When flu comes home...

This week's New England Journal of Medicine has a study that looks at transmission of H1N1 flu in the household setting. The investigators studied 216 persons with flu (index cases) and their 600 household contacts over a 7-day follow up period. The attack rate for household contacts developing influenza-like illness (ILI) was 10%. The median age of the secondary cases was 14.5 years (median age of all household contacts was 26). Risk of acquiring ILI was age-dependent (compared to adults aged 18-50 years, children 0-4 years had a 3-fold risk, children 5-18 had a 2-fold risk, while the risk for those over 50 years was one-third that of adults under 50 years). The time from onset of symptoms in the index case to onset of symptoms in a secondary case was a median of 2.6 days.

Pomegranates and MRSA

Travelling in Ohio, but had to get in a quick post to suggest what to eat in 2010. Well, not really but perhaps spread on your skin. Researchers in England have found what might be a new class of antibiotic. When mixed with a metal salt, presumably cupric sulfate, and vitamin C, pomegranate rinds have activity against MRSA and other hospital pathogens. You can read the full story in the Guardian here and look at their list of publications here. What I particularly liked is that the story mentioned that there were 20 classes of antibiotics created between 1940 and 1962 but only 3 classes in the 48 years since. I guess if NIH could increase funding for antibiotics beyond the budget dust level, we might have a chance. Hopefully other countries can step in with funding and creative science like this. That is my wish for the new year.

Media and the Public Health Response

Recently, I have become interested in how the media influences the public health response and watched with fascination as the H1N1 saga unfolded. As Mike pointed out earlier, the New York Times has written about the recent transplant-related transmission of Balamuthia mandrillaris and whether this one-off event should change overall transplantation guidelines nationwide. I hope the NY Times' assertion that patients with undiagnosed neurological conditions should be barred from donating organs is analyzed and public health officials don't make a knee-jerk decision based on immediate/transitory media attention or political pressure.

Decisions like these are quite complicated and proper analysis can turn-up unexpected findings. Two years ago, I co-authored an article in the American Journal of Transplantation with Eugene Schweizer and others at the University of Maryland that analyzed what would happen if kidneys were transplanted from donors considered high-risk for HIV or Hepatitis C, yet had tested negative. The current practice is to discard these valuable organs. Our most surprising finding was that the total number of viral infections in recipients was actually LOWER with the policy of transplanting these organs. The reason? It turns out that discarding kidneys from high-risk donors led to more time on hemodialysis which resulted in a higher Hepatitis C incidence in recipients. The transplant policy also resulted in higher quality of life and lower cost of care.

Now, the NY Times article is quite balanced, but this won't necessarily stop public health officials from making decisions before a proper analysis is completed. Let's hope cooler heads prevail before a "national policy on whether to bar people with poorly defined neurological disorders as donors" is decided by officials and not scientists. The one thing that is certain is that there is nothing harder to define than a neurological condition.

More on infections transmitted by donor organs

Over a week ago I noted the two cases of Balamuthia mandrillaris infections transmitted to two organ transplant recipients from a donor in Mississippi. Until today, the media attention had only been local. This morning's New York Times is covering this story and raises the question of whether patients with undiagnosed neurologic conditions, such as the donor in these cases, are acceptable donors or whether they should be excluded from the transplantation process.

Anthrax in the US

The Associated Press is reporting that a New Hampshire woman is in critical condition due to gastrointestinal anthrax. It is believed that transmission occurred via an African drum. Three other cases of anthrax in the US (2 inhalational, 1 cutaneous) have occurred since 2006 associated with goat hides imported from West Africa for djembe drums. Click here to hear djembe drums.

Honesty and fairness in public reporting: Some wishes for the New Year

In the latest issue of Critical Care Medicine there is a study that attempts to determine the role of cross-transmission in the development of nosocomial infections. The two-year study was performed in 11 ICUs in 2 large German hospitals. Surveillance for nosocomial infections was performed and all isolates from cultures which yielded 6 indicator organisms (E. faecium, E. faecalis, K. pneumoniae, P. aeruginosa, Acinetobacter, and S. aureus) were archived for genotyping. Also included were MRSA strains obtained from active surveillance. Over the two years, 1,216 nosocomial infections were identified. Molecular typing revealed that there were 462 episodes of cross transmission (i.e., patients shared the same strain).

What are the implications of this study?
(1) 38% of nosocomial infections had an exogenous source (the infection occurred due to an organism transmitted to the patient in the ICU). One could argue that nearly all of these infections could be prevented by better hand hygiene compliance and perhaps to some degree by reduced contamination of healthcare worker clothing (e.g., a bare below the elbow approach to prevent contamination of sleeves) and decontamination of shared patient care equipment.
(2) 62% of infections had an endogenous source (the infection arose from the patient's own microbial flora). Some of these infections could be eliminated with practices such as central line and ventilator bundles, as well as chlorhexidine bathing. However, there will always be infections in this group which are not preventable (e.g., bloodstream infections of enteric origin in the neutropenic patient). Even if 100% of exogenous and 75% of endogenous infections could be eliminated, that would still leave 15% of all nosocomial infections as non-preventable (i.e., the irreducible minimum).

So in an era of heightened transparency and accountability with public reporting of healthcare associated infections, what needs to be done? Here are my wishes for 2010:
(1) CDC needs to improve surveillance definitions to improve specificity. For example, enterococcal bacteremias in the neutropenic patient should be not classified as line associated infections since these are mostly non-preventable infections with endogenous flora.
(2) States with mandatory public reporting of HAIs need to focus on validation of data submitted by hospitals so that consumers can compare apples to apples. In an informal survey of hospital epidemiologists, I recently learned that some hospitals disregard the CDC central line associated bloodstream infection (CLABSI) definition in the case of enterococcal bacteremia in the neutropenic patient, though a strict interpretation of the CDC definition would not allow this. Were we to do this at my hospital, our CLABSI rates in the medical ICU would fall significantly since enterococci are the predominant bloodstream pathogens in that unit.
(3) CDC also needs to allow hospitals to count each central line present in denominator calculations. Currently, one line day per patient can be counted, even though patients may have more than one line present, each of which is a risk factor for infection. This overestimates the CLABSI rates in my medical and surgical ICUs by 20% and punishes hospitals who care for the sickest patients.
(4) CDC and the professional societies need to educate the public with an honest approach to the concept that most, but not all, healthcare associated infections are avoidable. Stop the APIC-driven "targeting zero" doublespeak (zero infections is not attainable but it's an aspirational goal)! It's confusing to patients, punishes the people who are working hard to prevent infections (ICPs, hospital epidemiologists and front-line providers), and undermines the credibility of ICPs in the medical community.

I still believe that public reporting is the right thing to do. But it sure would be helpful to have a level playing field.

The weekend: It's a good thing!

A new study in BMC Infectious Diseases uses data from eight European countries to model transmission dynamics of an infectious disease spread by close contact in schools. The key finding: the basic reproductive number (the number of secondary cases transmitted by a primary case in a fully susceptible population) falls about 20% on weekends when compared to weekdays.

A video worth a thousand words

This week's New England Journal of Medicine has a video using Schlieren optics demonstrating the plume created by a cough with no mask, with a surgical mask and with an N95 mask.The masks redirect the plume upward which may reduce the risk of transmission of respiratory infections.

Schlieren photography allows visualization of transparent material that is not visible to the human eye. The Schlieren photo of a cough shown here (with no mask) is from the New York Times (10/28/08) by Madeleine Robins.

