TB Vaccine effective in HIV+ with BCG history

This study, to be published in an upcoming issue of AIDS, tested the effect of an inactivated whole cell mycobacterial vaccine, Mycobacterium vaccae, in HIV+ (CD4+>200) outpatients in Tanzania who also had a history of childhood BCG vaccination. Ford von Reyn and his Dartmouth and Tanzanian colleagues completed a double-blind placebo controlled trial testing the effect of 5 intradermal injections on subsequent disseminated and definite TB. Vaccinated patients had reduced disseminated TB (HR=0.52, p = 0.16), and definite tuberculosis (HR=0.61, p = 0.03). The study was stopped early do to significant protective effect but it prevented the assessment of longer-term effects.

Big payouts from a for-profit & a non-profit

An article in ModernHealthcare.com reports that a for-profit health system is about to pay out $1.75 billion to its investors. As one who strongly believes that healthcare is a basic human right, I can't help but wonder how many uninsured patients could be treated or how many healthcare associated infections and other complications avoided by investing those dollars in prevention research and implementation. On a happy note, however, the Gates Foundation is investing an additional $10 billion in its vaccine programs.

Avoid TPN in patients with ventricular assist devices

There's a new paper in Clinical Infectious Diseases on fungal ventricular assist device (VAD) infections. If you have ever seen these infections, you will appreciate the need for a better understanding of the risk factors for them. This paper reviewed 300 patients with VADs, of whom 108 developed infections, 23 of these due to Candida spp. Crude mortality in patients with Candida infection was 91%. Using mulitvariate analysis to compare patients with fungal VAD infections to those with bacterial VAD infections, the only independent predictor for fungal infection was total parenteral nutrition (OR 6.95). The authors of the paper strongly recommend that TPN be avoided in VAD patients. 

The Toyota Way went

Based on the high quality of its products, Toyota has been viewed as an exemplar in the quality world, and the Toyota Way has been a quality model adopted by many hospitals. Now the quality giant has suspended production of 8 of its cars in the US and Canada and has recalled over 7 million cars due to two different accelerator problems. Click here and here to read two completely opposite views of the state of quality at Toyota. To add insult to injury, this morning's Wall Street Journal has an article about how poorly Toyota is performing crisis management.

Who is that masked...college student?

Researchers Allison Aiello and colleagues at the University of Michigan just published a study in the February issue of JID that assessed the benefit of (a) face masks or (b) face masks + hand hygiene vs. (c) control in preventing ILI in college residence halls (dorms) during the 2006-7 flu season. Each group (cluster) consisted of either one very large hall or a combination of 3 smaller halls (2 groups) for a total of 7 randomized halls. 1297 students were included in the study. Interestingly, spring break occurred during the study period which may have impacted the results. To bad the analysis couldn't tell us whether heading to the beach or skiing reduced the risk of influenza. In any case, they reported significant reductions in ILI in the mask+hand hygiene group during weeks 4-6 and in the mask only group during weeks 4-5 after influenza was first detected on campus.

An accompanying editorial by Titus Daniels and Tom Talbot, both at Vanderbilt, places the new findings in the context of the recent H1N1 'pandemic' and the N95 respirator debate. Importantly they suggest that the benefits seen in both face mask arms of the study may have been secondary to reduced viral shedding from infected mask wearers. They are correct to point out that the Michigan study supports the benefits of hand hygiene and it was also great to see them re-emphasize the importance of annual vaccination, particularly in health care workers, staying home when sick and compliance with proper respiratory etiquette.

Note: Both the article and editorial full-texts are available for free on the JID website; which is very nice for all who don't have a personal or university-based subscription.

Make room for patient safety

The New York Times has a piece by two medical students that points out how little medical schools are doing to teach future doctors about patient safety. It's a shame that schools can't scale back biochemistry to carve out some time for concepts that would actually save lives. And wouldn't it make more sense to inculcate good practices at the outset rather than trying to break bad habits later?

