Wednesday, September 30, 2009

Time to postpone the seasonal vaccine?

Here is an edited excerpt from a post on the ClinMicroNet, a listserve for clinical microbiologists. The author is with the Ontario Public Health Labs and has seen the Canadian data we’ve blogged about here and here.
Yes, unfortunately the study is still under review--however it is the worst kept secret in the country. Basically, data derived from a cohort of patients in a vaccine efficacy study that has been ongoing for a number of years has shown that persons under 50 that got seasonal vaccine last year were at 2X the risk of getting H1N1. Data looks very compelling and although never seen with influenza (no one has had opportunity to look) there is other viral precedents (antibody dependent enhancement). As a result Ontario (and probably most provinces will follow) will first vaccinate those >65 (and nursing home residents)---they are least susceptible to getting H1N1 but at greatest risk for H3N2—and then provide H1N1 for high risk people, and then for everyone else. Then decision will be made re rollout of seasonal vaccine, if at all.

If you take into account these admittedly preliminary (and unconfirmed) findings, the fact that over 95% of influenza A viruses being typed in the U.S. right now are H1N1, and the imminent availability of the novel H1N1 vaccine, you have a strong argument for taking the approach described above—reverse the order of vaccination, get H1N1 vaccine out first, and worry about the seasonal vaccine later…….

Tuesday, September 29, 2009

H1N1 vaccine: The basics

A little Q&A from the CDC, to be posted on the Emerging Infections Network listserve shortly, is posted below. See this link for more details from CDC on H1N1 vaccine safety, and in case you missed it, check out this NY Times piece that nicely outlines the challenges associated with monitoring for adverse events during this massive vaccine rollout.

Looking at the CDC's web site it looks like vaccine distribution has been pushed back to mid November; is that correct? Planners should assume shipping of vaccine will begin in early October.

What dose of antigen (15 or 30 micrograms) will be used? 15 micrograms

Will an adjuvant be utilized?
No. According to current federal plans, only unadjuvanted vaccines will be used in the United States during the 2009-2010 flu season. This includes all of the 2009 H1N1 and seasonal influenza vaccines that will be available for children and adults in both the injectable and nasal spray formulations. None of these influenza vaccines will contain adjuvants.

2009 H1N1 vaccines with adjuvants are being studied to determine if they are safe and effective. Experts will review these data when they are available. There is no plan at this time to recommend a 2009 H1N1 influenza vaccine with an adjuvant.

There are 5 companies that are under contract to provide the vaccine. Are they all using the same seed virus? Yes, they all use the same master seed strains.

Uh-oh...more on the flu vaccine study from Canada

Today's Toronto Globe and Mail gives us more detail on the potential link between receiving seasonal flu vaccine and an increased risk for H1N1 infection. From the article:
Their paper (Danuta Skowronski and colleagues) found that consistency across four epidemiologic studies and one animal experiment suggested "an association that cannot be dismissed on the basis of chance and is unlikely to be explained entirely by bias." "If this association is real, these studies together suggest that recipients of seasonal [influenza vaccine] were at moderate 1.5-2-fold increased risk of medically attended H1N1 illness during the spring/summer 2009," the paper said.
Let's hope the paper is published soon. This will surely complicate vaccination campaigns.

State versus Feds

One thing I’ve been pleasantly surprised by during this H1N1 season is the willingness of some state departments of public health to issue guidance that differs from that of the CDC. I’m a little surprised that the media hasn’t paid more attention to this.

CDC says all health care workers with ILI should stay home for 7 days? Iowa says nah, come back if you’ve been afebrile for 24 hours and your cough has improved.

CDC says wear an N95 mask for all direct contact with patients with suspected H1N1? Iowa says no, surgical masks are fine except for aerosol-generating procedures.

On the one hand, this makes it easier for hospitals like ours to establish sensible, and feasible, policies during the long H1N1 season….on the other hand, neither the state public health department nor the CDC is going to come in to your hospital and slap you with a big fine. OSHA might….and they will require you to follow CDC guidance.

