Krampus visits Atlanta

The CDC has taken a lot of heat this year, about lab snafus involving anthrax and avian flu, and about some early problems in Ebola response. Now we have front page stories about another lab error—live Ebola virus mistakenly sent from a BSL-4 to a BSL-2 lab environment, at least according to the NY Times account. I’m sure there is more to this story, but the incident has already resulted in another loud chorus about CDC’s failings. Like Krampus, the anti-Santa of Bavarian legend who comes to punish naughty children, many will want to sanction CDC. 

That would be a mistake. Krampus should instead visit Washington DC, and severely punish the politicians who consistently underfund the CDC. I agree that CDC needs to improve the safety culture in their laboratories, and hold people accountable for following established procedures. They are working on that. The saddest part, to me, about these incidents is that they always garner far more attention than the hundreds of things that the CDC does right every day, and that are essential to protecting the public health. The challenges faced by CDC get larger every year (Ebola, MERS-CoV, Enterovirus D68, carbapenemase producers, and on and on). Yet the budget trend (see below and online) is in the other direction. I hope Santa eventually brings CDC a larger budget, while Krampus stays busy on Capitol Hill.

The dumpster fire (part 2)

Earlier this week Dr. Stephen Calderwood, President of the Infectious Diseases Society of America, posted on our blog a response to several posts that we have written to shed light on the problems plaguing the specialty of Infectious Diseases, which are primarily the interlocking issues of low pay relative to other subspecialties of Internal Medicine as well as hospitalists, and the dwindling number of young physicians pursuing training in our field. While we thank Dr. Calderwood and IDSA for his post, we remain unconvinced that the leadership of IDSA appreciates the gravity of the situation at least as gauged by their response.

I spent some time this morning reviewing IDSA’s website with regard to the issues of low reimbursement/salaries and the inability to recruit new trainees. I couldn’t find much. In a recent newsletter to the membership, Dr. Calderwood mentions “the decline in match results” in one sentence that contains a link to his post on our blog. That’s as much as I could find about this year’s dumpster fire. There are also a few letters to CMS urging some reforms in payment.

Dr. Calderwood rightfully points out the importance of mentoring our trainees to foster more interest in ID. But ethical mentoring now requires that we have frank discussions about the relatively low pay of ID physicians with young doctors who are in the process of career discernment. I tell would-be ID physicians that they need to come to terms with the fact that they will work harder and make less money than their peers who are hospitalists. And the issue isn’t just about money, it’s about how valued you feel. Several months ago in the midst of such a discussion with an internal medicine resident, the response of the idealistic young doctor was jarring. “I know all about the salary problems in ID,” he said. “My dad is an ID doc who had to close his practice because he couldn’t generate his salary.”

The situation for ID is likely to worsen. There is now a CMS demonstration project on eConsults. In this model, primary care doctors ask specialists for consults that are electronic only (chart review without seeing the patient) with expectations for a response within 72 hours. Sort of like a curbside on steroids. Here’s the really crazy part of the concept: for this service the requesting physician is paid the same as the specialist who provides the consult (i.e., each receive 1 RVU). Who’s the loser here?

As I see it (and as many others do from my discussions with colleagues across the country), ID is in free fall, yet we have a la-belle-indifference response. To give benefit of the doubt, I guess another explanation could be that IDSA is actively engaged but too shy to let its members know. As I think through all these issues, for the first time I’m asking myself: why am I a member of IDSA?

There are many questions that should be addressed. Here are some:

• How do we truly demonstrate the value we add? The few papers that address this question don’t provide convincing results (i.e., they seem to underestimate our value and provide fodder for maintaining the status quo).
• How can compensation models be changed to fairly reward the work we do and acknowledge the additional training and skills we possess? More directly, why is the pay of the ID subspecialist less than the pay of the hospitalist?
• Should the ID fellowship be shortened to positively affect the cost-benefit calculus of additional training? Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities? Would it be more fruitful and time conserving for these trainees if research projects were substituted with more training to better interpret evidence? 
• Should hybrid models of training be developed to lessen the economic impact on trainees (for example, could training be integrated with hospitalist practice? Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship)? This would increase the fellow’s salary, and even if the total duration of training were extended, may entice more residents to consider ID training). Some would probably continue this model beyond training into employment.

The reality is that few people are pursuing ID training, and even among those who do, very few want to pursue an academic career. Despite all the voting that residents have done with their feet, we continue to mostly offer a one-size-fits-all training model with financial punishment when training is over. It's time to put out the dumpster fire and thoughtfully begin to rebuild our specialty. But first we should spend some time contemplating the words of Albert Einstein: “Insanity is doing the same thing over and over again and expecting different results.”

GBV-C Co-Infection Associated with Improved Ebola Survival

GB virus C (GBV-C or Human Pegivirus - or even Hepatitis G) is associated with high viremia but there is little evidence that it causes disease in humans. Back in 2001, Jack Stapleton and colleagues (including Dan) showed that GBV-C co-infection significantly improved survival in HIV+ patients. The thought behind this association is that GBV-C attenuates aberrant immune activation.

Given that GBV-C infects between 10-28% of individuals in the three countries that have experienced the highest level of Ebola infections in the recent outbreak, Michael Lauck and colleagues in Madison wanted to examine the influence of GBV-C co-infection on Ebola outcomes. Using a cohort of 49 Ebola infected patients with outcome, age and gender data available they assessed the association of GBV-C co-infection on mortality.

Overall, mortality in the cohort was 69%. However, while mortality was 78% (28/36) in GBV-C negative patients, it was "only" 46% (6/13) in GBV-C co-infected patients. The unadjusted and adjusted analyses are in the Table below. The higher p-value with unchanged OR in the multivariable model likely represents a loss in power and not age-related confounding as the authors claim. Minor quibble - they presented a case-control (OR) analysis for this cohort of patients with a significant p-value. Analyzed as a cohort study, the RR=0.59 (0.32-1.09), p=0.0950. Either way, if I had Ebola, I'd also want GBV-C.

