Monday, August 31, 2009

Refusal to care for H1N1 patients?

I hope this doesn't become a trend. A recent entry on the Emerging Infections Network listserve describes ICU nurses refusing to care for very sick H1N1 patients, requesting reassignment for fear of contracting the virus. From the listserve responses so far, this appears to be a rare phenomenon, fortunately.

This is an interesting counterpoint to the finding Mike previously highlighted, of healthcare workers suggesting that they would refuse the vaccine! It is often interesting how people perceive risk, and what behaviors they choose to reduce that risk. Education will be key throughout this respiratory virus season—provide healthcare workers with the information and tools they need to protect themselves, and support them fully after any documented exposure. For those with valid concerns about the consequences of H1N1 acquisition (e.g. pregnancy, other high-risk condition), I believe counseling about risk, and case-by-case accommodation (including potential reassignment) is the correct approach.

Sunday, August 30, 2009

Improving health care: A double-edged sword?

An article in today's Salt Lake Tribune focuses on the Intermountain Health System, which is widely known for its focus on electronic medical records and informatics to improve the quality of health care. The article points out a paradoxical impact. By using their rich databases to the improve the quality of care delivered, Intermountain has allowed insurers to reap big savings while the hospital system actually lost millions of dollars since fewer services are required when complications are avoided. Unfortunately, bad care begets more care which begets revenue.

Thursday, August 27, 2009

Healthcare reform and infection prevention

From an excellent piece in the NEJM, by Dr. Nicole Lurie, that nicely links healthcare reform, infection prevention and the public health:
"Early detection of a new infectious disease—and potentially the survival of those who are infected—requires that sick people have access to the health care system and receive early treatment. Delays in seeking care can lead to delays in the recognition and control of an epidemic and in the treatment of patients. Indeed, experts have hypothesized that one reason the mortality associated with the current epidemic of swine-origin influenza A (H1N1) virus (S-OIV) was so high in Mexico is that many people delayed seeking care, in part because of its cost. In the United States, lack of health insurance is a key reason for delays in seeking care; health care reform that results in universal coverage would facilitate earlier detection of new diseases, enable disease-control efforts to be instituted, and alleviate the population’s vulnerability that is attributable to delayed care."
Read the whole thing here.

Whither utilitarianism?

In an OpEd piece in this morning's Wall Street Journal, Betsy McCaughey attacks Ezekiel Emanuel, an oncologist and medical ethicist at the NIH, for his view that in making medical decisions physicians should not only take into account the needs of the individual patient but those of society as well. She argues that this is a dangerous way to think. But it's ironic coming from a woman who when not attacking health care reform is writing and speaking about the dangers of multidrug resistant organisms. If physicians made decisions purely on the basis of the need of the patient without regard to a greater collective good, then the entire concept of antibiotic stewardship would be abandoned. With that thinking doctors should prescribe the most potent and broad-spectrum antibiotic in every case without concerns for the development of antibiotic resistance that reduces our ability to have effective antibiotics for the future. As I see it, the thoughtful physician often thinks of the impact of decisions beyond his or her patient. And that's really no different from how a thoughtful human should approach life in general. The real argument in the healthcare reform debate, which underlies the tension between the views of McCaughey and Emanuel, is whether health care is a public good or whether it's a commodity. Unfortunately, the United States can't seem to figure that out.

Wednesday, August 26, 2009

Hong Kong Healthcare Workers: We're Not Gonna Take It

A new study in the BMJ, which surveyed a large number of healthcare workers in Hong Kong, found that less than half of them would accept the swine flu vaccine. This is particularly interesting given that the survey was performed in May 2009 at the height of the panic about the disease and also because Hong Kong was the epicenter for the SARS epidemic several years ago. The investigators believe the findings are applicable in other countries. Reasons given for refusing the vaccine are familiar--fear of side effects and questions of efficacy.