Action Threshold: Banning White Coats, Ties and Long Sleeve Shirts

There has been debate among hospital epidemiologists whether to ban white coats, ties and long sleeve shirts in order to reduce transmission of MDR-bacteria in healthcare settings. One of the arguments used against banning certain elements of physician attire is that there isn't enough data to prove that transmission occurs from said attire to patient. Of course there aren't any randomized trials showing that banning white coats reduces MRSA transmission, but is this a fair argument? I don't think it is and my reasoning has to do with a concept called action threshold that physicians use when making decisions, but rarely discuss.

The action threshold is the probability of an outcome at which it makes sense to undertake a specific intervention. In this case, how sure do you need to be that white coats or ties are harmful to patients before it's worth banning them? A useful clinical example is the use of the Centor Criteria to diagnosis strep throat (or better to rule it out) based on history and physical and treat with antibiotics without getting a throat culture. Do you really need to be 100% sure they have strep throat before giving antibiotics or is 60% good enough? Of course, before you diagnose someone with HIV or cancer you need to be close to 100% sure you have the right diagnosis because the treatments are so harmful.

In Richard Gross’s book he derived a formula: Action Threshold = Harm/Improvement, where harm is the adverse events associated with the intervention and improvement is how much better the patients are with the intervention compared to without the intervention. If expected improvements outweigh potential harms then the intervention should be considered; the action threshold is the tipping point in modern parlance. All of this flows from the the expected utility model developed by John von Neumann and Oskar Morgenstern, but I digress.

So, how certain do we need to be that removing white coats (or ties or long sleaves) will benefit patients before pulling the trigger on an all out ban? What harm could possibly occur from such a ban? How would this hurt patients - I would say not at all and physicians could certainly find another way to uphold their professional standing. The white coat ceremony didn't even exist prior to 1993 at Columbia University, so how sacred could these stained, unwashed garments really be?

Semmelweis suggested that hand washing could prevent infections and save lives years before Louis Pasteur confirmed the germ theory. How many lives could have been saved if physicians listened to him in the interim? In fact, not enough people even listen now! How bad will we feel if future investigators prove by cluster-randomized trial that white coats harm patients? White coats need to go and when white-coat backers complete the trial showing they are safe and can actually stay clean between patient visits, we can let them back in our hospitals. Until then the burden of proof should be on those that want to keep white coats; use the action threshold and do the right thing.

Mandatory Influenza Vaccination

In the current issue of CID, investigators at BJC HealthCare in St. Louis report on a mandatory influenza vaccination policy instituted during the 2008-2009 season. All employees who were not vaccinated or who didn't have an approved exemption, where not scheduled to work beyond Dec 15 and were terminated on January 15th if still not vaccinated. They achieved an impressive true vaccinated proportion of 98.4%. Quite an achievement for patient safety. Only eight employees out of 25,561 were terminated and 321 (1.2%) had approved exemptions.

An editorial by Andrew Pavia provides a nice balanced summary of healthcare worker vaccination policies and successes. Mandatory vaccination policies have been implemented by several organizations including Virginia Mason Medical Center (Seattle, WA), Hospital Corporation of America, Johns Hopkins Health System, University of Iowa Hospitals, Hospital of the University of Pennsylvania, Children’s Hospital of Philadelphia, and the Department of Defense. Dr. Pavia is right to suggest that influenza vaccination targets should be set at 90% or higher; however, it's unlikely these targets can be widely achieved without mandates similar to what BJC has just described.

Welcome news on the C. diff front

This seems like old news already, but for those who missed it, there is a promising report in the New England Journal of Medicine this week on the use of monoclonal antibodies against toxins A and B for C. difficile disease. The treatment didn’t reduce the severity or duration of the primary episode, but was associated with an impressive reduction in recurrent disease (7% in the treatment arm, 25% in the placebo arm, at the 84 day endpoint). Check out the article if you haven’t seen it, and the accompanying editorial.

Not only is this welcome news for those suffering from C. difficile disease, but it has infection prevention implications—fewer episodes of disease and fewer hospital admissions mean less transmission……

P.S. I also love any treatment that doesn't involve the prolonged use of antibiotics, or the collection and infusion of donor feces....

Speaking of mandates.....

....Eli alerted me to a new screening law in Maine that went into effect last week. According to this news account, the law requires MRSA screening of all new admissions with recent hospital or long term care facility exposure, those on dialysis, and prisoners. Interestingly, it appears the law only mandates screening for six months, and then allows hospitals to decide themselves how to proceed with MRSA prevention….if true, it is a curious wrinkle. I was especially interested in this law, given that I practiced infectious diseases in Maine for 3 years before returning to Iowa to get further training in microbiology.

