Getting Less for More

There’s an excellent piece in this week’s New Yorker, by the surgeon-author Atul Gawande….must reading during the ongoing debate about healthcare reform. Gawande uses real life examples from a Texas community to illustrate just how broken our healthcare system is. The larger points of the article aren't exactly new, but the way he addresses them makes them very accessible. Go read it for yourself.

PPIs: The Dark Side

Two new studies add two more infections to the list of those that are associated with the use of proton pump inhibitors (PPIs). Previous papers have shown that ventilator-associated pneumonia, community-acquired pneumnonia, and Clostridium difficile associated disease are associated with PPI use. The large cohort study in today's JAMA found that PPIs were associated with a significant increase in the rate of hospital-acquired pneumonia in non-ICU, non-ventilated patients. And this month's American Journal of Gastroenterology contains a study showing that PPIs are associated with a higher rate of spontaneous bacterial peritonitis in patients with cirrhosis. Given the mounting evidence of risk for infection, coupled with the high frequency of use in hospitalized patients (the JAMA paper found that 52% of inpatients were prescribed PPIs), hospitals should probably begin to restrict the use of these agents.

Another reason to be a vegetarian

I just finished reading The Face on Your Plate, a book by Jeffrey Masson that explores the impact of eating meat on the environment, the cruelty the animals endure, and the denial that humans continue to exhibit with regard to all of this. He notes that the intense animal production by huge agribusiness is linked to zoonotic diseases, including new strains of influenza. The specific link to H1N1 influenza is outlined in an interesting article in The Guardian last month by Mike Davis. Although H1N1 has received a huge amount of media attention, this aspect of the story has seen little coverage.

What would Freud think?

In earlier postings here and here, I've discussed the incongruent nature of the actual risks of adverse events and the perception of those risks widely held by the public--more fear of plane crashes than automobile accidents, more fear of pandemic flu than seasonal flu, etc. This is the subject of a new book, Panicology, by two statisticians, Hugh Aldersey-Williams and Simon Briscoe. Of note, the book includes a section on hospital acquired infections. The authors postulate that the fear of HAIs and interest in the topic by the public may actually be the manifestation of a deeper fear, the fear of hospitalization itself. This is an interesting theory. Despite working in infection control for nearly two decades, I had never thought of that possibility.

How about a flu-free vacation?

According to today's New York Times, it's a great time to travel to Mexico. Discounts and upgrades at Mexican resorts are impressive. There are even flu-free guarantees. One resort chain is offering to pay the medical bills and give a free future vacation to anyone who develops influenza within 7 days of staying at its resorts. Another is offering three free future vacations to those who get infected.

When infection control and religion collide

The BBC News reports today that a healthcare worker in the UK is facing disciplinary action because she wears a cross around her neck on a chain, which is reported to impose an infection control risk. This is not the first time that infection control and religion have crossed paths in the UK. Last year a female Muslim healthcare worker was fired becaused her faith does not allow women to show their arms in public and her long sleeves violated the hospital's bare below the elbow policy. While the UK's serious attitude about infection control is noteworthy, the actions beg the question as to whether some reasonable accomodations could be made for observant workers (e.g., plastic isolation gowns for patient contact, ensuring that necklace chains are short to prevent jewelry from coming into contact with patients). If the UK's National Health Service continues its strident approach, then infection control will have become a religion unto itself.

WHO rewrites the rules

We’ve blogged about this before, but it now appears that WHO will soon be incorporating disease severity and potential harm into their global alert system.  From today’s NY Times article:

Dr. Keiji Fukuda, the deputy director general making the W.H.O. announcement, said that he could not predict exactly what the new rules would be but that criteria would include a “substantial risk of harm to people,” not just the geographic spread of a relatively benign virus.

In case you mist it.....

Two articles and an editorial in the June issue of ICHE discuss the use of hydrogen peroxide (vapor or mist) in hospital room disinfection. The hydrogen peroxide systems are appealing—the by-products, water and oxygen, are harmless, while H2O2 itself is sporicidal (i.e. kills C. difficile) and effective in eradicating other nosocomial pathogens from environmental surfaces.

