Volume 28, Number 1—January 2022
Synopsis
Extensively Drug-Resistant Carbapenemase-Producing Pseudomonas aeruginosa and Medical Tourism from the United States to Mexico, 2018–2019
, D. Cal Ham1, Gillian McAllister, Amanda R. Smith, Maureen Vowles, Kelly Kauber, Melba Zambrano, Gretchen Rodriguez, Kelley Garner, Kaitlyn Chorbi, P. Maureen Cassidy, Shannon McBee, Rhett J. Stoney, Kathleen Moser, Margarita E. Villarino, Oscar E. Zazueta, Amelia Bhatnagar, Erisa Sula, Richard A. Stanton, Allison C. Brown, Alison L. Halpin, Lauren Epstein, Maroya Spalding Walters, and for the Verona Integron-Encoded Metallo-β-Lactamase–Producing Carbapenem-Resistant Pseudomonas aeruginosa Medical Tourism Investigation Team2
Table 2
Characteristics and interview responses from 160 US residents who underwent surgery at facility A in Tijuana, Mexico, August 1, 2018–March 1, 2019*
| Characteristic | Total, n = 160 | Case status‡ |
|||||
|---|---|---|---|---|---|---|---|
| Risk period† |
Confirmed, probable, and suspected, n = 18 | Confirmed and probable, n = 12 | Noncases, n = 142 | ||||
| High risk, n = 92 | Low risk, n = 68 | ||||||
| Sex | |||||||
| M | 28 (18) | 20 (22) | 8 (12) | 2 (11) | 0 | 26 (18) | |
| F |
132 (83) |
72 (78) |
60 (88) |
16 (89) |
12 (100) |
116 (82) |
|
| Median age y (IQR) | 43 (34–49) | 43 (36–49) | 43.5 (32–49) | 45 (32.5–52.5) | 41 (31–53) | 43 (34.3–49) | |
| Unknown or declined to answer |
11 (7) |
7 (8) |
4 (6) |
1 (6) |
1 (8) |
10 (7) |
|
| Procedure performed | |||||||
| Gastric sleeve | 131 (82) | 70 (76)§ | 61 (90)§ | 15 (83) | 10 (83) | 116 (82) | |
| Laparoscopic gastric sleeve¶ | 50 (31) | 23 (25)§ | 27 (40)§ | 5(28) | 4 (33) | 45 (32) | |
| Unspecified gastric sleeve# | 79 (49) | 47 (51) | 32 (47) | 10 (56) | 6 (50) | 69 (49) | |
| Open gastric sleeve | 2 (1) | 0 | 2 (3) | 0 | 0 | 2 (1) | |
| Revision of previous surgery | 8 (9) | 2 (3) | 3 (17) | 3 (25)** | 7 (5) | ||
| Gastric bypass | 9 (6) | 5 (5) | 4 (6) | 0 | 0 | 9 (6) | |
| Other | 9 (6) | 4 (4) | 5 (7) | 0 | 0 | 9 (6) | |
| Unknown or declined to answer |
11 (7) |
10 (11)§ |
1 (2)§ |
1 (6) |
0 |
10 (7) |
|
| Surgeon who performed procedures | |||||||
| Surgeon 1 | 139 (87) | 82 (89) | 57 (84) | 16 (89) | 11 (92) | 123 (87) | |
| Surgeon 6†† | 1 (<1) | 1 (1) | 0 | 0 | 0 | 1 (<1) | |
| Unknown or declined to answer |
20 (13) |
9 (10) |
11 (16) |
2 (11) |
1 (8) |
18 (13) |
|
| Factors contributing to decision to have surgery abroad | |||||||
| Lower cost | 132 (83) | 75 (82) | 57 (84) | 14 (78) | 9 (75) | 118 (83) | |
| Recommendations from friends or family | 83 (52) | 46 (50) | 37 (54) | 8 (44) | 7 (58) | 75 (53) | |
| Did not meet weight qualifications for surgery in the United States | 36 (23) | 22 (24) | 14 (21) | 1 (6) | 1 (8) | 35 (25) | |
| Convenience/shorter wait time | 36 (23) | 22 (24) | 14 (21) | 7 (39) | 6 (50)** | 29 (20) | |
| Insurance would not approve/lack of insurance | 9 (6) | 3 (3) | 6 (9) | 1 (6) | 1 (8) | 8 (6) | |
| Other |
13 (8) |
8 (9) |
5 (7) |
3 (17) |
0 |
10 (7) |
|
| Unknown or declined to answer | 7 (4) | 5 (5) | 2 (3) | 0 | 0 | 7 (5) | |
| Had concerns over quality of care before surgery (yes), n = 151 |
45 (30) |
30 (36) |
15 (22) |
7 (41) |
4 (36) |
38 (28) |
|
| Of those with concerns, what were they?, n = 45 | |||||||
