Thursday, September 30, 2010

Communicating beyond the walls of academia

Tara Smith has a nice post discussing the methods for and importance of moving scientific discovery into the public sphere. She goes on to suggest that including additional funding for the purpose of outreach might be necessary because currently, only peer-reviewed communication with other scientists "counts" towards promotion and tenure.  She also recently gave a nice talk on Science Denial and the Internet; I've posted a link describing her talk below.  David Dobbs, a blogger at Wired had a recent post in the Guardian discussing similar issues, particularly why the scientific publication in the traditional sense is of little value or may actually be a cost.  It should be the data that counts, not the publication.

When I think about all of the wasted time we spend trying to format our papers for specific journals, then waiting 3-6 months to hear back from the journal, and then repeating the process until the paper is accepted, it makes me wonder how much more we could accomplish if we removed these hurdles.  This process enriches not scientists, but societies and others and serves as a method for "conflicted" direct-to-physician advertising. It's not like we find articles by reading the paper journals anymore.  Perhaps we could adopt a process where we publish a working paper online and then journals could compete for the rights to publish the data in their journal.  Wouldn't it be cool to turn a journal down?

Any other ideas for re-working the scientific communication system, both within the scientific community and creating incentives for outreach? We have to try harder to advance science against the pervasive pseudoscience that is forever expanding on the internet and within public policy. For example, if we could spend time communicating the benefits of vaccines instead of spending 15 months getting our vaccine paper accepted, we could serve the public more effectively and the public might actually see the value of science

Smith's Aetiology post: "Moving science communication into the public sphere"

Smith's recent talk on scientific communication, the internet and the anti-vaccine movement 

Dobb's Guardian Post: Publishing your science paper is only half the job

The white coat is back! (Sort of)

There's a new development in the UK with regards to doctor's attire. In 2008, white coats were banned as part of the bare below the elbow campaign. However, some hospitals in the UK are now mandating that doctors put the white coat back on, but there's a twist! The new coats have short sleeves. I wonder what the GQ Style Guy would say about this. I'm not a sartorial expert, but these coats sure look goofy to me. Click here if you want to order one.

Photo:   Internet Workwear Limited

Wednesday, September 29, 2010


A humorous video that makes a few serious points about antibiotic overuse (hat tip to Neil Fishman, antimicrobial steward par excellence, who forwarded it along)....

Creativity: Not always a good thing

There's a paper in this month's American Journal of Infection Control which looks at surveillance for CLABSI in pediatric ICUs. Surveys of personnel at 16 PICUs, mostly in academic medical centers, revealed that surveillance practices varied widely. Other practices which could affect the CLABSI rate also had great variability (e.g., blood culture practices--when they are drawn, how they are drawn, and how much blood volume is obtained). Interestingly, 100% of IPs surveyed reported that they applied the CDC CLABSI definition; however, when they were tested with clinical vignettes, none of the IPs applied the definition as written.

There really are no surprises here. This study confirms what many of us already knew--surveillance for HAIs is currently a mess, and little has been done to improve validity.

This week, through an informal email discussion with several hospital epidemiologists, I learned that the process of HAI case detection varies widely, with some hospitals involving front line providers in the decision as to whether an HAI exists. As the stakes associated with infections become greater, there is obviously a natural inclination to look hard at every potential case. But here's the real problem: whether the patient truly has an HAI or whether the patient meets the CDC definition of HAI are two different questions. At some hospitals, a strict black and white reading of the definition is applied. At others, clinical judgment is also considered, and in some cases, allowed to trump the definition.

Given the increasing practice of public reporting of HAI rates, improving the validity of data must become a priority. As a first step in this process, better definitions, with more specificity, would be of great help.

Tuesday, September 28, 2010

Importance of leadership in the public health response

The Republic of Turkey
We are all influenced by those around us.  On an individual level, this is particularly true if the person nearby is senior or has an elevated rank in comparison to those being influenced. For example, Mary Lankford and others from Chicago published in EID (Feb 2003) a study which aimed to determine if a new hospital design would improve hand hygiene compliance.  What they ultimately found was that health-care workers in a room with a senior (e.g., higher ranking) medical staff person who did not wash hands were much less likely to wash their own hands (OR = 0.2). Of course seniority in another more direct way, say a CEO who supports HAI prevention initiatives, can also influence a hospital's HAI response. Could others, such as political leaders,  also influence our HAI prevention behavior?

An interesting new study out of Turkey in BMC ID reports what factors most influenced HCW uptake of 2009 H1N1 influenza vaccine. In a two hospital survey of HCW, where the vaccination rate was only 12.7%, the factors that were associated with poor influenza vaccine uptake included the vaccine's perceived side effects, disbelief in the vaccine's protectiveness, negative news about the vaccine and the perceived negative attitude of the Prime Minister to the vaccine. Thus, our leaders can have a big impact on our public health response.  Perhaps this is something we should take into account when we vote this fall.

Lankford et al, EID, February 2003
Savas et al BMC ID, Sept 2010

Why coding matters or why we shouldn't use ICD-9 codes?