Guest Post: IDSA’s Take on the Match Results

This is a special guest post by Dr. Stephen B. Calderwood, MD, FIDSA, President, Infectious Diseases Society of America (IDSA)

The first annual IDWeek Mentorship Lunch, IDWeek 2014    

The IDSA community is over 10,000 doctors strong, and we’re all concerned with the match results for this year. But the dumpster fire metaphor is only half right: Yes, it’s a crisis, but we aren’t shrinking from it. Everyone at IDSA is fighting for our specialty, and we need our whole community to join in. 

Compensation

HAI Controversies has talked before about this, and Mike Edmond put the blame squarely on the economics of being an ID doctor. The Society continually advocates for better compensation for ID services and how to value their input differently under health care reform. This past year, IDSA has pushed hard for ID specialists to be required for hospital stewardship programs. To help individual doctors with compensation, several IDSA veterans compiled The Value of the ID Specialist, a comprehensive study that documents how ID consultations result in better outcomes and lower costs.  And for IDSA members, we offer a Value Toolkit (login required), which collects presentations, videos, and documentation to help ID doctors make the case to their own employers, hospital administrators and health plan executives.

Funding for Research and Public Health

Funding cuts in research and public health affect all of us, not just ID specialists, and IDSA joined hundreds of other professional societies to Rally for Medical Research. In addition, our policy and government affairs team works tirelessly, advocating for more research funds for HHS agencies and encouraging the White House and Congress to commit more of the federal budget to infectious disease research and public health.

We actively encourage our members and the public to join these efforts. In three minutes, you can let your congressional representatives know that budget cuts hurt the infectious disease community, and ultimately the patients we serve. Of course, you can also contribute more directly: the IDSA Education and Research Foundation supports medical students and young investigators with fellowships, travel grants, and research funding to help recruit more people to our specialty and to help with their early career development.

Mentorship

Mike Edmond’s post led with a moving tribute to the mentor who inspired him to choose ID. IDSA is dedicated to expanding our mentorship efforts. In addition to our two Fellows’ meetings every year and our scholarships for medical students, we launched a new Mentorship Program at IDWeek 2014. Students, residents, and fellows were teamed up with seasoned ID professionals and explored the meeting together. We’re actively trying to expand our mentorship programs, and encourage our members to volunteer for these efforts.

Responding to the match is a community effort that will require a multi-pronged approach. We at IDSA are all thankful to have an active, involved, and passionate community of ID doctors in our Society who want to see the specialty thrive and expand; we welcome all thoughts individuals may have in better addressing this issue. We certainly want to ensure that we continue to attract the very brightest and committed individuals to our specialty. We’re committed to ensuring that the future workforce brings the clinical expertise and new knowledge needed to address the many problems we face, including the enormously important areas of antimicrobial resistance and stewardship, HIV, TB, emerging infectious diseases (such as Ebola!), and all the other key areas our specialty contributes to so uniquely on a daily basis.  

What is Healthcare Quality Improvement?

Dr. Mike Evans, a staff physician at St. Michael's Hospital in Toronto, and his team at the Evans Health Lab have released another excellent whiteboard video. This time they cover QI in healthcare.  Brilliant and clear as always.

The world will end in 2050 because...resistance

UK Prime Minister David Cameron requested a review of the health and economic burden of antimicrobial resistance in July. Quicker than you can say supercalifragilisticexpialidocious, economist Jim O'Neill has delivered his report and the results are surprising (at least for those who don't follow this blog). Utilizing commissioned studies from KPMG and Rand Europe, the Review estimates that the economic losses attributable to antimicrobial resistance will total $100 trillion and 10 million excess deaths will occur annually by 2050. In fact deaths do to resistance will surpass other major causes of death even the 8.2 million due to cancer. (see figure on right) Of course, cancer deaths might rise due to the fact that we can no longer safely give chemotherapy without effective antibiotics. The report covers these issues in a sobering section titled: "The secondary health effects of AMR: a return to the dark age of medicine?"

Good times.

The independent Review will outline recommendations for an international response by 2016. In the meantime, I leave you with my favorite figure from the report below. Just for reference, $100.2 trillion is 6 times the size of the US GDP (2013). Perhaps this will wake up the world to antimicrobial resistance?

Additional Source: BBC

Infectious Diseases and the Terrible, Horrible, No Good, Very Bad Match

Here we go again. Another internal medicine subspecialty “match day” and another record (bad) day for ID. How bad? The previous record (set last year) for unfilled ID programs was 54. This year 70 programs went unfilled, meaning that for the first time ever there were more programs that didn’t fill than that did. Almost 100 funded ID training positions unfilled in a single year!

We’ve blogged about this trend before, here and here, and discussed some of the reasons that ID is in decline as a specialty (along with some suggestions for how to turn this around). I don’t have any new insight, except to make the point that this is now beyond a crisis situation for our specialty. It’s a dumpster fire.

Killed by an Abundance Of Caution?

Back in August, I wrote:

“most patients returning from the outbreak area with febrile illness (those meeting the Person Under Investigation (PUI) definition) will not have Ebola, but they may be very sick. If an overly stringent lab protocol prohibits or delays laboratory testing, substandard medical care may lead to adverse outcomes.”

In September, I wrote:

“the overwhelming majority of those with febrile illness upon return from the outbreak areas will not have Ebola—but they may well have something requiring urgent attention and appropriate therapy (malaria, typhoid, meningococcemia). Prompt laboratory testing will be essential, and potentially life-saving…..However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. [This] could be dangerous for patients presenting with “severe non-Ebola infection” who happen to have been in an outbreak area in the prior 21 days.”

