Infectious disease exposures and outbreaks at a South African neonatal unit with review of neonatal outbreak epidemiology in Africa.
BACKGROUND
Hospitalized neonates are vulnerable to infection, with pathogen exposures occurring in utero, intrapartum, and postnatally. African neonatal units are at high risk of outbreaks owing to overcrowding, understaffing, and shared equipment.


METHODS
Neonatal outbreaks attended by the paediatric infectious diseases and infection prevention (IP) teams at Tygerberg Children's Hospital, Cape Town (May 1, 2008 to April 30, 2016) are described, pathogens, outbreak size, mortality, source, and outbreak control measures. Neonatal outbreaks reported from Africa (January 1, 1996 to January 1, 2016) were reviewed to contextualize the authors' experience within the published literature from the region.


RESULTS
Thirteen outbreaks affecting 148 babies (11 deaths; 7% mortality) over an 8-year period were documented, with pathogens including rotavirus, influenza virus, measles virus, and multidrug-resistant bacteria (Serratia marcescens, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci). Although the infection source was seldom identified, most outbreaks were associated with breaches in IP practices. Stringent transmission-based precautions, staff/parent education, and changes to clinical practices contained the outbreaks. From the African neonatal literature, 20 outbreaks affecting 524 babies (177 deaths; 34% mortality) were identified; 50% of outbreaks were caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae.


CONCLUSIONS
Outbreaks in hospitalized African neonates are frequent but under-reported, with high mortality and a predominance of Gram-negative bacteria. Breaches in IP practice are commonly implicated, with the outbreak source confirmed in less than 50% of cases. Programmes to improve IP practice and address antimicrobial resistance in African neonatal units are urgently required.
Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa. Electronic address: dramowski@sun.ac.za.
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Dramowski
Academic Unit for Infection Prevention and Control, Division of Community Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Aucamp
Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa.
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Bekker
Academic Unit for Infection Prevention and Control, Division of Community Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Mehtar
D000349:Africa / Q000453:epidemiology; D003428:Cross Infection / Q000453:epidemiology*; D004196:Disease Outbreaks; D006801:Humans; D007231:Infant, Newborn; D017053:Infection Control; D007363:Intensive Care Units, Neonatal; D013019:South Africa / Q000453:epidemiology
Africa; Infection prevention; Neonates; Nosocomial; Outbreaks