Marin Schweizer, our colleague at Iowa, has a nice post up on the Center for Disease Dynamics, Economics & Policy (CDDEP) blog concerning the downsides and difficulties of using ICD-9-CM codes for HAI research, surveillance or CMS's 'no pay rule'. It's definitely worth the trip over there for a read...

Marin Schweizer's CDDEP post

Staph: It's deeper than you think

For decades it's been known that the primary site of staphylococcal colonization is the anterior nares. Now there is a new, interesting paper in the Journal of Hospital Infection that provides a better understanding of colonization. Nasal swabs were performed on 37 cadavers and 9 were found to have colonization with S. aureus. The noses were then surgically removed and tissue sections taken. An antibody stain against S. aureus was applied to visualize the site of colonization. There were two important findings: (1) colonization only occurred distally in the stratified squamous epithelium (i.e., there was no colonization of the more proximal ciliated mucosa; and (2) in 6/9 cadavers, staph organisms were visualized in the hair follicle shaft, and in 2 the bacteria were visualized deep in the follicle. The presence of S. aureus deep in the hair follicle may explain why some patients do not decolonize or recolonize after decolonization with mupirocin since the drug may not be able to penetrate that deeply.

Monday, September 27, 2010

VIM-producing carbapenem-resistant Klebsiella pneumoniae

CDC just released in MMWR a report of the first case of a Verona integron-encoded metallo-beta-lactamase (VIM) carbapenemase in an Enterobacteriaceae in the United States. The patient was initially hospitalized in Greece and then transferred to a US hospital.  CDC was notified in July and, fortunately, the screening of the 22 patients whose U.S. hospital stays overlapped with this patient were all negative. I would write more, but a nice post by Alex Kallen from the CDC puts this in the proper context.

Sept 24 MMWR article
Alex Kallen CDC post

Sunday, September 26, 2010

My new VAP definition is unstoppable!

As we have blogged on numerous occasions, existing ventilator-associated pneumonia (VAP) definitions (for both clinical and surveillance purposes) are craptastic. In Mike’s recent post about this problem, he calls for CDC to collaborate with IPs and hospital epidemiologists to help develop better definitions. Well, the CDC is doing just that. They have been working with critical care and ID physicians, as well as with some of the CDC Epicenters, to develop and assess a new definition for “VALORI” (Ventilator Associated Lower Respiratory Infection). A simple algorithmic summary of the approach is below, courtesy of Dr. Shelley Magill, who gave an excellent talk at a recent CDC/HHS meeting I attended in DC:

The major objection voiced to the draft VALORI definition is that by removing some aspects that introduce subjectivity, the definition becomes more of a severity of illness measure than a description of what we know clinically to be VAP. The definition also retains some elements that are subjective (or hinge on clinician behavior, such as use of antibiotics), so it isn’t clear if it will have better performance characteristics than the current NHSN definitions.

In my view, we should not use VAP as a quality measure, period. VAP rates should not be compared across hospitals, publicly disclosed, or used in any pay-for-performance schemes. For as soon as they are, hospitals will quickly learn to reduce their rates without doing anything that actually improves patient outcomes (e.g. by narrowly interpreting clinical signs or CXR findings, by seeking consensus among multiple IPs for each case, or by incorporating clinician’s opinions regarding the diagnosis).

In the meantime, we can probably agree on some practices that could be selected for public reporting and benchmarking (i.e. process measures). The practices chosen should be those that are demonstrated to improve meaningful patient outcomes in controlled clinical trials. A great example is this 4-center study of spontaneous awakening + spontaneous breathing trials. The investigators, recognizing the futility of defining VAP, instead demonstrated reductions in ICU days, vent days, hospital days, and mortality in the intervention group.

Why are quality and infection prevention programs like oil & water?

This week, I analyzed our most recent performance in the HOP project. HOP is an acronym for the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), a CMS program that is publicly reported at Hospital Compare. HOP is the outpatient analogue of SCIP (the Surgical Care Improvement Project), though HOP has only 2 metrics--pre-procedure antibiotic selection and appropriate timing of the antibiotic dose. We slice the data by procedure, service and surgeon to look for areas where performance is suboptimal. I received an email from one of our senior surgeons who complained that he had several cases where he was deemed noncompliant because the pre-procedure anitbiotic was not given within the window period 60 minutes prior to incision. He pointed out that the reason for his "noncompliance" was that these were dialysis patients who had received a dose of vancomycin at dialysis the day before. And he was practicing good medicine because the patients would still have a therapeutic level of vancomycin at the time of the procedures (all vascular access procedures). So we posted a query as to why this situation would be considered noncompliant (i.e., could the rules be changed to allow for this situation?). We received prompt responses from the physician in charge of the national project, but he avoided answering the question. After multiple emails back and forth, he finally stated that the surgeon did the right thing, but it would still be deemed noncompliant. He went on to say that hospitals should not use the data in this way (i.e., drill it down to the provider level) and the project leadership could not possibly think of all the exceptions for when an antibiotic should not be given within 60 minutes of incision. Now I have some problems with his thinking--if you are going to publicly report our performance then I think you need to be flexible enough to allow for exceptions that actually reflect good practice, and in an environment of 24/7 communication it shouldn't be hard to have a panel of experts make decisions on requests for exceptions to the rules. With SCIP we've actually been dinged when a pre-op antibiotic was not given before incision for a patient who entered the OR in cardiac arrest! I've blogged before about how these types of problems really turn physicians off not just to these specific projects but to quality improvement projects in general.

