Friday, July 31, 2009
Wednesday, July 29, 2009
Looks like IOM is now going to weigh in. You can find their project scope (or “charge”) here, along with links to the committee membership. The project specifies “novel H1N1”, but that seems very silly to me. No robust data exist to suggest that transmission of the novel H1N1 differs in any substantive way from that of seasonal influenza. So any conclusions or recommendations that come from this committee should be applicable to all influenza viruses, not just the “novel H1N1”.
The ad hoc committee has to report its findings to CDC by September 1st. So what do you think the likelihood is that we’ll be using N95s for care of all patients with seasonal influenza, every year?
Tuesday, July 28, 2009
Monday, July 27, 2009
One segment of the show hits pretty hard, and is directly relevant to health care reform—it covers, in a very moving way, the health insurance industry practice of “rescission”. For those of you who live in a developed nation with a sane health care system, “rescission” is a practice whereby an insurer can revoke your health care insurance policy after you become ill, based upon a careful review of your application for any evidence (even minor, technical evidence) that you incorrectly or inaccurately completed your application.
A must-listen for any of you who think our health care system isn’t in desperate need of reform. Click on this link, then “full episode”, and go to 35:22 in the broadcast to listen.
Sunday, July 26, 2009
Dr. Judah Goldberg, an emergency medicine physician and ethicist, wrote a compelling paper in Academic Medicine last year, in which he compares and contrasts professionalism and humanism, and how the white coat fits into these constructs. It's a must-read for those interested in the white coat debate. He writes that one comes to understand humanism simply through the experience of life, whereas, professionalism is acquired through the socialization process of entering a profession. Humanism’s motivation is to serve the welfare of humankind. On the other hand, professionalism’s primary motive is to strengthen professional identity. Most importantly, Dr. Goldberg points out that the outcome of humanism in medicine is to link the physician to the patient. The outcome of professionalism is to separate the doctor from the patient. Thus, once the differences between humanism and professionalism are delineated, it becomes apparent that the white coat serves the latter.
Another physician, Dr. Matt Bianchi, in a paper in the Journal of General Internal Medicine, is able to distill the entire issue into a few sentences as he writes about his own experience:
“I have had the good fortune to encounter a wide and rich spectrum of opinions from patients, friends, and colleagues on the matter of proper physician attire, perhaps encouraged by my absent white coat, absent necktie, shaved head, bilateral black hoop earrings, and tattoos covering approximately 17% of my skin (according to the Lund-Browder burn chart). With only one exception (a mildly demented man in heart failure), every one of the uncommon suggestions to upgrade my appearance for the sake of patient care has come from a physician colleague. In contrast, there have been countless moments of connection with patients who confided that some aspect of my appearance made them feel more comfortable… One can only hope that each doctor-patient interaction affords the participants the chance to transcend the cursory impressions of attire and engage in the “real” work of medicine, the alleviation of suffering and the healing potential of a positive, productive relationship.”
In the end, the white coat is all about the doctor, not the patient. The New York Times article quotes a physician who says, “The coat is part of what defines me, and I couldn’t function without it.” Now that’s magical thinking at it's finest!
Saturday, July 25, 2009
As an example, following a case of meningococcal meningitis, my approach to who should receive postexposure prophylaxis is typically more lenient than my public health colleagues. Given the severity of the disease, the ease of giving a single dose of ciprofloxacin, and the comfort this provides to the contact and family members (a placebo effect of sorts), it doesn’t seem appropriate to me to make a big production of “the rules” about who should receive prophylaxis, especially since the rules are relatively arbitrary anyway. A death from an infectious disease may be viewed as a case by the public health community. To the clinician, it’s a patient—someone’s child, mother, father, brother or sister. A few years ago, I attended a conference about a rabies case given by a public health colleague. It was technically an excellent presentation, but what I remember most was how proud she was about how few doses of rabies prophylaxis were given to contacts of the case. All I could think about was how would she have felt if one of those contacts developed rabies? In the New York Times article from this morning we see the tension between Dr. Marc Siegel (the parent and clinician) and Dr. Anne Schuchat (the public health official), who seems to be applying the rigid rules in a not too empathic way. Maybe public health doctors should spend some time in the clinical setting to be reminded that behind every case of a reportable disease is a real human being and that decisions at the bedside are rarely so black and white.
