Records indicated that three of the mothers who came in for childbirth already had fever. Another suffered from upper-respiratory-tract infection on her eighth month of pregnancy; and still another with urinary-tract infection at three weeks of gestation. One mother had history of a sexually transmitted disease. Others were taking medications, presumably for minor illnesses, at the time they came into the delivery room. There was also a 40-year-old first-time mother and two who admitted to having irregular prenatal checkups. As expected, most of these mothers had their prenatal checkups in other health facilities, only coming to the RMC for childbirth.

    Out of the 15 neonatal sepsis cases born on October 4, 11 were from mothers with notable risk factors. The earlier argument or excuse of medical personnel that infection control had been difficult at the time due to the intermittent electric power and water supply after typhoon Milenyo was dismissed as irrelevant to the incident.

Whodunnit?

    Dr. Eric Tayag, National Epidemiology Center director, told MEDICAL OBSERVER that the initial results of the investigation, based on patient records, seemed to indicate that the sepsis infections that caused the death of these newborns were already present at the time of admission to the hospital. This is primarily due to the known natural history of the disease and its incubation period vis-à-vis the circumstances of the sepsis infections among the newborns on October 4.

    All the babies who succumbed to the infection exhibited symptoms very early (within 90 hours) after their birth. Symptoms to watch out for are fever, breathing difficulty, poor feeding, diarrhea, jaundice, and seizure. Medical literature invariably defines such cases as early-onset neonatal sepsis, which are better described as "mother-acquired."

    As the DOH investigation was evaluating the charges of negligence against the hospital personnel, it was still necessary to rule out hospital-acquired infection. Scientifically, late-onset sepsis should show the first symptoms at seven to 30 days after exposure. None of the fatalities lived beyond their third day, indicating that it was impossible for them to have acquired the infection from the hospital environment.

    Nevertheless, the investigation team still tried to establish a link between the hospital and the fatal infection. "All newborn infections are considered hospital-acquired unless proved otherwise," Tayag said. Microbiological studies were done on samples taken from the infected babies and the hospital environment. Comparison of the pathogens identified showed that there was no link because they were entirely different organisms.

    Baffling as the facts were, the epidemiology team still went on to test a final theory. "Is it still possible for an early-onset case of sepsis to be hospital-acquired?" To the best of their knowledge, it is impossible; yet the team chose to keep an open mind.

    "To check this out, we reviewed all existing literature to see if there might be one article citing an early-onset case that was hospital acquired," Tayag recounted. The search proved futile. There was, indeed, never a case of a hospital-acquired infection of sepsis resulting in an early-onset of the disease.

Witch hunt

    When the DOH announced the findings of the investigators, the negative response and uproar was thunderous. The aggrieved mothers and health activists that gravitate toward any apparent controversy screamed "whitewash!" The objectors argued that it was improper and untrue for the DOH to conclude that the source of the sepsis infection was the mothers themselves, as it seemed that the hospital personnel were pinning the blame on the mothers.

    "I can understand why they would feel that way," Tayag said. The babies were born on the same day in the same hospital that has been criticized in the past for being dirty; therefore one may be quick to conclude that the hospital was at fault. Tayag empathized with how it must feel to lose a child after only two or three days. He stressed, however, that the findings of the investigation did not lift the blame off the doctors, nor did it slap the blame on the mothers. It just showed that the bacterial infection had been present in the mothers before they arrived at the RMC to give birth.

    "There will be no sacred cows in this investigation; and the DOH is not about to spare the rod with anyone who will be proved to have neglected his duties in ensuring that no pregnant woman or her baby will be put at risk during delivery," Duque announced amid allegations that the investigating body sought to cover up the indiscretions of the hospital personnel.

    Push came to shove, however, when the aggrieved mothers and their allies in the health-activism circles shifted their ire toward Duque himself. Duque, Tayag, and the DOH personnel that made up the panel were hit with graft charges on the ground that the DOH was extending them undue favor and preferential treatment.

    But are they really off the hook? Not quite yet. Tayag pointed out that although the scientific evidence proved that the fatal infection was not contracted from the hospital environment, it does not mean that the hospital need not have acted to avert the fatalities.

    The intervention necessary to address hospital-acquired, late-onset neonatal sepsis revolves around preventing exposure to the pathogen by maintaining a clean and sterile environment. The mother-acquired early-onset sepsis should be addressed by administering appropriate medicines at the correct time.

    Therefore, the doctors did their jobs as doctors, but failed to do their jobs as public-health workers. Tayag argued that if the hospital personnel had been more vigilant in monitoring the rise in sepsis infections seen among childbirths at their delivery room, they would have been properly alerted so the necessary intervention could have been carried out.

Great divide

    The failure to act promptly on the impending outbreak is another example of the problem created by the "great divide" between public health and hospital care, according to Tayag. He lamented the long-standing fact that hospitals and private physicians in general tend to address the concerns of a patient as an individual case, often failing to regard the patient as part of a larger whole.

    Epidemiologists and public-health workers, on their part, tend to maintain a curiosity and concern over what diseases may be rampant every time they attend to a patient. For example, if a small hospital notes that it has had five deaths from neonatal sepsis in one year, it may seem like no cause for concern. But if that small hospital is one of 240 such hospitals in the country, that means there may be 1,200 babies dying every year from neonatal sepsis. Such a figure is definitely a cause for alarm.

    At the same time, this great divide may lead public-health workers into a dangerous rut of complacency. If the typical annual deaths from neonatal sepsis total 1,200 nationwide as reported in 2002, then a hospital administrator who realizes that his facility only accounts for a single fatality each year may write it off as an acceptable occurrence since it is way below the expected prevalence. This, Tayag said, is totally unacceptable.

    Systems are in place among government hospitals and some private hospitals to monitor epidemic trends and even share such data with the larger system. This enables decision makers to spot patterns and hotspots, thereby enabling a timely response to an impending disease outbreak situation. In most cases, though, an epidemic taking place in a local health system may only be known to central authorities when the health statistics are compiled and printed a year or so later. M