Well, the CDC has just released a report on their initial experience with “PUIs” in US hospitals, and there’s this disturbing little nugget buried within:

“At least two persons who tested negative for Ebola died from other causes. Based on reports from health departments and health care providers, in several instances efforts to establish alternative diagnoses were reported to have been hampered or delayed because of infection control concerns. For example, laboratory tests to guide diagnosis or management (e.g., complete blood counts, liver function tests, serum chemistries, and malaria tests) were reportedly deferred in some cases until there were assurances of a negative Ebola virus test result. In other instances, radiologic studies, such as computed tomography and ultrasound scans, or evaluation for noninfectious conditions, such as severe hypertension and tachycardia, were reportedly delayed while a diagnosis of Ebola was under consideration.”

Given the ratio of PUIs to actual Ebola patients presenting to US hospitals, it is quite likely that more patients will die in the US from AOC (“Abundance of Caution”) than die from Ebola. Back to CDC now:

“…it is important to recognize that the likelihood of Ebola even among symptomatic travelers returning from these countries is very low. In the hospital setting, where policies and procedures should be in place to safeguard health care workers, consideration of Ebola should not delay diagnostic assessments, laboratory testing, and institution of appropriate care for other, more likely medical conditions.”

In other words: diagnose and treat the patient, not your Fear of Ebola.

Image from The Keep Calm-O-Matic

Toilet lids for infection prevention

Back on clinical service again and having more thoughts on poor hospital design. Last month I wondered why there were no stethoscope wipes available outside of every patient room. This month while caring for patients with C. difficile and viral gastroenteritis infections, I looked over and noticed toilets without lids. Of course most toilets in hospitals (and many public spaces) lack lids. Reasons given for lack of lids are (a) lids might be hard to lift for some folks and (b) lids would be another surface to clean. But lids also prevent the aerosolization of pathogens into the environment, as Mike discussed three years ago.

Lack of toilet lids in hospitals is a patient safety issue and there should be no excuse for not having and using them. First, most patients can and will close the lid before flushing if reminded to do so. In fact, there should be public services announcements in the media that remind us all to close the lid and kids should be taught to do this in school. Second, if a small minority of patients can't or won't close the lid, it's not a reasonable excuse for going lidless in hospitals. This would be like not providing seat belts because some folks can't or won't use them!

So here are my recommendations:

1) Put a plastic, cleanable lid on every toilet and train hospital staff to clean the lid daily
2) Create education campaigns to get patients and staff to close the lid before they flush
3) Put a big "CLOSE BEFORE YOU FLUSH" sign on both sides of the toilet seat in every bathroom in hospitals, including public spaces
4) Help start local "CBYF" campaigns in your cities
5) If hospitals are worried about patients not being able to open or close the lid, they should spend $6400 on this toilet that automatically opens and closes, among other features. Given the cost of HAI and the amount we spend on other HAI prevention interventions, the $6400 will easily be cost-effective or there's even a touch-free sensor toilet seat for ~$100.

It's time we give a crap about having and closing toilet lids.

image source: http://www.dudeiwantthat.com/household/bathroom/friendly-toilet-seat-reminder.asp

Potential Risks and Benefits of Gain-of-Function Research - December 15-16

About 3 months ago we posted a letter from Marc Lipsitch highlighting the risks of "gain-of-function" research. He described this research as "experiments that create potential pandemic pathogens from virulent precursors that are not readily transmissible." The concerns about this particular kind of research are particularly acute when applied to pathogens with pandemic potential like MERS, SARS and influenza. In two weeks (December 15-16) there will be a 1.5 day meeting in Washington DC at the National Academy of Sciences on this topic. The meeting is open to the public with each session including 30 minutes for audience discussion. In addition, public input is sought electronically before the meeting via the meeting meeting web page. A very important topic - hope some of you can attend.

The agenda and registration information are here: http://dels.nas.edu/Upcoming-Event/Risks-Benefits-Gain/AUTO-9-61-70-Q

An abundance of "abundances of caution"

Googling “abundance of caution Ebola” yields 213,000 hits and a treasure trove of misguided responses to Ebola fears. You can even refer to this excellent Washington Post article about how to make “an abundance of caution” work for you! It’s to the point now that if I hear “abundance of caution” being used in a sentence about Ebola, I translate it to “what I am suggesting makes no actual sense but demonstrates my extreme seriousness about fighting the very idea of Ebola”. 

Some “abundance of caution” (AOC) actions are completely off-the-rails, like preventing students or teachers from attending schools when they had no risk for Ebola exposure, while others may appear reasonable but have no scientific basis (like the excessive movement restrictions some states have applied to asymptomatic returnees from outbreak areas). Another example of the latter category of AOC actions recently took effect in California, as CalOSHA issued updated Ebola guidance for hospitals. The CalOSHA guidance for personal protective equipment meets CDC recommendations, but allows only one option for respiratory protection (PAPR) and only one option for skin covering (full body coverall). I’ll outsource the rest of this post to a SHEA press release from last week. Suffice it to say that I sincerely hope they dial this back, and that it doesn't become a standard for federal OSHA guidance.

SHEA Supports Scientifically Sound Approaches to Ensure Protection for Healthcare Personnel Fighting Ebola

November 24, 2014 (Arlington, VA) – The Society for Healthcare Epidemiology of America (SHEA) is dedicated to the prevention of infection in healthcare settings, including the protection of healthcare personnel (HCP) who provide care to patients with known or suspected Ebola virus disease (EVD). 

SHEA supports the current Centers for Disease Control and Prevention (CDC) guidance on Personal Protective Equipment (PPE) to be used by HCP caring for patients with EVD. This guidance is consistent with the established science regarding how EVD is transmitted.