All of this made me think some more about the differences in quality improvement and healthcare epidemiology. The table below is modified from a plenary talk I gave at SHEA a few years ago. These differences really become sources of friction when QI and hospital epi folks are pulled into common projects like SCIP and HOP.

Healthcare Epidemiology
Quality Improvement
Philosophic orientation
Primary influences
Science & medicine
Analytic orientation
Population based
Often case based
Exploration & analysis
Primary audience
Internal stakeholders
External stakeholders
Primary task
Define problems, elucidate risk factors
Design & implement interventions
Content expertise
Almost always
Usually not
Rigorous methodology
& validity
Process design
relatively uniform
Delivery style
Data oriented,
relatively dull
Flashy campaigns, catchy slogans
Long term
Short term, evolving
Relatively slow
Relatively fast

I don't have any solutions for how to make the groups work together more effectively. But perhaps starting with a recognition that our approaches to problems are different is a start.

Saturday, September 25, 2010

Making the cut: Inside the grant review process

Everyone's life is difficult, but one of the best ways to understand what someone's life is really like is to 'walk a mile in their moccasins.' That's what a recent Nature article let's us do.  They recently secured access to an American Cancer Society grant review meeting.  One in which the previous review resulted in a 9% funding rate and it may be getting worse. Having been on both sides of the review process, I found the description very compelling and accurate.

Link to Nature article (html) or (pdf)

Happy Weekend: How 'bout getting off these antibiotics

Yes.  I know most will mock me for posting an Alanis video; but hey, how many people can get a whole crowd to shout about getting off antibiotics, in Japan no less.  Some of my old co-fellows will get the humor behind this too...come on eileen...thank u

Friday, September 24, 2010

No HAC-king next week....

CMS announced today that its plan to publicly release hospital-specific data on hospital acquired conditions (HACs) next week has been put on hold. Apparently the data were flawed. We recently reviewed our data report that was to be released, and compared the hospital acquired CLABSI and catheter associated UTI data to that collected via concurrent surveillance by our IPs. To describe the CMS data as wildly inaccurate would be an understatement.

Prior seasonal influenza infections protective against 2009 Pandemic flu (if you're a ferret)

Looking back at the 2009 flu season, I realize how calm it is now compared to then.  I hope it stays that way!  In that pandemic, the attack rate was 50% in young populations compared to perhaps 10% in adults.  Why would this be the case? Serologic analysis showed little cross-reactivity between recent seasonal influenza A(H1N1) viruses and pandemic A(H1N1). The authors of a recent JID paper postulated that the lower attack rate in adults could result from multiple past exposures to viruses with similar B epitopes or since there is conservation of T cell epitopes between pandemic H1N1 and seasonal influenza A, then cellular immunity may also reduce disease severity. There's also the fact that adults responded to a single dose of pandemic H1N1 vaccine, while children did not, suggesting that past exposure to seasonal strains is important.

To examine the role of prior immune reponses in seasonal influenza on exposure to pandemic H1N1, Laurie et al. in the Oct 1 JID, studied the impact of one or two prior infections in a ferret model.  The found that a single prior infection with a seasonal influenza A virus, A/Fukushima/141/2006 (H1N1) or A/Panama/2007/1999 (H3N2), reduced the duration of shedding following challenge with 2009 pandemic H1N1, but not reduce the infection rate nor did it reduce the transmission to other ferrets.

The authors then tested whether two prior infections with seasonal influenza was protective against pandemic H1N1.  They determined that infection with seasonal A(H1N1) followed by A(H3N2) reduced the infection rate along with the amount and duration of shedding in ferrets challenged with pandemic A(H1N1). Interestingly, no virus was transmitted to other ferrets, nor did the exposed na├»ve ferrets experience seroconversion to pandemic flu.

Good news, if you're a ferret.

Laurie KL, et al JID, October 1, 2010.

Thursday, September 23, 2010

Why I took the job? Low HAIs and high flu vaccine compliance!

Dr. Churchwell
Delaware's only children's hospital, Alfred I. duPont Hospital for Children, just announced that Dr. Kevin Churchwell will become chief executive officer in December.  I'm not sure even why I read the article, but what caught my eye was why he said he took the job:

Churchwell said the new (renovation) project was one issue that factored into accepting the job. He also was impressed with the quality of care delivered at duPont, which has low hospital-infection rates compared with other local and national hospitals. It also has high vaccination rates for the flu among its health care workers.

"They have a great safety infrastructure," Churchwell said. "A.I. is a leader in that, and they need to step out and teach other hospitals how it's done. That will make a big difference."