Take note of this quote from Dr. John Jernigan at CDC:

"There are some studies that suggest that programs that have employed active screening have been very effective at reducing MRSA infection rates. On the other hand there are those that have used the strategy and not been so effective. Also there are studies that suggest that MRSA infection rates can be reduced effectively without the use of active screening. It may have to be tailored to local situations and circumstances."

I’m scheduled to present a “pro-con” debate with John next month….since I agree entirely with this quote, I’m worried that our “debate” will be very boring.

Addendum: I found the legislation on the interwebs. This is what was submitted, and this is what passed (can you detect the subtle changes?). So the details above must be what the Maine Quality Forum cooked up.

If you are interested.....

....in reading more about the tedious MRSA screening debate, I wrote one half of a pro-con piece for the March issue of the Journal of Clinical Microbiology (can you guess which half I wrote?).

I don’t like the “pro-con” format for this issue, because it tends to oversimplify the role of multidrug resistant organism (MDRO) screening in MDRO prevention. If the question is whether screening for asymptomatic MDRO carriage can be a valuable tool in certain situations, the answer is “yes”. If the question is whether every hospital should be forced, by directive or legislative mandate, to screen everyone for a specific MDRO….then, well, my answer is “no”. SHEA and APIC feel the same way, apparently.

MRSA is a regional problem too

Years ago, Belinda Ostrowsky, then at CDC, showed in the NEJM that VRE could be controlled through regional infection control efforts in the Siouxland region of Iowa, Nebraska, and South Dakota. David Smith, then at NIH, was motivated by this success to test whether this regional response was necessary for control of a generic hospital pathogen using mathematical models. (see his PNAS study). He found that regional coordination may be necessary. So what about MRSA?

Hajo Grundmann and others in Europe have just published a very interesting paper in PLoS Medicine with an accompanying editorial by Frank Lowy. The authors collected MSSA and MRSA samples from 450 hospitals in 26 countries during 2006–2007 and completed spa typing on all of the isolates to determine genetic relatedness. They then geographically mapped the spa types. What they found was the unlike the widely distributed MSSA, dominant MRSA spa types formed distinctive geographical clusters within regions. Check out their interactive map (here). I think this shows that regional efforts will be required to control the spread of MRSA since it appears that it's mainly spread by patients who are re-admitted to different hospitals.

I won't begin to suggest what those efforts should be, but we certainly have multiple potential interventions and a single approach won't work in all places all of the time. However, since JJ Furuno's Archives of Internal Medicine paper a few years ago found that patient self-report of a hospital admission in the previous year detected 76% of MRSA carriers on admission, we have been using this regional spread hypothesis to control MRSA at University of Maryland Medical Center. Instead of obtaining nares swabs on 100% of admissions, we've swabbed only the highest-risk patients (admissions in the past year to any hospital and/or active skin infection) and detected and isolated almost all patients who subsequently developed MRSA infections - saving lives and saving millions of dollars too. Dollars we can spend to reduce CLABSIs or SSIs or another MDRO.

Excellent video on hand hygiene and behavior change

Some of you may have seen this already. It was forwarded to me by the communications guru on our hand hygiene task force. I love it.

Haiti and the Dominican Republic: How to help

Many of you are no doubt following the humanitarian crisis unfolding after the earthquake. The large scale damage to healthcare facilities in Haiti complicates treatment of trauma victims and will challenge efforts to control communicable disease outbreaks.

The simplest way to help is to give money to support the earthquake response, to outfits like the Red Cross, Partners in Health, and Doctors Without Borders.

Journal editors and conflict of interest

Here's an interesting article from the Milwaukee Sentinel Journal about a University of Wisconsin faculty member who edits a journal that has published numerous articles, mostly positive, on products made by a company from which he has received more than $20 million. Of note, an orthopedic surgeon, who is the president of a professional ethics association, is quoted as saying that no one on an editorial board of a journal should receive more than $50,000 from a device or drug company. Seems a little generous to me, but I don't know the conversion factor for orthopedic to infectious disease dollars. I'll give him the benefit of the doubt and speculate that it's the equivalent of 50 infectious disease dollars.