The main drawback, besides the added cost, is feasibility. There are two systems (vapor and “dry mist”), and the vapor apparently requires that the room be sealed (doors, windows, ventilation ducts, etc.) during application. The Rhode Island group reports that H2O2 vapor decontamination required a mean of 2 hours and 20 minutes—not an appealing prospect for hospitals that run at or near capacity and for which short room turnaround times are critical.

Quote of the day

From a teenager whose school in Queens is closed due to H1N1, interviewed at a shopping mall: "I'm still kind of sick (cough), but I wanted to come and hang out."

Improving hand hygiene in the OR

A study in the May issue of Anesthesiology reports on a small trial of a personal hand hygiene device by anesthesiologists in the OR. The small alcohol dispenser attaches to clothing and contains a microchip that time stamps usage and emits an audible signal every 6 minutes from the last usage to remind the wearer to wash up. Hand hygiene increased 27-fold and significant reductions in bacterial contamination of the anesthesia cart and peripheral IV tubing were documented. Any way that we can harness technology to increase hand hygiene seems like a good idea to me.

H1N1: Not going away without a fight

As I walked from the ASM General Meeting to my hotel room a couple days ago, I noticed that our novel H1N1 was having a brief media resurgence—CNN and MSNBC were on in the hotel bar, broadcasting alarming new stories about what might happen if the WHO moved to “level 6” on the pandemic scale, and discussing more school closures in New York.

Meanwhile, the CDC is confirming something I blogged about earlier—those over 50 years of age appear to have some protection against this virus, presumably due to exposure to H1N1 strains circulating until the late 1950s. 

Finally, the weekly report on influenza and pneumonia mortality reveals…….nada.  The influenza and pneumonia mortality in 122 U.S. cities has still not reached epidemic threshold.  What does this mean?  For starters, it means that if this novel H1N1 introduction had happened 10-15 years ago, we probably wouldn’t have even detected it.

Quote of the Day

“The Hajj will take place, it’s not like a…Pink Floyd concert.”

That quote, by our friend and colleague Andreas Voss, is from an interesting news piece looking ahead to the Hajj and the potential impact it could have on the spread of the novel H1N1 virus. Ideally, a vaccine will be available by then.

It’s no coincidence that Andreas chose Pink Floyd, a band that foresaw the ominous role swine would play in the future in their song “Pigs on the Wing” from the Animals LP.

That said, I certainly wouldn’t cancel a Pink Floyd concert for this virus.

I’m at the ASM meeting in Philadelphia, and I should note that I haven’t seen a single person yet with a mask on (Neil Fishman, who gave a great talk on antimicrobial stewardship this afternoon, said he saw one person wearing a surgical mask). Our division (nosocomial infections) has another symposium tomorrow afternoon on MRSA—Mike Edmond will be talking about MRSA in the ICU, Mary Claire Roghmann will cover long term care, Jeff Bender the veterinary angle, and Loren Miller will talk about community MRSA. Should be a great session.

The CDC, the states, and credibility....

Yes, I’m posting again about the CDC’s seeming inability to back down from an unreasonable and unsustainable infection control guideline for the novel H1N1. Why, you might wonder, should I care about this any longer? After all, the Iowa Department of Public Health has now joined Minnesota in adopting the WHO approach to preventing transmission of H1N1 in healthcare facilities (droplet + standard, with N95s for aerosol-generating procedures). So we’ve used that guidance to support a change in approach at our university hospital.

However, we have a university-affiliated VA as well. As our VA hospital epidemiologist, I’ve recommended we take a consistent approach to this at both hospitals (since many of our clinicians see patients in both facilities). Today I’ve been told we can’t do that—as a federal facility, we are bound to follow the CDC guidance. So now we have two very different approaches to prevention of H1N1 transmission in our two hospitals, a less-than-ideal situation.

I understand that CDC may be having a push-and-pull with OSHA on this, and feels obligated to fully investigate instances of healthcare worker infection with novel H1N1 before they change their guidance. But what will they possibly learn from healthcare worker H1N1 cases that will provide the evidence they seek, when we know that the use of N95 versus standard surgical masks to prevent pathogen transmission is not evidence-based to begin with? Sigh.