Something is up. Not only is it great that a CEO has HAIs as a major priority, which is hopefully becoming more common, but also that he selected the job based on the quality and safety of the hospital.  Perhaps it's because he's a pediatric critical care doc. Either way, it's pretty cool.

Delaware online announcement

Wednesday, September 22, 2010

Healthcare reform explained. The Kaiser Family Foundation video

Cokie Roberts explains all or at least a little

Sorry about the earlier video; this one should work on iDevices. -e

Tuesday, September 21, 2010

Contact precautions: A very personal view

The latest issue of the Annals of Family Medicine has an interesting essay, "Losing Touch in the Era of Superbugs," by a physician who struggles with contact precautions. Recently hospitalized with a MRSA infection, he has a new fear of becoming infected at work, yet realizes how important human touch is in the practice of medicine. It's a great reminder of how contact precautions interferes with providing the most humane care to our patients. You can read the full text of the essay here.

Monday, September 20, 2010

Thomas Jefferson and financial conflicts of interest

the Egyptian Building
While reading Peter Orszag's excellent column on the role that rising medical costs have had on the declining state-funding of state universities, I came across an interesting historical example of medical conflicts of interest.  Initially, I was trying to determine the public/private status of Mike's institution, Virginia Commonwealth University, when I learned about Augustus Warner and Thomas Jefferson.

In 1837, Dr. Augustus Warner, a surgeon at University of Virginia and graduate of the University of Maryland, became disillusioned with the clinical material available and felt that Richmond would provide a much broader patient base, so he started and became Dean of what was to become the Medical College of Virginia (VCU). Most interestingly, Dr. Warner was said to have left the University of Virginia’s medical school because he didn't agree with Thomas Jefferson’s philosophy that professors shouldn’t corrupt their teaching by making money caring for patients.

I guess I can imagine that physicians enrolling patients in RCTs might have conflicts between science and their patients (hence blinding and perhaps random assignment).  It still seems so foreign to me that this would be a financial conflict.  Wait, I guess the current medical system, where physicians are paid more if they do more procedures, leads to the conflicts that Mr. Jefferson was worrying about.  I wonder why Jefferson wasn't quoted during the recent health care reform debates?

Peter Orszag's NY Times column

VCU Surgical Department History

VCU Health Sciences page

Sunday, September 19, 2010

More cases of Balamuthia encephalitis transmitted via organ transplantation

Late last year, we blogged about the transmission of Balamuthia mandrillaris from an organ donor with an undiagnosed encephalitis in Mississippi to 2 organ recipients (liver and kidney-pancreas) who subsequently developed encephalitis. One recipient died of encephalitis and the other survived with neurologic sequelae. These cases are described in the most recent MMWR. Then there was the report in Clinical Infectious Diseases of transmission of rabies to 2 organ recipients who died. Again the donor had an undiagnosed encephalitis. Seven other cases of transplant-associated rabies had been previously described. Now the Arizona Star and MMWR are reporting another cluster of two Balamuthia encephalitis cases who received organs from a 27-year old man who died of what was thought to be a stroke (no details on brain imaging are included in either report).

Several months ago, I argued that there should be an immediate ban on transplanting organs from donors with undiagnosed encephalitides (and I would now add other neurologic diseases without a confirmed diagnosis) in cases where transplantation is not immediately life-saving (e.g., cornea, kidney, intestine, pancreas, musculoskeletal grafts). And where transplantation is potentially immediately life-saving (e.g., heart, liver), full disclosure of the donor's diagnosis and its implications should be made available as part of the informed consent process. I was surprised that CDC did not make this recommendation earlier, and even more so after additional cases have been reported.

It's that time of year again...

I suspect that many of you are brushing off your flu lecture and updating it with new information for the upcoming season. CDC has posted some amazing images of flu viruses which are great for inserting into your PowerPoint slides. Click here to access the images.

Friday, September 17, 2010

Happy Weekend: It's difficult to see the whole picture...

...when you are inside the frame.  Framing effect, confirmation bias, anchoring, financial conflicts of name it. We all live in the same place. The yellow "I" could stand for Iowa, but it doesn't. Who doesn't love Sesame Street?

Thursday, September 16, 2010

Sensitivity of perianal swabs for MDR-GNR

Quick last abstract from ICAAC.  Graham Snyder et al. from Beth Israel Deaconess Medical Center in Boston enrolled 35 patients with known multidrug-resistant Gram-negative bacteria in clinical cultures (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter cloacae, Proteus mirabilis, and Morganella morganii). Each patient received a perianal swab. The sensitivity was 79%. It was a small study with the usual caveats.

Conflict of Interest: Graham was a medical resident that I worked and published with at Maryland.

link to medpage article

Wednesday, September 15, 2010

More on presenteeism

This week's JAMA has a short report on presenteeism in medical residents across 4 specialties in 12 hospitals. The survey was sent to 744 residents and had a 72% response. Overall, 58% of residents reported that they had worked while sick at least once in the past year, and 31% reported doing so more than once. A higher proportion of presenteeism was found in 2nd year vs. 1st year trainees. This is directly related to my posting yesterday on control of nosocomial influenza and provides some food for thought as we begin to plan for the upcoming flu season.