So maybe, one day, CDC and OSHA will get their collective “stuff” together and issue guidance that actually makes sense for busy, understaffed hospitals, and that can be sustained through future influenza seasons (since H1N1 is, after all… INFLUENZA virus).

Saturday, September 26, 2009

Mandating flu shots for healthcare workers

Today's Washington Post has an article on hospitals, health systems and states that are mandating flu shots for healthcare workers. While I certainly support the vaccination of healthcare workers, mandating it makes me uncomfortable. What I find grossly unfair is when hospitals exempt physicians from the mandates. While in many hospitals physicians are not employees, they are credentialed by the hospital. So hospitals that believe that all healthcare workers should be vaccinated should make this a requirement of the credentialing process. Otherwise, it creates a double standard that further undermines employee buy-in.

Friday, September 25, 2009

Infection prevention: The media backlash!

A couple news articles today are designed to generate annoying e-mails to tired infection preventionists….

The first story, from CNN, is really a non-story that takes the fact that influenza is a respiratory virus (that spreads, you know, from respiratory droplets) to insinuate that hand hygiene is not an effective flu prevention measure. Numerous experts are cited, not all of them say the same thing.

The second is a bigger deal, because it appears to already be affecting vaccine policy in at least one Canadian province. Apparently some Canadian studies have linked prior receipt of seasonal flu vaccine to an increased risk for H1N1 infection. The news account is here and I wish I could link to the study data—but it isn’t published and won’t be released by the investigators until it is peer-reviewed (then why leak it to the media, is my question…..). Tom Frieden had little to say about this issue at the CDC press conference, except that data from the U.S. and Australia have not shown such an association.

Thursday, September 24, 2009

Light posting this week....

Sorry about the infrequent updates this week. As many of you are no doubt doing, I’m still spending a lot of time dealing with H1N1-related issues. We already have a shortage of N95 masks, so have been working with units to educate them about re-use. H1N1 vaccine may be arriving sometime in early October, in limited quantities, so we are busy prioritizing risk groups for vaccination. We are also starting to see symptomatic healthcare workers in our employee health clinic for testing (we are testing those who meet “influenza-like illness” criteria in an effort to get those who test negative for H1N1 back to work sooner than the current CDC recommendation of 7 days). Meanwhile, our state department of public health is preparing to recommend that healthcare workers can return to work after 24 hours afebrile with improvement in other symptoms. We’ll soon be in a situation where our state department of health has substantially different recommendations than CDC for both isolation precautions (surgical vs. N95 masks) and healthcare worker sick leave. Unless the CDC issues updated guidance soon…..

Time for another reality check—pneumonia and influenza mortality remains below the epidemic threshold:

Sufficiently bored now? Then read more about MRSA everywhere, this time in our favorite animals….

Monday, September 21, 2009

MRSA miscellany....

I wanted to pass along an interesting moment from an MRSA session at ICAAC, entitled, “Controversies in the Management of MRSA Infections”. The session started with Chip Chambers, from UCSF, discussing the emergence of USA300 as a healthcare-associated pathogen. Near the end of his talk, and just prior to the “pro-con” session on active MRSA surveillance (with Lance Peterson “pro” and Stephan Harbarth “con”), Dr. Chambers showed the past few years of data from San Francisco General Hospital. The data revealed a dramatic reduction in MRSA infection (I can’t recall if it represented bloodstream only, all nosocomial infections, or all infections….), in line with what many have reported over the past few years (~60-70%). After he showed these data, he revealed SFGH’s aggressive approach to MRSA, which active surveillance, and no use of contact precautions for colonized or infected patients. That’s right—no “MRSA specific” measures. Then, for good measure, he good-naturedly implored the audience to remember, while listening to Lance Peterson extol the benefits of MRSA screening, that his hospital achieved the same reductions without any of the expense and trouble! Sadly, California’s MRSA screening legislation no longer allows hospitals to successfully reduce MRSA infections without the use of at least some screening.