Tuesday, August 25, 2009

Balancing patient safety with patient safety

Mike has already pointed out the degree of uncertainty surrounding how to prepare for (and respond to) the spread of novel H1N1. One of the challenges is maintaining a focus on overall patient safety and the potential unintended consequences of our H1N1 response.

One example that comes to mind is the question of how long to keep ill health care workers (HCWs) at home after their symptoms improve. The current CDC guidance suggests HCWs stay at home for at least 7 days after onset of “febrile respiratory illness” (temp greater than 37.8 C and cough or sore throat).

This may not be a problem now, but soon there will be a multitude of circulating respiratory viruses (see here for a partial list). If it is a bad “respiratory virus season”, even if H1N1 represents a minority of the circulating viruses, then a very large number of HCWs will be staying home from work for at least a week. And we know that understaffing is a problem for patient safety.

What are the alternatives? Three that come immediately to mind include: (1) sending HCWs back to work once they are afebrile for 24 hours, as the CDC is now recommending for schools and other workplaces, (2) sending HCWs back to work once afebrile, but making them wear a mask until the 7 day point is reached , or (3) screening all sick HCWs with a test that has a rapid turnaround time and high negative predictive value, and sending those that are negative for influenza A back to work once symptom-free and afebrile. Investigators from Beth Israel-Deaconess in Boston recently reported a negative predictive value of 96% for the rapid DFA test.

As Mike alludes to in his post, the most important thing is to remain flexible, and nimble, realizing that the response to novel H1N1 will evolve with the pandemic. Many hospitals will try initially to adhere to CDC guidance, but must be willing to modify their approach if they begin to experience staffing shortages that threaten patient care.

Monday, August 24, 2009

Planning frenzy

There seems to be a lot of activity in hospitals now focusing on planning for swine flu and I am getting numerous highly specific questions on how we will deal with vaccine, ill employees, post-exposure prophylaxis, visitor policies and other infection control issues. At this point, detailed planning is likely to be futile since there are many unknowns. Just about the only thing that we can say for sure is that the flu is always unpredictable. As I see it, how we approach swine flu in the hospital will depend on the following:
• Vaccine supply and efficacy
• Susceptibility of the virus to antivirals
• Supply of antivirals
• Supply of consumables (surgical masks, N95 masks, etc)
• Prevalence of influenza in the community
• Virulence of the circulating virus and severity of illness
Since it is likely that some of the variables above will change over time, we will need to make many decisions in real time, and our swine flu plan is likely to have a dozen or more iterations as the flu season unfolds. Stay tuned.

Sunday, August 23, 2009

The kindest cut.....

If an HIV vaccine were proven to reduce the risk for HIV infection by 60% in a high risk group, it would be front page news. We’ve known for some time, though, that male circumcision can reduce heterosexually-acquired HIV infection in men to that degree. Nonetheless, public health authorities and professional societies have generally been lukewarm about the practice, and there is vocal opposition to circumcision.

According to this article in today’s NY Times, the CDC is getting close to recommending routine circumcision for all male babies born in the United States, and the American Academy of Pediatrics is also considering endorsing routine circumcision.

Thursday, August 20, 2009

Zombie control

In this blog, we focus on controversial prevention issues. About some issues, however, there is no debate. For example, how to control zombie outbreaks. Quick, decisive action is essential. As these authors rightly conclude from their novel mathematical model:
"An outbreak of zombies infecting humans is likely to be disastrous, unless extremely aggressive tactics are employed against the undead."
Now if we only had a rapid screening test…..

Wednesday, August 19, 2009

Ghostbuster

Blast! My cunning plan to outsource future writing projects is in jeopardy. It appears that my own senator, Chuck Grassley, is ready to crack down on the practice of medical ghostwriting. One interesting tidbit from this story….one of the academics who put her name on a Wyeth-financed, ghostwritten article also happens to be the Wyeth-Ayers Professor of Women’s Health at Columbia. I am not joking. At least that’s truth in advertising.