Another H1N1 Vaccine Recall (FluMist)

Maryland-based MedImmune is recalling FluMist doses shipped in October and November after tests showed that it lost strength quickly after shipment. Per the CDC, this is a voluntary and non-safety related recall of 4.7 million doses similar to the one last week by Sanofi Pasteur. I know all indications are that this didn't impact the effectiveness of the vaccine, but I'm sure the anti-vaccine crowd will pounce on this and suggest that the vaccine was rushed and experimental. However, I won't glorify them by linking to them.

The revolving door syndrome

For the second time in a week, I'll refer you to an interesting piece in the blog Effect Measure.

Walter Stamm (1945-2009)

Sad news in the infectious disease world. Dr. Walter Stamm died last week after a long battle with melanoma. His mentorship and science have no doubt touched most who practice ID. He was head of the Division of Allergy and Infectious Disease at the University of Washington from 1994 to 2007. The Seattle Times and New York Times have nice obituaries.

What is happening to public health departments?

There's an excellent piece in the Effect Measure blog on the shrinking resources in state public health departments. It's sad and scary...

In the news

Just about every day, I take a look at what's appearing in the mainstream media so that readers of this blog can link to the latest, hottest happenings in the world of infectious diseases and infection prevention. Today's foray yielded a treasure trove:

• First it was Christmas decorations. Then aquariums. Now British hospitals are banning flowers on wards in the name of infection prevention. I suggest they next ban food, water, and air, since none of those are sterile either.
• Two of four patients who received organs from a patient who died at the University of Mississippi Medical Center last month have been diagnosed with infections due to Balamuthia mandrillaris, a free-living amoeba that can cause encephalitis. Both patients are critically ill. Infections with these organisms are rare, and these are the first to be transmitted via transplanted organs.
• Dr. Sidney Wolfe, the well known patient advocate at Public Citizen, has added Tamiflu to his list of worst pills. The title of the press release says it all--"Tamiflu? More like Scamiflu."
• In Scotland, three injection drug users have developed cutaneous anthrax, one of whom has died of the infection.
• Lastly, if you are planning on having plastic surgery anytime soon in Connecticut, be careful! A plastic surgeon there has been cited because inspectors found mouse poop on her surgical instruments. I didn't make this up, really! See the link here.

Spiraling empiricism

I did my residency training at the University of Virginia just before ward-based wet labs were eliminated from hospitals....so I fondly (and sometimes, not-so-fondly) recall gathering samples from newly admitted patients and carrying them around the corner to perform a Gram stain, KOH prep, wet prep, or India Ink exam. One patient in particular was very influential in my choosing infectious diseases as a career--a septic patient admitted in the middle of the night to our medical intensive care unit, for whom we made the diagnosis immediately by performing a cerebrospinal fluid Gram stain in a small lab just a few steps away from the unit. Something about the entire experience of caring for that patient, who made a complete recovery, was extremely compelling....but there were a lot of things about my training at Virginia that drew me to infectious diseases. Not least of which the fact that half my medicine ward attendings were ID faculty, beginning with Dr. Ed Hook, who was my first general medicine ward attending.

Anyway, I'm digressing terribly. This post is meant simply to direct you to this piece by Dr. Abraham Verghese, infectious diseases physician and bestselling author. The piece needed no introduction--it's great, just go read it!

Last Minute Gift Suggestions

Who has time to shop these days, with all the CLABSI tracking and public reporting. To satisfy everyone's inner geek, I've compiled a few gift suggestions. (Note: no one affiliated with this blog has any relationship, financial or otherwise, with any of the retailers mentioned or linked)

1) Giant Microbes - Cuddle up with a stuffed E. coli or even an H1N1 virus - perfect for those cold nights.

2) A Staphylococcus aureus bowtie would be nice. Look good and protect your patients. You certainly would be in good standing around here.

3) DNA Mini-Portraits - Swab your cheek, mail it in and get a beautiful picture of your DNA to share with that special significant other. Maybe you could compare a friend's DNA to your locally circulating Acinetobacter strain and marvel at the similarity.

4) Charles Darwin poster - Chicago artist Diana Sudyka has many amazing posters for sale, but none speak to the constant struggle of infection prevention more than the one of young Darwin. If we could just get bacteria to stop believing in evolution our jobs would be so much easier. Come to think of it, we might be out of work all together. Yeah evolution.

5) Finally, from Baltimore - epidemiologist JJ Furuno recently received a frog tank in the mail with everything one needs for a special frog habitat: tank, gravel, rocks, food, bamboo....and two dead frogs. He was pretty sad. We don't recommend shipping living things in the mail, but if you must, wait until summer.

Come to the Decennial!

As I type this, I’m on a conference call to review abstracts for the Fifth Decennial International Conference on Healthcare Associated Infections. Along with a tremendous slate of invited speakers, we have a record number of abstracts, including a lot of very interesting work from around the world. Now is the time to clear your schedule to come to Atlanta in March……if you miss it, you’ll have to wait another ten years!

Also, if you have some interesting, late-breaking research in healthcare epidemiology, the late-breaker abstract deadline is January 29, 2010.

Atul Gawande - The Checklist Manifesto

Dan has commented several times on Atul Gawande's New Yorker articles (here and here). As he stated, his writing is highly influential both politically in Washington and in driving patient safety. Those who like his articles and books will be excited to know that he has a new book coming out next week titled "The Checklist Manifesto." You'll be even more excited that you can hear him now on APIC's website and see him July 12th at the New Orleans APIC conference where there will be an "exclusive book signing at the premier conference for infection prevention education." I was going to comment on the fact that SHEA might be considered the premier conference by some, but then I realized SHEA's meeting will be going away in a few years, so it's probably not worth mentioning...

I'm sure we'll write more about his newest book when we've had a chance to read it. In the meantime, I will be sitting next to my fireplace hoping Santa finds it in his heart to place a copy in my stocking.

H1N1 Vaccine Recall (Sanofi Pasteur) - Swine Flu Vaccine Recall

Although not a safety-related recall, Sanofi Pasteur has voluntarily recalled approximately 800,000 doses of low-dose, thimerosal-free vaccine in 0.25 mL prefilled syringes used in kids ages 6 months and 3 years according to the CDC. The recall is for reduced potency and impacts the only vaccine type that was thimerosal-free and licensed for children under 2 years old. Kids older than 2 can typically receive the intranasal spray vaccine, which is thimerosal free. I suppose this will create anxiety. However, there is no evidence, after much study, that thimerosal is harmful. The mercury levels are far below those achieved when eating fish. Fortunately, there are declining levels of circulating 2009 H1N1 in the US, so if a child under 2 needs their first or second shot, they can probably wait until new supply arrives.

Why can't we do this in hospitals?

Wouldn't it be interesting if we could get all health care workers to wash their hands when they come to work, before lunch and before they go home? We could at least be sure that they all washed their hands 3x/day! Would it work? Who knows, but a study done in Denmark by Inge Nandrup-Bus did just that in school children ages 5-15 (AJIC December 2009) and reported significant reductions in absenteeism in the intervention school versus the control school during a wintertime 3-month pilot study.

Now, I have some issues with the methods (you can't really randomize only two hospitals, for instance), but all pilot studies can be criticized. At the intervention school all pupils were required to wash their hands when they arrived, before lunch and before they left school for home. All students in the intervention also received 2 lessons in theoretical and practical hand hygiene. Each sink hand a poster above it with proper step-by-step techniques displayed and all students were tracked for 5 types of absenteeism: URI, GI infection, skin infection, other infections and non-infectious reasons.