| Surgery in a foreign country | 13 (29) | 8 (27) | 5 (33) | 3 (43) | 2 (50) | 10 (26) | |
| Infection or other adverse outcome | 8 (18) | 7 (23) | 1 (7) | 3 (43) | 2 (50) | 5 (13) | |
| General | 11 (24) | 6 (20) | 5 (33) | 0 | 0 | 11 (29) | |
| Unknown or declined to answer | 14 (31) | 10 (33) | 4 (27) | 1 (14) | 0 | 13 (34) | |
| Aware of negative media stories or travel advisories about facility A before surgery (yes), n = 155‡‡ | 41 (27) | 24 (27) | 17 (25) | 7 (39) | 6 (50) | 34 (25) | |
| Awareness from CDC Travel Health Notice before surgery, n = 41§§ |
5 (12) |
5 (21) |
0 |
3 (43)** |
3 (50)** |
2 (6) |
|
| Factors contributing to decision to have surgery, n = 41 | |||||||
| Cost | 22 (54) | 12 (50) | 10 (59) | 4 (57) | 3 (50) | 18 (53) | |
| Already paid | 9 (22) | 8 (33) | 1 (6) | 2 (29) | 1 (17) | 7 (21) | |
| Unable to receive deposit refund | 3 (7) | 2 (8) | 1 (6) | 1 (14) | 0 | 2 (6) | |
| Already booked travel | 6 (15) | 6 (25)‡ | 0‡ | 2 (29) | 1 (17) | 4 (12) | |
| Short wait time | 2 (5) | 2 (8) | 0 | 1 (14) | 0 | 1 (3) | |
| Received assurances from travel agency/facility | 16 (39) | 12 (50) | 4 (24) | 5 (71) | 4 (67) | 11 (32) | |
| Received assurances from previous patients | 9 (22) | 6 (25) | 3 (18) | 2 (29) | 1 (17) | 7 (21) | |
| Other | 8 (20) | 2 (8)§ | 6 (35)§ | 2 (29) | 1 (17) | 6 (18) | |
| Unknown or declined to answer | 1 (2) | 1 (4) | 0 | 0 | 0 | 1 (3) | |
*Values are no.(%) unless indicated otherwise. CDC, Centers for Disease Control and Prevention; IQR, interquartile range. †Persons who had surgery on or after January 1, 2019, were classified as higher risk for new onset or ongoing postoperative infections. Persons who had surgery before January 1, 2019, were classified as lower risk because of the longer elapsed time since surgery. ‡A confirmed case was isolation of Verona integron‒encoded, metallo-β-lactamase‒producing, carbapenem-resistant Pseudomonas aeruginosa from a patient who had surgery during January 2018–December 2019, and within 45 d before specimen collection. A probable case was isolation of carbapenem-resistant P. aeruginosa, with isolate unavailable for carbapenemase testing, from a patient who had surgery during January 2018–December 2019, and within 45 d before specimen collection. A suspected case was infection (subjective or measured fever and >2 of the following at incision sites: pus, fluid draining, or warmth, redness and swelling) within 45 d of surgery in a patient who had surgery during January 2018–December 2019, and sought medical care but did not have a culture collected. §Statistically significant difference; p<0.05. ¶One patient underwent laparoscopic gastric sleeve and cholecystectomy. #Four patients underwent unspecified gastric sleeve and cholecystectomy. **Statistically significant difference compared with noncases; p<0.05. ††Persons who were interviewed reported surgery by surgeon 1 and another surgeon (surgeon 6) not reported by any case-patients. ‡‡Negative media stories about Facility A might have predated this outbreak §§Centers for Disease Control and Prevention issued an Alert Level 2 Travel Health Notice on January 9, 2019.
1These authors contributed equally to this article.
2Members of this team are listed at the end of this article.