Recently updated guidance from California's Division of Occupational Safety and Health (Cal/OSHA) meets the CDC recommendations, but specifies only one form of respiratory protection (powered air purifying respirator (PAPR)) and only one form of barrier protection (impermeable coverall) for all inpatient and emergency department (ED) care of those with suspected or confirmed EVD. However, there are no data to suggest that these specific forms of PPE provide better protection for HCP than alternatives that are also included in CDC guidance (e.g., N95 respirators, fluid impermeable hoods, AAMI-4 gowns and leg coverings). 

There are several types of PPE that provide full protection against Ebola transmission, and the local preference of nurses, physicians and other HCP is paramount to select the best PPE for their facility (from among CDC-adherent options). Considerations of familiarity, tolerability (e.g. discomfort, overheating), risk for self-contamination during doffing, and amenability to training all require local input. Thus wide adoption of the narrow requirements established by Cal-OSHA could have unintended adverse consequences. For example, hospitals that have already trained their HCP in safe use of AAMI-4 gowns may inadvertently increase exposure risk by switching to unfamiliar coveralls that are widely considered to be more difficult to doff without self-contamination. Furthermore, mandating PPE that is excessive for the fluid risk of a suspected or confirmed EVD patient results in unnecessary impediments to timely and effective clinical care (e.g., requiring PAPR and coverall for evaluation of an ED patient with low grade fever and no other symptoms). Since most suspected EVD patients cared for in US hospitals test negative for EVD but may have other life threatening conditions that require timely therapy (e.g., malaria), such impediments can lead to harm. Finally, unnecessarily narrow limitations on PPE types will exacerbate already critical PPE shortages and limit the ability of US hospitals to be prepared to care for those with known or suspected EVD. 

HCP have a right to a safe work environment during the care of patients with any communicable disease, including Ebola. SHEA believes that the current CDC guidance, when practiced correctly and reinforced by adequate training of HCP, protects HCP from Ebola transmission. 

Photo by John Spink

Maybe Sheldon was right...

A new study from Ohio State University published in the American Journal of Infection Control sought to determine whether buses are contaminated with MRSA. Forty buses in a midwestern city were sampled. MRSA was detected in over 60% of the buses, with seats (33%) and seat rails (30%) the most common sites of contamination.

Those of you who are fans of the Big Bang Theory know that Sheldon Cooper, PhD, ScD, a genius theoretical physicist who has never learned to drive, wears bus pants when using public transportation. In the video clip below, Sheldon explains the concept.

Maybe we should have public reporting of contaminated buses. Because no American should have to wear bus pants, ever. Bazinga!

something something antibiotics something something

It's been a crazy couple weeks out here on the edge of the prairie. Clinical service, grants, papers, holidays, Ebola?, the ESCMID-SHEA course in Phuket and SHEA2015 have swallowed up my fall. Get those SHEA abstracts ready folks - the deadline is fast approaching - January 16th.

In the middle of this chaos, the CDC's Get Smart About Antibiotics Week seemingly appeared out of nowhere and CDDEP investigators just published a very nice antibiotic use point prevalence study in 6 US hospitals in this month's Lancet ID to coincide with the 'Get Smart' Campaign. Nikolay Braykov and Dan Morgan led the study and Nikolay wrote up a nice post describing what they found, which I've excerpted below:

We undertook a chart review study at six institutions – two teaching centers, three community hospitals and one VA – looking at the indications for starting antimicrobials, the use of culture and radiology results and the patterns of modifying empiric therapy in the first five days of treatment. We found nearly two-thirds of inpatients were receiving antibiotics, with empiric starts dominated by combinations of vancomycin, piperacillin/tazobactam and fluoroquinolones. It is likely that a lot of those initial prescriptions were unnecessary, as 30% of patients lacked fever or abnormal white blood cell counts at the start.

Appropriate cultures (on or before start of therapy) were collected from 59% of patients, and although 60% came back negative, only 22% of all evaluated patients and had their antibiotics narrowed or stopped (Figure). More specifically, 22/59 (37%) of patients with negative urine culture and 11/22 (50%) of those with negative blood culture had antimicrobials stopped or narrowed. Of pneumonia patients with negative chest imaging that proportion was 12/50 (24%).

Narrowing or discontinuation (of antibiotic therapy) was more likely when cultures were collected at the start of therapy and no infection was noted on an initial radiological study. In turn, escalation was associated with multiple infection sites and a positive culture (see table below).

It seems like diagnostic uncertainty drives a lot of possibly unnecessary antibiotic use. These results underscore not only the need for rapid diagnostics, but also the importance of mechanisms to assure tests are ordered in time and their results are actually used to optimize therapy – goals attainable through better stewardship programs and physician education.

A great point made recently is that the government’s resistance action plans should include steps to incentivize and expand the training of more ID physicians. Although the threat of drug resistance gets more public attention each year, “getting smart” about antibiotics, including their timely withdrawal and adjustment, ultimately requires the buy-in of current and future prescribers. 

Band Aid 30 (West Africa 2014)

Band Aid, a charity group founded by Bob Geldof and Midge Ure in 1984, raised money to combat starvation in Ethiopia. The original song (despite controversial lyrics) led to the successful Live Aid concerts the following summer. With the current plight of Ebola in West Africa, they formed a new group to sing revised lyrics like "where a kiss of love can kill you and there's death in every tear" to help raise money to combat the epidemic. I would have written where a break in PPE protocol can kill you and, of course, epidemiologically speaking, there's not death in every tear. The song is available on iTunes and a CD will be released soon. And if you dislike the song or want to give more, you can head over to Oxfam, MSF,  MSF (USA), UNICEF, or the CDC Foundation.