The multivariate analysis showed that the intervention was associated with fewer absences (0.97 vs. 1.24 periods) and fewer days missed (1.95 vs. 2.65 days). Interestingly this was seen with what can only be described as poor self-reported compliance with 19%, 31% and 9% of students in the intervention school washing their hands every day before school, before lunch and before leaving, respectively. However 52 to 69% did report compliance once in a while (around 50% of the time), so their compliance does stack up well with health care worker compliance rates.

So, should we try this in hospitals? Should we "mandate" and directly observe people coming on/off units? Should we require hand hygiene before entry into the cafeteria or on-site coffee shop?

Healthcare reform and cost containment

Back in May I flagged an article by Atul Gawande. That piece, which put McAllen, Texas on the map (but not in a good way), illustrated nicely the consequences of the perverse incentives built into the fragmented U.S. healthcare system. The article became required reading in the White House during the debate over healthcare reform.

Dr. Gawande has another article in the New Yorker this week, this one addressing strategies for cost containment. Although failure to more aggressively curb costs has been a common criticism of the current reform bills, Gawande argues that pilot programs such as those included in the bill (including one that would penalize hospitals with high infection rates) are the most promising long-term approach to cost containment and quality improvement.

He uses the history of U.S. agricultural practices as an analogy, arguing for a form of positive deviance writ large--establish small-scale pilots around the country, and expand or replicate those that are successful. The process would be guided by government but not with big comprehensive mandates.

I agree with that general approach to quality improvement and infection prevention, and I think we are already seeing how certain interventions that clearly work (e.g. the central-line associated bloodstream infection prevention bundle) are being more widely adopted. What we desperately need is more funding to quickly study competing approaches and determine what works best.

Grassroots health care reform

I know this is an infection prevention blog, despite it being only my second day on watch, but I thought I'd wade into the "controversies" end of things. My friend Cary Gross, a physician and researcher from New Haven, helped organize a grass roots event for physicians to support our patients and the Senate healthcare bill. I met with aids for Senators Dodd (CT), Mikulski (MD) and Harkin (IA) and focused on the issues surrounding the comparative-effectiveness research portions of the bill. Specifically, the proposed new non-governmental Institute which could block all funding for 5 years from researchers who attempt to publish findings that the Institute doesn't approve of. I also brought up the lack of funding for antibacterial resistance research- both drug discovery for Gram-negative rods and infection control. I'm not sure how to bring down costs in a post-antibiotic world.

At the end of the day we had a press conference with Senators Reid, Schumer, Murray and Durbin. They were all excited to hear from people that thought they were doing a good job - which they are. Cary and Stan gave fantastic speeches and I thought Stacy's comment about the 'perfect being the enemy of the good' was spot on. It looks like the bill will go to conference and there will be reform! Hopefully before the holidays...and you know, I've had patients with medical charts longer than 2000 pages, so I don't know what the big deal is.

"The Truth about Tamiflu"

A few months ago, Dan and I both blogged (here and here) about an interesting article in The Atlantic that questioned the effectiveness of the influenza vaccine. Now, the same investigative journalists, Shannon Brownlee and Jeanne Lenzer, have a new piece, "The Truth about Tamiflu," in The Atlantic. They examine the controversy about the effectiveness of tamiflu that I blogged about yesterday. Like their previous article, this one is well-written and definitely interesting.

Looking for bugs in all the wrong places

A few days ago I blogged about a hospital in England that banned Christmas decorations to reduce the risk of nosocomial infections. Now a hospital in Scotland is removing 11 aquariums for the same reason.

The end of the beginning...

...or the beginning of the end? I want to thank Dan and Mike for inviting me to join the blog. I have always enjoyed reading and occasionally commenting on their posts. This is an exciting time for infection prevention/control. For instance, the new bill (H.R. 3590) currently winding its way through the Senate contains specific language concerning AHRQ's Center for Quality Improvement and Patient Safety that requires research around practical methods to control HAIs including MRSA, VRE and other emerging infections and building capacity for patient safety research. It even authorizes appropriation of $20 million for FY 2010-2014. Given that MRSA alone is associated with 18,000 deaths/year in the US, while antibacterial resistance gets only a small proportion of the $200 million devoted to antimicrobial resistance (antiviral, anti-malarial, anti-TB and antibacterial) by NIH , more funding is desperately needed. So, as awareness and research funding increase we will have more to write about and can finally move forward from what I call the "absence of evidenced based medicine."

In the end, I hope I'm up to the task and high standards Mike and Dan have set and this is the end of the beginning. Perhaps someday we will be able to steal a phrase from Jay-Z and can say "99 problems but MRSA ain't one"

Tami-fly-by-night?

This week's BMJ contains an updated Cochrane Review on neuraminidase inhibitors for treating and preventing influenza. The journal issue also contains several other related articles, primarily focusing on the controversial aspects behind the review. The previous Cochrane Review used a meta-analysis that relied heavily on unpublished data. For the update, the Cochrane reviewers tried to obtain the primary data from Roche, but were unable to do so, and the study in question was eliminated from the new review. The review concludes that the drugs are modestly effective in the treatment of influenza and not effective at preventing influenza-like illness since only a small fraction of ILI cases are caused by influenza. In a separate publication in the same issue, Peter Doshi, one of the authors of the Cochrane review, states: "We are no longer sure that oseltamivir offers a therapeutic and public health policy advantage over cheap, over the counter drugs such as aspirin."  


So, how much money has been spent on a drug of questionable effectiveness?

Welcome, Eli!

Mike and I started this blog almost ten months ago, posting observations about infection prevention issues that we might previously have just e-mailed to each other. It has been a lot of fun so far, and for me it has been a very useful way to focus my thoughts about events and issues as they develop. We’re also happy to have gathered a small but loyal readership.

We are now very pleased that Dr. Eli Perencevich—infectious diseases physician and healthcare epidemiologist extraordinaire—will be joining us! Eli is a talented and accomplished hospital epidemiologist and investigator, and we are excited to add his fresh perspective to our humble blog!

Water

After Mike's recent posts on food safety, he asked, "What's next?" As if on cue, the NY Times has a scary front pager on the safety of our water supply. About 20% of U.S. water treatment systems have violated the Safe Drinking Water Act in the last 5 years, but only a fraction were ever fined or punished. One of the more common violations? Elevated bacterial levels.

It's worrying that one of the more developed nations in the world is having trouble supplying safe water to its citizens. The availability of safe potable water is already a global crisis that will only grow more urgent with time.

On a lighter note, learn more about the importance of safe drinking water from General Ripper.

So how bad was the H1N1 pandemic?

According to a new paper in PLoS Medicine, Marc Lipsitch's modelling estimates that among persons with symptomatic H1N1:

• 1 in 70 required hospital admission
• 1 in 400 required ICU care
• 1 in 2,000 died

With data in hand, he argues in an NPR piece that this is a very mild pandemic. Not so, says Dr. Tom Frieden, Director of the CDC. An expert in risk communication speculates that CDC is avoiding describing the pandemic as mild out of fears that vaccine uptake will fall.

Slimmer faster

As if yesterday's posting on contaminated chickens wasn't bad enough, today the Wall Street Journal reports that Unilever is recalling 10 million cans of Slim-Fast due to potential contamination with Bacillus cereus. What's next?

Carnivores beware!

Consumer Reports has released a study evaluating contamination of store-bought chickens. They tested 382 chickens from 100 grocery stores in 22 states. The results were appalling--62% of the chickens were contaminated with Campylobacter, 14% were contaminated with Salmonella, and 9% were contaminated with both organisms. So if you're gonna eat it, you better cook it well!

