§ Motion made, and Question proposed, That this House do now adjourn.—[Dr. Liam Fox.]
11.37 pm§ Mr. Harry Cohen (Leyton)I welcome the Minister to his new post and wish him well in it. I am very pleased to have secured this debate on metticillin-resistant staphylococcus aureus. That is the only time that I shall mention its full title. From now on I shall refer to it as MRSA. I declare an interest in that Unison pays me £500 towards my office allowance for payment of staff, but I am not raising this debate on its behalf. I also apologise for the cold that I am carrying. I look as if I am rehearsing for the role of Santa Claus with this red nose. For reasons that will become clear in my speech, I am not taking any antibiotics for my cold.
I decided to raise this subject after an article in my local paper, the Waltham Forest Guardian Series, on 14 September gave me quite a start. It said that Mr. David Chudley, a 44-year-old father of seven, was admitted to my local hospital, Whipps Cross, with a routine leg fracture after a road accident. Within a little while of being admitted with that minor leg injury, he died from the MRSA infection. His wife, Christine, is quoted as saying:
When someone says your husband has got a broken leg, you don't expect him to die.The report then says that his is not the only death and that there have been two connected with the bug. A consultant at the hospital has admitted that the hospital has 20 or 30 patients carrying the bug at any one time. The other man who died was Mr. Kevin Cox from Chingford; he died in February from MRSA.The bacterium has become immune to the strongest of antibiotic drugs. It sticks to the windpipe of its victim and infects the lungs. It forms pus and can cause pneumonia, according to the local paper. The coroner wrote to the Whipps Cross medical director suggesting that the hospital should set up special isolation wards to contain the bug. The article concludes:
MRSA is a problem in hospitals across the country but is particularly bad in the south of England.The first few cases of the bacteria were reported in 1991. Two years later there were 300 cases in more than 40 hospitals. Now 129 hospitals in the UK are reporting it.That is an amazing figure which shows the rapid spread of MRSA. In the same edition of my local paper, Bryan Harrison of Forest Healthcare trust said that hospitals were not a healthy place to be in. He was clearly alluding to the MRSA bug.The 1990s have seen a massive increase in MRSA infection in hospitals. The privatisation of cleansing services in the mid- 1980s, worsening the standards of cleanliness in hospitals, has been a contributory factor, but I acknowledge other factors, especially the over-use of antibiotics. My mother's common-sense dictum to me as a child was that people should not take antibiotics unless they really needed them. If people did, antibiotics would not have the necessary effect when they had to have them. There has been indiscriminate and 277 inappropriate prescribing, although probably less in this country than in other countries. That has resulted in more antibiotic-resistant bacteria such as MRSA.
In the 1990s, there has been a worldwide resurgence of bacterial and viral diseases. Virtually all major disease-causing bacteria seem to have acquired antibiotic-resistant characteristics. There has been a massive increase in the population at risk because their immune system has been compromised in some way. Examples are cancer and leukaemia treatments and transplants, AIDS high-dose steroid treatments, invasive medical intervention and the prolonged survival of patients with chronic debilitating diseases. That resistance has come about and MRSA has spread.
I thank Dr. Jane Cushion of the House of Commons Library for her excellent briefing on MRSA; I shall summarise some of it. Staphylococcus aureus is a common bacterium which may be carried in the nose; about 50 per cent. to 75 per cent. of healthy people may carry it. Less often, it is carried on the skin, usually in the armpit or in other warm, moist areas, or in the mucous membranes, such as the lining of the mouth and gut. A significant proportion of the population are reservoirs for the bacterium from whom it can escape and cause disease. Its optimum temperature for growth is 37 deg. C, which is roughly equivalent to normal body temperature.
MRSA causes infections and diseases which can result in the production of pus. The infection may be superficial, with boils, carbuncles and abscesses. Deep infections, although less common, are much more serious and include septicaemia, endocarditis—infection of the heart valves—osteomyelitis, pneumonia, toxic food poisoning, toxic shock syndrome and skin exfoliation syndrome.
