenovirus entered the
pediatric center but said that germs were cultured from the hands of a
health-care worker and that several staff members also became ill from
the virus. The germ, investigators theorize, may have gained a foothold
in the pediatric center after infecting a child who left the facility
for special-education classes.
In all three cases, the CDC records do not name the facilities, only the
cities where they are located.
CDC investigators now believe the Ad7d2 germ is more rooted in the
United States than previously known.
The first Chicago children stricken four years ago at Misericordia had
not been bused to outside classes, leading investigators to believe that
a visitor, a health-care worker or another child carried the germ into
the facility.
From Misericordia, many of the fever-ridden children were sent for
treatment to Rush-Presbyterian-St. Luke's Medical Center. A registered
nurse assigned to track germs in the intensive care unit was the first
to suspect a pattern.
Based on the nurse's report and laboratory findings, Dr. John Segreti,
chief of the infectious disease department at Rush, said he immediately
recognized that the hospital, and potentially the city, was dealing with
a deadly germ.
Three days after the children were admitted to the hospital, laboratory
tests confirmed the presence of adenovirus. During this time, the germ
spread inside Rush, infecting a 5-month-old boy who later recovered,
Segreti said.
Infected children were isolated and health-care workers were ordered to
adhere to strict infection-control procedures.
"We think it was spread on the hands of a health-care worker," Segreti
said.
No vaccine available
There are more than 50 strains of adenovirus, but there was no way to
eradicate the germ. The nation's sole vaccine was discontinued in 1996
by pharmaceutical giant Wyeth-Ayerst. At the time, company officials
said demand was too low for the $1-a-pill medicine.
Healthy people typically fend off the virus, which might cause fever or
other flulike symptoms. But critically ill patients, particularly
children whose immune systems are paper thin, can face life-or-death
struggles.
Segreti said he immediately notified the city health department, which
later requested CDC investigators.
Segreti and other health-care officials believe the hospital's quick
discovery of the germ may have prevented a wider, more devastating
outbreak.
But Rush administrators say they also learned an important lesson about
problems inside their own hospital.
Through staff surveys and laboratory tests, Segreti discovered that 36
Rush-Presbyterian health-care workers were confirmed or suspected
carriers of the infection, probably picking up germs from the
Misericordia children.
At least 30 doctors, nurses and technicians had fevers and other
symptoms but continued to work among young patients throughout the
hospital, Segreti said.
At least 26 employees failed to follow strict infection-control
procedures, such as wearing gloves or washing hands.
"It's not uncommon for people in health care to think they are not part
of the problem," Segreti said.
Infected workers were sent home for up to two weeks. The staff was
retrained on the importance of infection control.
At Misericordia, once the outbreak was apparent, ill children were moved
together in the same rooms to limit exposure to healthy children, and
family visits were temporarily restricted.
"We were certainly battening down the hatches," said Deb Ryan, director
of nursing at Misericordia.
Although nobody located the source of the germ, Misericordia employees
received training on hand-washing procedures and wearing gloves and
masks.
Like the nurses at Rush, at least one Misericordia employee contracted
adenovirus, and some employees may have continued to work while ill,
Ryan said. Since the outbreak, the staff of 180 has been told to stay
home if suffering any symptom of illness, but the message is tough to
enforce.
"As nurses, we've always been taught to drag yourself to work," Ryan
said. "It's been the culture for 30 years. If we don't show up to work,
who will take care of the children?"
Copyright © 2002,
Chicago Tribune