Influenza miscellany

Today's LA Times has an article on the effect that H1N1 influenza has had on the pork industry even though pigs haven't been part of the pandemic. On the other hand, here in Virginia, a flock of turkeys has been found to be infected with H1N1. Also in Virginia, 2 patients have been diagnosed with tamiflu-resistant H1N1, as have 2 patients at Johns Hopkins Hospital. And lastly, H1N1 has been diagnosed in a cheetah in a California zoo.

Scrooge!

A newspaper in the UK reports today that a hospital there has banned the display of Christmas decorations because they are an infection control hazard. What in the world is going on there with regard to their approach to infection control? Recall that some months ago I blogged about a phlebotomist who was fired because of a small piece of jewelry worn on a chain under her shirt on the grounds that this was an infection control risk, and earlier this week I blogged about a piece in their leading infection control publication. As I look at the news items in the mainstream media regarding infection control on a daily basis, I am struck by the fact that the vast majority are in UK publications. Clearly, the public in the UK is very interested in the topic. But you have to wonder whether some of the actions taken in British hospitals are designed more to make headlines rather than a true attempt to reduce infections.

Quieting down on the H1N1 front

Iowa has now officially moved from “widespread” to “regional” to “local” activity. As the graphs below demonstrate, H1N1 has left our state for the time being. We haven’t had a positive influenza A in our hospital lab for over 2 weeks, the percent of visits due to ILI at Iowa ILINet sites is back to near baseline, and the number of patients hospitalized for influenza has plummeted.

Ironically, it is just this week that we got our first really big shipment of H1N1 vaccine (before, it was trickling in a few hundred doses at a time). So we’ll be doing most of the vaccinating after the virus has left town…yes, a “wave number next” could come along, but I doubt we’ll see another big bump in H1N1 cases in our state during the 09-10 season.

Decisions now begin to revolve around “walking back” the H1N1 response….when to lift visitor restrictions, how to approach vaccination going forward, and when we can begin treating H1N1 like……an influenza virus.

Azoles on the farm

There’s another agricultural antimicrobial controversy brewing. This time it isn’t antibacterial use in animals, but rather the widespread use of azole antifungal agents to protect crops from fungal disease. The Science summary, here, is good, so read it for yourself (subscription required for access to full text). The bottom line: Paul Verweij's group in the Netherlands is building a strong circumstantial case that agricultural azole use is contributing to the emergence of azole-resistant A. fumigatus infections in humans.

Since I have a particular interest in antifungal resistance, I have long been following the reports from the Netherlands of azole resistant Aspergillus fumigatus infections. Our group has been doing global surveillance for azole resistance among Aspergillus for years, and it has remained very uncommon, although last year we found an apparent cluster of azole-resistant A. fumigatus (we’ll publish the details sometime soon, in collaboration with CDC investigators).

Despite my interest in antifungal resistance, I had no idea until recently that there were so many different azoles being used on crops (at least 30 are marketed for agricultural use!). Interestingly, there is little agricultural azole use in the U.S., far more in Europe and elsewhere. As most of you know, invasive aspergillosis is a devastating infection with a very high mortality rate, and the newer azoles are the drugs of choice for both treatment and prevention in high risk patients. Widespread emergence of azole-resistance among Aspergillus would be a very bad thing, indeed.

Infection control across the pond

An upcoming issue of the Journal of Hospital Infection has a perspective written by Dr. Stephanie Dancer, the journal's editor. Entitled "Pants, policies, and paranoia...," her piece examines the push in the UK to reduce infections by focusing on the role of clothing and poor hand hygiene compliance in infection transmission. Her primary argument is that these issues are distractors from the real problems that are not being addressed by the National Health Service, namely suboptimal facilities that are suboptimally cleaned and understaffed.

She, like many others, argues that no studies have demonstrated that clothing transmits infections. You can read my counterargument here, but I'll simply state that no study has demonstrated that you need a parachute when you jump out of a plane either. Absence of evidence is not necessarily evidence of absence. But most disappointing is her fatalistic approach to hand hygiene: we can't improve it, so why bother? The reality is that with a lot of work, hand hygiene can be improved (see here and here), and I think this can have a major impact on the incidence of infections in hospitals.

I don't have any first hand knowledge about the state of hospitals in the UK, but I can tell you there are many beautiful, spacious, visibily clean hospitals in the US with terrible infection control problems. While it may be true that the NHS is using hand hygiene and bare below the elbows to divert the public's attention from infrastructure problems, I still think infection control is mostly about what happens at the bedside and how well healthcare workers observe good practices.

Infections in the ICU: New data, new insights

This week's JAMA contains an important paper and editorial for all of us in infectious diseases and hospital epidemiology. The EPIC II study was a one-day point prevalence study of infections in 1,265 ICUs in 75 countries involving 13,796 adult patients.

Key findings include:

• 51% of the patients had infections (this includes both community-acquired and hospital-acquired)
• 71% of the patients were receiving antibiotics
• Gram-negative organisms accounted for 61% of the infections (up from 39% in the EPIC-I study done 15 years ago)
• MRSA accounted for 10% of infections
  

In my medical school psychiatry course, I learned that a delusion is a fixed false belief. And it's a delusion to continue to think that hospitals should fixate on MRSA and continue with a search and destroy strategy. The gram-negatives are a major threat not only because they are increasing in incidence but also because the therapeutic options are quite limited. 

Positive deviance and common sense

When I first heard about “positive deviance” (and learned that research funding was being distributed to study it), I assumed it was a new, high-level approach to quality improvement that I needed to master. But every time I read about it, or asked someone to explain it to me, it seemed very much like common sense…..empower people to change things for the better, then recognize and learn from those who succeed.

So I enjoyed this article about positive deviance from the Boston Globe, loaded with examples (several from healthcare settings). The first sentence of the last paragraph sums it up for me:

“At bottom, positive deviance amounts to simple common sense”

Many of the controversial infection control approaches we discuss in this blog are best understood as the opposites of positive deviance. I’m thinking of legislative mandates and other dogmatic, punitive approaches to infection control (e.g. legislation requiring hospitals to adopt a single approach to MRSA control, mandating an annual vaccine under threat of dismissal, etc.).

Any of you out there who consider yourselves black-belt positive deviants, feel free to enlighten me about its many complexities.

A low-cost but effective hand hygiene observation program

The December issue of Academic Medicine has a paper that describes UCLA Medical Center's hand hygiene program, which uses pre-health career college students as volunteer observers. The students are trained to use standardized tools and the program yields about 9,000 observations per year. The authors of the paper note that the advantages of the program are that it gives the students experience in the healthcare setting and its low cost ($5,000/year). Disadvantages are the lack of nighttime observations and gaps in observations when the university is not in session. Hand hygiene across the institution has increased from 50% to over 90%. Click here to view the program's website.

At VCU Medical Center we are currently in the third year of our observer program, which also relies on students (undergraduate and graduate). Our observers are paid an hourly wage, which allows us to obtain nighttime observations as well as year-round coverage. Although our program is four times more costly (still a bargain), it yields four times as many observations, and the results in improvement in hand hygiene compliance are very similar to those at UCLA.

New Jersey hospital bans neckties

Jersey City Medical Center will now prohibit healthcare providers from wearing neckties. Bowties are still allowed. From the infection control standpoint, I think banning white coats would have a bigger impact, but it's a good start to push healthcare workers to become more cognizant of the role of clothing in infection control.