Penicillin dealt a big blow to bacteria infections. In the 1950s bacteria developed which were resistant to penicillin. The antibiotic flucloxacillin was subsequently developed and kept down infections by such bacteria. There has been a large increase particularly since 1983–84 in staphylococcus aureus, which is resistant to the commonly used antibiotics. That is a serious problem. Some strains of MRSA possess the capacity to spread with ease. They have caused hospital outbreaks which have proved difficult to control.
Risk management programmes are clearly needed in hospitals to improve the quality of patient care and the occupational health of the staff. Hospital management has legal duties. The Government have introduced the Control of Substances Hazardous to Health Regulations 1994, which cover disease-causing organisms. About 130 hospitals have reported cases of MRSA infection. The presence of MRSA has virtually become a fact of life in most hospitals. There have been larger outbreaks in the west midlands and at Southend hospital. It is a most serious problem.
The document "Hospital Infection Control" prepared by the hospital infection working group of the Department of Health and the Public Health Laboratory Service refers to the need to have in place infection control staff in hospitals. It says that some of the highly resistant strains of MRSA
are already resistant to most of the available antibiotics and are likely to create major therapeutic problems in the future.It says that those strains of MRSA are278
particularly hazardous in high risk units such as intensive care. Implementation of effective antibiotic policies…are necessary…Surveillance for rapid detection and the provision of adequate isolation facilities are important in every hospital…Every hospital should have an infection control team.Such teams have expert membership and include an infection control doctor and consultant medical microbiologist. The document also said:
Every hospital should be covered by a Hospital Infection Control Committee.Such committees include, as well as the experts in the infection control team, the chief executive and the consultant in communicable diseases control.The Department of Health should require every hospital authority to implement the administrative procedure that I have outlined and check that it does so. MRSA is a major drain on resources. It is costly for hospitals because it means that patients have to stay in hospital for extra time. For example, when Kettering general hospital had a bout of the disease in 1991 it cost the hospital almost half a million pounds. The Government keep saying to health authorities and trusts that the cost of MRSA can be met from existing resources. Increasingly, they cannot. The Government should recognise that and compensate health authorities and trusts.
The hospital infection working group said of MRSA:
The total annual costs in the UK, although not yet fully quantified, are undoubtedly high.The cost is not just to the health authorities but to the people affected and their family because patients are forced to stay in hospital longer.The hospital infection working group said:
Overall we believe it is possible that currently about 30 per cent. of hospital acquired infection could be prevented by better application of existing knowledge and implementation of realistic infection control policies…It must also be recognised that infection control action will be constrained by the resources available.Again, the pressure is on the Government to deal with the problem.There is one other important feature—the danger that MRSA, which is currently a hospital infection, could spread into the community and especially into nursing homes. Time is short, so I cannot go into that in greater detail.
This is an important public health issue. I pay tribute to the work of the Public Health Laboratory Service, which includes the Communicable Disease Surveillance Centre. It collects and analyses information on drug resistance. The Government should put in the resources to boost the service and the information that it gives to GPs and hospitals.
The British Society for Antimicrobial Chemotherapy, the BSAC, in a report last year stated:
the steady rise in antibiotic prescriptions needs to be reversedand that
failure to do so would increase the prevalence of drug-resistant bacteria.The Office of Science and Technology has also given me information about the prevalence of antibiotics in foods. Some were brought in as scientific markers; others were introduced in animal feeds. Earlier this year evidence was given to the Ministry of Agriculture, Fisheries and Food that there had been a big increase in 279 adult cattle with antibiotic resistance. There were something like 400 cases in 1990 in England and Wales, which increased to 1,600 in 1993. The cause was thought to be the routine feeding of low antibiotic doses to intensely reared livestock to boost growth and heavy doses to prevent heal infection.Scientists have expressed concern that the increasing resistance to antibiotics could pass through the food chain but MAFF sticks to the 1969 Swann report, which says that new potent antibiotics should not necessarily be precluded from therapeutic use in animals. The Government should have a co-ordinated policy on MRSA. The MAFF line should not be independent of but subservient to the best interests of public health.
In the few minutes left, I will spell out some of the essential policies needed to tackle MRSA effectively. First, there need to be improved cleanliness standards in hospitals. That must include stricter enforcement. Those responsible, the managers, must be taken to the courts for neglect if they do not keep up with such standards. However, the Government must recognise that such higher standards of cleanliness need more, not fewer, resources.
