The manufacturing plant in Minas Gerais, Brazil, where the medications implicated in this outbreak were made, was closed when inadequate quality-control testing was observed by the Secretary of Health of Minas Gerais. Although all Brazilian state secretaries of health were notified of the closure, no nationally coordinated product recall was performed. Based in part on the findings of this investigation, the Secretary of Health of Minas Gerais decided not to allow reopening of the manufacturing facility until quality-control measures were improved. The routine surveillance of nosocomial infections at the hospital level is essential for the early detection and control of such epidemics. Clusters of pyrogenic reactions should always lead to an evaluation of possible product contamination.
Surveillance also is important at a nationwide level.
In this outbreak, contaminated medications were distributed widely throughout Brazil, and similar episodes of sepsis among neonates were reported from other nurseries around the country. The pathogenesis of sepsis. Endotoxemia in human septic shock. Burrell R. Human responses to bacterial endotoxin. Comparative pyrogenic reactivity of rabbit and man to bacterial endotoxin.