Thursday, August 28, 2014

Give Directly-Observed Hand Hygiene Compliance Monitoring a Chance

As I've said before, "It's amazing how little evidence is required before infection prevention interventions are adopted." This phenomenon is particularly evident in the setting of automated hand hygiene monitoring systems. Few trials have been completed that have assessed the efficacy, effectiveness or cost-effectiveness of these systems, at least as of our recent systematic review.  However, it appears that many facilities are purchasing these systems anyway. Why is this?

It appears that there are two potential limitations of directly-observed hand hygiene monitoring driving the purchase of automated systems: (1) the fear that the Hawthorne effect renders all direct observations invalid and (2) the idea that all hand hygiene opportunities must be counted, i.e. it's unacceptable to sample opportunities. There is a third potential reason for adopting these systems - anecdotal reports that automated systems improve compliance. However, there is little published evidence that compliance increases are sustained and some evidence that automated systems actually decrease compliance.

With the potential limitations of directly observed compliance monitoring in mind, our research group just completed a study published in ICHE that sought to determine if/when the Hawthorne effect appears in hand hygiene observation data. The idea being, if it takes some period of time for HCW to know they are being observed, shorter periods of hand hygiene monitoring could be less susceptible to bias from the Hawthorne effect. After 3,432 hours of observations and 11,444 witnessed opportunities in a multi-center study, we calculated that room-entry compliance increases after 38 minutes and room exit compliance increases after 14 minutes and then again after 50 minutes (Figure below). Thus, it appears that limiting direct observation periods to less than 15 minutes limits the impact of the Hawthorne effect.

The other aim of our study was to determine the number of hand hygiene opportunities that must be observed to have an adequate sample size for comparison. For example, if hand hygiene compliance in your ICU is 80% this month and you would like to get it to 90% next month, you would need to observe 108 opportunities in each month to have enough power to detect a difference. We provide a table (below) so that anyone can quickly determine the number of observations in a month/quarter/year needed to compare time-periods or units/wards or facilities. We hope you find this information useful and that you'll still give directly observed hand hygiene compliance monitoring a chance.

Friday, August 22, 2014

Nightmare in Liberia

I posted yesterday on the nightmare unfolding in Liberia, as the health care system has collapsed under the weight of the Ebola outbreak, with civil order breaking down as entire sections of Monrovia are placed under quarantine. Last night I spoke with a friend of ours, Chesca Colloredo-Mansfeld, the Executive Director of miraclefeet, an organization dedicated to treatment of clubfoot in developing countries, including Liberia. As you might imagine, the Liberia clubfoot treatment clinics have had to focus all of their efforts on Ebola response. The situation there is truly awful—below is an excerpt from an email exchange that Chesca forwarded: 
"…help is really needed. He [Augustine Chiewolo, head of the Liberia clubfoot treatment program] told me that his cousin’s body was just removed from her house yesterday. It took four days for her to be removed. Her two remaining children are isolated in a church—and he is trying to make sure that people will deliver them food. He said that if they do get sick, there is no one who is willing to transport sick people to the hospitals, so many people aren’t able to access treatment. People are dying of ordinary illnesses because they are isolated as soon as they are ill and don’t access treatment."
Augustine is currently in the U.S., working with miraclefeet to gather supplies to send back to Liberia. A list of supply needs below was provided by the Liberian Ministry of Health:

If you are interested in helping, you can do so either by donating to miraclefeet (online here or by mail to miraclefeet, 410 West Main Street, Carrboro, NC 27510—please note that it is for Liberia in the dedication line and it will go towards buying critical supplies), or if you prefer to send donated supplies directly you can send to: Augustine B. Chiewolo, 1000 Andrews Ave, Collingdale PA 19023-4004—any donated materials need to arrive to that address by September 10th.
Augustine Chiewolo

To CDC or not CDC - That is the Ebola Question

It's been a busy couple weeks out here in infection control land. We had our SHEA 2015 planning committee meeting in DC. There's an exciting program planned - can't wait to share it with you. While I've been planning Ebola symposia for the May meeting in Orlando, Dan and Mike have been very busy discussing and implementing Ebola management plans. If you haven't had a chance to read their excellent posts, you can peruse them all here.

The debate over the CDC droplet+contact precautions guidance is strangely similar (in an opposite day kinda way) to discussions around N95 masks during the 2009 H1N1 outbreak. To remind yourself of the debate, you can read one of Dan's 2009 posts on the topic. What is almost ironic is a quote included in the post: "when did influenza become Ebola." What is actually ironic is that back in 2009/2010, CDC recommended "respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza." Yet now, CDC does not recommend N95s in most clinical situations for Ebola. And if you're keeping score, in 2009 CDC wanted "higher-level" protection and hospital epidemiologists wanted "lower-level", while in 2014 most hospital epidemiologists are implementing policies that extend way beyond CDCs recommendations.