Tuesday, September 14, 2010

(Financial) Conflicts of Interest: The Randomized Trial

A study out of Carnegie Mellon University in JAMA tested whether reminding pediatric and family medicine residents of their personal sacrifices might make them more willing to accept a gift from industry.  In the online survey, if the residents where asked about their sacrifices, such as work hours, hours of sleep, salary and education related debt, prior to questions about the acceptability of gifts, then 48% found the gifts acceptable vs 22% in the control group who were asked about the gifts first.

Interestingly, if the residents were also read this: "Some physicians believe that the stagnant salaries and rising debt levels prevalent in the medical profession justifies accepting gifts and other forms of compensation and incentives from the pharmaceutical industry. To what extent do you agree or disagree that this is a good justification?" then 60% found the gifts acceptable.  So reminding residents of their sacrifices, especially if they are provided a rationalization really changes their perceived acceptability of industry-sponsored gifts. Pretty scary.  But what can be done?

An accompanying editorial by Pauker and Wong from Tufts discusses, among many things, the lack of training medical students receive in managing their many conflicts "regarding ethical principles about personal economic behavior, the ethics of patient care (eg, beneficence vs autonomy), or multifaceted loyalties (eg, to patients, institutions, society, or third-party payers)."  They highlight the 'theory of constraints thinking process" (TOCTP) and it's core conflict resolution diagram, the evaporating cloud. This 'dark cloud' can be evaporated when subjected to logic techniques.  The example they provide might take a few readings to understand, but seems to make sense on paper.  I'm not sure how such techniques could be implemented, however.

Sah and Loewenstein JAMA RCT
Pauker and Wong JAMA editorial

85% wash their hands in public places!

An ICAAC report found that that 85% of people in Atlanta, Chicago, New York and San Francisco washed their hands after using the bathroom. The report states that women were more compliant than men.  Now,  I wonder if this was because the women observers were just more observant?  Either way, these are the highest rates since the surveys began in 1996.  Since it is safer these days, high fives!

NY Times article

Another reason why mandating flu shots is stupid

I wanted to share with readers a simple, back of the envelope calculation that points out the folly of trying to control respiratory illness in healthcare workers by mandating influenza vaccine.

Here are the assumptions for the calculation:
  • Our hypothetical hospital has 5,000 healthcare workers
  • It’s a nonpandemic influenza season, in which 7% of the population (including healthcare workers) gets an influenza-like illness (ILI), of which 7% is due to influenza (these estimates are from the control arms of 95 influenza vaccine trials involving 1 million subjects over the course of four decades). Now of course the 7% of the 7% (those with influenza) can be reduced by influenza vaccination.
  • The hospital has a baseline influenza vaccination rate of 70% without mandating the vaccine
  • We’ll generously assume that influenza vaccine is 90% efficacious at preventing influenza (though it has no impact on non-influenza ILI)
  • Presenteeism is 70% (i.e., 70% of healthcare workers come to work when they are sick)

Now let’s take 2 different approaches to reduce the risk of transmission of ILI to patients. In the first approach, we’ll mandate influenza vaccine and achieve a vaccination rate of 98% (we'll assume that 2% of HCWs have a contraindication). In the second approach we won’t mandate vaccination and we’ll maintain the vaccination rate at the baseline of 70%, but we undertake an educational campaign to reduce presenteeism.

So, the question is this: what reduction in presenteeism would have the same impact as achieving 98% influenza vaccination in terms of the number of HCWs at work with ILI? The answer is an astonishing 1% absolute difference. Reducing presenteeism by 1 percentage point (from 70% to 69%) would have the same impact as increasing vaccination from 70% to 98%. So in our 5,000 employee workforce if we could get 4 HCWs with ILI to stay home it would have the equivalent effect of mandating influenza vaccine. 

Now one could argue with the assumptions and we could re-run the numbers using different percentages for any of the variables. But the primary and irrefutable message is this: pathogen-specific interventions (i.e., vertical approaches) for controlling transmission of infection in the hospital are inefficient when compared to multipotent, horizontal approaches. And remember that a sizable fraction of the patients are vaccinated against influenza (we don't have vaccines for the rest of the ILIs), which actually increases the differential impact of the strategies in favor of reducing presenteeism.

Unfortunately, the horizontal approach to controlling ILI won’t make any companies any money, and in our sound bite culture, the path of least resistance (which SHEA and others have fallen prey to), is to simply call for mandating flu vaccine.

Let me once again emphasize I am not anti-vaccine. I get a flu shot every year. But I think the costs of forcing resistant healthcare workers to get vaccinated in terms of unintended consequences outweigh the benefit. So I can live with 70% compliance and find other ways to protect our patients.

