Hospitals Not the Only Superbug Source

Sir, Andrew Jack ("New superbug raises 'medical tourism' fears", August 12) reports on an emerging problem with "medical tourism". Yet, the basis of an infection such as NDM-1 isn't always down to the hospital where the tourist received a clinical service. There are many points along the road to and from that hospital where a bacterial agent can infect the body.

A patient leaving, say, the mid-west US for Mumbai, India, for an invasive medical procedure (heart, lung, liver and so on) is already immune-compromised. The long 18 to 24-hour flight and transit time exposes that patient to any number of free-floating bacteria not found in the patient's local environment.

Once in a five-star "medical tourist" hospital, the patient can be assured that the operating room personnel follow strict measures of infection control. The quality of those measures deteriorates as the patient is moved to post-operative care by nurses, nursing assistants and orderlies, and is further jeopardised by janitors, administrative staff and cleaning personnel.

Part of the "medical tourist" package includes a recuperation period at a beach resort such as Goa. Once there, the recovering patient, now more immune-compromised than before he entered the hospital, is exposed to new opportunistic infections by waiters and other beach personnel. Louis Pasteur once observed that "we drink 90 per cent of our illnesses". The beach is a potent reservoir for that eventuality.

The immune-compromised patient then endures another 18 to 24-hour flight and transit time back to the US, and once en route is exposed to another set of waiting bacterial agents. Because these are indifferent to time and space, whichever latent bacterium missed its chance with the tourist in India can now mutate with those present in the new environment and infect the patient.

A new generation of therapies to fight infections such as NDM-1 will greatly alleviate the situation. But there are many other points along this long road to and from treatment where a bacterial infection can attack an already immune-compromised "medical tourist", presenting a challenge to the effectiveness of those therapies.