New Pennsylvania report on HAIs

Pennsylvania has just released its state-wide report on healthcare associated infections (HAIs). This is the first report generated under the new rules that require all PA hospitals to use NHSN definitions and report infections occurring hospitalwide via NHSN. It covers the time period July-December 2008. The report is huge and I suspect it's a bit overwhelming for the average consumer. But it contains a large amount of data on bloodstream infections and urinary tract infections. Approximately 14,000 HAIs were reported over the 6-month period from 213 hospitals, for an overall rate of 2.84 infections/1,000 patient days. Of note, MRSA accounted for 8% of the HAIs occurring hospital-wide.

Let the “false pandemic” debate begin!

Last Spring, we had quite a few posts about whether the emergence of H1N1 should be termed a pandemic. Turn back the clock, ‘cause it looks like we’re going to have that debate all over again. What self-respecting pandemic virus kills fewer people than seasonal influenza?

Read it for yourself, but the Council of Europe just passed a resolution calling for an investigation into the role of big pharma in the WHO decision to declare a pandemic. An emergency debate is scheduled for later this month…..pass the popcorn, this should be interesting.

Hand hygiene compliance >98%, do you believe it?

Stephen Dubner of SuperFreakonomics fame has an interesting post relaying a story by Dr. Jeffrey Starke from Texas Children’s Hospital in Houston. His hospital got their hand hygiene compliance rates to >98% by first making it part of the employee bonus plan and then part of the hospital executives’ performance bonus. Physicians got compliance that high even though they didn't fall under the bonus plans. Few details are given about amount and frequency of the bonus payouts, what the total cost was and what happened to their infection rates. However, I guess people do respond better to carrots than sticks.

Anthrax update

The death toll from anthrax infections in IV drug users in Scotland has now reached 7, and 7 others have become infected. Meanwhile, in the US, the woman with gastrointestinal anthrax, who was infected from a contaminated djembe drum in New Hampshire, is improving and has been moved from intensive care.

When is an MRSA reduction not really an MRSA reduction?

Like the proverbial tree falling soundlessly in the forest, MRSA reductions apparently make no noise unless someone is spending millions of dollars on screening and isolation.

In the latest example of this phenomenon, Dr. Bill Jarvis* ignores evidence that MRSA infections can be prevented without active detection and isolation (ADI). For example, he attributes the impressive MRSA reductions in the UK to ADI. Unfortunately for Dr. Jarvis, ADI for elective admissions wasn’t mandated in the UK until March 2009, and still hasn’t been mandated for urgent admissions. But MRSA bloodstream infection (BSI) rates began falling in the UK in 2005, and had fallen 56% by the end of 2008. An NHS website and a recent parliamentary report attribute these reductions to improvements in horizontal infection control practices (primarily hand hygiene and environmental disinfection), not to ADI.

Similarly, Jarvis doesn’t mention the over 50% reduction in MRSA BSI achieved in U.S. hospital ICUs (again, without widespread ADI). Mike will soon report (at the Decennial Meeting) the elimination of MRSA infections from ICUs without ADI. At Dan’s hospital, where only the burn unit performs ADI, the MRSA infection rate (nosocomial MRSA BSI/10K patient days) is lower than the lowest rate achieved by universal ADI in this much-heralded study.*

Jarvis belittles those who believe MRSA infections can be prevented without resorting to ADI as “active resisters and organizational constipators” who have only “emotional” arguments. In doing so he alienates those who share his goal (the prevention of all healthcare associated infections, including those due to MRSA) and who have taken concrete strides to achieve it (he also appears to have forgotten that the largest controlled trial of ADI demonstrated no benefit).

Dan and Mike (joint posting)

*COI alerts: Dr. Jarvis, and five of the eight authors of the Robiscek study, all have documented conflicts-of-interest with makers of rapid MRSA detection tests.

Cutting edge change in physician CME, or self-satirizing bamboozle?

Here’s an interesting piece in the NY Times on Stanford’s plans to develop a new continuing medical education program that is completely devoid of industry influence…except for the minor detail that it is underwritten entirely by Pfizer.