P.S. my calculations are below:

Alternative strategies
70% vaccinated,
70% presenteeism
98% vaccinated,
70% presenteeism
70% vaccinated,
69% presenteeism
Total HCWs
Vaccinated HCWs
Unvaccinated HCWs
HCWs with non-flu ILI (6.5%)
Unvaccinated HCWs with flu (0.5%)
Vaccinated workers with flu (0.5% x 10%)
Total HCWs with ILI
HCWs at work with ILI

NDM-1 in the US (Boston, California and Illinois)

MGH - where one NDM-1 patient was treated
Out of ICAAC there is a report of three carbapenem-resistant (NDM-1) cases in the US, all of whom had medical care in India prior to travelling to the US. Per a Tribune article, "the three U.S. cases involved three different bacteria that remain susceptible to at least one of three antibiotics: colistin, polymixin and tigecycline, said Karen Bush, an Indiana University professor..."  If you'll notice, the reports all call NDM-1 a 'superbug.'  I find this funny since NDM-1 isn't even a bacteria but a gene that can be found in several pathogens, as described in this ICAAC report.  Anyway, gotta feel bad for MRSA.  Just when it let its guard down, this new guy just takes over.  Kinda like what Nadal has done to Federer.

Boston Globe Article
Chicago Tribune Article

NDM-1 MMWR report from June 25 (thanks to Maryn McKenna for the tip)

Monday, September 13, 2010

American Academy of Pediatrics Recommends Mandatory Influenza Immunization of all Health Care Workers

We have already posted several times in the last week regarding the SHEA Position Paper.  The AAP Policy Statement comes to a similar conclusion.  They appear to come from the position that compliance with vaccine is low, low is bad and mandatory programs can increase compliance. No good information in the document regarding financial COI, but they do include a statement that they were internally disclosed and resolved through a Board-approved process.  Not being a member of AAP, I'm not sure what that means.  Perhaps someone can enlighten us.

Interestingly, the AAP paper has 24 references vs SHEA's 63.

AAP Policy Statement

Previous SHEA Position Paper posts: here, here and here.

Sunday, September 12, 2010

Conflicts of interest are not always financial. Role up your sleeves...and get your flu vaccine?

I joined this blog in December 2009.  There were several reasons for this including what I saw was a great need for conversation among hospital epidemiologists and infection preventionists around complex and important issues such as N95 masks in 2009 novel H1N1, ADI for MRSA and mandatory influenza vaccination of HCW.  That's why I was so excited to see that SHEA was finally releasing a position paper endorsing "a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges."  I was so excited in fact, that I haven't read the document.  To be fair to myself, I've been pretty busy and I've seen several talks and debates on the issue. However, I was excited because it would awaken the debate again within the medical community and, more importantly, this blog.

Dan, Mike and I have all commented on the conflict of interest issue. It is true that several authors of the SHEA position paper have financial ties to vaccine manufacturers.  I agree, as I probably said 1000 times during high school debates, that 'perception is key' and that ideally we could produce documents such as this SHEA paper free of financial conflicts.  However, given that this document has been produced, what can and should we do with it?  How will we interpret it in the light of other organizations (e.g. AAP) coming to the same conclusion? Additionally, to be fair to the document and process, this isn't purely a SHEA position paper, but rather it was "approved by the Board of the Society of Healthcare Epidemiology of America and endorsed by the Infectious Diseases Society of America."

You could argue that we should post or even eliminate all of the potential "financial" conflicts of all of the board members of these societies and I would, at first pass, agree with you.  So now, in the future, we might have all board members and all guideline writers be free of all financial conflicts of interest. That may be theoretically possible for one subject, but all subjects? I doubt it.  I also don't think that "financial" conflicts of interest are the most important or result in the most bias.  I think it's not even close; but more on that in a minute.

Now if you think I've gone off my rocker (again), well, I was lead author on a SHEA guideline back in 2007 titled "Raising standards while watching the bottom line : Making a business case for infection control," and that guideline was conceived of, supported, edited, modified and approved by many members of the SHEA board.  In my opinion, a majority of those on the SHEA board must have pushed for this new flu vax position paper knowing what the outcome would be.  In fact, didn't SHEA produce a 2005 position paper containing a different recommendation? So why go through the effort to produce another document so soon, if they didn't know it would produce a different or this exact recommendation? Importantly, the SHEA position paper adheres to all current guidelines and lists financial conflicts of the authors. Nothing is perfect, but I don't think we should discount the recommendations for that reason.

On to another subject.  In April and June of this year I wrote posts discussing what I see is the most important bias in science and in life. That bias is confirmation bias.  My first post on the subject discussed how all of us that have pre-specified opinions, especially ones that are well known to others, root for results of new trials to support our pre-existing beliefs. It's just natural. This tendency for people to favor information that confirms preconceptions regardless of whether the information is true can influence our search for information, how we interpret information and even our memory.  Now, I'm not sure a definitive study has been done, but I suspect that if you have stated a strong public opinion for or against a certain "thing" it would take a lot of money to get you to change your mind and I haven't even mentioned status quo bias. Cognitive biases....if only the solution was so simple as listing or eliminating financial relationships!

While I'm on the subject of definitive studies, I will first state that I have great respect for the Cochrane reviewers and the SHEA position paper authors (and of course my co-bloggers).  However, no amount of genius can overcome the lack of studies/data/funding that exists for the evaluation of infection prevention interventions. So, again, even though I've not read the SHEA paper or the Cochrane reviews, I can definitively say that they are both wrong. Why? No one has completed the necessary cluster-randomized trial in 50-100 hospitals during different influenza seasons with different vaccine-virus matches in different countries with different acuity levels of the hospitalized patient populations etc, etc, etc.  No one will.