More freaky feedback, please

In a post today on his “Freakonomics” NY Times blog, Stephen Dubner continues the hand hygiene discussion Mike blogged about recently. He highlights a reader comment about “closing the loop” by providing real time reminders to doctors that their hands are contaminated. I agree that providing frequent and timely reminders is a critical part of improving hand hygiene, but I don’t think it is necessary that such reminders focus solely on the presence of microbes….I (unlike some of my colleagues) believe that most physicians have accepted the germ theory of disease, and most also realize that their hands can (and do) carry pathogens that pose risks to patients.

So I think several varieties of feedback will do: adherence rates, infection rates, bedside reminders from patients, families or healthcare workers, the intermittent presence of a discreet observer, any of these will help. It is essential, though, that such feedback be provided as close to the point of care as possible (we all know how effective feedback is when given in a large auditorium or conference room!). And as for the common refrain that we’ll never achieve sustained adherence rates over 60-70%? Wrong. We have plenty of experience now that higher rates can be both achieved and sustained.

Looking for a flu shot?

If you're wanting to get a flu shot, Google has a great tool--FluShot Finder. Click here, enter your zip code, and you'll get a listing of where the seasonal and H1N1 vaccines are available near you, along with a map. Pretty cool!

Impact of bare below the elbows on hand hygiene

A new study in the Journal of Hospital Infection evaluated the quality of hand hygiene in physicians and medical students using an alcohol based product that contained a fluorescent marker, which allowed for a highly quantitative measure of surface area that was decontaminated. (I'll post a link to the PubMed citation as soon as it's available). Hand hygiene effectiveness was compared between study subjects who were bare below the elbow and those who were not. As might be predicted, there was no difference in decontamination of hands between the two groups; however, decontamination of wrists was significantly better in the bare-below-the-elbows group.

Tamiflu-resistant H1N1

Two clusters of patients with tamiflu-resistant H1N1 infections have been reported today. One cluster is in Wales, and the other is a cluster of 4 immunocompomised patients at Duke University. The Duke cases were nosocomial in origin. Very worrisome....

Move over, MRSA and VRE....

As we’ve discussed here previously, multidrug-resistant Gram negative rods (MDR-GNRs) are emerging in many hospitals as the major MDRO problem. This month’s ICHE has several interesting articles on MDR-GNRs, including another study by Erika D’Agata’s group in Boston on the high rate of MDR-GNR carriage among long term care facility residents (I previously highlighted this study by the same group). The rate of MDR-GNR carriage among residents of this LTCF was twice as high as that of MRSA (23%, vs. 11%), and VRE were virtually absent. There are other studies in this issue on KPC-producers and carbapenem-resistant Acinetobacter (both from Penn), and on Stenotrophomonas maltophilia pneumonia.

I expect (and hope) that the inane MRSA active surveillance debate will become increasingly irrelevant as more hospitals learn they can reduce MRSA without active surveillance, and as they begin facing the MDR-GNR problem….unless, of course, we all assume that the universal active surveillance paradigm is essential to controlling all of our MDR-GNRs as well! Let’s see, now all we need are simple, rapid, sensitive tests that can detect carriage of all known MDR-GNR phenotypes.

Good luck with that!

Doctors and neckties

Today's Wall Street Journal has an article on the infection control risks posed by doctor's neckties. There's not much new to be learned from this piece, except that there is another hospital in the US in addition to mine that has recommended no ties and bare below the elbows. A CDC spokesman recommends that neckties be thoroughly cleaned often. Hmm...his ties must be made of vinyl.

Occupational hazard

The Associated Press reports today that the professional association representing Santa Clauses is requesting high priority status for H1N1 vaccine for its members.

I guess we left compassion off the checklist

Dr. Dena Rifkin, a nephrologist at UC--San Diego, has a piece in this morning's New York Times that reminds us that there's more to good hospital care than appropriate documentation and following the myriad rules promulgated by regulatory agencies. She describes the hospitalization of a relative whose care met all the standards but was characterized by inattentive doctors and nurses. As she puts it, we've gone from treating patients to satisfying the system.

She writes:  "As we bustle from one well-documented chart to the next, no one is counting whether we are still paying attention to the human beings. No one is counting whether we admit that the best source of information, the best protection from medical error, the best opportunity to make a difference — that all of these things have been here all along. The answers are with the patients, and we must remember the unquantifiable value of asking the right questions."

This essay is important for those of us who work to improve the quality of health care. As a hospital epidemiologist who has spent an entire career trying to prevent healthcare associated infections, I think it is important to acknowledge that an infection-free hospital stay is not necessarily the be-all, end-all. Infection control is only one component of a successful patient care encounter, and yes, sometimes infection control is trumped by something more important to the patient.

Thanks to Dr. Rifkin for reminding us that even when every box on the checklist is ticked, it's not enough. In 1925, long before The Joint Commission came along, Francis Peabody taught that "the secret of the care of the patient is in caring for the patient." And so it was. And so it is.

More on doctors' attire

Over the past few years, I've become interested in the role of clothing in infection control and how clothing affects patients' perceptions of doctors. Two new studies in the Journal of Hospital Infection examine these topics. In the first study by C.L. Shelton et al, 100 inpatients in the UK were asked to rate the appropriateness of physician attire by examining photographs of mannequins dressed in various ways (e.g., suit and tie, dress clothes with tie but no white coat, dress clothes and tie with white coat, scrubs, jeans). No significant differences were noted except that patients did not believe that jeans were appropriate. The participants were then read the following:  "Scientific studies have shown that disease-causing bacteria can survive on items of clothing. Those items which are particularly prone to carrying bacteria include ties and long-sleeved clothes, as they frequently come into contact with patients." The patients were then asked to repeat their evaluation of attire. Scrubs were then significantly preferred over all types of formal attire.

In the second study by S. Palazzo and D.B. Hocken, 75 inpatients in the UK were surveyed regarding their preferences for physician attire. In this study, there was no educational intervention about clothing and infection control. However, 73% of patients preferred that doctors not wear a necktie and 59% preferred that doctors not wear a white coat. Scrubs were deemed appropriate attire by 83% of respondents. Interestingly, in both studies patients stated that they wanted to be able to identify doctors by their dress.

So what's the take home message? Patients get it--they want what is safest. As I have argued before, the white coat is much more about the doctor than the patient.

Tunnel vision

The Telegraph, one of the UK's newspapers, reports that hospitals there have so focused on controlling MRSA and C. difficile that infections due to other organisms are being ignored. The article points out that this has occurred because infections due to these two organisms are required to be publicly reported, whereas infections due to other organisms are not. The problem is that the others account for 80% of infections. In a 2004 paper, Martin Marshall et al describe seven adverse unintended consequences of public reporting of healthcare quality data. One of these is tunnel vision--a concentration on the issue being measured to the detriment of other important problems. This could be avoided by adopting a non-pathogen specific approach to infection control, which will reduce infections due to all pathogens transmitted via contact.

Genetically engineered viruses, distributed from the air by government officials!

Don’t be alarmed, it’s just the Department of Agriculture’s multi-state oral rabies vaccine program. Targeted to raccoons, foxes and coyotes, it involves spreading bait (fishmeal or dog food) containing hidden vaccine packets. The vaccine is a live recombinant vaccinia virus with a gene encoding rabies glycoprotein.

This MMWR report details the second human case of vaccinia infection from contact with vaccine bait. In both human cases, contact occurred after a dog got into the bait and punctured the vaccine packet. This particular case was pretty scary, given that the infected person was immunocompromised from treatment of inflammatory bowel disease.