--The University of Wisconsin Hospitals has notified 53 patients that they may have been exposed to Creutzfeldt-Jakob disease after a patient who had undergone surgery at the hospital died of the infection. These patients were operated on with the same instruments used in the CJD patient's operation. Standard sterilization processes may not effectively eliminate the prion responsible for causing CJD.
--A hospital in Utica, New York discloses that 3 patients have acquired Legionnaires Disease, at least 1 nosocomially, over the past few months.
Friday, July 24, 2009
Thursday, July 23, 2009
I can’t speak for Mike, but I haven’t commented upon the current debate for two reasons. First, I don’t find the key elements of healthcare reform all that controversial (and this blog is supposedly about controversies in infection prevention). Among other things, meaningful healthcare reform should provide universal coverage, should reward quality over quantity of healthcare delivery, should pay for preventive care, should prohibit insurers from denying coverage for pre-existing conditions, and should require transparency from hospitals for key infection prevention measures. As a part-time VA doc, I think the federal government can do healthcare, and can do it well. There are certainly controversial elements of the debate, such as how to pay for reform, but those are mostly outside my expertise.
The second reason I’m not blogging about healthcare reform is pure cynicism about our political system. I’m frustrated by the way the media portrays this debate as a political horse race, and with how many politicians use the debate as such. And I’m sad that many, if not most, of the members of Congress are hopelessly conflicted by financial relationships with key interest groups in this debate. Rather than listening primarily to their constituents, who are in constant peril of losing healthcare coverage, being denied care, paying exorbitant rates for inadequate coverage, etc., they keep busy with fundraisers that provide exclusive access to industry lobbyists. Here is a telling section from a recent NPR story on Max Baucus, for example:
"Baucus courts these inside-the-Beltway donors by inviting them to Montana for weekend getaways — skis and snowmobiles in February, fly fishing and golf in June, and coming up on July 31, "Camp Baucus," which is billed as "a trip for the whole family."
Tickets start at $2,500.
So as Baucus and other lawmakers attempt to craft a bill that can smash through a virtual gridlock of interests, the awkward question lingers: To whom are they more attentive — their voting constituencies back home or the dollar constituencies who are at the Capitol every day?"
This explains why I’d rather watch overpaid athletes play baseball. Go Cubs!
Also of interest, the Church of England realizes it may not be wise to have an entire congregation drink from the same chalice.
Schools are closed, and will be for 4 weeks, and all high risk, young adults (e.g., pregnant women) are not allowed to work. Only young adults screened at hospitals can get oseltamivir. Met with the Minister of Health of Buenos Aires, and he told me yesterday that of 85 deaths in the region - half of the total deaths in Argentina- one fourth were in pregnant women. In Sao Paulo, Sergio Wey told me that there pregnancy was the leading risk factor for severity. In Argentina obesity is a close second risk factor for dying with H1N1. Also in Argentina I was told that diarrhea occurred in 10-20 percent, in the 12 percent range I heard about in Mexico. So far no one has tested stool for virus. I also heard about severe cases in Chile and Argentina in solid organ and bone marrow transplant patients. Not sure how many were nosocomial.
Wednesday, July 22, 2009
So I took special note of this report from David Henderson’s group at NIH. This group linked a cluster of nosocomial legionellosis to a decorative hospital water fountain, using pulsed field gel electrophoresis to match isolates from patients with those from the fountain (which was located in the radiation oncology suite). Notably, the fountain was equipped with both a filter and an ozone generator. I heartily agree with the authors that “decorative fountains and water features present unacceptable risk in hospitals serving immunocompromised patients.”
