Friday, October 30, 2009

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

Thursday, October 29, 2009

“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.

Monday, October 26, 2009

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.

Saturday, October 24, 2009

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.

Friday, October 23, 2009

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.

Wednesday, October 21, 2009

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.

Monday, October 19, 2009

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.

Sunday, October 18, 2009

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.

Saturday, October 17, 2009

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.

Friday, October 16, 2009

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.

Wednesday, October 14, 2009

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.

Tuesday, October 13, 2009

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.

Monday, October 12, 2009

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.

Sunday, October 11, 2009

Public reporting of HAIs: Getting it right

The October issue of American Journal of Infection Control has an important commentary on public reporting of healthcare associated infections (HAIs). The authors, who include Don Goldmann, stress the need for reliability and validity in publicly reported metrics, two important concepts that have been largely ignored by many states that have mandated public reporting. They call on the CDC to develop online clinical vignettes which could be completed by ICPs in order to assess the accuracy of case ascertainment. This is a great idea and should be a relatively easy way to begin the process of improving validity. While the CDC HAI case definitions appear straightforward when simply read, in the context of application in real time numerous questions arise. My ICPs not uncommonly ask me to review cases where ambiguities preclude their ability to decide whether the patient's clinical picture meets the definition of an HAI. Moreover, in preparing ICPs for mandated reporting in Virginia, we developed case vignettes for training and testing, and found wide discrepanices in the application of definitions, even among ICPs who were epxerienced in NHSN methodology. Hopefully, funding to states from the American Recovery and Reinvestment Act will be used for training of ICPs to improve case ascertainment, as well as to establish programs to assess validity of data submitted by hospitals.

Saturday, October 10, 2009

Save the masks!

In our flu planning meeting yesterday I learned from our materials management director that we are having difficulty obtaining surgical masks and that our in-house supply is being depleted. Whether this is a local problem or whether it's more widespread I don't know. But it concerns me that hospitals are implementing policies requiring asymptomatic healthcare workers to wear surgical masks at all times, in some cases those refusing to get vaccinated, in other cases universally in high-risk areas of the hospital. Perhaps we all need to take a step back and think through the long-term implications of such policies.

It seems to me that we are seeing an exceptionalism applied to H1N1 much like that applied to MRSA--that is, we are singling out certain diseases to focus attention and apply interventions while other diseases or organisms, perhaps of equal risk and impact, are not given the same attention. With regard to H1N1, the two major differences from seasonal influenza being observed are a larger population of susceptible individuals due to the antigenic shift the virus has undergone and the overall milder disease course (though there are certainly severe cases being reported). So if you think that all healthcare workers, or even just the unvaccinated fraction, should wear masks at all times during H1N1 season, are you prepared to do the same in all subsequent influenza seasons? Even if the flu season is prolonged? Even if the vaccine and circulating strains are mismatched, meaning in essence that all healthcare workers are unvaccinated? What are the triggers for starting and stopping masking? Is prolonged mask use a practical strategy? I could go on, but you get the point, I'm sure. I think a lot of policy is being driven by the media's attention on certain diseases and organisms with a short-term focus, rather than on priorities that are grounded in the magnitude of risk and impact and the long-term implications. Perhaps key questions to ask are: How many patients died in your hospital in the last month from a catheter-related bloodstream infection? How many died from ventilator-associated pneumonia? How many died from a surgical site infection? And how many died of nosocomial H1N1?

I long for the post-H1N1 era......

Friday, October 9, 2009

Mandatory flu shot smackdown!

Our occupational health doc forwarded this link to me, a listserve posting by the medical director of the occupational health clinic at Vanderbilt (my alma mater!). Read it for yourself, but it is a concise critique of the references that IDSA cites in support of their mandatory vaccination position.

Pay particular attention to the conflict-of-interest issue to which she repeatedly refers. Regular readers of this blog know that this is a popular topic here. As well-meaning as they may be, strong proponents of mandatory vaccination always should disclose all of their financial relationships with vaccine manufacturers….and if they wish to maintain credibility in the long run, they should attempt to limit relationships that extend beyond legitimate research funding.

Questioning the ethics of MRSA active surveillance

For some time, Dan and I have questioned the ethics of performing active surveillance cultures for MRSA in order to isolate colonized patients. In this week's BMJ, Dr. Michael Millar from London, notes the ethical issues surrounding the policy of mandating MRSA screening of all patients electively admitted to English hospitals. In addition to the ethical issues, we believe there are other effective ways to control MRSA that also control other pathogens, and do so in a more patient friendly and cost effective manner.

Thursday, October 8, 2009

Wait 'til next year

Regardless of your view on mandatory influenza immunization of healthcare workers, I can tell you from personal experience that this year is not the best time to institute a mandatory program. We chose this path here, and it has been an unproductive distraction during a very busy time.

For starters, we felt we couldn’t mandate a vaccine for which the supply was then uncertain, so we only mandated the seasonal vaccine….putting us in the awkward position of mandating the vaccine that doesn’t cover the predominant circulating strain. Moving ahead now to mandate the nH1N1 vaccine might place us in the equally ridiculous position of forcing healthcare workers to be vaccinated just as the nH1N1 epidemic is waning, or even after the epidemic, depending upon when the full vaccine supply arrives and how long our local H1N1 activity lasts (we haven’t received a single dose as of today, and H1N1 activity is already widespread on our area, and will soon be widespread across the state).

The mandate also resulted in our union filing an injunction to suspend the program, setting up an immediate adversarial relationship with many of our healthcare workers at a time when we most need to foster trust and communication (e.g. during a pandemic response!).