Dr. Peterson gave his standard talk, but spent even less time than usual on his disclosure slide…several nanoseconds, but not enough time for the audience to note the degree of financial support he has received, both in honoraria and research support, from the makers of rapid MRSA detection tests. He also spoke in the evening at a satellite symposium, complete with dinner, funded by Roche. I didn’t go to that session…..

Imagine this scenario: your hospital has successfully reduced MRSA infection rates (and those due to other pathogens) using a broad-based strategy that includes excellent hand hygiene adherence and significant reductions in device-associated and surgical site infection rates. You are nonetheless forced (by state legislation) to start an active MRSA screening program, draining money from other important prevention priorities and exposing patients to important noninfectious adverse outcomes. All this as a result of the efforts of MRSA screening advocates who have major conflicts of interest with companies that stand to reap financial benefit from MRSA screening. Our colleague Kathy Kirkland hit this nail on the head (really!) in her response to a recent letter to the editor from Farr and Jarvis:
“It is said that to a person with a hammer, everything looks like a nail, and perhaps this is even more true of someone who consults for a hammer company. When 2 experts in the field of health care epidemiology repeatedly call for “every health care facility” to implement a program of active detection and isolation, they rightfully attract our attention. When one of these experts discloses potential conflicts of interest that include a relationship with a company that markets a diagnostic test for MRSA, we must view these calls with caution.”

Saturday, September 19, 2009

Drowning in swine flu garbage (literally)

Remember when Egyptian authorities, spurred on by pandemic hysteria, made the misguided decision to kill all that nation’s pigs? Turns out those pigs processed (i.e. ate) most of Cairo’s organic waste! Without the pigs to eat it, that waste is now piling up in rotting, stinking heaps.

Thursday, September 17, 2009

Let's get a grip....

For this hospital epidemiologist it looks like this will turn out to be another week consumed by H1N1. The number of questions regarding who to test, who to treat, how to isolate, and which mask to wear seem to be accelerating. And in the midst of this pandemonium, there is something discomforting about all of this that makes me wonder whether my reality testing is intact. Whenever I get those feelings, I head for the data so that I can determine if I have lost my mind. So below are two important graphs from the most recent data release from CDC (week ending September 5):

In a nutshell, outpatient visits for influenza like illness are higher than expected for this time of year, while deaths due to pneumonia and influenza are lower than expected. That's right--lower than expected! Thus, we have lots of people with mild disease. We're acting as if this has never happened before, and as Dan noted in an email to me earlier today, that we have to create a zero-risk environment for this mild infection. Meanwhile, the usual work we do to prevent important healthcare associated infections with high attributable mortality is set aside, so we can respond to the H1N1 "emergency." But in a world of 24/7 news and daily CDC teleconferences, is it any wonder that we find ourselves in this situation?

OK, I'd like to write more but it's time to get ready for my next H1N1 meeting...

Wednesday, September 16, 2009

Who you callin' unethical?

Many of you have probably already seen the news articles about the Australian study on the effectiveness of surgical masks versus N95s for prevention of influenza. The lead author of this study was quoted as saying, “It would not be ethical to recommend surgical masks for health-care workers”.

That’s a bold statement, and wrong. Even if one posits the superiority of N95 masks over surgical masks for protection of health care workers against influenza, there is a very old ethics principle (attributed to Immanuel Kant) that “ought implies can.” And at this time, it is simply not feasible for all front line health care workers to don N95 masks for the entirety of their shifts (for many reasons, not the least of which is that there simply aren’t enough masks).

But this assumes that this single study is definitive. I understand it is to be published soon, but I am unaware at this point of the results of peer-review of this work.