All of that is by way of background to a thoughtful commentary in Annals of Internal Medicine by Michael Klompas, Daniel Diekema, Neil Fishman and Deborah Yokoe. The authors carefully review the data behind the CDC's current guidance and suggest that hospitals stick closely to the current recommendations. They claim that exceeding the CDC guidance could paradoxically increase health care worker risk and anxiety while also increasing cost and waste. They also suggest that exceeding "CDC's recommendations fans a culture of mistrust and cynicism about our nation's public health agency." The only thing I would add is that no matter what's included in your local Ebola management plans, don't forget the ice cream.

image source: The Onion

Thursday, August 21, 2014

The horror

Mike recently posted about Emory’s state-of-the-art isolation unit, where the only two Ebola-infected patients in the U.S. have been treated. Compare that unit with this Ebola isolation unit set up in an abandoned school in Monrovia, Liberia.

 Or with this new Ebola treatment center being set up by Doctors Without Borders, in Monrovia, soon to be the largest Ebola treatment and isolation center in history. Large open tent, mattresses on the ground just feet from each other, no modern plumbing (see wash station in the corner)—it is easy to see how personal protective equipment might also need to be adjusted for those who spend hours on end caring for sick and dying patients in this environment. 

The recent news from Liberia is horrendous. Earlier this week the residents of West Point, described by one journalist as “the worst slum in Liberia, which makes it one of the worst slums in Africa, which makes it one of the worst slums in the world”, looted a school-turned-Ebola-isolation unit, freeing the isolated sick patients and making off with blood soaked sheets and mattresses. The entire community is now under quarantine, and is responding violently.

I spent several weeks in Liberia about 30 years ago, and I’ll never forget the conditions I saw at West Point. From the Washington Post:
"According to the United Nations Office for the Coordination of Humanitarian Affairs, which reported on the slum in 2009, there were only four public toilets servicing 70,000 residents. Using the toilet cost 3 cents, and bathroom operators estimated they got about 500 patrons per day. “The facilities can be smelled 50 meters away, with the floor of each squalid cubicle 15 cm deep in soiled newspaper that residents use to wipe their posteriors,” the service reported. “Staff use gloved hands to scoop the used paper into a wheelbarrow, which they lug to the nearby river or beach to dump its contents into the water.” Other residents prefer not to deal with all that, and instead use the beaches as public bathrooms. “Before I can take my first step into the sand [I see] the small black and brown piles underfoot,” a Providence Journal missive says. “A few yards ahead, a scattering of about a half a dozen or so small children squat, eyes towards the sea.”"
Most Ebola outbreaks to date have been smaller events, confined to rural areas. This is much different, and now that the epidemic involves a huge population center with no health care or public health infrastructure, it is hard to see how it will come under control anytime soon.

First two photos, by John Moore/Getty Images, third photo of West Point taken by me in 1983.

Monday, August 18, 2014

Emory's Ebola Unit

This NPR interview gives additional information about the unit.

Saturday, August 16, 2014

Ebola protection: How much is enough?

There's an excellent piece in today's New York Times that focuses on the key question hospital epidemiologists across the country are struggling with: what are the appropriate infection control measures to protect healthcare workers caring for patients infected with Ebola virus? We've blogged on this issue to some extent before (here and here). Are contact and droplet precautions enough (as recommended by CDC), or do we need Tychem suits, PAPRs, and fluid resistant booties, or maybe even something beyond that?

What do we know about Ebola viral disease to guide us in this decision?
  • The virus is transmitted via multiple routes: direct or indirect (fomite) contact with blood and body fluids (including urine, stool, vomitus, sweat, tears, semen, breast milk, and saliva), droplet, and fecal-oral. Airborne transmission is also possible if aerosolization occurs.
  • Healthcare workers are a major risk group for infection.
  • The disease manifestations drive transmission (bleeding, vomiting, diarrhea), leading to environmental contamination and contamination of HCW clothing, unprotected skin and mucosal surfaces. Simulated vomiting studies have shown that droplets can travel over 10 feet. The virus can remain infectious 1-2 days outside the human body.
  • Healthcare workers have become infected despite use of maximal barrier precautions.
  • If transmission occurs, the disease has a high mortality. 
  • There is no known effective antiviral therapy. Experience is too limited to understand the impact that state-of-the-art supportive care can have on improving mortality.
  • We have no post-exposure prophylaxis.