So why does this ghostwriting business fascinate me so, and what does it have to do with infection prevention? As Mike and I have alluded to several times in this blog, industry influence is becoming increasingly pervasive in the infection control world. As more companies develop devices that aid in infection prevention, they have an obvious interest in seeing their technology widely adopted. The companies won’t continue to exist if they don’t turn profits, and much of the technology is good! So they adopt a variety of practices to enhance the adoption of said technology, including co-opting experts and “opinion-leaders” through the use of research funding, speaking honoraria, consultancies and advisory boards, hiring lobbying firms to influence legislative and other government decisions, funding “grass roots” consumer advocacy around specific infection prevention issues, etc., etc. The major area where we see this now is with MRSA screening.

So as you are reading and assessing the literature, keep a careful eye on potential conflicts of interest with entities that stand to gain from the results of a study or from the conclusions of an editorial or review. One recent (thankfully, non-MRSA) example was brought to my attention by a colleague: the June issue of ICHE had two articles and an editorial on H2O2 mist systems for hospital room disinfection. I blogged about these interesting articles here. What I failed to point out in my post was that ICHE allowed the editorial to be written by someone who is both a paid consultant to Bioquell (makers of an H2O2 vapor system) and who was senior author on a Bioquell-supported research study in the same issue (a paper with four authors that are employed by Bioquell). I have no questions about the integrity of this person, a true giant in the academic infection control world, and the editorial did disclose the conflict. But the fact that he is a paid consultant to Bioquell should have disqualified him from writing the editorial, period.

P.S. As regards glass houses and stone-throwing, I must point out that I am no innocent when it comes to industry ties. Though I dropped all speaker’s bureaus over 5 years ago and do not do any consulting or advisory board work, I lead an antifungal resistance surveillance laboratory that has received research funding from Pfizer, Schering-Plough, Astellas and Merck. Full disclosure! I can go into boring detail on how I manage these potential conflicts with anyone who cares to know.

Tuesday, August 18, 2009

Another bandwagon loses a wheel

This morning's New York Times has an interesting article on a story that is becoming a familiar one: a treatment guideline written by experts morphs into a rule, is applied widely, and bad things happen. Add the catalyst of industry funding (via various financial relationships with authors of the guideline and industry's ability to widely promote the guideline), and a wildfire spreads. In the New York Times piece the treatment guideline focused on tighter control of blood glucose in diabetic patients. Seems like a simple and good idea, but it was obviously complicated, and after deaths were associated with application of the guideline, the guideline was withdrawn. I recently blogged about how Medicare required hospitals to deliver the first dose of antibiotics within four hours of arrival to the Emergency Department for patients with pneumonia. Again, sounds like a great idea, but critics of the idea were ignored, bad outcomes occurred, and the rule was relaxed. An expert quoted in the New York Times today nailed it when he said, “This was a case in which the advocates of a disease got caught up in their disease rather than the interests of patients.”

Those of you who are regular readers of this blog might be having deja vu since a very similar story could be written about testing every patient who enters the hospital for MRSA. One major difference, however, is that states are passing laws to force hospitals to do this. Counterarguments are being ignored, and industry works behind the scenes as a catalyst. A few weeks ago I attended a lecture on treatment of skin infections, which seemed like a unbiased clinical talk until an off-site physician was teleconferenced into the lecture to deliver an infomercial on the Cepheid PCR instrument for rapid detection of MRSA.

Hopefully, someday I'll pick up the New York Times and find the story to be about MRSA testing, which will signal the end of this very strange chapter in the annals of hospital epidemiology.

New frontiers in stupid

My previously expressed cynicism about the healthcare reform “debate” appears warranted, as the discourse reaches new depths of stupidity and disingenuousness. My favorite recent example comes from the Investors Business Daily. In an editorial opposing Obama’s healthcare reform, that paper argued that a UK-style system would result from Obama’s proposals, and that such a system would consign to an early death none other than Stephen Hawking, the world renowned physicist who suffers from Amyotrophic Lateral Sclerosis. Mr. Hawking “wouldn’t have a chance in the U.K.”, his life deemed “worthless”, the paper breathlessly reported.