In addition, there is another randomized trial that came to a different conclusion about the effectiveness of surgical masks versus N95s. The complete results of this study can found at this link (to see specific outcome differences one must scroll down and open those windows). I’ve pasted the abstract below, which was presented at the 26th International Congress on Chemotherapy and Infection in Toronto in June. Both studies will apparently be published in JAMA in the near future. Until then, I’d advise Dr. MacIntyre to tone down the rhetoric about what’s “ethical” as we all do our best to protect both patients and health care workers during this trying flu season.

Randomized Control Trial to Study the Efficacy of the Surgical Mask Versus the N95 Respirator to Prevent Influenza

Mark Loeb, MD, et al.

Context: Data about the effectiveness of the surgical mask compared to the N95 respirator for protecting healthcare workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance.
Objectives: To compare the surgical mask to the N95 respirator in protecting healthcare workers against influenza.
Design: Non-inferiority randomized controlled trial Setting: Emergency departments, medical, and paediatric units in eight Ontario tertiary care hospitals.
Participants: 446 nurses
Interventions: Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.
Main outcome measures: The primary outcome was laboratory-confirmed influenza measured by PCR or a four-fold rise in haemaglutinin titres. Effectiveness of the surgical mask was assessed as non-inferiority of the surgical mask compared to N95 respirator.
Findings: Between September, 2008, and January, 2009, 478 nurses were assessed for eligibility and 446 nurses from eight centres in Ontario were enrolled and randomly assigned the intervention; 225 were allocated to surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 (23.6%) of nurses in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference 0.73%, 95% CI -8.8 to 7.3; p=0.86); the lower confidence limit being inside the non-inferiority limit of -9%.
Interpretation: The surgical mask was non-inferior to the N95 respirator for preventing influenza among healthcare workers. number NCT00756574.

Monday, September 14, 2009

ICAAC 2009

I've been in San Francisco, at ICAAC, since Friday, returning to Iowa tomorrow.

Every time I come to ICAAC I marvel again at how huge the meeting is, and how difficult it is for me to separate the wheat from the chaff. I guess that's why I generally prefer smaller meetings like SHEA. Too bad SHEA will be merging its annual meeting with IDSA starting in 2012....

Anyway, I was all ready to blog about some of the sessions I've attended, and to propose a complicated rule prohibiting all future presentation of single-center, control group-free, before-after studies of active surveillance for MRSA control.....but instead I'm going to the Giants-Rockies game.

New predictions for H1N1 activity

There's a very interesting new paper in BMC Medicine that uses sophisticated modeling to predict influenza activity for the upcoming flu season. Here is what the model predicts for the US:
  • The peak of flu activity will occur between late September and early November
  • At the peak of the epidemic, 1% of the population (3 million people) will become infected daily
  • By October 15, the US will have had 5-30 million cases of influenza
  • Each person infected with influenza will infect on average 1.75 other people
Unfortunately, the model predicts that the arrival of the H1N1 vaccine will be too late to have a great effect on the epidemic. However, the model also predicts that if 30% of cases could be treated with antivirals, the peak of the epidemic could be shifted forward in time by about 4 weeks, in which case the vaccine would have a much greater impact.
We'll know soon how accurately the model predicted reality. 

Sunday, September 13, 2009

A must-read for germophobes

For those of you who are really worried about swine flu, today's New York Times has an interesting article and video of Ariel Kaminer, the Arts and Leisure editor, going about the city in full personal protective equipment--a jumpsuit, mask, gowns and goggles.

Photo:  Patrick Andrade for the New York Times

MRSA everywhere?

A study presented at ICAAC this week showed that MRSA was found in samples from ocean water and sand at seven public beaches on Puget Sound. Interestingly, according to press reports, the organisms resembled hospital associated strains. The clinical significance of this finding is not clear, but I think that this is just another example of how ubiquitous this organism has become. And given the widespread nature of its presence, does it make sense for us to attempt to control it in the hospital setting by culturing patients and isolating them? Patients represent only one, albeit important, source of pathogens in the hospital. It is likely that MRSA also enters the hospital through healthcare workers and students, visitors, and service and therapy animals. So it seems that the best options for MRSA control in the hospital revolve around driving environmental hygiene to high levels while minimizing hand and clothing contamination. The beauty of this approach is that any organism transmitted via direct or indirect contact will be simultaneously controlled.