Tuesday, July 21, 2009
Made rounds in the adult and peds ICU of one of the university hospitals- hospital clinico UC. They nodded concurrence that about one-third of non-icu admissions have no fever. More interesting they volunteered that half of the outpatients with H1N1 confirmed had no fever. Each had anecdotes that they have screened patients with rhinorrhea only and confirmed H1N1. The point is that the clinical expression of H1N1 is extremely broad. Obviously screening patients with fever will miss many. Lastly, for counting patients, if fever is part of the case definition, the denominator will be greatly underestimated.
The adult in the ICU was an obese 34 year old man whose weight was 150 Kg and BMI was 40. Obesity was recognized informally in Mexico City when I was there earlier. The recent MMWR notes obesity as well. Obviously the question is whether the weight per se is an issue, and maybe these patients have no reserve when they get viral pneumonia. However, I suspect that insulin resistance is a factor: many have underlying hypertension and diabetes (i.e., metabolic syndrome).
Of interest is how H1N1 is managed in Chile vs Brazil. Here clinicians make a clinical diagnosis- confirmation is not essential - and order oseltamivir. The drug is given to patients free of charge.
Sunday, July 19, 2009
Arrived earlier in Chile and will be at the Ministry of Health tomorrow. H1N1 spreading here in their winter but I'll know more tomorrow. Chile prepared well after Mexico. I'll get first hand information in Argentina about their preparations later in the week.
Had dinner with former fellows- Claudio Pannuti and Sergio Wey- and their colleagues in Brazil. There is an upsurge in influenza thought to correlate with vacationers returning from Argentina and Chile. Pregnancy is the risk factor for severity of illness in cases that they have seen. What is unusual is how the government is managing the outbreak. Ill patients with ILI can be screened in this megacity of approximately 15 million by law only at 7 hospital ERs. The screen is with an immunoblot with a sensitivity of 70 percent. If and only if a patient with a positive screen also has some defined high risk elements will oseltamivir be given. A confirmatory PCR test is then done and sent to a single lab. The results of the PCR are available only after 10 or more days. The important point is that ID specialists cannot write a prescription for oseltamivir or screen for flu; this is controlled by law by the physicians at the 7 EDs.
Friday, July 17, 2009
Mexico has a new spike of H1N1 cases and the focus is especially high in Chiapas in the south. They have many on respirators with approximately 50 percent mortality - reminiscent of the severe cases in April in Mexico City. Just as in the cases earlier in Mexico City, the Chiapas cases have underlying conditions in only half. Also cases now appearing in Cancun and Merida. Very odd for flu to be here in summer. The big question is how Mexico might distribute the 20 million doses only that they will have by December--to young adults vs high risk young adults vs children who may be efficient transmitters. Even when they target a group, there will be too few doses, and how do you announce the program?The WHO has quietly announced that it will no longer be tracking H1N1 cases and deaths. The numbers they report have always been grossly inaccurate estimates, given that only a fraction of actual cases are tested. Nations are now asked to report their first few cases only, and to be vigilant for clusters of deaths attributable to H1N1.
I’ve also noticed that, despite all the hullabaloo about the name of this virus when it first swept across the U.S., “swine flu” is now back in vogue. Even the NY Times is back to using “swine flu”.
Wednesday, July 15, 2009
The first success story is from the world of infection prevention, highlighting the Keystone Project. Yes, this is old news to us: any hospital with an infection prevention program should by now have implemented bundled interventions to reduce device associated infections. The challenge going forward will be to sustain reduced infection rates in the face of daunting financial pressures….if hospital layoffs increase, nurse:patient ratios fall, infection preventionist positions remain unfilled, and morale suffers, the team-based prevention approaches that have been so successful may come undone in some hospitals.
I’m at my own camp of sorts, on Lake Michigan, so there will be few posts from me this week. Yes, more time away—do I ever work?