One small problem: Stephen Hawking lives in the U.K., and the N.H.S. has helped keep him alive, by his own report.

….and here’s some bonus stupid from Betsy McCaughey, who has taken a break from spreading disinformation about infection prevention in order to spread what AARP accurately describes as “flat-out lies” about Obama’s healthcare reform plans

Friday, August 14, 2009

What were they thinking?

A few months ago, CDC recommended that facilities consider reassigning pregnant healthcare workers to avoid caring for patients with confirmed or suspected swine flu. This week, SHEA, APIC and IDSA issued an opposing recommendation. These groups state that “automatic and uniform reassignment of high-risk healthcare personnel is neither necessary nor feasible.” The rationale is that reassignment of pregnant workers undermines confidence in the efficacy of personal protective equipment and infection control recommendations, and it creates privacy concerns for the reassigned workers. On this one, I must side with CDC, and am quite surprised that SHEA and APIC would issue such advice.

For many years, pregnancy has been known to be a major risk factor for morbidity and mortality in influenza. A recent paper analyzing the swine flu epidemic in the US showed that pregnant women were 4-5 times more likely to require hospitalization than others when infected with swine flu, and 13% of all deaths in the US from swine flu occurred in pregnant women. In my experience, pregnant healthcare workers often have anxiety related to acquiring infections in the workplace, and it seems reasonable to provide reassignment. Personal protective equipment is effective in reducing transmission but who hasn’t inadvertently been noncompliant with PPE because of an emergent situation or distraction, simply forgotten to don the appropriate gear, or touched an itchy eye or nose before hand hygiene? Moreover, the reality is that healthcare workers want minimal risk at work, even though they may be much less risk averse in their personal lives. In the end, effective infection control is a team sport and is built on trusting relationships between infection control personnel and frontline providers. Preventing infection is all about what happens in the messy, shades of gray world at the bedside, not in the black and white environment of the tidy conference room. If hospitals adopt policies that are interpreted as overly harsh and unsympathetic to the needs of their workforce, infection control in general will be undermined. SHEA and APIC need to apply a little common sense.

Tuesday, August 11, 2009

The Boss in the Paper of Record


Today's New York Times has an interesting article written by Dr. Larry Altman on current persepctives regarding swine flu. The story features Dr. Richard Wenzel and his thoughts about the epidemic based on his first-hand observations made in Latin America.

PHOTO: Jay Paul for the New York Times

Sunday, August 9, 2009

Do we really need healthcare reform?

If you are sitting on the fence about whether this country needs healthcare reform, see this story from NPR. Then make a donation to Remote Area Medical (RAM). By the way, a gallery of patients and providers accompanying the NPR story shows a number of students from the Virginia Commonwealth University School of Dentistry who donated their services to this event. I practice at VCU and what makes me proudest of this institution is it's long and deep commitment to the poor.

The MRSA active surveillance debate continues...

A few days ago, I blogged about sources of bias in the MRSA active surveillance debate. Drs. Barry Farr and Bill Jarvis, two supporters of active surveillance for MRSA, responded to my posting. Please click here to see their comments, to which I respond.

First, let me state that I am not an ageist. Epidemiologists of all ages should actively participate in debates on important topics in our field. My point was that academic societies should not develop guidelines, which are increasingly viewed as mandates by regulators and accrediting agencies, with individuals chosen on the basis of a single viewpoint. It is much more likely that former trainees will agree with their mentors on controversial issues, which should not come as a surprise to anyone. While I might prefer the outcome of a guideline written by Dick Wenzel (my mentor and an opponent of active MRSA surveillance) and his former trainees, such a committee composition would be just as inappropriate.

