4 Days in China
By Carla Garnett
On the Front Page...
It started out as an ordinary consultation among colleagues. In early June, two physicians from China attended a conference on current technologies at the Clinical Center's department of transfusion medicine. General transfusion and blood-handling issues were discussed; a few lectures on the state of the science were given. The meeting ended. The Chinese doctors, loaded with conference handouts and other materials, returned home. Business -- or rather, science -- as usual.
A couple days later, however, Dr. James Shih, supervisor of molecular diagnostics, DTM, received a message from China: Upon returning home, the two physicians had been met with something of a crisis. A series of persistent infections had broken out in a hospital in Shenzhen, a metropolis in southern China, bordering Hong Kong. Were there some NIH'ers familiar with this particular infection who perhaps could discuss treatment options and methods for controlling the outbreak? Shih directed the message to the CC's Hospital Epidemiology Service, where Nurse Consultant Amy Collins offered preliminary outbreak control information to the Chinese physicians.
In the meantime, the doctors were also busy searching for additional resources in the pages of one of the NIH booklets they'd brought home -- the 1998 Clinical Studies. They looked up the disorder's causative agent -- mycobacterial infection -- and found that clinical trials were being conducted by NIH scientists. The services of NIAID's Dr. Steve Holland were requested.
Fielding such consultations was pretty much routine for both Collins and Holland, and they began collaborating via email for several days to determine the extent of the problem.
At the outset of these communications, though, it seemed that the outbreak was still occurring. The Chinese government extended an urgent, formal invitation: Please come to Shenzhen ASAP. The two were headed to Hong Kong by week's end.
On the Road to China
"I didn't want to go," Holland recalled, during an interview weeks after his return. "My wife was pregnant, going into the ninth month. I'd just gotten back from a meeting in Switzerland. I really wanted us to try and handle it from here. But they weren't sure they were treating it properly, and it didn't seem to be clearing up. They also needed Amy to do the epidemiology."
"There was a sense of urgency and essentially we just realized we needed to go," Collins summed up. "It took us about a week to decide what was needed -- clearing it with both governments, getting visas, and working out the travel arrangements."
Mycobacterium infections, due to the rapidly growing species, are occasionally reported in association with problems in disinfection techniques, or inadvertently contaminated fluids used in hospital procedures, explained Collins. Basically, patients contract it while in the hospital for something else. An infection that can form around recent surgical incisions, Mycobacterium abscessus can be persistent, prying sutures open and working its way inside the body. While not generally life-threatening, Holland continued, the infection is a nuisance, not allowing routine wounds to heal and further delaying rehabilitation and release from the hospital. Clearly visible on the skin, the infection can also cause disfiguring scars in some, if left unchecked. It is extremely uncommon in the United States.
When Collins and Holland arrived at the women's and children's hospital in Shenzhen at 9 on a Saturday morning -- following an evening meeting with several grateful Chinese medical specialists -- they began examinations of 71 inpatients with evidence of the infection.
"That was a lifetime's experience," said Holland, recalling his surprise at the sheer number of cases. "It was only surpassed by the 81 outpatients we saw the next day."
The patients ranged from a toddler who had recently undergone a hernia operation to new moms who had delivered by caesarean section. All had one thing in common -- a poorly healed incision, discolored, inflamed and oozing. A few had infections that had spread beyond the local site to nearby lymph nodes. As it turned out, the doctors there were in fact doing nearly all that could be done to control the infections.
"They had made a concerted effort to treat the problem," Holland said. "They had already put the patients on a variety of antibiotics. This infection can be obnoxious, though. They wanted to collaborate on how long to treat it. Unlike a lot of other infections, this one gets treated for months, not days. I recommended a few other antibiotics that might be useful, and an immune modulator. They were basically doing the right things, they just needed to do more of them."
NIH'er Gains National Spotlight
During the 4-day journey, Holland conducted several conferences with the hospital's medical staff, lecturing to groups of 35 and 75 people at a time on infection therapies under current review at NIH. Warmly welcomed for his expertise, he was also interviewed by several representatives of the national news media there, including China's equivalent of Good Morning, America.
One concern voiced most often involved which antibiotics were safe for women to use while breastfeeding. "I had to place a call to NIH's pharmacy for that one," Holland said. "They searched the NIH databases and came up with the answer."
Collins, meanwhile, was collecting data for the epidemiological evaluation that could shed light on the origins of the outbreak and perhaps reveal how future infections like it could be prevented. The clinical photographs and information would also be a boon for research efforts in this country, which does not often witness such an outbreak. Contacts with the Chinese physicians will continue, Collins stressed, as both NIH'ers maintain communications. All involved also remain curious about how the situation will be finally resolved.
"After much investigation and discussion," she said, "we identified a probable source of the organism. Control measures were implemented and changes in disinfection practices were made with the assistance of many local hospital professionals. They are well on their way to eradicating this occurrence of infections."
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