A photo of the rash, from the MMWR report:

Swine flu mortality estimate

The New York Times reports this morning that CDC has revised its estimate of deaths due to swine flu in the US at 4,000. The revision now will make the swine flu mortality estimate more comparable to the mortality estimate for seasonal flu, which on average is about 36,000 persons yearly in the US.

Swine flu and the blood supply

The Wall Street Journal reports today that blood banks are facing shortages of blood products because blood drives have had fewer donors due to illness from swine flu. On top of that, donors are instructed to call the blood donation center if they develop illness in the few day period following donation and the blood is destroyed.

Puscast

For those of you who have long commutes or other stretches of time in which you need a mental diversion (e.g., aerobic exercise), I recommend Puscast, a bimonthly podcast which reviews the infectious diseases literature in roughly 30-minute segments. You can subscribe for free at iTunes or by going to this website. Puscast is brought to you by Dr. Mark Crislip, an infectious diseases physician in Portland, Oregon. He also writes a blog, Rubor, Dolor, Calor, Tumor, which can be viewed here.

I'll beat a dead horse...

See here for CNN's coverage of the swine flu mask debacle, which is well written and a primer for anyone who hasn't been following the debate.

More on the vaccine maldistribution problem

The Chicago Tribune reports that Wall Street banks have received H1N1 vaccine for their high-risk employees. Now we can all breathe a sigh of relief!

"Not a retraction"....the pushback

Not surprisingly, the lead author of the now-infamous mask study is defending her findings and claiming her data still demonstrate superiority of N95s over surgical masks for protection against influenza. She also claims (as does another IOM member) that this study didn't influence the IOM report.

Really? Dr. McIntyre was a member of the IOM committee, and her recent comments make it quite clear that she long ago decided which mask should be used during influenza epidemics.....to claim that the work her group presented to IOM did not influence the final report is laughable. Us infection control types might not be sharp enough to detect critical flaws in a cluster randomized trial analysis......but we're not stupid.

Mask study FAIL

This is the audio of the IDSA presentation I referred to here.

I'm pretty sure someone has presented data from the same study at ICAAC and IDSA before....but I'm not sure if anyone has ever done so and also changed their conclusion 180 degrees....and in the process influenced a major IOM report that led to a misguided national recommendation for infection prevention that resulted in nationwide shortages of personal protective equipment.

How can a single study do so much damage before undergoing peer review? Yikes.

Intermountain Healthcare

Here's a preview of this Sunday's NY Times magazine piece on the Intermountain Healthcare approach to improving health care quality, which relies upon standardization and protocol-driven approaches to care.

Posted without comment, both because I haven't finished the article myself, and because I'm on the ID consult service right now--keeping busy seeing patients who for the most part do not fit easily into any diagnostic or treatment protocol.

H1N1 infects cat

The American Veterinary Association announced today that a cat in Iowa was diagnosed with H1N1. The virus is believed to have been transmitted from an infected human in the household. The cat has now recovered.

SuperFreakonomics and the hospital epidemiologist

In their new book, SuperFreakonomics, Steven Levitt and Stephen Dubner give us their analysis of why hand hygiene compliance is poor among doctors. They cite the following reasons: the large number of patients that may be seen in a day and how busy doctors are; inaccessibility of sinks, though they note that conveniently placed alcohol-product dispensers are often ignored; perception deficit, that is, doctors believe their compliance is much better than it actually is; and arrogance. Then they put on their economist hats and talk about negative externalities. By this they mean that the doctor bears little risk personally when he or she is noncompliant with hand hygiene and thus the doctor has little incentive to comply. So far, so good. But then they downplay trying to change behavior in favor of solutions that bypass the need for change in behavior (e.g., antimicrobial impregnated products). I think the answer is both behavior change and non-behavioral solutions are required since there aren't enough of the latter to overcome dirty hands. I was particularly happy that they advised doctors to stop wearing neckties to improve infection control (though my happiness is not just infection control related). Also of note, they profile our colleague, Dr. Rekha Murthy, hospital epidemiologist at Cedars-Sinai Medical Center, and her successful program on hand hygiene.

So what's the importance of this? The economists haven't really added any new insights or solutions to the problem of healthcare associated infections. But they clearly will have impact by offering their analysis to the general public. Their previous book, Freakonomics, has sold over 4 million copies, and led to the launching of a blog with a full time editor, and a movie is in the works. How did I learn about their interest in infection control? I saw Stephen Dubner on CNN talking about why doctors shouldn't wear neckties. Interestingly, if you do a Google image search of him, you'll note that he rarely wears a tie.

Never mind!

The same authors who claimed their study results were so convincing that it was no longer ethical to recommend surgical masks for the care of patients with influenza have now admitted that their analysis was flawed, and that their study (when analyzed correctly) shows no difference between N95s and surgical masks for protection of health care workers from influenza transmission (a conclusion now consistent with the JAMA study by Loeb, et. al.).

These data were cited as being of major import in the IOM report, which of course was a major determinant in the CDC decision to stick with N95s for all care of those with ILI during the H1N1 influenza pandemic.

I wasn't at the IDSA presentation where this retraction occurred, but I imagine it involved one of the authors going up to the microphone, meekly stating, "never mind", and rushing off to catch a flight back to Australia.

Public perception of flu vaccine categories

Whatever we might be saying, this is what they are hearing (must be cartoon day today!).

Happy Halloween!

From the Columbus Dispatch

“Does the Vaccine Matter?”

Mike just blogged about this article in the Atlantic, which questions conventional wisdom about the effectiveness of influenza vaccination. I agree that the article is not to be dismissed as an anti-vaccine screed, as it balances discussions with both skeptics and high profile advocates of influenza vaccine (including Nancy Cox and Tony Fauci).

The title of the article (“Does the Vaccine Matter?”) grossly oversimplifies the question. I agree that estimates of vaccine effectiveness in the elderly are inaccurate, as they rely on imprecise outcome measures (death rates) and are confounded by variables associated both with receipt of vaccine and risk of death from all causes (see here and here for the references cited in the article).

But, as the article concedes, flu vaccine appears to effectively prevent symptomatic infection in the young and healthy. While these individuals are very unlikely to die from influenza, they are critical in sustaining influenza spread during epidemics. Blunting an epidemic by vaccinating as much of this population as possible will thereby reduce infections among the elderly and among other groups at higher risk for complications and death.

This begs the question—what is the best way to utilize a limited vaccine supply? Is it better to flood those population groups who are most likely to generate protective immunity and are most important in community transmission? Or should we concentrate on those most vulnerable to death from influenza complications, even if the effectiveness of the vaccine in that population is lower?

Flu vaccine: Too good to be true?

There's a well written, provocative article in the November issue of The Atlantic on influenza vaccination and how the evidence for its effectiveness is overstated. In the article Tom Jefferson, the head of the Vaccines Field at the Cochrane Collaboration, says "For a vaccine to reduce mortality by 50 percent and up to 90 percent in some studies means it has to prevent deaths not just from influenza, but also from falls, fires, heart disease, strokes, and car accidents. That's not a vaccine, that's a miracle." The writers describe how Jefferson has been shunned by the vaccine research community. The article has been branded by some as anti-science and anti-vaccine, but I didn't sense that. I still think the benefits of influenza vaccine outweigh the risks and continue to promote vaccination of healthcare workers, but I don't believe the evidence for effectiveness is strong enough to mandate vaccination.

More on H1N1 after seasonal flu vaccination

We’ve blogged before about the as-yet-unpublished Canadian data suggesting that prior receipt of seasonal influenza vaccination may increase risk for nH1N1 infection. Now a case-control study is out in the BMJ that suggests just the opposite—a protective effect of the 2008-09 seasonal vaccine during the early days of nH1N1 emergence in Mexico City. This study should be viewed as preliminary, given the small numbers and the case-control design. I’ve still heard no word on when (and where) the Canadian data will be published.