Next, I want to point out an irrefutable fact: not all epidemiologists agree with the viewpoint of Drs. Farr and Jarvis on active surveillance, despite all of us having access to the same literature on the topic. I don’t see the issue as a single, yes or no question of effectiveness, but rather my thinking about active MRSA surveillance can best be encapsulated by a series of questions:

(1) Is active surveillance for MRSA effective in reducing infections due to MRSA in the inpatient setting?
(2) Is MRSA active surveillance associated with adverse unintended consequences?
(3) If implemented, does MRSA active surveillance control other important pathogens in the hospital (e.g., MSSA, multidrug resistant gram-negative rods)?
(4) Even if active surveillance is effective at reducing MRSA infections, are there other interventions that may be equally effective, or more effective, perhaps at a lower cost? Might these other interventions, also reduce infections due to other organisms? Could other interventions reduce MRSA infections with fewer adverse unintended consequences?
(5) Could it be that the effect of active surveillance is modulated by the level of hand hygiene compliance (i.e., what is the incremental effect of active surveillance if hand hygiene compliance is >90%)?
(6) Are contact precautions (with or without active MRSA surveillance) even necessary if hand hygiene compliance is driven to very high levels?

Drs. Farr and Jarvis and I differ on the fundamental issue of certainty: I readily admit that the holy grail for controlling multidrug resistant pathogens in the hospital has not yet been determined, and I remain open to the possibilities. They argue that their way (active surveillance) is the only way—an argument that I reject based on my own experiences. In looking at the data for the first half of 2009, we again demonstrate a progressive decline in MRSA infection rates in my hospital without the use of active surveillance. In a nutshell, I see active surveillance as an intervention that may be sufficient to control MRSA, but clearly not necessary. So at my hospital we continue to pour our time, talent and resources into interventions that have the capacity to reduce all infections, not just those caused by MRSA, namely high rates of hand hygiene compliance, increasing use of chlorhexidine for patient bathing, and removing healthcare worker contaminated clothing (e.g., ties, sleeve cuffs, lab coats) from the inpatient setting. I have always stated that if active surveillance for MRSA works at your hospital and you can demonstrate that there’s no harm, then continue with that intervention. Hospitals are highly complex organizations in which differing effects of interventions can be seen from one institution to another. As such, perhaps there is no holy grail. To those that are implementing active surveillance, I would simply ask that you keep your mind open to the possibility of other effective, cheaper, and/or broader spectrum interventions. Most importantly, mandates ought to be reserved for interventions in which there is no doubt as to safety and effectiveness, and for which equally or more effective and safe alternatives do not exist.

Lastly, the active surveillance debate has become more complicated now that companies that make rapid pathogen detection technologies (e.g., Cepheid, Becton Dickenson) have much to gain when hospitals adopt active surveillance and particularly when it is mandated by states. Some patient advocates, infection control experts, and even professional societies (e.g., APIC) are the recipients of funds from these companies, which raises at least the appearance of conflict of interest.

Thanks again to Drs. Farr and Jarvis for taking the time to post their comments and keeping the theme of this blog true to its title.

Wednesday, August 5, 2009

Where's my ghostwriter?

Wow. This is just so wrong.

I also don’t really understand it. I enjoy writing, and it would never occur to me to pay somebody to write something for me (or, more accurately, to put my name to something that a drug company paid someone else to write).

I might, however, consider a “ghost” for a few other tasks…..maybe a drug company would be interested in hiring someone to attend a few committee meetings for me?

Tuesday, August 4, 2009

Watch out for the drop outs!

Some of you astute readers may have noticed that in my photo (to the right), there is a Cepheid GeneXpert machine in the background. I didn’t choose this photo with that in mind—I simply thought the last photo was too close up, and I look much better from a distance (a long distance).

I should make clear, however, that this photo should not imply my support for this product over other available diagnostic products. Nor have I received honoraria from the makers of any rapid MRSA detection test (unlike, say, 5 of the 8 authors of a widely-cited study supporting active MRSA surveillance….but I digress……).