So if you don’t already have a mandatory flu vaccine program for healthcare workers, my advice mirrors that of Cub fans everywhere: “Wait ‘til next year”. Dr. Thoman Freiden, head of the CDC, said the same about NY State’s program recently:
“This is just not the right flu season to take this on”
Nonetheless, IDSA has decided now is the right time to recommend mandating the nH1N1 vaccine. You can link to their reasoning from the front page of the IDSA website.

H1N1: Pay me now or pay me later...

The New York Times reports today that areas of high H1N1 activity last spring are now enjoying low disease activity. Conversely, the hardest hit areas currently had relatively little flu activity in the spring.



Tuesday, October 6, 2009

Killing the live vaccine?

A Denver television station is reporting that some hospitals there are refusing to administer the intranasal (live) H1N1 vaccine because of concerns of transmission of the virus to immunosuppressed patients. While CDC recommends that the vaccine should not be administered to healthcare workers in contact with severely immunocompromised patients (e.g., bone marrow transplant patients), I have heard from a number of clinicians who are expressing concerns regarding whether workers in contact with other immunosuppressed patients (e.g., solid organ transplant patients) should be vaccinated.

Monday, October 5, 2009

Pennsylvania: The poster child of public reporting

A new article in the Wall Street Journal examines public reporting of healthcare quality data in Pennsylvania. The article is a little unbalanced, but does quote Dr. P.J. Brennan, former president of SHEA, on the issue of difficulties with risk adjustment. According to Wikipedia, the term poster child "signifies that the very identity of the subject is synonymous with the associated ideal; or otherwise representative of its most favorable or least favorable aspects." I'll let you decide.

Sunday, October 4, 2009

More on mandatory influenza vaccination

I just ran across this essay by George Annas on mandatory vaccination of healthcare workers. He outlines other reasons for not mandating immunization that I had not noted in my piece.

Taking the long view...

This week there was a flurry of emails amongst hospital epidemiologists about approaches to influenza vaccination of healthcare workers. I was surprised at the number of hospitals mandating the vaccine. Another approach being implemented at some hospitals is to require that unvaccinated healthcare workers wear a surgical mask at all times (how practical is that?). In addition to masking, one hospital is also requiring unvaccinated healthcare workers to wear some type of tag noting their noncompliance. While the tough tactics might be useful PR tools, I think it's a punitive, petty and mean-spirited approach to your hospital's most precious asset. I also think it's dangerous, because the ill will that will be created by such tactics is likely to have impacts on other infection control outcomes. While an effective infection prevention program requires creativity, good policies, and sound interventions, infection rates are ultimately determined by what happens at the bedside. Most interventions are wholly or partially behaviorally based, so we need healthcare workers to cooperate in implementation. Thus, infection control programs need to be forging healthy, trusting relationships with their healthcare workers. Strong arming is short-sighted, adversarial, likely to backfire, and infection control in general will be undermined. And if there's a serious adverse vaccine related event in a healthcare worker who was forced to be vaccinated, I suspect that will not only be the end of mandates, but compliance with vaccination in future campaigns will plummet, and the responsible infection control program will lose credibility. So plead, cajole, beg, sing songs, do whatever it takes to get them vaccinated, but stop short of issuing mandates or stigmatizing providers.

Friday, October 2, 2009

They write letters

SHEA sent a letter to Secretary Kathleen Sebelius today on the mask issue, in the wake of the JAMA study by Loeb, et al. I’ll link to the whole letter later if I can find it online, but I wanted to highlight this sentence:

“Rigid policy mandates that are not based in science but rather in fear will have an unintended, negative impact on our ability to deliver safe and effective care to our patients…...”
This applies to so much more than the question of which mask to wear to protect health care workers from influenza.

Thursday, October 1, 2009

H1N1 myopia not uniquely American

I've blogged before about the H1N1 frenzy in US hospitals. Today I was accompanied on Infectious Diseases Consultation Service rounds by the Chief of Infectious Diseases at one of India's largest hospitals. He was lamenting the fact that such a large proportion of his time recently has been spent on H1N1 planning. And he brought it all into perspective when he said "I'm more worried about the 30 patients with cholera in my Emergency Department."

Mask vs. Mask

Well, the results of the Loeb study I previously referenced are now published in JAMA. This represents the ONLY randomized controlled trial comparing N95 masks to surgical masks for protection of HCWs against influenza that is published in the peer-reviewed literature. The accompanying editorial, by Arjun Srinivasan (CDC) and Trish Perl (Hopkins, and member of IOM committee), is here.

Is the H1N1 vaccine the new smallpox vaccine?

You may recall the ambitious public health campaign several years ago to vaccinate over 400,000 Americans against smallpox. It was a huge failure, meeting only about 10% of its target. A new paper in Biosecurity and Bioterrorism, reporting on a national survey done in June 2009, suggests that the H1N1 vaccine may be headed for the same fate. Respondents were asked whether they would be willing to receive an H1N1 vaccine approved under Emergency Use Authorization by the FDA. Only 9% of the sample reported that they were willing to receive the vaccine. Although it is important to note that the soon-to-arrive H1N1 vaccine is not being released under Emergency Use Authorization, I suspect that the public won't make the distinction. Interestingly, willingness to receive the vaccine was lower in higher income groups and those with higher educational attainment. Moreover, over half of those individuals who get the seasonal flu vaccine yearly reported they would not take the H1N1 vaccine. (Anecdotally, we are hearing the same from many of our healthcare workers who regularly accept the seasonal vaccine). What should be most worrisome to the CDC is the survey's finding that a sizable fraction of the population does not trust the government's messages or its competence to manage the H1N1 epidemic.