Wanted: Ebola test with perfect negative predictive value at time zero

The tragic death of Dr. Martin Salia has triggered a spate of news articles about the limitations of Ebola diagnostic testing. According to news reports, Dr. Salia tested negative twice early in his symptomatic period, and was already quite ill by the time he tested positive.

The fact that the most sensitive Ebola virus diagnostic test (PCR applied to a blood sample) may not be positive until 3 days after symptom onset is well known, however. The reason for this has to do with the pathogenesis of Ebola virus infection. The point of entry and initial replication for Ebola is the “dendritic” cell. Present in large numbers in the skin, mucosa and intestinal lining, dendritic cells are sentinels, guarding the interface between the human immune system and a hostile environment. They encounter invaders, engulf them, and present their antigens to cells of the adaptive immune system. Dendritic cells carry the virus to lymph nodes and other organs of the “reticuloendothelial system” (liver, spleen). So before the virus reaches detectable levels in the blood, there may be hours-to-days of replication in these cells and organs, along with symptoms of fever and fatigue. A test, even a very sensitive test, that is applied to blood will not detect the virus until it appears in the bloodstream in larger numbers. 

This lack of a rapid and accurate diagnostic test early in the Ebola disease course is a major problem—not only for early initiation of therapy for those infected, but also for the management of “persons under investigation” (who may require Ebola-level isolation precautions for several days while awaiting a negative test that has been taken at least 3 days after symptom onset). 

But this problem plagues infectious diseases diagnostics generally. As this recent Lancet ID article points out, the lack of early and sensitive diagnostic testing is one reason why so many patients in our hospitals receive days of unnecessary antimicrobials. More on this study later, perhaps from Eli, one of the authors!

Image by Sean Gallup, Getty Images

Why can't we easily clean our stethoscopes?

I just finished two weeks on the inpatient internal medicine service. When we round on the service every morning, I insist on 100% hand hygiene and 100% stethoscope hygiene but one of these targets is far easier to achieve than the other. As Mike mentioned last year, almost 50% of stethoscopes are contaminated with pathogens including S. aureus and MRSA. Despite this level of contamination, hospitals have done almost nothing to make cleaning them quick and easy. Like many (? all) hospitals, we have hand rub dispensers every few feet but nothing easily available to clean our stethoscopes. I usually end up "bothering" nurses to give us a few alcohol prep pads, but this uses up their daily supply and generally seems like an unnecessary barrier. Why can't we have wipes next to the hand rub dispensers outside of every room? That way we can actually achieve 100% stethoscope hygiene. If we don't develop good systems, we can't expect good results. How do you guys practice stethoscope hygiene at your hospital?

Getting to zero

By my count, there are now zero persons in the United States who are actively infected with Ebola virus.  This is the perfect time to donate your time or your money to Ebola response in West Africa.

Also, Kaci Hickox still doesn't have Ebola. She should be allowed to go bowling.

Finally, one observation about our weirdly, uniquely American response to Ebola virus. The CDC Guidance for Monitoring and Movement Restriction treats healthcare workers who have "direct contact while using appropriate personal protective equipment (PPE) with a person with Ebola" differently based upon whether they were caring for patients in countries with or without "widespread Ebola transmission". Thus brave volunteers returning from West Africa are under more stringent monitoring and movement restriction guidance than are those who might care for a patient in New York, Texas or Iowa. Yet if you compare the ratio of 'healthcare worker acquisitions/Ebola infected patients' in the US versus West Africa, I'm not sure there is any contest (2 acquisitions/9 Ebola patients = .22--what's 22% of 13,268, the total number of cases thus far in West Africa?).  This isn't an argument to be more restrictive about those who care for Ebola patients in the US, it's an argument to chill the #&*% out about humanitarian healthcare workers returning from the outbreak zone.

Geography

Courtesy of Anthony England, via the Washington Post.

Causal opacity

Medicine as a science is predicated on causality. We seek to understand the causes of disease. Similarly, in the field of patient safety, we aim to determine the causes of adverse outcomes: What factors led the nurse to administer the wrong dose of heparin to Mr. Smith? What caused the surgeon to operate on the wrong knee? Using root cause analysis, we can work backwards from the adverse event to determine the underlying causes. 

Now consider the case a of 24-year old man hospitalized for 3 months following multiple, life-threatening injuries following a motorcycle crash. He required 17 operative procedures, a 4-week ICU stay, and had numerous invasive devices (including central venous lines, endotracheal tube, urinary catheter, ventriculostomy catheter, arterial line, and external fixating devices). On hospital day 93, he develops MRSA bloodstream infection. The magic question is this: when was MRSA transmitted to this patient? And, of course, in cases such as this, we are never able to answer that question. The field of infection prevention is plagued by causal opacity—we are rarely, if ever, able to connect cause to outcome in non-epidemic healthcare associated infections.

In infection prevention, causal opacity is the result of two factors. First, the transmission event is silent since the pathogens are invisible to the eye. Second, the incubation period temporally separates cause from effect. With multidrug resistant organisms, the intermediate state of colonization, which can extend for very long periods of time, can separate transmission from onset of infection by months or even years.

Causal opacity also negatively impacts hand hygiene compliance. Imagine if you failed to wash your hands, examined a patient, and the infection in the patient manifested within seconds after touching the patient. Like an instantaneous electric shock, the immediate feedback would probably keep you from ever failing to wash your hands again. Recently, causal opacity has hampered our ability to understand why currently available personal protective equipment may be failing us in caring for patients with Ebola virus infection.

The end result is that causal opacity makes it harder to hold persons and systems accountable with regards to infection prevention. Yes, causal opacity sucks. But it’s an integral part of what we signed up for. Otherwise, we’d all be cardiologists or urologists—driving better cars, but bored silly.

