On 29-30 November 2015, five deaths occurred within 24 hours in the Neonatal Intensive care unit (NICU) of King Fahad Hospital (KFH), Al-Baha. Deaths occurred within few hours after blood transfusions (BT).
Objective: To determine the cause of the neonatal deaths and possible public recommendations to prevent future deaths.
Methodology
We conducted active case finding to define the scope of the outbreak and two retrospective cohort studies to identify any potential Iatrogenic causes. A case was defined as any patient admitted to KFH, Al-Baha throughout the year 2015 and received blood transfusion followed by demonstration of hypotension, bradycardia and hypoventilation or oxygen desaturation (HBH) during or within 12 hours following BT. Data was collected through clinical records using a structured data collection instrument tailored to serve the purpose of each study.
Results
Number of deaths by international week (8 deaths) exceeded the average (1.86) on week 48 of the international year which corresponds to this cluster. Eight patients met the case definition (including one adult case); 6 died and 2 survived. All cases received blood transfusion from three specific units on serial order donated on the morning of November 15, 2015. The seven affected neonates were the only recipients of the first two units. None of the other potential risk factors showed significant association to HBH. No autopsies were performed.
Conclusion
This investigation revealed HBH was exclusively related to three consecutive blood units donated on the same day. Having excluding recipient associated risk factors, the cause of HBH is most likely a toxin-producing pathogen but could not be confirmed due to lack of supporting evidence.