I believe that the CDC response to the novel H1N1 has been excellent overall—rapid, transparent, and calibrated over time to reflect new information as it is available. On this point, however, the CDC risks losing some credibility—once state departments of public health lose patience and begin to change to the WHO guidance, as is currently happening, the CDC looks increasingly out of touch with what is happening on the ground

CDC guidance on respiratory protection: Still missing the point

This evening, CDC updated its recommendations for H1N1 infection control in healthcare facilities. However, CDC continues to recommend N95 masks for the care of confirmed, suspected or probable novel H1N1 influenza cases. As I noted in an earlier posting there is a shortage of N95 masks which prompted us to change our recommendation to droplet precautions, and as Dan noted, some states have now recommended the use of standard surgical masks. CDC has added that "facilities should implement plans to ensure appropriate allocation of personal protective equipment, including N95 respirators, and antiviral medications." That's easier said than done if you follow CDC's recommendation to continue to use N95 masks.

Every ten years....

...there is a "Decennial Meeting" devoted to prevention of healthcare-associated infections, co-sponsored by CDC, APIC, SHEA, and IDSA.  I'm heading to Atlanta today to attend a planning meeting (provided my flight leaves--I hear thunder as I'm typing this).

With dwindling travel budgets, increasing (and appropriate) restrictions on industry-medical society relationships, and in the age of webinars and video-conferencing, I wonder if the Decennial should be our new model for professional society meetings.  Maybe every 10 years is too infrequent, but do we really need to meet each year?  Moving first to every other year might be sensible, with societies working together to coordinate schedules (for example, SHEA and APIC alternating, IDSA and ICAAC alternating, or ICAAC and ECCMID).  This would probably increase the attendance at each meeting, as attendees would no longer have to choose one meeting over another.

Anyway, if I do get out of rain-soaked Iowa to Atlanta for this planning meeting, I'd be happy to pass along any ideas for speakers and/or sessions for the Decennial meeting in 2010.  Just leave them in the comments section.

Empty laboratories?

The Wall Street Journal reports this morning on the national shortage of laboratory personnel. It notes that Vanderbilt University had to pull staff from other parts of the hospital and have technologists work double shifts in order to manage the influx of testing for H1N1 influenza. The report cites the salary disparities with nursing as one of the reasons for the shrinking workforce of laboratory workers.

Crackdown on conflicts of interest

The medical news section in this week's JAMA focuses on industry funding of professional medical associations. It reports that Senator Charles Grassley is interested in these conflicts of interest and specifically notes that he has been in contact with the American Psychiatric Association and the American College of Cardiology regarding his concerns. The writing is on the wall. Professional associations can no longer enjoy the largesse of industry. And once they cut the cord, we'll all be better off.

Help!

If there is anyone out there who thinks they understand the Joint Commission's National Patient Safety Goal on multidrug resistant organisms, please let us know. We really worked on it today, but you get the feeling that it was written by someone with fluent aphasia. You read a sentence and the words sound good, but then as your brain processes it, you have the uncontrollable urge to say "huh?"

H1N1 in Mexico City

Here is a link to a piece by Dr. Richard Wenzel that appears on The Huffington Post with more details on the H1N1 epidemic in Mexico City.

Charts and Graphs

I’ve pasted a couple graphs below, from the CDC’s surveillance report for influenza (the data are 1-2 weeks behind, ending the week of May 2nd). If you look at the first graph, it appears we’ve had a massive increase in influenza. This represents increased testing in response to concerns about H1N1 spread, as is reflected in the big jumps not only in the novel H1N1, but also in the other circulating strains of influenza A and B. In fact, the majority of the positive tests constitute influenza strains other than the novel H1N1. The other chart shows that influenza and pneumonia mortality remained below the epidemic threshold. I expect, and hope, that it will remain below the epidemic threshold through the end of this flu season.


In other news, I expect that Iowa will soon join Minnesota and adopt infection control recommendations that reflect the WHO guidance, rather than that of CDC. As Mike pointed out previously, CDC really needs to update their interim guidance on this—too many hospitals are running short of N95 masks, and now that basically anyone in the U.S. with fever (or no fever) and cough has suspected H1N1, requiring N95s for patient contacts is not sustainable.