Anti-vaccine movement gaining strength

Click here to read a very interesting article in Wired.com about Dr. Paul Offit, the pediatric infectious diseases specialist and vaccine expert, who has been hounded by the anti-vaccine movement.

No MRSA here!

At the end of each quarter I prepare a report on HAIs in our ICUs and examine the trends. In doing so last week, I had a pleasant surprise--for the first time ever, we had no device related MRSA HAIs in any of our 8 ICUs (136 beds, >8,600 patient days for the 3-month period). Moreover, our infection rates from all pathogens was the lowest ever. Now I didn't fall out of my chair since we have been watching a progressive decrease in the rate of MRSA infections over the past several years. This decline in MRSA parallels the fall in our infection rates in general. To what do we attribute all of this? Our belief is that a strong horizontal platform of infection control with non-pathogen specific strategies has led to this success. Probably most important has been our focus on hand hygiene (median ICU rates consistently exceed 90%) and the use of chlorhexidine for patient bathing. Now one could correctly argue that our uncontrolled observations cannot establish causation. However, I think the most important and irrefutable fact is that this fall in infection rates, including those caused by MRSA, cannot be attributed to active surveillance for MRSA, since our NICU is the only ICU in which active surveillance is performed. Despite my happiness at MRSA's absence, I'll refrain from the use of words like elimination or eradication, and won't even say we got to zero, since I'm certain this crafty bug is not about to leave us alone.

Ethanol lock for the prevention of CLABSI

For those of you who are interested in ethanol lock to prevent central line associated bloodstream infection (CLABSI), there is a nice review in the November issue of Infection Control and Hospital Epidemiology. I think this is a very promising intervention that deserves further study.

Statins and surgical site infections

A large retrospective cohort study in the October issue of Archives of Surgery demonstrates that preoperative statin use was not associated with a decreased risk of surgical site infections (SSI). Patients were matched on procedure, hospital, and surgeon. However, for the subgroup of patients who did develop a SSI, the risk for death was 17% lower in those on statins. The authors of the papers note that "statins are not antibiotics." Now if we could only get our colleagues to agree that antibiotics are not antipyretics.

Shortages and Confusion

I'd say that describes it pretty well.

Vaccine mandate terminated

The New York Times has reported that New York has dropped its mandate on flu vaccination of healthcare workers, citing a shortage of vaccine as the reason for abandoning the plan.

I got nothin'

I'm too busy doing H1N1 response (it is the new Ebola!). Our community epidemic is picking up speed, so we are setting records in our Emergency Department, where 15% of the visits are now for influenza-like illness. Pages, e-mails, and drop-ins are eating up almost every spare minute for our infection prevention staff. Is [fill in the blank] an aerosol generating procedure? Why don't you have filters on the ventilator exhaust? Why won't you give the injectable H1N1 vaccine to [fill in with any person not on our current list of approved recipients]? I heard they had vaccine in [random location], why don't we have it available here? [Hospital X] is not allowing anyone under 18 to visit, why haven't we made that our policy? How come we aren't using N95s for all patient care, don't you know the CDC recommends it?

If I had time, I'd put a link here to the sound of a primal scream.

Pregnancy and H1N1

Take a moment to read an interesting story about one pregnant woman’s tragic experience with H1N1. In an ironic twist, the physical therapist helping this woman recover after her four month hospitalization also happens to be an anti-vaccine loony.

The danger this virus poses to pregnant women is impressive, and we’ve had some very frightening cases here as well. One of the many inconsistencies in public health guidance is the extent to which we go to provide a zero-risk environment for health care workers, while allowing pregnant day care workers and school teachers to continue working. Who do you think is at greater risk for H1N1 exposure?

Anyway, get them vaccinated.

High O2 and SSIs

In the October 14 JAMA a randomized controlled trial of perioperative hyperoxia failed to show any impact on the incidence of surgical site infection. 1,400 patients were randomized to receive either 80% oxygen or 30% oxygen during laparatomy and for the first two hours post-operatively. Surgical site infections occurred in about 20% of patients in both groups.

A grand celebration

Mike Edmond and Gonzalo Bearman with Dick Wenzel

Last night we celebrated Dr. Richard Wenzel's achievements as he prepares to step down as Chair of Internal Medicine at Virginia Commonwealth University. Many of his former trainees were in attendance. Widely regarded as the world's leading hospital epidemiologist, he has published over 500 papers and three textbooks, along with founding two journals. An endowed professorship has been established to honor his numerous contributions to VCU. See the photo gallery here.

I have included my prepared remarks from last night's program:

Although it may seem somewhat odd, I decided on the subspecialty of infectious diseases as a career choice when I was a second year medical student. Perhaps even more strange, I decided to become a hospital epidemiologist when I was a third year medical student. So I carefully laid out my plan to complete an internal medicine residency, fellowship in infectious diseases and a Masters in Public Health, so that I would be ready to be a hospital epidemiologist. And that's exactly what I did. Years later, when I had completed my MPH degree and was three-quarters of the way through my ID fellowship, I somewhat suddenly came to the realization that I didn't know the first thing about hospital epidemiology. So I began to ask infectious diseases physicians that I knew how I could become a hospital epidemiologist, and every single answer started like this: "there's this guy in Iowa and he wrote the book, and if you're serious about this, that is where you need to go." Less than a year later, I drove across the country and settled in to a new chapter of my life in Iowa City.

I went to Iowa City with more than a little trepidation, but based only on my brief interactions with Dick Wenzel to that point, I knew this was the right thing to do. I soon found myself part of a vibrant community of young doctors with the aspiration of becoming hospital epidemiologists, all like me, who came to Iowa City to learn from him. We were at the global epicenter of hospital infection control.

With a person as accomplished as Dick, who has a CV so large that  it requires wheels, it would be easy to say that the record speaks for itself. But that would only give you half the story. So I want to focus my comments on something known only to those he has trained, his role as a mentor.

Over the course of his career, Dick has trained 50 hospital epidemiologists who now lead infection prevention programs around the world. I suspect that all of them would describe their fellowship as a magical time--a time of exploring exciting ideas, of learning to think critically and to refine analytical skills, of feeling that you were a part of a community of scholars—past and present—all sharing the same goals. All of this was wonderfully and carefully shepherded by Dick. There was never a time when any of us ever felt that he was too busy to discuss our research. He never missed an opportunity to promote the work we were doing or to give us opportunities to share authorship with him. His enthusiasm for the work was infectious and most importantly, he inspired all of us. In his warm, encouraging manner, he made you feel good about your work while he taught you to do it even better. He handed down to us a way of thinking and approaching problems. Without question, he served all of us as the ideal mentor, and in doing so launched all of our careers. As a testament to his mentorship, when he asked me to come to Richmond and join the VCU faculty in 1995, I didn't say “yes”, I simply said: “what day do I start?” And I moved here without ever having visited Richmond previously.

There is an upside to being in the remedial program for fellows as I have been. Unlike my counterparts who all graduated and moved on, I have had the great fortune of continuing to learn from Dick for the past 17 years. And I have to say that when I think of my favorite moments of work life here at VCU, it's when just the two of us sit in his office and discuss the important issues in our field.

I think the mark of a good mentor is the degree of affection in which your trainees hold you across time and space. And by that measure, Dick is the gold standard. If you have ever attended a national or international meeting with him, you quickly see that he holds rock star status, as a crowd of people persistently follow him through hotel and convention hall lobbies.