As further evidence of my neutrality regarding diagnostic devices, I’m going to point out an annoying little problem we’ve been having lately with the MRSA Xpert assay—false positive tests due to so-called “MRSA drop outs”. This phenomenon results from the fact that the currently FDA-approved assay doesn’t detect the mecA gene itself (the one that encodes resistance), but rather a sequence that includes part of the staphylococcal chromosomal cassette mec element (SCCmec) and the S. aureus orfX gene. Since the SCCmec element is the cassette that carries the mecA complex, the assay should be good—that is, unless the mecA complex has “dropped out”, resulting in an "empty cassette", leaving a methicillin-susceptible S. aureus that tests positive by the Xpert assay. The manufacturer claims that these “drop out” strains are very rare in North America, and there is some data to support this claim. However, MRSA epidemiology is a moving target, and if you don’t run culture in parallel with this assay you’d never know if such strains were becoming more common. In addition, I’m not sure how the manufacturer can know that this is a rare phenomenon unless they’ve sampled very widely across the continent—data I have not seen. In fact, their recently published multicenter trial did not carefully assess for the prevelance of such strains, a limitation they point out in their discussion.

We’ve had several false positives in the past two months due to these MRSA drop-outs. By DNA fingerprinting the isolates are different (meaning we haven’t had one “drop-out” strain emerge, but are seeing several). We don’t do a lot of screening at our University Hospital, and our rate of positivity in the screened population is fairly low....so these false positives are messin' with our positive predictive value.

Cepheid has a new assay nearing FDA approval, one that contains mecA-specific primers. That should solve this problem. But until then, if you are using this assay for MRSA screening, you may wish to periodically (or continuously) perform culture in parallel, to see if you have any of these isolates circulating in your hospital.

MRSA active surveillance: More sources of bias

A few days ago, Dan blogged about some sources of bias in the MSRA active surveillance debate--publication bias, citation bias, and editorial bias. To that I would add another form of bias, which I'll term "guideline committee bias." In 2003, the SHEA Guideline for Preventing Nosocomial Transmission of Multidrug Resistant Strains of Staphylococcus aureus and Enterococcus was published. This guideline has been used repeatedly by those outside the infection control community to argue that all hospitals should perform active surveillance for MRSA, a position actively espoused by Drs. Farr and Jarvis, two authors of the guideline. The guideline lists 7 authors, each of whom is a reputable healthcare epidemiologist. However, what is not apparent to many readers is that of the 7 guideline authors, 3 were relatively senior and 4 were relatively junior. All 4 of the relatively junior authors were former trainees of 2 of the senior authors. So it leads me to wonder whether there were 7 independent minds sitting at the table when the guideline was developed. Moreover, one must speculate as to whether the outcome of the process was predetermined and the individuals chosen to make that outcome happen. All trainees are heavily influenced by their mentors--the entire process of mentoring centers around the handing down of a thought process for approaching problems. In my own case, though my professional decision making is now independent of my mentor, I would venture to guess that we agree almost always on our approaches to problems in infection control. The proverbial apple doesn't fall far from the tree.

There's one last form of bias that is worth mentioning and was noted by Wachter et al in an editorial in the Annals of Internal Medicine last year. They criticize a CMS policy that required that the first dose of antibiotics for pneumonia patients be given within 4 hours of arrival to the emergency department. This policy, which was not well thought out, had unintended consequences that ultimately required that the rule be revised. They write:
In addition to financial conflicts of interest, caution should be exercised when individuals are both key investigators and policymakers, particularly when the stakes are high. In the case of TFAD [time to first antibiotic dose], several key researchers had positions with CMS and IDSA and helped drive the conversion of their own studies into performance standards. None of us can be entirely impartial when judging the merits of our own research.

