Friday, October 30, 2009
Thursday, October 29, 2009
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?
Monday, October 26, 2009
Saturday, October 24, 2009
Friday, October 23, 2009
Wednesday, October 21, 2009
If I had time, I'd put a link here to the sound of a primal scream.
Monday, October 19, 2009
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
Saturday, October 17, 2009
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
Wednesday, October 14, 2009
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.”
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 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
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/.
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.
Tuesday, October 13, 2009
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
On an related note, a bunch of early release papers out from JAMA today on nH1N1 in critical care.
Sunday, October 11, 2009
Saturday, October 10, 2009
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
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.
Thursday, October 8, 2009
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.
Tuesday, October 6, 2009
Monday, October 5, 2009
Sunday, October 4, 2009
Friday, October 2, 2009
“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.