To me, the key issue around mandatory vaccine for HCW is not whether the vaccine works, as Mike discussed on Saturday. Rather, it is how much better HCW compliance would be under a mandate. I think most can agree that mandates greatly increase vaccine compliance, but if the data suggests that the vaccine doesn't work, then the question shouldn't be whether or not to mandate the vaccine. The question should really be whether we even offer it to HCW at all, or less seriously, even bother tracking compliance.  I think Mike's post or rather the Cochrane reviews have far more serious implications that stretch way beyond HCW mandates. To me though, there is enough data to support the efficacy and safety of influenza vaccine both in direct protection and also herd immunity. Thus, I think the key issue is compliance; but again, I haven't read it (yet).

So, what would I have done if asked to determine the benefits of mandatory influenza vaccine in HCW?  I might have completed a different type of research synthesis, altogether. I could have taken data like Mark Loeb's 2010 JAMA paper showing the benefits of herd immunity imparted on the unvaccinated by vaccinating children in small rural communities in Canada. Then, I'd have built a decision-analytic type model accounting for the non-linearity of influenza transmission in hospitals, adjusted for various levels of HCW vaccination compliance, completed numerous sensitivity analyses and then reported in which hospitals, in which countries and in which influenza seasons (H3 vs H1) we would expect influenza mandates to be most effective. Too bad that's not gonna happen.  Oh, and people wouldn't believe the model anyway.  It's just math for goodness sake and nobody trusts equations. No, most of us would much rather put our faith in conflicted human beings.  Go figure.

No links today; gotta spend time reading SHEA's new position paper

Saturday, September 11, 2010

More on SHEA's Flu Vaccine Mandate for Healthcare Workers

Last week, Dan blogged about SHEA’s new position paper, which calls for annual influenza vaccination as a condition of initial and continued employment for healthcare workers (HCWs). Simply put, SHEA is recommending that HCWs without a contraindication to influenza vaccine be fired if they refuse to be vaccinated. That’s a strong stance coming from an organization that typically avoids strong stances. I’ve blogged before about why I think that mandating influenza vaccination is a bad idea, but in this posting I want to focus on the evidence behind the recommendation.

Of note, there are 3 Cochrane reviews on influenza vaccination published this year that are worth reading. If you’re not familiar with Cochrane Reviews, you can read more about them here. These reviews are generally thought of as the highest quality, most rigorous reviews of the medical literature, and the reviews are developed free of any commercial funding.

The first Cochrane review, Influenza Vaccination for Healthcare Workers Who Work with the Elderly, is most applicable to the SHEA position statement. SHEA’s position on the utility of vaccinating HCWs to prevent influenza transmission to patients is based on 4 studies in long-term care facilities (LTCFs). And of note, those 4 studies are part of the Cochrane review, which comes to the following conclusion: “We conclude there is no evidence that vaccinating HCWs prevents influenza in elderly residents in LTCFs.”

Another recent Cochrane review evaluated the utility of influenza vaccination of healthy adults, which presumably represents the majority of HCWs. The authors concluded: Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.”

The last Cochrane review is least applicable to our current discussion, but interesting nonetheless. In reviewing the effect of influenza vaccine for the elderly, the authors conclude “The available evidence is of poor quality and provides no guidance regarding the safety, efficacy or effectiveness of influenza vaccines for people aged 65 years or older.”

So given the lack of rigorous evidence supporting the utility of vaccinating HCWs to prevent transmission to patients, I find it astonishing that the Society for Healthcare Epidemiology would adopt such a position. I certainly would have no problem with a position statement that strongly encourages vaccination, but to recommend that HCWs be fired for noncompliance with vaccination is over the top and undermines SHEA’s credibility. The level of compliance with any intervention to improve the quality or safety of patient care must be correlated to the strength of the evidence, and in this case, the evidence for a mandate is lacking.

As I was looking at the Cochrane reviews, I wondered aloud how the SHEA guideline writers could have come to their conclusion. My good friend and colleague, Gonzalo Bearman, quickly responded, “they were blinded by dogma.” Amen, Gonzalo!

Friday, September 10, 2010

Natural Disaster - Happy Weekend

I've always thought of antibiotic resistance as a natural disaster; "one that’s been happening over and over and over again." Every epidemiologists' favorite whistler, Andrew Bird, sings "Natural Disaster" for your weekend viewing/listening.  He even works in malaria,  kittens with pleurisy and a wolf with lung disease.

The angle gets better after a few seconds...

Thursday, September 9, 2010

Is APIC leadership paying lawyers and consultants to read blog posts?

The back story is this: Over the weekend, Mike posted an item that was critical not of APIC members, but of APIC’s leadership. He was critical of the APIC CEO in particular, and the close relationship she fostered between APIC and Becton Dickinson (a company she is now joining as a Vice President). I can’t speak for Mike, but I assume he did this because he recognizes, as do I, that APIC is an essential and influential voice in infection prevention—it simply cannot allow its agenda and vision to be co-opted by an industry partner.