Now tonight is a wonderful night to celebrate Dick's many achievements, but we would be remiss if we stopped there, because JoGail has been so much a part of all that he has done. She has been instrumental in helping fellows and their families not just move to and settle into a new part of the country, but in many cases to a brand new continent. She has a special ability to relate to and understand people. Her warmth and sincerity make all who meet her feel immediately at ease. Together JoGail and Dick have so graciously welcomed all of the fellows into their home and their family.

And so Dick and JoGail, on behalf of all the fellows that you have mentored, I'll leave you with the elegantly simple words of Sebastian from Shakespeare’s Twelfth Night:  I can no other answer make, but thanks and thanks and ever thanks.

More on vaccine mandates

There is one issue that we haven't discussed previously. Almost all of these mandates for influenza vaccination have been promulgated after the seasonal vaccine was produced for the upcoming season. Hospitals place their order for seasonal vaccine in the spring, which means that the supply of vaccine will not be sufficient where the late mandates have occurred. I don't think that will be an issue for the H1N1 vaccine since there appears to be low interest, at least among healthcare workers.

Judge nixes NY State flu vaccine mandate, for now

NY times report here. We've blogged about this several times, and I have work to do, so no further comment....

OSHA places health care workers at risk

Here is OSHA's statement on "H1N1 related inspections". By encouraging (i.e. requiring) hospitals to use their existing N95 supply for all contacts with probable H1N1 patients (as recommended in current CDC misguidance), they are increasing the likelihood that N95 masks will not be available when they are really needed to protect health care workers.

Stupid

To quote David St. Hubbins, "it's such a fine line between stupid, and clever." I'm listening right now to the CDC conference call on their new infection control guidance, and I reluctantly conclude that they've crossed that fine line. This is stupid.

How much actual, front-line, hospital-based infection control experience do these CDC, OSHA and NIOSH experts have? And to paraphrase an e-mail I recently received from a colleague: "when did influenza become Ebola?"


Addendum: See below for excerpts from SHEA's response, with which I agree:

Scientific Community Urges Thoughtful Application of New CDC Guidelines Regarding H1N1 Prevention and Protection Procedures

Infectious Disease Experts Express Concern over N95 Recommendations; Support CDC’s Call for Multipronged Approach

Today’s announcement by the Centers for Disease Control and Prevention (CDC) that it is modifying its guidance regarding measures that should be taken by healthcare workers who are in contact with either confirmed or suspected cases of H1N1 was met with concern by the scientific community that had submitted its recommendations to CDC.

CDC emphasizes a multipronged approach to protecting healthcare workers from H1N1, including priority use of N95 fit-tested respirators. The Society for Healthcare Epidemiology of America (SHEA) had urged CDC, based on clinical experience and scientific evidence, to remove the use of N95 respirators from its recommendations for routine care in favor of the first-line use of surgical masks, as one component of a cadre of prevention measures. Instead, N95 respirators should be reserved for procedures associated with a higher risk of aerosolization of the virus.

“Our position was and continues to be that N95s are neither necessary nor practical in protecting healthcare workers and patients against H1N1,” said Mark Rupp, MD of the University of Nebraska Medical Center and President of SHEA. “The best science available leaves no doubt that the best way to protect people is by vaccinating them.”

The scientific community acknowledged that the CDC came under intense pressure from labor unions to recommend the use of N95 fit-tested respirators despite the fact that respirators do not provide any added protection in clinical situations against droplet transmissible diseases such as H1N1. SHEA, whose membership is comprised of doctors and nurses on the front lines caring for patients with the flu, emphasizes the concern that continuing to recommend that respirators be used in routine care has major implications for both patient care and healthcare worker safety. “We could actually put healthcare workers at greater risk by further reducing an already short supply of a device that is needed for high-risk procedures such as bronchoscopy by using it for routine care,” said Rupp.

.....“unfortunately this debate on respirators versus masks has distracted hospitals and clinics from investing in efforts that we know will pay off such as rigorous and consistent application of basic infection control and personal hygiene practices including adherence to cough etiquette and hand hygiene, rapid identification and separation of patients with the virus, and excluding sick workers and visitors from the hospital.”

New H1N1 infection control guidance from CDC

The CDC will soon issue updated infection control guidance for nH1N1 in health care settings. Details of the impending conference call are here:

The Centers for Disease Control and Prevention (CDC) and the Department of Labor would like to invite you to join them on a conference call to update and inform stakeholders about the release of the revised 2009 H1N1 Influenza: CDC Guidance on Infection Control in Healthcare Facilities. This conference call will have speakers from the CDC, National Institute for Occupational Safety and Health (NIOSH) and Department of Labor/Occupational Safety & Health Administration (OSHA). Speakers will address various topics related to updated recommendations in this guidance. Call information is provided.

What: Conference Call/Information Sharing Session
Date and Time: Wednesday October 14, 2009 at 1:00 PM ET
Speakers: representative from CDC, NIOSH, and Department of Labor/OSHA
Call-In Number: 888-283-2960
Passcode: 7113863

Please note that there will be a question and answer session following speaker
presentations. The revised 2009 H1N1 Influenza: CDC Guidance on Infection Control in Healthcare Facilities will be available following the conference call on the CDC H1N1 Flu Website at http://www.cdc.gov/h1n1flu/guidance/.

Expect the new guidance to be mostly the same as the old guidance, but to allow some "wiggle room" for hospitals to use surgical masks instead of N95s in order to preserve N95 masks for aerosol-generating procedures, TB control, etc.

The only reason to care about this is if you are in a facility or state that is bound by CDC guidance. We already follow the Iowa Department of Public Health guidance, which mirrors that of the World Health Organization. Oh yeah, the other reason to care is if OSHA decides to enforce the CDC approach and to punish hospitals that have chosen reasonable and feasible alternatives. As described above, an OSHA representative will be on the call.

Whoa!

A new commentary in BMJ's Clinical Evidence challenges the dogma that seasonal influenza is a relatively common infection. The author uses data from the control arms of 95 influenza vaccine trials involving 1 million subjects over the course of four decades to demonstrate his point. The bottom line is that 7% percent of the population will develop influenza-like illness (ILI) yearly; however, only 7% of the group with ILI actually have influenza, with the remaining 93% infected with other pathogens. So doing the math (0.07 x 0.07 x 100), you can see that only 0.5% of the population develops influenza yearly. To be clear, these data are for seasonal, not pandemic, influenza, so we would not expect these data to be applicable to the current situation in the US. Nonetheless, I'm astounded by this analysis.

Does anyone want this vaccine? Anyone? Anyone?

Mike has already mentioned the reluctance of both health care workers and general public to receive the nH1N1 vaccine. We’ve received the live attenuated version only so far, and I can tell you that we are having a very hard time giving it away to our health care workers. Among those eligible for the nH1N1 LAIV, there is very little enthusiasm and a lot of unfounded fear. Yes, we need to do a better job of combating misinformation, but the level of sheer BS circulating about this particular vaccine is breathtaking.

There is an interesting piece in Slate that documents the bipartisan nature of the balderdash. My favorite examples are: that the government is using the H1N1 scare to implant microchips in our bodies, and that the vaccine contains a “Bible Code” connecting the pandemic to the Book of Revelation.

Refreshing

It is always reassuring to see an infection-related Op-Ed in the NY Times that (a) is written by a non-crazy person, and (b) seeks to dispel, rather than stoke, irrational fear.

On an related note, a bunch of early release papers out from JAMA today on nH1N1 in critical care.