Secondly, there has to be funding for extra capacity for hospitals where wards have had to be closed due to MRSA outbreaks. Ward provision has been cut right to the bone and there is not the extra capacity that MRSA requires. If such action is not taken, there will be problems right through the system. There should be smaller wards. The effect of MRSA when it strikes is far less devastating with smaller wards. Whole wards have to close when it does strike.
The Department of Health must take a proactive role in ensuring that every hospital has an effective risk management programme, which should include isolation facilities, infection control teams, and appropriate-use-only antibiotic policies.
Appropriate-use-only antibiotic policies should also apply to GP prescribing and the Government should institute an immediate programme of education for GPs. With such widespread ignorance about MRSA, a programme of education should be introduced for all health workers who are likely to come across it.
The possibility of MRSA spreading from hospitals into the wider community is a real danger that requires active consideration and policies to deal with it. Increased use of day surgery and early discharge from hospital may increase the risk of MRSA, and those practices should be monitored.
A higher priority should be given to research into the causes of and cures for this killer bug. The Government should get their act together across Departments so that the Ministry of Agriculture, Fisheries and Food does not merrily continue pumping antibiotics into animals, so spreading antibiotic resistance through the food chain. The interests of public health should take precedence.
More needs to be done to combat the increased incidence of virulent MRSA, which killed Mr. Chudley and Mr. Cox, who were referred to in my local paper. I hope that the Department of Health will now devote far more thought and action to combating it.
§ The Parliamentary Under-Secretary of State for Health (Mr. John Horam)I thank the hon. Member for Leyton (Mr. Cohen) for his kind welcome. I am sorry that he is not in perfect health, but despite that, and the seriousness of the subject, I am glad to se that he has retained his cheerful demeanour. I am glad that the hon. Gentleman has raised the important issue of metticillin resistant staphylococcus aureus—like the hon. Gentleman, I hope I have passed the test of pronouncing it—commonly known as MRSA, and that I have the opportunity to respond to the debate.
This is an issue that causes considerable concern to many people, but I must emphasise that it is not a new problem. The NHS has spent many years controlling it. I must say that in most countries the spread of that micro-organism has now been accepted as more or less inevitable. It is only because our health service offers high quality infection control systems that we are in a position to control it.
Perhaps I might start by setting the record straight on what MRSA actually is and how it causes infection. MRSA is a relatively antibiotic-resistant form of the bacterium staphylococcus aureus. Staph. aureus, the alternative way of referring to it, is one of the commonest and most ubiquitous of all the bacteria with which we are surrounded. As the hon. Gentleman said, normally it does us no harm.
About one third of us carry the bacteria on our skin or in our nose and throat and it causes us no problem. But if the skin is cut, or if resistance to infection is lost for any reason, the germ can multiply and set up an infection. Mostly, it is a trivial infection of the skin, but in patients who are in hospital it can sometimes become more serious. Many hospital patients have catheters and drips of various sorts going through the skin, which give bacteria like staph. aureus an easy route into the body. Many patients have had operations, so they have a wound that can become infected; some have poor resistance to infection because of their illness or their treatment, and are vulnerable to serious infections such as septicaemia or pneumonia. Staph. aureus can cause all those problems—a range of infections from the trivial to the life threatening.
MRSA, which is the antibiotic resistant variety of staph. aureus, acts in exactly the same way and causes the same range of infections. Again, the majority of people who carry it come to no harm at all, and if it does cause an infection, the range of problems is just the same—the infections are no worse than those caused by the ordinary bacterium.
The reason why MRSA is seen as more of a problem is that if an infection develops it is more difficult to treat because many of the commonly used antibiotics are not effective against it. There are antibiotics that can be used—the infection is not untreatable. Those antibiotics are, however, more difficult to use, they have more side effects and, of course, they are more expensive.
Some strains of MRSA show a greater tendency to spread easily from person to person than others. The first three of those strains appeared in the early 1980s and patients in many hospitals were affected. Those strains became less common after a few years, thanks to the efforts of hospital infection control teams to prevent it from spreading, and for a time the spread of MRSA appeared to have receded.