Ebola primer, v2.0

Epidemiology

• The current outbreak in Guinea, Liberia, and Sierra Leone is the largest ever recorded, with approximately 14,000 cases to date. Mortality rates in African treatment units exceed 60%.
• The natural reservoir of the virus (a filovirus) is suspected to be fruit-eating bats.
• Transmission occurs via contact with infected human body fluids (blood, saliva, sweat, vomitus, stool, semen, breast milk, and tears). Most transmission events are associated with direct contact with blood and body fluids. Transmission via indirect contact (i.e., fomites) can occur but appears to be uncommon.
• Nosocomial transmission is a key driver of outbreaks. Healthcare workers are at high risk for infection.
• Transmission has not been demonstrated from individuals who are in the asymptomatic incubation period. Even in the early stages of symptomatic disease, risk of transmission appears to be very low. As the disease progresses, infectivity increases. Infectivity is highly positively correlated with the patient's viral load.

Clinical

• The incubation period is 2-21 days (usually 5-7 days).
• The illness is characterized by onset of fever, chills, myalgias and malaise. This is followed in a few days by GI symptoms (nausea, vomiting, profuse diarrhea and abdominal pain), and headache. GI fluid losses can be as high as 10 L/day. Relative bradycardia is common.
• Hemorrhagic symptoms usually occur at the peak of illness and include maculopapular rash, petechiae, bruising, and bleeding from venipuncture sites. Gross bleeding from the GI and GU tracts is usually only seen in dying patients. Of note, overt bleeding has been uncommon in the current outbreak.
• The late stage of disease is manifested by cytokine storm, multiple organ dysfunction syndrome, shock, capillary leak syndrome, seizures, delerium, coma, bleeding and anuria.
• Laboratory findings include azotemia, leukopenia, thrombocytopenia, elevated transaminases, severe electrolyte abnormalities, proteinuria, and markers of DIC. Bilirubin is typically normal.
• Spontaneous abortion occurs at high rates in pregnant women and mortality rates are higher in pregnant women.
• Age is associated with mortality (highest survival rates are seen in those <21 years old).
• Mean time from onset of symptoms to death in African treated cases is 10 days.
• In survivors, the convalescent phase is long.
• Ebola viral disease should be suspected in a patient with a history of travel to an outbreak area who has fever or other associated symptoms, though other infections (e.g., malaria, typhoid fever) must also be considered.

Diagnostic Testing 

• Diagnostic testing focuses on PCR, which may be negative in the early stages of infection.
• In the United States, most testing is currently performed in public health laboratories. 
• A commercially available PCR assay (by Biofire Defense) with a 1 hour turn around time was given an Emergency Use Authorization by the FDA on 10/25/14.
• Viral load in serum increases as the disease progresses and may be as high as 10 billion/mL at the time of death.
• Viral load mirrors clinical response and when undetectable establishes that the patient is no longer infectious and can be released from isolation.
• Viral load at the time of presentation predicts mortality (VL <100,000 associated with 33% mortality, whereas >10 million was associated with 94% mortality in data from Sierra Leone). 

Treatment

• Treatment is focused on aggressive supportive care, particularly fluid and electrolyte management. Antiemetics and antimotility agents should be used to reduce GI fluid losses. 
• Hyperimmune serum from recovered patients has been used in the United States.
• No approved antiviral therapy is currently available. 
• Experimental therapies include brincidofovir (by Chimerix), monoclonal antibody (ZMapp by Mapp Biopharmacuetical), and TKM-Ebola (small interfering RNAs by Tekmira).
• Corticosteroids, nonsteroidal anti-inflammatory drugs, and aspirin are contraindicated. 
• Early treatment in developed countries appears to be effective.

Resources:

• CDC Ebola site
• WHO Ebola site
• New England Journal of Medicine Ebola publications

Photo: Frederick Murphy, CDC.

If you can ride a bike - YoU CaN't SpREAd EbOLa!!!!

Since Ebola is only spread very late in the disease, like when you are sick and in the ICU, it goes without saying that Kaci Hickox is no risk to her community. But she looks to be in great shape, so any squirrel in the road better watch out!

Ebola - Some Hope for Control in West Africa

Ebola, as we all know, is out of control. As an example, every time I turn on the TV there is Dan or Mike or Dan staring back at me. Eventually, we will calm down in the US and begin to focus our attention on the critical outbreak in West Africa. My prediction is that this will happen sometime soon after November 4th (Election Tuesday). In the meantime, there is some possibly, maybe, hopefully good news out of West Africa in today's NYT. As of a few days ago, fewer than half of the 649 available treatment beds in Liberia were occupied. Of course this could be good or bad, but I'm holding out for good.

There was also some potentially good news in a report published in the Annals yesterday. Dan Yamin et al. analyzed a stochastic model of Ebola transmission populated with parameters from a 2000-2001 Uganda outbreak and the current outbreak in Montserrado County Liberia. The authors used the model to determine the number of secondary cases infected by survivors or non-survivors and also evaluated the effect of isolating/hospitalizing patients. I have included the key figures from the paper below. In Figure 1a, they estimate the Ro stratified by whether the index case was a survivor or non-survivor. For the whole cohort, the Ro was 1.73. However, the difference between non-survivors and survivors is striking. It appears that non-survivors infect four times as many people as survivors (2.36 vs 0.66). This may explain why the two Dallas nurses were infected after being exposed to a non-survivor while no secondary cases have yet occurred in other US hospitals, where everyone else (so far) survived.

Figure 1a

In Figure 1c, the authors provide an estimate of the average number of secondary cases per day of symptomatic disease. You can see that there is very little transmission in the community at day 1 and it remains very low for survivors but jumps up after day 2 for non-survivors. This implies that waiting for symptom development is a scientifically valid strategy for preventing community transmission of Ebola even in Africa. (We expect these numbers to be far lower in the US where our communities are less crowded and we are fortunate to have toilets, indoor plumbing and clean water.)