Friday, September 11, 2009

It's a slippery slope....

The Joint Commission issued press releases yesterday to announce its new initiative, the Joint Commission Center for Transforming Healthcare. The concept is that the Joint Commission will play an active part in assembling key organizations to develop solutions to some of healthcare's toughest problems. One of the first initiatives is on hand hygiene. While the goal of this new center is laudable and the intent seems to be pure, what is concerning to me is that this project has corporate sponsors, at least some of whom would appear to have vested interests in the solutions that may be developed. Given the intense spotlight on conflict of interest currently, I'm surprised that TJC would allow corporate sponsorships.

New England Journal wins the Most Ghosts Award

A few weeks ago, Dan blogged about ghostwriting--when journal articles appear to have been written by academic researchers but were actually written by anonymous industry employees. An article in this morning's New York Times tells us that this practice is more common than most people thought. In a study commissioned by JAMA, authors of papers published in 2008 were surveyed. The proportions of ghostwritten papers per journal were as follows:
  • New England Journal of Medicine:  10.9%
  • JAMA:  7.9%
  • Lancet:  7.6%
  • PLoS Medicine 7.6%
  • Annals of Internal Medicine:  4.9%
The New England Journal editors were described as "puzzled" and "skeptical." I think "appalled" would have been a better choice of words.

Thursday, September 10, 2009

Potential new option for treatment of severe swine flu

A new case report in Lancet documents the first use of IV zanamivir in a patient with respiratory failure from H1N1. Sequential testing of the H1N1 viral load in bronchoalveolar lavage fluid suggests that the novel therapy was effective after trials of oral oseltamivir and nebulized zanamivir were not. Of course, as I teach our first year medical students in their epidemiology course, case reports are prone to over-interpretation. Nonetheless, given the dearth of therapeutic options for patients with severe manifestations of H1N1, this new option deserves further study.

One dose should do it...

There are a number of novel H1N1 articles, and an editorial, now available online from the New England Journal of Medicine. The one you will be hearing about on CNN is this one, which demonstrates that a single 15 microgram dose of the non-adjuvanted vaccine produces protective antibody titers in over 95% of healthy adults (aged 18-64). There are a few caveats about the trial that are covered in the accompanying editorial, including that it was conducted in Australia while the novel H1N1 was circulating. But overall, the study is reassuring—it will be a lot easier to roll out this vaccine if only one dose is needed for most adults. Whether this holds up in kids, the elderly, and the immunocompromised remains to be seen.

More on Getting to Zero

I've written before about the Getting to Zero concept and why I think it's a bad idea. Unfortunately, APIC continues to push the issue. The September 1 issue of Clinical Infectious Diseases has a thoughtful essay on the topic by Jean Carlet and colleagues that's worth reading.

That’s 1 cent for every family of three in America!

My colleague Eli Perencevich sent me a link to this article yesterday, to be published in Health Affairs. Turns out that the Medicare policy of refusing to reimburse hospitals for the costs associated with certain preventable adverse events, including selected hospital infections, is not going to net very much money (about $1 million nationally, according to their model).

The press has already noticed.

I have always thought this policy to be mostly symbolic, and I recall a SHEA plenary speaker two years ago describing even the optimistic projections of cost savings as “budget dust”.

Tuesday, September 8, 2009

The Ridiculously Annoying Mask Fiasco

I’m so tired of blogging about this; I’ll try to make this my last entry on this topic. But the brilliantly-timed IOM report has now placed incredible pressure on U.S. hospitals to procure enough N95 masks to allow use for all direct contact with patients who have febrile respiratory illness.

But there aren’t enough masks. Not even close, from what I understand. Our hospital was just informed that our large order is “behind 15 other very large orders”. Who knows when we’ll get them?