Mandatory reporting of HAIs

Today's Denver Post has an article on public reporting of healthcare associated infections by local hospitals. It's a balanced report. The positive effect of more interventions to reduce infections is noted. On the other hand, the report also notes problems such as validity (can we believe that a hospital had no infections?) and misclassification (some patients with prosthetic knee infections had traumatic injuries outside the hospital setting), and questions whether patients are actually using the data.

A hotel with really bad karma

It was widely reported that after a man from Mexico staying at the Metropark Hotel in Hong Kong was recently diagnosed with H1N1 influenza, the 280 guests and employees at the hotel were quarantined for a week. The Independent, however, takes the story a step further. It turns out that the Metropark was formerly known as the Metropole Hotel, which became infamous, at least in epidemiologic circles, for being the epicenter of the SARS epidemic in 2003. If you're planning a trip to Hong Kong soon, better note the hotel address because I suspect another name change is coming soon.

Blackmarket Tamiflu?

Like many hospitals, we have restricted use of oseltamivir to patients meeting predetermined criteria. However, I heard today that the drug could be purchased on eBay. I went to investigate the rumors and found that as of this evening there was no tamiflu for auction on eBay. There were, however, 2 Tamiflu pens available for immediate purchase at $9.99. A little overpriced, don't you think?

Postcard from the epicenter #3

More from Dr. Wenzel in Mexico City:

Getting ready to return to Richmond. Schools in Mexico City open on Monday but in other cities where cases are increasing, they are waiting another week. The "no wearing a tie" rule anywhere in Mexico City is still in effect. Not sure of its origin or basis. To get to the ticket counter I had to fill out a form re: respiratory symptoms and then had to stand on a special area for remote temperature that registers on a huge screen on the side. Traffic is still only half of its usual and the restaurant this morning was mostly empty.

Pandemic alerts and disease severity

In a previous post, I asked whether the term “pandemic” should be used to describe any epidemic with global reach, regardless of the severity of disease manifestations. Tomorrow's NY Times has a front page article quoting several public health leaders addressing the same issue. To quote the article:

"Many predicted that [WHO] would find some way to reflect the severity, and not just the geographic reach, of a new threat."

Boys will be boys OR Swine will be swine

The LA Times reports that Hector Reynoso, a professional soccer player for Guadalajara's team, is in big trouble. Reynoso spit and released nasal secretions at the face of an opposing team member, Sebastian Penco, then claimed to have swine flu. He subsequently apologized but his punishment is pending. So what's an appropriate punishment for faking swine flu?

Pet therapy & human pathogens: Bad combo

A study by Dr. Scott Weese, a specialist in veterinary nosocomial infections at the Ontario Veterinary College, evaluated 26 pet therapy dogs to determine whether contamination with human pathogens occurs when the animals are brought to healthcare facilities. He found that two of the dogs became contaminated--one dog had contamation of the paws with C. difficile and the other had contamination of the fur with MRSA. This raises the question of whether the dogs should be bathed after contact with patients in healthcare facilities.

Postcard from the epicenter #2

More from Dr. Wenzel in Mexico City:

I made rounds on wards for H1N1 and in the ICU today. I saw some very sick patients- on respirators-and the very ill have a brief course to ARDS. I still don't know why the clinical difference here and home. But this virus can be virulent. The cases nationally are declining and less so at the referral centers. The worries here include what happens as it enters rural Mexico. Cases are up in some cities. More to come.

Postcard from the epicenter

My colleague at VCU, Dr. Richard Wenzel, arrived in Mexico City yesterday to consult with the Mexican Ministry of Health on the influenza epidemic there. In a short email from him late last night he wrote:

Only 15 percent of seats filled on the flight from Atlanta to Mexico City, and the airport is almost empty. All waiters wear masks, and at dinner I had to have a skin probe to measure temperature and hands out for alcohol. But shops are beginning to open up.

A swine flu free posting!

For the last week we've all found ourselves immersed in swine flu. I don't know about you, but I'm having swine flu fatigue. I'm starting to believe it would be fun to think about MRSA again, or maybe Acinetobacter. As bad a bug as it is, there's been no emergency meetings, daily briefings or calls from the local media about Acinetobacter. So I thought I'd find you something tonight to take your mind off of H1N1.