Now we have two new strains which spread particularly easily and again many hospitals are having to take action to control it. We think that that is an effort worth making, 281 although, as I have already said, in many other countries, where antibiotics are available much more freely than here and infection control arrangements are less effective, the majority of staph. aureus in hospital patients is already antibiotic resistant. That has simply been accepted as inevitable, and requiring no particular action.
The Department of Health takes the whole subject of infection control in hospital very seriously. We issued comprehensive new guidance to the NHS earlier this year, covering the structure and activities of infection control services, surveillance of infections—including those due to antibiotic resistant organisms—and the control of outbreaks. It suggests that every hospital should have an infection control team, consisting of a medical specialist—usually a consultant microbiologist—and one or more trained infection control nurses. I can assure the hon. Gentleman that that is the case at Whipps Cross.
The guidance covers the role of the team in leading and co-ordinating infection control activity in the hospital. We also give advice to commissioners of health care about what infection control arrangements they should be looking for in trusts.
The guidance to which I have just referred deals with control of infection generally in hospitals. More detailed guidelines on the control of MRSA in hospitals have been produced by two of the interested professional organisations—the Hospital Infection Society and the British Society for Antimicrobial Chemotherapy.
The first of those guidelines was produced in 1986, but they have since been updated. The Department of Health gave them its formal support last September and is now working with the same organisations to produce a further revision in the light of advancing scientific knowledge and experience in controlling the micro-organism.
The Public Health Laboratory Service provides specialist strain-typing facilities and expert advice to help hospitals affected by MRSA. It carries out surveillance of the prevalence of the organism and can provide information, for example, when a patient is transferred from abroad to a hospital here. The PHLS is presently carrying out a special study of hospitals affected by the two main epidemic strains of MRSA to determine the epidemiology and most effective method of control of the organism.
The hon. Gentleman is particularly concerned about the problem locally and he also made a number of important points about the national position. It stems in part from comments made at the inquest into a tragic death at Whipps Cross hospital last winter. I am assured that the NHS trust concerned—Forest Healthcare—has made a high priority of its efforts to prevent the spread of MRSA. Patients known to be carrying MRSA are nursed in isolation, and those admitted to the intensive care unit are screened regularly for the bacterium. The effectiveness of those measures is kept under review and we are confident that the situation in Whipps Cross is being controlled satisfactorily.
282 On the national position, the hon. Gentleman mentioned a point on which I would like to comment. There has also been concern among owners and managers of some of the nursing and residential nursing homes that MRSA may been a problem for their residents. It is based on a misunderstanding of the nature of the bacterium and the type of infection that it may cause.
Residents in most of those community settings are at no greater risk of infection than the general population. They do not have medical devices such as drips penetrating the skin and they do not have surgical wounds. There has never been an outbreak of infection due to MRSA in such a home, nor is there likely to be one.
Last year, the Department of Health worked with the professional organisation representing consultants in communicable disease control to produce guidance on infection control in nursing and residential homes. The guidance advised that a person carrying or infected with MRSA was not a risk to other residents in most of those homes and that routine arrangements designed to prevent all types of infection, such as good personal hygiene, are sufficient to deal with it.
The Department, however, recently held a seminar for insurers of such homes to inform and reassure them about MRSA. It will also take part in a further seminar for owners and managers of homes and for local and health authority staff responsible for the registration of homes and will issue further guidance to those groups in the new year.
It is important that we maintain a balanced view of the problem of MRSA in hospitals. The majority of cases of all types of infection in hospital patients cannot be prevented with our current knowledge. MRSA does not cause more infections than other types of staph. aureus with which we are surrounded. Despite the huge increase in the complexity of medical treatment and in the number of patients with reduced resistance to infection treated in our hospitals in the past 10 or 15 years, there is good evidence that hospital-acquired infection, including MRSA, is no more common now than it was in 1980. That evidence is based on a wide survey including hundreds of thousands of patients in at least 200 hospitals. MRSA is not untreatable and nor is it a new scourge, but it is a problem worth considerable efforts to control. Doctors and nurses in hospitals in many parts of the country are working hard to do just that.
I am grateful to the hon. Member for Leyton for raising the subject, and I hope that I have assured him about the position in Whipps Cross hospital. The total situation is much more satisfactory than the hon. Gentleman might have thought.
§ Question put and agreed to.
§ Adjourned accordingly at four minutes past Twelve midnight.