What do you think—“OK” if Pfizer really has no say in the content, or “not OK” because the conflict of interest is inherent in the Pfunding mechanism? (take our blog survey!)

Since this is an infection prevention blog, I’ll pose a parallel example specific to our field: what if Cepheid approached your infection prevention program and agreed to give you a million dollars to put together a year-long series of CME programs on MRSA control…..no strings attached, and you get to choose the speakers and content. Would you take it?

Multiplex PCR and diagnosis of sepsis

Just came across a really nice paper in the Journal of Clinical Microbiology by Ephraim Tsalik, Chris Woods and others at Duke and the Durham VA. They tested whether multiplex real-time PCR can be a useful addition to blood culture in patients presenting with suspected sepsis to the ED of their two hospitals. Over an almost 6-year period they enrolled 306 patients with suspected sepsis (43 were eventually excluded for non-infectious etiology). Patients had blood samples taken within ~2-3 hours and a questionnaire administered to determine recent exposures and symptoms. Most of the confirmed etiologies were S. aureus (34%) and E. coli (23%).

Results showed that blood culture had a sensitivity of 25% vs. 20% for PCR, a similar negative predictive value (18% vs. 17%), and an area under the curve of 0.63 vs 0.60. Using blood culture as the gold standard, PCR had a sensitivity of 61%. Both PCR and culture detected organisms in 40 patients (38 were the same organism). As far as individual methods, there were 24 organisms only detected by PCR (largely E. coli and Klebsiella) and 52 only detected by blood culture (E. coli, S. pneumo, S. aureus and a large number of CoNS considered contaminants). Six species detected by culture were not in the PCR menu (e.g Listeria, Salmonella).

I think these results speak for themselves. Neither method is perfectly sensitive at this point suggesting that both methods should be used if possible to improve diagnosis. PCR can be quicker and detect additional organisms, but still missed a significant number. Interestingly, blood culture was more sensitive in detecting organisms from patients who had previously received antibiotics (P = 0.06). This is counter to what I would've suspected.

What I really liked about this paper is that it was completed in a way that was clinically useful since they enrolled patients as they presented to the ED and asked the question in the way a clinician would. This was not some convenient sample study which we so frequently see in diagnostic test comparisons. I also liked how they presented the information, giving the sensitivity/specificity, predictive values and AUC. It will be interesting to see if future studies can document a clinical benefit in terms of reduced mortality and length of stay when PCR is added to our diagnostic battery. Finally, I was impressed that this study was completed at all. Enrolling so many septic patients with questionnaires over such a long period of time is no small feat. The authors should be congratulated.

Chart of the day

Today's New York Times has an interesting graphic of deaths due to influenza and pneumonia during the pandemic of 1957-58. CDC is using this to encourage vaccination against H1N1 in the event that a similar subsequent spring peak is seen.

Everybody loves chlorhexidine!

There are two randomized controlled trials* about surgical site infection (SSI) prevention published in the New England Journal of Medicine this week. In one multicenter study, investigators randomized 849 patients undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine (CHG)-alcohol or povodone-iodine (P-I), using a primary outcome of SSI at 30 days postoperatively. By intent-to-treat analysis, CHG-alcohol use resulted in lower overall SSI rates (9.5% vs. 16.1% for P-I; p=0.004), and lower rates of superficial (4.2% vs. 8.6%) and deep (1% vs. 3%) incisional SSI.

So CHG, which is already preferred for skin prep prior to intravascular catheter placement, and which is being used increasingly to bathe ICU patients, in catheter dressings, and in oral care, should probably also be preferred for preoperative skin prep. CHG for everyone, everywhere!

In a second multicenter study, Dutch investigators screened 6771 newly admitted patients for S. aureus nasal carriage, using real-time PCR. Of the 1251 S. aureus carriers, 918 were randomized to receive 5 days of either nasal mupirocin (2% ointment twice daily) and CHG soap (daily), or placebo. The rate of healthcare-associated S. aureus infections was almost 60% lower in the mupirocin-CHG group (3.4%, versus 7.7% for placebo; relative risk 0.42 [0.23-0.75]. Most enrolled patients were surgical (88%), and most S. aureus infections were SSI (82%). Among surgical patients, the rate of deep SSI was lower in the mupirocin-CHG group (0.9 vs. 4.4%; RR 0.2 [0.07-0.62]).

