At the end of 2018, we remember and respect Influenza, 100 years after the great pandemic

The Mother of All Pandemics
In the 1918-1919 calendar year, the world experienced the worst influenza pandemic in modern times. Coming on the heels of WWI, the H1N1 pandemic occurred in three waves – in the spring of 1918, fall 1918 and spring 1919. Estimates suggest that the pandemic infected a third of the world’s population, with 50 million people dying worldwide, including 675,000 Americans. Mortality was high at extremes of ages, but what sets this particular pandemic apart was the significant mortality (over half of all deaths) in young, healthy 20-40yr olds. Why such devastating morbidity and mortality? Perhaps a combination of war-ravaged, crowded conditions, malnourishment, inadequate healthcare resources (many doctors/nurses were deployed at war), and poor hygiene. In the early 20th century, there were no influenza vaccines to prevent flu or lessen its symptoms; no antivirals to help reduce transmission; no antibiotics to treat post-influenza bacterial pneumonia. The Smithsonian National Museum estimated that the total death toll of the 1918 pandemic outnumbered military deaths in both World War I and II. You can watch a video created by the CDC about the 1918 pandemic here. This avian-origin H1N1 pandemic has been called “The Mother of All Pandemics”, setting the stage for all of the subsequent epidemic and pandemic strains of influenza we have experienced.

After 1918: Influenza still deadly, though not as devastating
In 1957-1958 an H2N2 avian influenza virus caused a pandemic resulting in 1.1 million deaths worldwide including 116,000 Americans. 10 years later, another avian-based virus H3N2 triggered a similar sized pandemic with 1 million deaths worldwide and 100,000 Americans. The H3N2 still circulates as a seasonal flu virus and is included in seasonal vaccines. The next major pandemic was triggered by a novel influenza A virus called H1N1pdm09 in 2009, originating in the United States. By this time, seasonal influenza vaccines had included H1N1 but this variant was completely different from the seasonal flu vaccine, resulting in an estimated over half million deaths worldwide and up to 18,000 Americans.

Today: There is still work to be done
Since 2009's pandemic, seasonal influenza is still prevalent, with an estimate of over 291,000-645,000 deaths from seasonal influenza worldwide. The highest mortality rates are in poorer, developing countries, with individuals at extremes of age being most vulnerable to death from seasonal influenza. We still do not have a universal influenza vaccine, though research is moving in that direction. The 2017-2018 influenza season brought a serious influenza epidemic, with 48.8 million illnesses, 959,000 hospitalizations and 79,400 deaths estimated in the United States alone. This week, the Infectious Diseases Society of America (IDSA) released updated guidelines for diagnosis, and management of seasonal influenza. In the guidelines, they recommend testing for influenza in upper respiratory specimens of high risk patients, when testing can reduce unnecessary additional testing/inappropriate antibiotics, or when testing can influence chemoprophylaxis for high-risk household contacts. Annual seasonal flu vaccination reduces the risk of influenza by 40-60% and is still recommended as the best way to mitigate the impact of seasonal influenza, but antiviral prophylaxis may be necessary in outbreaks or for certain at-risk populations. Other ways to prevent spread include hand hygiene, limiting contact with people who have influenza-like illness, and if you have such an illness yourself, STAY HOME. 

More than 166.6Million influenza vaccines have been distributed in the US as of December 20, 2018.The influenza vaccine may not always be a 100% match to all circulating strains, as we saw with last year's flu season.  This year’s vaccine contains an influenza A H1N1pdm09-like strain, an influenza A H3N2-like strain, and influenza B strains from the Victoria and Yamagata lineages. Updated this year, the Advisory Committee on Immunization Practices (ACIP) also recommends the live-attenuated influenza vaccine (FluMist); however, the American Academy of Pediatrics suggests this only be used if the alternative would be no flu shot at all. The CDC can explain the types of vaccines available and who should get them. 

Final thoughts about the flu 

Regardless of which vaccine is more appropriate, our ancestors would probably encourage us to just get ANY vaccine if it would help avoid recreating the influenza pandemic of 1918. There's still time - it's not too late so if you haven't gotten your flu shot, consider getting it today!

Final thoughts

This is my last post on Controversies. I’ve been writing online since 2000, first with residency and fellowship friends on qfever.com and then on various medical sites to pay off school debt and buy some non-futon furniture. In 2009, Dan and Mike were kind enough to invite me to join this blog and I’ve greatly enjoyed the camaraderie and experience. I could write a book about what I’ve learned and unlearned and the tremendous colleagues and science journalists that I’ve met.

Back in 2009, Mike, Dan and I were all at different institutions. For me, this blog was a place to try out ideas. I didn’t have any expectation to be perfect – only our families were reading. In fact, the blog name Dan/Mike selected was great – they acknowledged the imperfection of infection control science and that we needed a place to work through ideas, to be wrong - to fail. And I greatly appreciated the feedback on my posts. Failure is how we learn.

But in 2018, we three are all at Iowa and even though we’ve added tremendous new talent to the blog, we are still seen as an Iowa blog. Now, when I write deeply questioning posts about hand hygiene, I’m seen as writing with an institution behind me and I have to be more careful or safer. And it’s not just Iowa. As SHEA treasurer, I had to worry about how my posts would be viewed. I direct a VA HSR&D Center of Innovation and sometimes I worried about how my posts would reflect on the 70 people in our Center. I now have positions with ICPIC, the Decennial, and as ID Editor for JAMA Network Open. Too many filters, too much noise. 

