Update on hospital deaths-Poor storage facilities led to contaminated syringes

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Poor storage facilities led to contaminated syringes

Sunday Times.lk - Columbo,Sri Lanka

By Kumudini Hettiarachchi

http://www.sundaytimes.lk/070527/News/nws13.html

Inadequate storage facilities may be the " most plausible "

explanation for the contamination of syringes which led to the death

of three young women who contracted meningitis after administration

of spinal anaesthesia for caesarean sections between July 2-25, 2005

in two main maternity hospitals in Colombo.These were the disturbing

findings by a high-level team of doctors who probed a meningitis

outbreak at the De Soysa and Castle Street Hospitals for Women.

According to the findings published in the New England Journal of

Medicine (February 15, 2007), titled `Aspergillus Meningitis in Sri

Lanka – A Post-Tsunami Effect?', an examination of the Health

Ministry's central stores of drugs and devices had revealed that the

three regularly used, renovated warehouses were full of donations

for survivors of the tsunami whereas the regular procurements of the

ministry were stored in a dusty and humid fourth warehouse with

leaks in the roof.

" Although the exact source of the contamination remains unclear,

inadequate storage facilities, owing to the mass influx of

donations, was identified as the most plausible explanation, given

the suboptimal storage conditions during the 6-month period after

the tsunami disaster, " the report said.

Immediate incineration of all unused syringes led to the effective

control of the outbreak, with no reports of aspergillus meningitis

in 2006, it reassures.

The events which led to the " intensive microbiologic investigations "

by Dr. Padma S. Gunaratne, Head of the Institute of Neurology,

National Hospital, Colombo; Prof. Chandrika N. Wijeyaratne,

Professor of Reproductive Health, Medical Faculty, University of

Colombo and Prof. Harsha R. Seneviratne, Professor of Obestetrics

and Gynaecology, Medical Faculty, University of Colombo are indeed

tragic. (See box for Sunday Times story published on August 14,

2005)

Five previously healthy women in the age range 21 to 38, with the

average age being 27 years had received spinal anesthesia from

different surgical teams in the two maternity hospitals. They

developed symptoms of meningitis and three died.

According to the report tests (fungal cultures) on the cerebrospinal

fluids or postmortem brain specimens from four patients had been

positive for Aspergillus fumigatus

The investigations which commenced when the possibility of an

outbreak was recognized had initially included examination of

randomly selected, unopened packages of medical supplies: 679

disposable plastic syringes, 159 intravenous and spinal needles, 87

cannulae, and 55 ampules of anesthetic agents. Fungal cultures had

confirmed that 43 syringes from three different manufacturers were

contaminated with A. fumigatus.