Friday, July 10, 2009
"I have received several calls from camp directors or physicians because of influenza in sleepaway summer camps. They are already working in accordance with ACA and state guidelines but as a result, many children are being isolated for 7 days or are being sent home regardless of duration and severity of symptoms without any testing as the current recommendations recommend this regardless of flu test result. In one camp, the sicker children were tested and tested positive for fluA. Now, any child who presents with a single isolated temp above 100 and any other symptom is being removed for 7 days. However, no one is particularly ill and many are well within a day.
For the children who test positive for fluA, the answer is fairly straightforward. However, summer colds and strep do happen at camps and many children may be isolated who either do not need it or who have something else that does not necessitate this (eg, strep after abx). I think it is reasonable for kids with sore throat and fever to be tested for strep--if positive, treat, etc. It may also be reasonable to test those with fever and cough for flu (they are picking it up on their rapid kit with some success)--if positive, follow the guidelines as they currently exist. The quandary is what to do with a child who is negative and is well within two days and whether or not they may return to their bunk and activities.
Obviously the camps will comply with local health authorities. Any other thoughts?"
So what do you think? If you were a summer camp director, or camp nurse, or local public health official, how would you manage H1N1 risk at camp?
Thursday, July 9, 2009
There is a big H1N1 summit today. This is one valiant attempt to keep us (in the U.S., at least) from becoming complacent about H1N1 during the dog days of summer. The announcement all the media outlets are touting is that our government is going to pump billions into an H1N1 vaccine program slated for October. IF an effective vaccine can be made in large enough quantities by then, state and local public health authorities will need to coordinate a massive campaign—meaning our own hospital seasonal flu campaigns will be occurring in parallel with this H1N1 campaign. We’ll see if hospitals will be distributed enough of this yet-to-be-produced H1N1 vaccine to deliver to our healthcare workers along with the seasonal vaccine.
Oseltamivir (Tamiflu) resistant strains of H1N1 have been isolated on 3 continents—the spread of oseltamivir resistance will further complicate H1N1 treatment and response.
Finally, the new NEJM has several H1N1 related pieces that are worth reading, one about managing uncertainty during the evolving pandemic, one about using commercial airline flight itineraries to predict H1N1 spread (a product of the Bio.Diaspora Project that was begun in response to the SARS experience), and one describing the origin of the H1N1 pandemic strain.
Tuesday, July 7, 2009
Monday, July 6, 2009
Our time in Ecuador was spent almost entirely in the northern and central highlands, and included a lot of high altitude hiking. I’ve attached a couple photos from our travels, one of the Laguna Quilotoa, and the other of the airport fever screening upon our arrival in Quito. “La grippe porcina” was definitely a concern there, and of course is even more of an issue thoughout the southern hemisphere.
Now that it is clear that H1N1 is widespread in many countries of the southern hemisphere, and will likely be circulating here throughout our next influenza season, vaccine questions will become more and more pressing. Will we have an H1N1 vaccine in sufficient quantities for all “at-risk” populations by October? Will one dose or two doses be needed? Will it be incorporated into the seasonal vaccine (no).
If we think it difficult to achieve good healthcare worker influenza vaccine coverage when only one shot is required, imagine a campaign that requires 3 doses! I’m thinking a jab in each arm at first visit, followed by an H1N1 booster a month later….
Friday, July 3, 2009
Thursday, July 2, 2009
Wednesday, July 1, 2009
--To compare the effectiveness of various screening, prophylaxis, and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA) in communities, institutions, and hospitals.
--To compare the effectiveness of strategies (e.g., bio-patches, reducing central line entry, chlorhexidine for all line entries, antibiotic impregnated catheters, treating all line entries via a sterile field) for reducing health care associated infections (HAI), including catheter-associated bloodstream infection, ventilator associated pneumonia, and surgical site infections, in children and adults.
The purpose of the IOM's project is to identify how to distribute $400 million in federal stimulus funds.