ABU DHABI // When civil war broke out in Yemen on May 4, 1994, following the collapse of an uneasy four-year alliance between northern tribes and their Marxist southern neighbours, the conflict was brief but brutal. It was all over by July, leaving the north triumphant, but thousands dead, wounded or driven into exile.
As the extent of the suffering of the wounded became apparent, Sheikh Zayed intervened and offered the services of Zayed Military Hospital and Mafraq Hospital in Abu Dhabi. A cruel and unexpected fate, however, lay in store for many of the war victims after they reached what appeared to be the safety of the UAE. They had escaped death on the battlefield only to fall victim to a killer in the wards of the very hospitals that had offered them sanctuary.
Many surgery cases were flown into the country but it was the burns victims, with their open wounds, who would be most at risk from a scourge of which few had heard. Shortly after the arrival of the wounded, Mafraq Hospital, the emirate's largest medical facility, suffered an outbreak of one of the most feared hospital-acquired infections, soon to reach epidemic proportions. For the UAE's medical professionals, it was a bitter introduction to the threat of methicillin-resistant Staphylococcus aureus, better known as MRSA, and doctors were unprepared for the consequences.
In Yemen, one battle had ended; in Mafraq Hospital, another had begun, as doctors and support staff fought to combat a new, deadly enemy. Now the man who was in the front line of that battle and documented its victories and defeats has told the story of how it was fought. Mohamad Hamad, who was Mafraq's infection control nurse for 26 years until his resignation last year, recalls when the outbreak began: "People were very afraid. It was a big shock. They weren't even aware of what MRSA was. We didn't have a background to tell us how to deal with it and handle it. There was no policy. The staff thought that this bacteria would eat away at the skin."
Some staff, he says, were "so afraid that many of them refused to deal with the affected patients, worried about their families. We were all told to bath before we went home." In a report he produced in April 2006, Mr Hamad recalled that the first cases of MRSA among the war victims in the hospital's burns unit began at the end of 1994; later, however, "an extreme outbreak of MRSA occurred in the hospital", leading to 163 cases - equivalent to 1 per cent of the hospital's total admissions of 16,100 patients in 1995. The outbreak had spread beyond the burns unit, whose patients accounted for only 24 per cent of the total cases, although 23 cases had been admitted or transferred to the hospital already carrying the infection.
Eleven patients out of the 163 died and, although MRSA strains were not identified as a direct cause of death, neither were they eliminated, says Mr Hamad. In his report on the battle with the bacteria, MRSA - Achievement in Al Mafraq Hospital, Abu Dhabi, Mr Hamad concluded that the increase in cases could be attributed to "lack of knowledge and information about MRSA and its control and prevention at that time" and an associated "unavailability of related policy and procedure".
As a result of the outbreak, the hospital's multidisciplinary infection control committee developed a new policy and procedures for dealing with MRSA, including measures to prevent and control its spread. High on the list of priorities was identifying and isolating the source of infection; this was done, says the report, by taking wound and nasal swabs from all admitted patients and hand and nasal swabs from all staff who came into contact with them.
People found to be carriers were isolated in single rooms and treated with antibiotics. By the end of 1997, the outbreak was at an end, with only "a few sporadic cases" in various units. But despite all the precautions, reports Mr Hamad, "this situation did not last for long". A combination of the leftover cases from the earlier outbreak and "the continuous" transfer from other hospitals of patients carrying MRSA caused another outbreak of 40 cases in 1999.
Once again, the main source was the burns unit, which accounted for more than 57 per cent of the total. This time, the infection control committee identified a number of possible causes and made a series of recommendations: to restrict the admission of MRSA carriers from other hospitals; to restrict the use of antibiotics; to enforce the use of disinfectant solutions for cleaning and to introduce an effective staff education policy and random screening of staff and surfaces in the workplace. The burns unit was closed for maintenance.
A few months after these measures were introduced, there was "a dramatic improvement in the number of cases in 2000, which dropped to 17". But Mafraq was to face a third outbreak - once again, partly a consequence of war in another country. As wounded were brought to the hospital from the conflict in Iraq, so numbers began to rise again and, by 2005, 43 people were reported to have contracted the bug, rising to 49 the following year. This time the main scene of the outbreak was the male surgical ward.
Again, much of the blame was attributed to a failure to screen patients transferred from other medical facilities, but poor hygiene - chiefly, inadequate hand washing - was also implicated in Mr Hamad's report. Again, controls were tightened: hand washing was made a priority, all wounds were screened after operations and the wounds of patients known to be carrying MRSA were dressed last. In his 2006 report, Mr Hamad concluded that his study of the MRSA statistics at the hospital between 1995 and 2006 illustrated "very clearly that there is a very dramatic improvement in detecting and controlling the situation of MRSA cases in Mafraq hospital, which reported 544 MRSA cases, which is equal to 0.18 per cent out of 289,580 patients admitted to all Mafraq hospital wards and units".
But events last year demonstrated clearly that no matter what measures are put in place, and however strong an individual institution's defences might be, the spectre of MRSA can never be assumed to be exorcised in a busy hospital to which thousands of cases are referred each year from around the UAE. Dr Mohamad Yaman, the chief medical officer of Al Mafraq Hospital, told The National recently that after introducing an infection control campaign last year staff detected 62 cases of MRSA.
"It takes time for these programmes to get implemented efficiently so the hospital will have a big task ahead of it," says Mr Hamad, who left Mafraq last year and now works at the Lifeline Hospital in Abu Dhabi. With the large gaps between outbreaks, the infection is rarely fresh in the mind of the hospital's staff, he says, and signs and posters should be used to raise awareness and reinforce hygiene procedures: "It's not enough just to teach people; people need to be constantly reminded and checked."
The battle against MRSA has been a steep learning curve for the medical profession in the UAE, says Mr Hamad, but there are more lessons to be learned before it is won. It was, for instance, vital to instil in all staff, from porters and administrative staff to nurses and surgeons, the concept of infection control, starting with the basics - correct hand-washing procedures, regular swab-checks on air-conditioning units, in the corners of rooms and in the bathrooms. He also recommends a monthly audit.
Dr Yaman said the large number of cases at Mafraq in recent years was due to a greater awareness of the bacteria, rather than a worsening problem."We are screening everyone who comes to the hospital now," he said. "We are doing very well at controlling this now and are very happy with the results." firstname.lastname@example.org