Figure 1c

Finally, in Figure 2 the authors evaluated at what time point non-survivors (very sick individuals) must be actively isolated to prevent community transmission. They estimate that if 75% of the non-surviving cases are detected and isolated by day 4 this results in a 74% chance of disease elimination and if 100% are detected and isolated by day 4 then there is a 94% chance of disease elimination. Currently, the authors report that the average time from disease onset to hospitalization in Liberia is 5 days, so there is some room for improvement. However, I suspect that the current expanded efforts could achieve 4 days. When I put the results of this Annals paper together with the NY Times report of empty beds, it suggests that there is available capacity to hospitalize and isolate patients within 4 days of symptom onset and it might even suggest that current efforts are already working. I'm certainly hoping this is the case.

Oh, and if isolating patients 4 days after symptom onset works in West Africa, it means WE DON'T NEED TO QUARANTINE ASYMPTOMATIC FOLKS IN THE US. So please stop it...and sorry for shouting.

Guest Post: Ebola and the Reversal of Transmission Dynamics

L. Silvia Munoz-Price, MD PhD

This is a guest post by Dr. Silvia Munoz-Price, Enterprise Epidemiologist at Froedtert & Medical College of Wisconsin Institute for Health and Society/Department of Medicine.

There is an interesting phenomenon occurring during this Ebola outbreak. The relationship between health care workers and personal protective equipment (PPE) has shifted. Let’s state a fact: up until now, most Infection Control providers have permanently struggled to ensure compliance with the use of gowns, gloves, and hand hygiene among healthcare workers. Even though all healthcare workers know these interventions (PPE and hand hygiene) are necessary to prevent transmission of pathogens among patients, healthcare workers persist being non-compliant with these measures. Why do we continue behaving this way? This is probably due to several factors, but one of the most relevant ones might be our inability to pinpoint whose non-compliance end up causing acquisition of hospital pathogens to individual patients. So, when patient X gets Clostridium difficile colitis on day 15 of hospital stay, who among the dozens of providers in contact with patient X caused this transmission? Nobody can tell. The result is a lack of accountability of medical teams.

This topic reminds me of healthcare worker’s attire. We know that white coats are laundered on average every 14 days but scrubs are spontaneously laundered by providers every day. The former is in contact with patients and the latter is in contact with the provider’s skin. Why this difference in laundering frequency? Could it be that we care of our well being much more than what we care of our patients?

Many times I have discussed with hospital leadership about why there is such a difference in compliance with protocols between airplane pilots and healthcare workers. We thought this difference was probably due to the fact that if airplane pilots are not compliant…they die. In comparison, if healthcare workers are not compliant with hand hygiene or PPE usage…nothing happens to them.

Ebola has clarified this point for us. This tiny virus has successfully reversed the transmission dynamic in hospital settings. Now healthcare workers are not the only one spreading disease across the unit …now healthcare workers are actually getting sick if they are not compliant with infection control practice. What is the result? We are frantically re-learning how to cover every inch of our bodies before and after patient contact. That said, I understand that the mortality in West Africa has been very high, which is causing a generalized state of panic, but so far we are observing that patients treated early and adequately seem to do just fine. Compare this with C. difficile colitis among our immunocompromised patients which causes thousands of infections a year. I understand that C. difficile is not in CNN 24/7, and fails to have an exotic name, but it can certainly be as devastating and much harder to treat than Ebola in US healthcare settings. So, let’s reflect on our current state of generalized paranoia. Maybe patients with C. difficile, CRE, MRSA, VRE acquired in the hospital should run the same press campaigns 24/7 clamoring for better compliance with PPEs and hand hygiene among healthcare providers.

So, let’s think again about our behavioral drivers to comply with PPE and hand hygiene…maybe the answer to improved compliance with these interventions is to have a strain of C. difficile that would make healthcare providers sick.

We need better PPE

The bloggers have just published a viewpoint in JAMA on the need for better PPE in the era of Ebola. You can read it here.

Photo: John W. Poole, NPR

Bloggers in the News: Quarantine of Uninfected Health Care Workers

Earlier today MSNBC put Dan in the middle, Hollywood Squares style, and asked him very good questions about SHEA's recent press release that supports active monitoring but warns against mandatory quarantine of health care workers. After watching this, my hope is that future discussions are this informative. Great work Dan.

 

Postmodern public health

An absurd situation has unfolded in New Jersey, where Kaci Hickox, a nurse who recently returned from Sierra Leone, is being quarantined. While she certainly could be incubating Ebola virus disease given her work with Ebola infected patients, she is asymptomatic, has had two negative Ebola tests, and currently poses no public health risk. To make matters worse, she was escorted to the hospital by a caravan of eight police cars and is being held in a tent (see photo) with no shower or flushable toilet. It is hard to believe that this is happening in the United States in 2014.

It seems that we have entered a new era of postmodern public health. No longer are decisions being made on evidence by experts who understand the epidemiology of infectious diseases, but by politicians who pander to the misinformed for political gain. It's reminiscent of the situation that existed for nearly a decade in South Africa where President Thabo Mbeki denied that HIV was the cause of AIDS, despite all evidence to the contrary.

David Gorski, in his blog Science Based Medicine, writes that from a post-modern viewpoint “scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine."

Returning to reality for a moment, we need to emphasize that mandatory quarantine of healthcare workers from West Africa will not make us safer. In fact, it is highly likely that fewer American healthcare workers will take on the difficult task of treating Ebola in Africa, despite the need for controlling the epidemic there. And without controlling the epidemic at its source, developing countries will continue to be ravaged, and there will continue to be sporadic imported cases in developed countries. Moreover, if one believes that returning healthcare workers should be quarantined, then logic would dictate that healthcare workers who care for Ebola patients in the US should also be quarantined. This will precipitate a crisis since it is highly likely that most healthcare workers would be unwilling to provide care in that situation. And the incredible expense of caring for the Ebola patient in the US would increase greatly.