Take a look at this recent article by Dr. Kent Sepkowitz in the online magazine Slate. In a piece that's both funny and factual, he describes how the New York Yankees have decided to coat their locker rooms, training rooms, showers, and coaches offices with an antimicrobial substance, and points out the folly of this endeavor. Although you will see his writing frequently in Slate and the New York Times, in his day job Kent's a card-carrying hospital epidemiologist who works at Memorial Sloan-Kettering Cancer Center in Manhattan.

Are MRSA infections more costly?

How much extra cost, morbidity and mortality are attributable to antibiotic resistance?  The conventional wisdom is: “a lot”.  However, those most likely to develop serious infections with resistant pathogens are usually much sicker than those infected with susceptible bugs.  I’m not sure that our traditional ways of “adjusting” for these differences are adequate.  Nonetheless, the most extreme estimates of worse outcomes are always cited (including by me!).  Len Mermel’s group in Rhode Island have an interesting paper in this month’s issue of ICHE that points out how difficult it can be to adjust for differences in population characteristics when comparing cohorts infected with susceptible versus resistant pathogens.  They examined 182 patients with S. aureus bloodstream infection, comparing those with MRSA versus MSSA infections.  Using standard multivariable regression analysis, hospital costs and lengths of stay were higher for the MRSA cohort.  However, when they used a propensity scoring method, there were no differences noted in costs or lengths of hospital stay.

Better guidance needed from CDC on respiratory protection

CDC continues to recommend contact precautions plus the use of N95 masks for the care of patients with suspected or confirmed H1N1 influenza. However, we have received noticed from a major manufacturer that the demand for N95 masks is outpacing the supply. Thus, we are not able to obtain any additional supply over our usual allotment and our inventory is falling. Better guidance from CDC is sorely needed. The WHO continues to recommend standard plus droplet precautions except when an aerosol generating procedure is performed, for which an N95 mask should be worn.

Sorry, kids.....

Mercifully, the CDC has provided more guidance on school closures. Kids everywhere will be disappointed, and we won't have a chance to study the burning question: does H1N1 spread faster at school, or at the mall?

H1N1 Predictions

I've been making my own predictions about the future of the virus-formerly-known-as-swine-flu, but that's an N of just one. For wisdom from the crowd, visit the Iowa Electronic health Market's H1N1 prediction market. How long will the outbreak last? In how many states and countries? If you think you have some wisdom to share, and you are in the clinical, public health or animal health arena, play the market yourself.

Freaked out on flu

In the car last night I heard an interesting interview on NPR with Dan Ariely, a behavioral economist at Duke and author of the book Predictably Irrational. He explains why we worry more about improbable events than those more probable (for example, worry more about terrorism than automobile accidents or worry more about swine flu than seasonal flu). You can listen to or read the interview here.

Hand hygiene & X-ray techs

A new study in Chest documents abysmal hand hygiene compliance by x-ray technicians in the ICU setting and high rates of contamination of the x-ray machine with nosocomial pathogens. It made me recall my days as a medicine resident in the ICU when the x-ray tech made early morning rounds and went from patient to patient throughout the ICU. The authors point out that x-ray techs are often not involved in the ICU's educational activities. Although it's a single center study, it does remind us of another thing to think about when we see transmission of nosocomial pathogens in the ICU.

Help! I can’t stop blogging about H1N1….

Over the next few days, H1N1 will be confirmed in all 50 states. Later today, the CDC will begin posting “probable” as well as “confirmed” cases (since 99% of “probable” cases are confirmed), and soon thereafter there will be too many cases for CDC to continue to count and report each case. This will allow them to go back to the mechanisms they use to track seasonal influenza activity. I like the shift away from identifying/tracking every case.

Next we’ll need stronger guidance about testing and treatment—both of which should be reserved for those with severe illness and for those at highest risk for the complications of influenza.

Also of interest: two lines of evidence (early in vitro data from CDC labs, and the age distribution of current H1N1 cases) suggest that those over 50-60 years of age may have partial protection against this H1N1. Not enough data yet to make definitive statements, but if these observations are borne out it will help explain some of the features we’ve seen so far (especially the low case fatality rate, given that “age over 65” represents the biggest category of those at risk for complications of influenza).