Occasionally I check up on visits to our blog, just to see what the general trends are, where our visitors are from, and what posts interest them most. When I last checked, I was surprised to see that one blog post in particular was getting a fair bit of attention from two unusual visitors: a law firm, and a firm that specializes in shaping public opinion and handling crisis management. Both have visited this particular blog post multiple times over several hours. The law firm happens to be the contact for the APIC research foundation, so I assume they do APIC’s legal work.

APIC members have been toiling for years to prevent infections and improve patient safety. Most are literally on the front lines of infection prevention—overworked, underpaid, and underappreciated. So I sincerely hope that APIC leadership isn’t squandering its members’ hard-earned dues on lawyer and consultant fees in response to a blog post.

That’s such a ridiculous thought, in fact, that I’m sure it isn’t true. There must be people in these firms who are just interested in infection prevention—if so, I’d encourage them to look at all of our posts, not just that one. There’s a lot of other great stuff on this blog!

Wednesday, September 8, 2010

To screen or not to screen? That's AHRQ's question.

AHRQ has just opened for public comment a potential research topic titled "Comparative Effectiveness of Screening for MRSA Carriage." It's open for comment until October 5. Hey! Now's your chance to influence the national research agenda! or at least answer 6 questions.

AHRQ Research Comment Page

Tuesday, September 7, 2010

The “vicious cycle of pseudoimprovement”

What am I talking about? Read this JAMA commentary from Drs. Muller and Detsky to find out.

Done reading? Now ask yourself these questions: is my hospital following indicator-based or evidence-based strategies to improve patient outcomes? What happens when publicly-reported indicators improve dramatically, but patient outcomes do not?

Saturday, September 4, 2010

What's the next step for APIC?

Last week, the Association for Professionals in Infection Control and Epidemiology (APIC) announced that Kathy Warye was leaving her position as APIC’s CEO to become Vice President for Infection Prevention at Becton Dickinson. Warye joined APIC in 2004 and according to the organization’s 2008 Form 990, her total annual compensation was $360,000.

Warye’s transfer to BD shouldn’t come as a surprise when one considers the two organizations’ close relationship and intertwining interests over the past several years, as shown in the timeline below:

 2004:  GeneOhm MRSA screening test is approved by FDA
 2006:  BD acquires GeneOhm
 2006:  APIC holds a conference on Managing MRSA and launches a nationwide MRSA prevalence survey
2006:  APIC holds a summit on the Economics of Infection Prevention, co-sponsored by BD
 2006-07:  APIC develops and presents MRSA Grand Rounds, which is held in cities across the US, sponsored by BD
 2007:  APIC holds an Infection Prevention Summit, co-sponsored by BD
2008:  APIC launches a nationwide C. difficile prevalence survey (Principal Investigator Dr. Bill Jarvis, a consultant for BD)
2009:  BD’s rapid test for C. difficile is approved by the FDA
2009:  At APIC’s national meeting, BD sponsors the session where results of the C. difficile prevalence survey were presented by Dr. Bill Jarvis, as well as sessions on the MRSA Elimination Guide, the VA MRSA Prevention Initiative, C. difficile in the UK, and Managing MRSA in Long-term Care Facilities
2009:  APIC Anywhere, an online education center, goes live, co-sponsored by BD

In addition, the BD logo appears on APIC’s website where BD is described as “a strategic partner since 2006,” and APIC’s logo appears on BD’s website. BD contributes to the APIC research foundation, which funds projects such as the prevalence studies. BD also provides funding for APIC chapters. All of this raises the question of how much impact BD has had on APIC’s policy agenda.

An interesting aspect of Warye’s role at APIC was as the CEO she appeared to be driving the organization’s policy agenda and was highly visible. In contrast, in many professional organizations, the CEO is charged with operationalizing the board’s agenda and plays more of a behind-the-scenes role. When the person setting the agenda has come from outside the profession, there exists the potential for problems, as these leaders have not been socialized via their training to have a full understanding of the profession’s ethos. Perhaps this explains APIC’s numerous industry relationships and its strategy to commodify infection prevention. You name it, they’ve tried to sell it. They have priced many of their own members out of their annual meetings, and sell their infection prevention textbook for a whopping $625 (members get a reduced price of $475). They have also developed a consulting service.

Warye’s departure creates a good opportunity for APIC to step back and assess its mission, vision and values. Maybe the organization can get back to doing what it is supposed to do by representing its members' interest. Maybe it can now act like a non-profit organization instead of a business that is focused on selling products (theirs and industry's). And maybe it can re-evaluate its relationships with industry. Going forward, it will be interesting to see how APIC’s relationship with BD changes given Warye’s high-ranking position in the company. Any financial support of APIC by BD now will only heighten concerns regarding conflict of interest.

To be certain, Warye has had an impact on APIC. She effectively used the media to spread the organization’s message, developed partnerships with industry, and enriched APIC’s coffers. But in the process, she also sold the organization’s soul.