Tom Freiden referred to this issue in the CDC conference call when he stated that IOM’s charge was only to look at the science (which is inconclusive), not at feasibility. If CDC plans to issue new guidance that takes feasibility issues into account, I suggest that they do so very soon.

Meanwhile, we have reassuring data from the Southern Hemisphere, which is now near the end of its annual influenza season. Almost all the circulating virus this year was H1N1, and the season was….(drum roll)…..much like other recent influenza seasons. Pneumonia and influenza related death rates in Australia since 2005 are illustrated below:

Monday, September 7, 2009

Labor Day reading

An interesting piece in The Atlantic, written by someone who lost his father to a hospital acquired infection. He ties poor infection control practices to the structure of our health care system, and provides his own proposal for reform at the end of the piece. Whether you agree or not with his prescription (I happen not to agree), the piece is thoughtfully written and makes several important points.

One particular issue that I’ve thought about lately has to do with how the structure of a health care system influences the risk for hospital acquired infection. I agree that incentives for infection prevention (and disincentives for higher infection rates) are important. But is there any evidence that countries with similar living standards but different health care systems have markedly different nosocomial infection rates?

I’m asking this not as a hypothetical, but because I honestly have no idea. I’ll need to find time to search for published data on this, unless someone can enlighten me in the comments section (and no, I’m not talking about rates of one specific drug resistant organism from one country to another, but overall nosocomial infection rates, which of course leads to big issues of standardized definitions, risk adjustment, etc.).

Saturday, September 5, 2009

H1N1 on campus: Club Swine

The front page of this morning's New York Times has an article about quarantine dorms for students with swine flu on college campuses. I have been receiving calls from our University Health Service and will spend several more hours this week working with university administrators on additional planning for swine flu. A number of questions keep circulating in my mind: How much of this planning activity is driven by continuous media reports? Would this have happened 10 years ago? Could our time be used more wisely? How much planning can be done for a disease that is so unpredictable?

So to ensure that my reality testing is intact, I again reviewed the latest CDC surveillance data. In a nutshell, here are how things stand:
  • Since mid-April there have been 9,079 hospitalizations and 593 deaths (in a typical flu season there are on average 226,000 hospitalizations and 36,000 deaths)
  • During this influenza season there have been 111 flu-related deaths in children, over half of which were due to seasonal strains (in a typical season there are on average 92 deaths in this group)
  • Only 1 of 10 national regions currently has an elevated incidence of outpatients with influenza-like illness (ILI)
  • For the most recent week reported (ending August 29), the proportion of deaths attributable to pneumonia and ILI were below baseline levels
  • 97% of subtyped viruses in the most recent reported week were H1N1
Now back to the situation on college campuses. If you consider that students are likely infectious one day before onset of symptoms, that some symptomatic individuals will ignore recommendations and continue with their normal daily activities, and that social distancing is essentially abnormal behavior in college, does it make sense to attempt to control transmission of swine flu by setting up quarantine dorms? Could it be that doing so may prolong the outbreak on any given campus? Since in the vast majority of students the acuity of disease is about the same as a bad cold, does any of this make sense? If we knew that a vaccine would be available tomorrow, then quarantining students might be a reasonable idea, but since the vaccine is weeks away at best, it's likely that any college community with disease activity today will already have high levels of H1N1 antibody by the time the vaccine arrives.
When the H1N1 epidemic is over it would be interesting to know the opportunity cost for hospital infection control programs. Since these programs run with fixed resources, which in most hospitals are likely inadequate at baseline, diversion from our normal work to plan, and plan, and plan some more for H1N1, is likely to result in more healthcare associated infections.

Friday, September 4, 2009

"A corporation in a suit..."