Over five years have elapsed since the SHEA guideline was published. It's time for a new guideline, and SHEA should ensure that the process is open, fair, and includes experts with varying viewpoints on how to control multidrug resistant pathogens.

Getting back to basics

Schoolchildren play a critical role in community influenza transmission, which is why everyone is getting so nervous as kids head back to school with the novel H1N1 circulating…..

So I really enjoyed this article, recently published online in ICHE. The authors describe implementing a simple “bundle” of infection control measures at a 240-child kindergarten in central Thailand: hand hygiene and cough etiquette education of students, parents and teachers; an annual influenza vaccination day; and enforced absenteeism for sick children. Observed hand hygiene and cough etiquette adherence increased from 14% during the preintervention year to >60% during the two postintervention years, and influenza vaccine acceptance increased from 35% to 75%. A monthly newsletter was used to feedback data on rates of hand hygiene and cough etiquette, as well as numbers of the monitored infections.

Read the paper for yourself—but the bottom line is that the intervention led to dramatic reductions in influenza-like illness, diarrheal disease, and hand-foot-mouth disease.

So as important as it is to review pandemic plans, assess stocks of oseltamivir and personal protective equipment, etc., etc., it is the simple measures that will control novel H1N1.

Wash your hands! Cover your cough! Get your flu shot (once it is available)! Stay home when you’re sick!

Sunday, August 2, 2009

Citation distortion and unfounded authority

We all know about publication bias—wherein those studies generating “positive” results are more likely to be submitted and published than are studies generating negative results. It’s easy to understand why, especially as it pertains to the single-center, before-after studies that predominate in the infection control literature. Who wants to tell the world that they spent hundreds of thousands of dollars swabbing noses and isolating patients, but didn’t see any reduction in infection rates? Likewise, if you invest a lot of time and energy in an intervention that works, you want to tell people about it (and, of course, add a publication to your CV).

A related phenomenon is “citation bias”. This occurs when authors selectively cite only those papers that support a claim, and either do not cite or distort those papers that are critical of the claim. Repeated citation of supportive claims and lack of citation of data that undercut the claims can then serve as “amplifiers” of the claim in question. Pure invention of facts can also occur in this way, as a proponent of a claim may state something as a hypothesis, and a subsequent author may cite the statement as a fact—a “fact” that then becomes firmly embedded through further amplification and citation bias.

I just ran across a fascinating paper in the British Medical Journal that examines these phenomena, using a specific belief system in the field of neurology as an example (the belief that beta-amyloid is produced by, and injures, skeletal muscle in patients with inclusion body myositis). The author, Steven Greenberg, uses social network theory to construct and analyze the “claim specific citation network” that undergirds this belief.

Many firmly held beliefs in the infection control world (e.g. that contact precautions prevent MDRO transmission in endemic settings, or that active surveillance is essential for MRSA control) are overdue for such an analysis.

Though I would add one additional form of bias to that discussed by Greenberg: editorial bias. For several years, the editorial leadership of one of our main infection control journals was held by persons with firmly fixed beliefs about how to control MRSA. Early in my career I submitted a letter to the editor that was critical of one of the papers published in the journal. I received a personal call from the editor telling me he couldn’t publish the letter. Not because he could identify anything factually incorrect about the letter, but because the letter would give “aid and comfort” to those who didn’t agree with his beliefs about MRSA control. Since then, I’ve spoken with investigators who have submitted papers to other journals that challenge the claim that active surveillance is essential to MRSA control, and have also had editors or reviewers express concern that the data undercut their beliefs about MRSA control (and therefore should not be published!).

Saturday, August 1, 2009

Want to see a good movie?

I highly recommend Food, Inc., a documentary on the food production industry with Eric Schlosser (author of Fast Food Nation) and Michael Pollan (author of The Omnivore's Dilemma). It's a sad and chilling look at exploitation--of animals, low-paid industry workers, farmers and consumers. Among the many unintended consequences shown in the movie are antibiotic resistance and the emergence of E. coli H7:O157.