Kudos to Dr. Anthony Fauci for speaking truth to power today, and to the Society for Healthcare Epidemiology of America for issuing an official statement opposing quarantine of returning healthcare workers.

In an interview several years ago, Stephen Colbert said, "It used to be, everyone was entitled to their own opinion, but not their own facts. But that's not the case anymore. Facts matter not at all. Perception is everything. It's certainty.” And because of that, a few politicians have been able to trump the brightest minds in medicine and public health.

Photo: Kaci Hickox, CNN.

SHEA Supports Evidence-Based Measures to Prevent Ebola Transmission, Opposes Mandatory Quarantine for Healthcare Personnel

FOR IMMEDIATE RELEASE: CONTACT: October 26, 2014 Kristy Weinshel, 703-684-1008 kweinshel@shea-online.org

ARLINGTON, Va. (October 27) – The Society for Healthcare Epidemiology of America (SHEA) remains deeply concerned about the Ebola virus disease (EVD) outbreak. The recent news about Dr. Craig Spencer’s infection, along with the infections of the many other healthcare personnel (HCP) who have risked their lives to provide care during this tragic outbreak, illustrates how difficult it is to protect HCP serving patients with severe EVD.

SHEA supports the recent infection prevention guidance issued by the Centers for Disease Control and Prevention (CDC), and the commitment healthcare facilities across the country have made to train and prepare their teams for the care of patients with EVD.  SHEA continues to support the rigorous application of evidence-based measures to prevent EVD transmission. Based upon the strong evidence that Ebola is not transmitted by those who do not have symptoms of EVD, we do not support mandatory quarantine of individuals, including HCP, who have provided care for patients with EVD.  Our concern is about both the ramifications for HCP returning from West Africa and the potential application of this quarantine to all HCP caring for patients with EVD.  SHEA believes that mandatory quarantine will lead to fewer volunteers and increased difficulty in assembling care teams in West Africa and in other countries, including the United States, preparing to care for EVD patients.

SHEA and its membership of infection control and prevention experts support the active monitoring (twice daily, for fever and symptoms of EVD) of all HCP providing care for EVD patients, including returnees from Ebola outbreak areas in West Africa. Mandatory quarantine should only be implemented for those who do not adhere to such monitoring.

SHEA continues to work with the CDC and all relevant stakeholders to ensure the safety of HCP and to promote positive outcomes for those who contract Ebola. 

###

SHEA is a global professional society representing more than 2,000 physicians and other healthcare professionals with expertise and passion for healthcare epidemiology and infection prevention to improve patient care in all healthcare settings. SHEA's mission is to prevent and control healthcare-associated infections and advance the field of healthcare epidemiology. The society advances its mission through advocacy, science and research, expert guidelines and guidance on key issues, the exchange of knowledge, and high-quality education.  SHEA focuses resources on promoting antimicrobial stewardship, ensuring a safe healthcare environment, encouraging transparency in public reporting related to HAIs, focused efforts on prevention and more. 

Visit SHEA online at www.shea-online.org, www.facebook.com/SHEApreventingHAIs and @SHEA_Epi

link to SHEA press release: http://www.shea-online.org/View/ArticleId/318/SHEA-Supports-Evidence-Based-Measures-to-Prevent-Ebola-Transmission-Opposes-Mandatory-Quarantine-for.aspx

Bowling Alone

The big news tonight is that the governators of New York and New Jersey decided to institute quarantine for everyone returning from West Africa after having contact with Ebola patients. This decision was driven by political considerations, including the costs (in time and money) expended due to the decision to do extensive contact tracing around Dr. Craig Spencer’s movements in New York City since 7 am on Tuesday, October 21.

Nothing that has happened during this tragic Ebola epidemic has called into question this simple fact: Ebola is not transmitted in the absence of symptoms. Nor is it transmitted to casual or household contacts during early infection. Consider Mr. Duncan, sent home from the hospital with fever, spending the early days of his Ebola illness with almost 20 close contacts (mostly family members), until he was finally taken back to the hospital after vomiting “wildly” in an apartment complex parking lot. Let’s count the community and family transmission events: ……..ZERO. 

Careful monitoring of symptoms and signs (fever) is sufficient for early detection of symptomatic Ebola infection and prevention of community transmission. Movement restrictions, including strict home quarantine, provide no additional benefit. The adverse consequences of misguided quarantine of caregivers are clear, however: fewer providers willing to assist in the outbreak area, and fewer providers willing to volunteer to join Ebola care teams in US hospitals, complicating preparedness efforts. If Ebola providers returning from West Africa are quarantined, how can we not also quarantine US healthcare workers who provide care for Ebola patients? How will such providers commute to work, if they depend upon public transportation? Conversely, how will we convince anyone to participate in care, if they cannot return home to family for the duration of caregiving (+ 21 days)?

Don’t take it from me, though. Listen instead to an infectious diseases doc who’s been fighting the outbreak in Sierra Leone:

Dan Kelly, 33, an infectious disease doctor and a founder of Wellbody Alliance, a nonprofit organization working in Sierra Leone, criticized the governors’ response as knee-jerk. 

“I think we are just digging the grave deeper,” he said in a telephone interview from Freetown, the capital. “Come on, that’s exactly the move to push people away from going to Sierra Leone and other affected areas. It’s going to escalate the epidemic and not help solve the crisis."

He added: “If we’re going to get in front of it, we need health care workers from abroad. They cannot feel shunned or discriminated against.”