The implications of this study are less clear, since the relative importance of the two topical therapies (nasal mupirocin and CHG soap) is unknown. Many centers now routinely use pre-operative CHG bathing for elective procedures. Until we know whether screening and targeted decolonization is superior to the preoperative bathing of all patients with CHG soap, this approach should be reserved for high risk procedures (e.g. cardiac surgery, orthopedic implants).

Dick Wenzel wrote a nice editorial about both pieces, and uses the opportunity to make a point we’ve made several times before in this blog: interventions that can be applied to all patients and that reduce all infections are preferred to organism-specific approaches that carry the added expense and logistical difficulty associated with identifying all carriers of an organism.

*COI alert: Both studies were industry supported—one by Cardinal Health, and one by grants from GlaxoSmithKline, Roche, bioMerieux, and 3M.

Our brains and infection control: Carrots work better than sticks?

One of the banes of infection prevention is poor compliance with best practice. Hand hygiene compliance is but one example. The way we attempt to improve compliance at our hospital is constant monitoring of compliance and feedback to specific poorly compliant individuals to try to get them to improve. We have anonymous tip lines and individuals reported into the system get a quick call or visit from our CMO or me. Thus, we have more of a stick approach than a carrot. Does this approach work? I would say there is always room for improvement.

So, there must be another way. A recent article in Harvard Business Review suggests that our brains actually respond to carrots and not to sticks. Discussing work done at MIT by Earl Miller, the article tells how our brains re-wire after rewards and actually work more efficiently towards the rewarded activity but nothing happens after failure. They do clarify that learning does occur after punishment that is severe (a shock) but in QI this would likely occur only if the offender was fired or had a paycheck withheld. Perhaps our hand hygiene dispensers should put forth a few bars of Beethoven's Ninth after each successful use?

Hawaii and health care reform

I try to keep my political commentary to a minimum, sticking to infection prevention issues that I might know something about.....but I thought this was pretty funny. More amusement here and here.

I was unaware of many of the details of Hawaii's health care system--maybe I should travel there soon to learn more....now would be a good time, given the weather around here lately.

New Year's Resolutions, Procrastination and Public Health

I suspect we've all made resolutions at some point, but studies show most of us fail to accomplish our goals. I mean, is Lindsay Lohan really going to stick to this? I give her until St. Patrick's Day, but I digress.

In a recent article, The Economist suggests that a major reason for our failure to accomplish our goals is that we have a tendency to procrastinate; no surprise there. We tend to put off unpleasant or costly things into the future. That would be OK if we would stick to a single delay, but it turns out that we are time-inconsistent or “present-biased” and will always put off tough or costly things to the next day. Tomorrow really is always a day away. They reference a paper by O’Donoghue and Rabin.

I suspect this tendency is at the heart of the public health problems we have in the US. When you build a road you have immediate gratification, but the gratification of a well-funded state health department is uncertain and certainly in the future. Perhaps a better example is one I suspect many of us in infection control will soon face: should we push our administration to restock our N95 mask cache that we used to meet the OSHA/CDC/IOM requirement to care for suspected H1N1 cases? Avian flu is still out there and is just as likely to become a pandemic as it was last year.

This issue really concerns me. Even in this mild pandemic, we all saw how quickly the supply chains dried up for critical supplies. However, I suspect that hospital administrators will assume that the next pandemic will be this mild or forget the supply chain difficulties we had. Even more of a concern for me is procrastination. Will they assume that they can delay purchasing N95s for a cache because we just had a pandemic so the next one won't happen soon? They can "wait 'til next year" just like our favorite Cubs fan. The problem is that next year they will wait until next year.

Fortunately, the Economist and authors Duflo, Kremer and Robinson offer a potential solution using an example of why so few African farmers use fertilizer and how this can be improved. The quick answer is that the tendency to procrastinate can be overcome by small upfront time-limited subsidies. This small investment ends up being far less costly than doing nothing or offering a larger subsidy later in the year. What this suggests is that public officials should offer a grant to hospitals who invest in their pandemic cache (mask, antivirals etc) in the next year, but remove the subsidy quickly. This could overcome the inertia to do nothing because of pandemic fatigue or procrastination. Of course, how can we overcome our public officials' tendency to procrastinate? They do have bridges to fix. Thoughts?