Today's New York Times has an article about Betsy McCaughey and her involvement in the healthcare reform debate, as well as her interest in healthcare associated infections. It points out that she recently resigned from the board of directors of a medical supply company due to conflicts of interest, though she denied having any. She seems to have difficulty with that issue. Several months ago she presented at a satellite symposium at the Society for Healthcare Epidemiology Meeting. SHEA required that she disclose her funding sources and the list was quite long. It reminded me of Ralph Nader's characterization of a famous politician as "a corporation in a suit." In the September issue of Infection Control and Hospital Epidemiology, she wrote a letter to the editor criticizing a paper written by our group (first authored by Dick Wenzel). While I think that her letter contained inaccurate statements, I was bothered more by the fact that she reported that she had no conflicts of interest. Our paper was entitled "Screening for MRSA: A Flawed Hospital Infection Control Intervention." Since she reported at the SHEA Meeting that she had funding from the makers of MRSA PCR testing kits, it's amazing that she had no conflicts of interest to disclose.

Photo: Comedy Central

IOM & face masks: Efficacy vs effectiveness

Yesterday's report from the IOM on respiratory protection for healthcare workers against H1N1 was quite disappointing. Unfortunately, IOM evaluated the question from the standpoint of efficacy (how well an intervention works in an ideal setting) rather than one of effectiveness (how well an intervention works under real world conditions). Effectiveness takes into account compliance, which is likely to be an issue when levels of disease activity rise and healthcare workers spend more of their day wearing a mask. But more importantly, the current supply of N95 masks appears to be insufficient for them to be used when encountering all patients with suspected swine flu. I don't disagree with IOM's conclusion that N95 masks are more protective then standard masks, but to ignore logistics and practicality when making a recommendation is of little help to those of us in the trenches. I received several emails yesterday from hospital epidemiologists at academic medical centers who stated they would not follow the IOM recommendation but continue with SHEA's recommendation (i.e., use of a standard mask except for aerosol generating procedures).

McKeflex in your McNuggets?

An interesting news story in the September 5 Lancet looks at cephalosporin use in poultry production. It notes surveillance data from Quebec showing an association between cephalosporin use on chicken farms and cephalosporin resistance in bacteria found in retail chicken products and humans. The US FDA proposed new regulations for cephalosporin use last year, including banning the practice of injecting chicken eggs with the drugs before they are hatched. The American Veterinary Medicine Association protested and the FDA withdrew the proposal.

Thursday, September 3, 2009

CDC press conference

Well, I got nothin' from that.......the CDC apparently doesn't want to talk about the IOM report until they have more time ("days to weeks") to study it. I can summarize it for them, if it would help: we think health care workers should wear properly fitted N95 masks while providing care to patients with known or suspected novel H1N1 infection. Also,.......more studies are needed.


IOM report out

And a CDC press conference is about to begin. As expected, the IOM endorsed the use of N95s for care of patients with suspected H1N1.....

Wednesday, September 2, 2009

What will they think of next?

There's a new iPhone app, Outbreaks Near Me, that allows the user to view maps of occurrences of infectious diseases based on media reports. Users can search by disease or geographic location. This must be a nightmare for germophobes.

IOM report

Looks like it will be later today or tomorrow before we know the details of the IOM recommendations to CDC regarding personal protective equipment for care of patients with suspected novel H1N1. I’ll wait to comment until those details are available. If, as expected, IOM supports the current CDC position, it will be interesting to see how the state departments of public health will react, at least in states that have gone with the WHO guidance until now. It will also be interesting to see if future CDC guidance for seasonal flu includes recommendations for N95 masks—or will we have to individually assess each individual influenza strain in the future, to determine exactly what PPE is required?

Tuesday, September 1, 2009


When will the media stop inviting a serial liar to misinform the public about healthcare reform? There are a lot of smart people out there with important things to say about making our system better. She is not one of them.


Just heard through the grapevine that the IOM is going to support the CDC guidance about respiratory protection for novel H1N1....which means using an N95 for all patient contact when H1N1 is suspected (i.e. everyone with febrile respiratory illness!). I'm in clinic right now, but I'm sure Mike and I will have much more to say about this later......