Where's George?

There's a nice article in today's NY Times about Dirk Brockmann's group at Northwestern, and how they have used data from the "Where's George" currency tracking project to inform their models for spread of infectious diseases, including the 2009 H1N1.  Dr. Brockmann spoke about his approach at SHEA 2009 in San Diego, and it was a terrific and informative talk.

Ethanol lock: A promising intervention

A new study from France evaluated the utility of ethanol lock on eradication of biofilms due to S. aureus, S. epidermidis, P. aeruginosa, and C. albicans in an in vitro model. A 20-minute treatment was shown to eradicate gram-negative and C. albicans bioflims, whereas a 30-minute treatment was required to eliminate gram-positive biofilms. We have previously found ethanol lock to be clinically effective in reducing bloodstream infections in a small observational study of adult patients requiring long-term TPN and a similar study has shown promising results in children on long-term TPN. Studies in the inpatient setting to evaluate ethanol lock on reducing central-line associated bloodstream infection are warranted.

Not H1N1

Contrary to popular belief, 2009 H1N1 isn’t the only, or even the most common, virus causing respiratory illness in the U.S. right now. Viral diagnostic testing is not usually performed on patients with mild respiratory illness—that’s different now, so it's interesting to see what else (other than H1N1) is out there. A question to that effect was posed on the “ClinMicroNet”, a listserve for directors of clinical microbiology labs across the country. So here is a quick summary list of what labs across the country are finding in the samples collected from patients feared to have H1N1 (in a rough order of frequency): parainfluenza, usual seasonal influenza (mostly H3N2 and influenza B), adenovirus, rhinovirus, enterovirus, respiratory syncytial virus (RSV), bocavirus, and human metapneumovirus.

Putting H1N1 into perspective

For the first time in several days, this morning's New York Times had no story about H1N1 on the front page. However, inside there's an interesting piece by Jim Dwyer that puts H1N1 influenza into perspective from a public health standpoint. According to the CDC website, we have now had 160 confirmed cases of H1N1 influenza with 1 death in the US. While this is an important health problem, Dwyer's column notes that there have been 14 shooting deaths in schools since August, and 13,000 people have died from seasonal influenza this year. Although Mexico has had 25 deaths from the new flu, last year there were 6,000 deaths related to drug violence.

Mapping the Snoutbreak

For those of you who haven't already seen it, this Google map of the H1N1 is pretty impressive, combining media accounts and details with cases as they occur.

And I'm happy to announce that non-H1N1 blogposts will begin again soon!

The Great Foot Fungus Pandemic of '04

If H1N1 continues to spread but the disease remains relatively mild, with low mortality rates (as we hope it will), can we still call it pandemic? WHO says yes.

Breaking News

Media blames media for overreaction to H1N1.

“I guess everything has to have a name”

So said Texas pig-aficionado Kyle Stephens, regarding our new epidemic influenza strain.  Now, it appears, there is finally agreement upon what that name will be:  Influenza H1N1!  Both CDC and WHO have adopted this language.  A longer descriptive version for use in polite conversation is, “this new H1N1 of swine origin”.

So where are we now, with this new H1N1?  More states and countries report confirmed cases each day, and over 90% of new cases are no longer linked to other confirmed cases.  This means the virus is widespread in the community, there are many folks shedding virus with mild symptoms, and the time is approaching when we need to manage this like any late-season influenza epidemic.  Freaking out about each new case, asking people with mild-moderate symptoms to come in for testing, trying to trace contacts, all these exercises are increasingly futile.  We should focus instead upon community mitigation strategies that emphasize common sense infection control to limit spread (hand hygiene, “respiratory etiquette”, staying home when sick), and prophylaxis of those at high risk for complications of influenza who have been (or are likely to be) exposed. 

I’m sticking with my earlier prediction that this will amount to a notable late-season epidemic that will burn itself out over the next few weeks, causing a lot of cases and some deaths, but that will not become the great global pandemic of 2009.  Others concur (but “quietly”, so as not to be seen taking this too lightly!).