A step in the right direction

A front pager in Sunday’s NY Times reports on new, more restrictive conflict-of-interest rules imposed by Partners Healthcare (which includes Mass General and Brigham and Women’s Hospitals). Read the whole thing for yourself, and marvel at the degree to which some of these academic leaders are awash in industry conflict! The chief of medicine at MGH received $220,000 last year from Pfizer, and over $700,000 since 2006?!

Despite the pains taken by the reporter to present both sides of the issue, I don’t see this as a difficult call. I agree completely with Arnold Relman, former editor of the New England Journal of Medicine:

“[it is] a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company. If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government…..They will be part of industry itself.”

When flu is on your plane...

A study in BMC Medicine uses mathematical modelling to determine the number of infections that result from a single H1N1-infected passenger on a Boeing 747. As shown in the table below, it depends on the duration of the flight and the price of your ticket:

	Number who become infected
Flight duration	1st class	Economy
5 hours	0-1	2-5
11 hours	1-3	5-10
17 hours	2-5	7-17

Soon there'll be a new user fee from the airlines--$100 for lowest risk of H1N1 infection, $75 for moderate risk, and only $25 for highest risk! But wait, for only $150, your flight attendant will sell you a course of tamiflu. Of course, correct change is appreciated. Oh, I kid the airlines....

Hand hygiene compliance: really important but impossible to measure

This morning I ran across an article in a Canadian newspaper, The London Free Press, that listed hand hygiene compliance rates for local hospitals. This piqued my interest. While nearly all hospitals in the US attempt to measure hand hygiene compliance, driven in large part by The Joint Commission's National Patient Safety Goals (NPSG 07.07.01 in TJC-speak), I am not aware of public reporting of hand hygiene rates in the US.

For public reporting, hand hygiene compliance is a double-edged sword. Given that hand hygiene is probably the most important measure to reduce healthcare associated infections, measuring it and publicly reporting it should be a high priority. On the other hand (no pun intended), it remains largely unmeasurable. I was interested to know how many observations were performed in the hospitals reported in the London newspaper since the denominators (number of opportunities observed) were not reported in the article. So I went to the Ontario Ministry of Health Patient Safety website, which has several publicly reported metrics for their hospitals (including central line associated bloodstream infection, ventilator associated pneumonia, and surgical site infection rates). There I learned that for hospitals with 100 beds, a minimum of 200 observations is required yearly.

So let's play with some numbers. Let's say that a 500-bed hospital performed 1,000 hand hygiene observations over the course of a year. We'll assume that the mean nurse:patient ratio across the hospital is 1:5, and that on average each nurse has 10 opportunities per hour for hand hygiene. If you do the math, you'll find that for nurses only, there are roughly 9 million hand hygiene opportunities per year in this hypothetical hospital. Measuring 1,000 of those opportunities accounts for one-hundredth of one percent. My conclusion: the hand hygiene compliance rates reported are meaningless. And my advice to the savvy Canadian consumer is to focus on the outcomes measures (infection rates) that are reported.

Unfortunately, at the moment, there's no valid way to measure hand hygiene compliance. Elaine Larson wrote a great review of the literature on methodologies for measurement a few years ago in the Journal of Hospital Infection. I still think it's useful to measure hand hygiene compliance, and the more opportunities observed, the better. And feedback of the data over and over in different ways is key to reinforce the importance of hand hygiene to healthcare workers.

Long story short: inside the hospital, hand hygiene compliance rates have utility. Outside, not so much.

When flu goes to school.....

In an interesting article now out in the Journal of Public Health Management and Practice, University of Pittsburgh researchers model various school closure strategies for control of influenza epidemics. Interestingly, the models they ran suggest that only very long (8-week) school closures are effective at blunting and delaying the peak of an epidemic. Shorter (e.g. 2-week) closures may even prolong an epidemic by releasing a large number of "susceptibles" into the population during the epidemic peak.

Also, Happy New Year!