Now put yourself in the shoes of a 26-year-old ICU nurse with a 1-year-old child at home who has just been assigned to care for an Ebola-infected patient with active vomiting and diarrhea for a 12-hour shift. What level of protection would you want? It's nurses who will likely face the highest risk since they care for patients for long periods of time and have the most contact with blood and body fluids.

It's interesting in the New York Times piece to contrast the perspective of Nancy Foster, a non-HCW executive of the American Hospital Association, who works in an office far removed from the patient care setting, to that of Dr. Michael Callahan, an infectious disease specialist who has direct experience in Africa with Ebola outbreaks. Ms. Foster tells us that gloves, gown, face mask and eye protection are “perfectly fine.” Dr. Callahan notes that the "perfectly fine" strategy “led to the infection of my nurses and physician co-workers who came in contact with body fluids.” The Ebola veteran notes, “I understand the desire to maintain absolute protection in U.S. hospitals.”

How we deal with perceptions of risk is fascinating. The risks we choose to accept and those we don't can't be explained rationally. But that's quintessentially human. As I see it, healthcare workers that accept the challenge of caring for Ebola patients are providing a great service and face a level of risk that is hard to define. These brave souls deserve to have input on the personal protective equipment they wear. And if they want Tychem suits, so be it. Our job is to then ensure that they can safely use them.

Photo: Boris Roessler/DPA.

Friday, August 15, 2014

Influenza "Gain of Function" Research - Worried? Read on

Marc Lipsitch (Harvard School of Public Health) and many others are highly concerned about influenza "gain of function" research.  Recently, Marc sent around an email that I've posted below as some of you might want to support this effort. Those who would like to learn more about this issue, I suggest you read his recent NYT op-ed, which he mentions below, and also listen to yesterday's NPR Morning Edition discussion on the subject.

Dear Colleagues: 

I want to reach as many colleagues as possible about a very important issue, the growing experimental program underway at institutions around the world to create novel strains of influenza that are transmissible in ferrets, the leading animal model for human flu infection.  These so-called "gain of function" experiments create potential pandemic pathogens from virulent precursors that are not readily transmissible; as such they are a uniquely risky approach to studying influenza. A group of scientists and other concerned experts is calling for a curtailment of such experiments until a serious, quantitative, disinterested risk assessment has been performed to ask whether these experiments offer unique benefits, unattainable by safer means, that justify their unique risks. We have called for an Asilomar-like meeting to start such a process, which would include all points of view under a neutral sponsorship.

These experiments create pathogens which have the potential to spread widely if accidental infection occurs and could, in the worst case, lead to an uncontrolled pandemic. Recent events in federal labs in the US show that even in the leading laboratories, human error leads to the risk of human exposure. This is not an unusual occurrence; in the period 2004-10 there were two loss or release events PER WEEK in biocontainment labs in the US involving Select Agents. While the probability of such incidents in any given lab in a year can be estimated from available data, experiments that deliberately enhance transmissibility of influenza viruses present orders of magnitude greater risk than anthrax or wild-type, poorly contagious avian flu strains, because of the risk of transmission.

I am writing you to invite you to join the Cambridge Working Group,, by supporting our statement that these experiments should be curtailed until there is a serious, quantitative, risk-benefit analysis of what benefits are uniquely obtainable by this exceptionally risky class of experiments, and whether these unique benefits justify the risks involved. Note that we are not calling for a halt to work on dangerous pathogens in general; our call focuses on the creation of novel, transmissible dangerous pathogens, one of many techniques available for studying such organisms but a uniquely dangerous one.

The website has a link for you to add your support to that of a growing number of scientists and others, as well as several pages of links to relevant articles, press coverage and the like. For those interested, I wrote a recent New York Times op-ed on the topic. Much more detailed and technical information is available on the website.

Thank you for considering this request.


Thursday, August 14, 2014

SHEA 2015: Abstract Site Open

The planning continues for an exciting SHEA Spring 2015 Conference, which will take place May 14-17 in Orlando. The meeting will have a broader format while retaining the highly successful SHEA-CDC Certificate Training Course in Infection Prevention & Healthcare Epidemiology. New additions include a SHEA Certificate Course in Infection Prevention for Long Term Care and focused scientific abstracts related to healthcare epidemiology, including poster and oral abstract awards. The SHEA 2015 abstract submission site just opened and the deadline for submissions is January 16th. So, get excited, tell your friends and start doing science - we can't wait to see what you're doing! And remember, you can't win an abstract award if you don't submit an abstract.