Finally, it needs to be acknowledged that our readers and our field are amazingly generous. You have been incredibly forgiving when I’ve tried and failed. I'm incredibly grateful for your generosity.

I will miss this blog and our readers. Thank you. The title of my first post in 2009 was “The end of the beginning.” I think that’s right.

Eye Protection and Seasonal Influenza

At the last HICPAC meeting, Drs. Bryan Christensen and Ryan Fagan led an excellent discussion of the following question: should eye protection be included in droplet precautions for seasonal influenza and other respiratory viruses? 

Eye protection is one aspect of Standard Precautions, of course, to be used whenever there is a risk for splashes or sprays of blood and body fluids (BBF), or during aerosol-generating procedures. However, there is no recommendation for routine use of eye protection as part of Droplet Precautions—it’s an “unresolved issue”. 

Nonetheless, whenever CDC has had to issue interim guidance for new respiratory viral threats (SARS, MERS, novel influenza A viruses, etc.), they’ve included the routine use of eye protection. But seasonal influenza kills far more people annually than any of the novel threats, and there’s little reason to believe that seasonal flu strains can’t use the eye as a portal of entry (in addition to rarely causing direct ocular disease). The same applies to various of the other respiratory viruses (adeno, RSV, rhinovirus, hMPV, etc.). 

As is so often the case, we don’t have much published data to help answer this question: some work done in the 80’s suggested that eye protection was important for RSV transmission prevention, and Dr. Werner Bischoff demonstrated in an experimental system (air chamber into which live attenuated influenza vaccine virus was aerosolized) that the eyes could serve a portal of entry for influenza. So definitely wear goggles if Werner invites you to enter an airtight test chamber.

Anyway, thanks to Bryan and Ryan for their review (I will link to it when the transcript is out), and to HICPAC members for the lively discussion that followed…so what do you think? Does your center use eye protection routinely for droplet precautions for seasonal flu?

Progress on HAI progress: CDC portals and data

I spent about 2 hours with the new CDC HAI Progress Report – loosen your belt, it’s a big meal!  We probably had mixed perceptions about the recent alert to the 2016 HA progress report. Loads of information and analysis condensed down to a handful of bullets, all pointing to improvements in patient safety! The (very pleasant) surprise to me was that the format and delivery of the report has advanced to digital!! CDC has added the HAI progress report to the existing (and now updated) HAI AR Patient Safety Atlas Portal If you stop reading now – at least click on that link and explore and I will call this blog a success!

This report is several steps forward.  First, it pushes all of us to go to a place where we, being inquisitive minds, can wander and perhaps connect some dots within and between datasets. With the digitalization and visualization provided in the portal, the novice and experienced can more easily access and utilize these data. One can click through four distinct datasets, which now include state-summary statistics HAI infection rates/SIRs, inpatient stewardship activities, outpatient antibiotic prescribing rates, and inpatient antibiotic resistance metrics.

Now – the email alert. This year, well 2016 data, is the first to use the 2015 “re-baseline” efforts.

Unstated, but implied – the re-baseline effort includes the use of MBI (mucosal barrier injury) LCBSI as an event excluded from reported CLABSI rates, exclusion of yeasts (or low colony counts) from CAUTI rates, exclusion of “infection present on admission” for SSI (along with better patient-level risk adjustment), first use of risk adjusted metrics for VAE, and maybe slightly better models using more contemporary data for MRSA and CDI. 

With that said, 2016 performance suggests nationally patients are safer overall compared to the experience of 2015. Other than VAE which decreased by only 2%, everything else declined about 7-10% (I am rounding) compared to 2015. I understand many of the problems with risk adjustment and reporting bias that make these surveillance events poor performance measures for individual hospitals – but on the national level – I think these data do suggest fewer infections (o.k., perhaps some  widespread under-reporting—mixed reports on validation efforts in place).

Next – the overview of the current HAI Progress Report.   Although at first glance it seems the same as the info posted in the emails – CDC is offering more ways to track progress nationally – the number of states showing improvements (or worsening) compared to 2015, as well as the number states currently performing at levels better (or worse) then their 2016 contemporaries: 12 state perform better on at least 3 infection types compared to other states at the same time (2016). Now positive deviance nerds need to learn from these states to help the other states (or perhaps identify accuracy and validation issues at these states). The contemporary juxtaposition of SIRs is new, perhaps confusing (especially with CDC’s arcane explanation on how to interpret this: “SIRs statistically significantly lower than the 2016 national SIR are considered better than the 2016 national SIR”; curious if it ends up being useful to state programs. This year also is the first with more detail on inpatient rehabilitation facilities and long-term acute care facilities. Fewer data mean fewer statistical significant results, but these data are ripe for academic partners to latch onto as they try to partner with ARHQ, CDC, and state-programs to branch out into stewardship and prevention efforts in these types of facilities.

Finally, the portal – access it here.  Use the table view. No graphics to export for HAIs, only for other datasets. My pet peeve is that CDC still refused to list the no. of SSIs reported next to the number of surgical procedures reported to allow a crude attack rate. We still need to go to the technical tables for these values and calculate ourselves (see below). CDC, please stop making us jump through this hoop to be able to use attack rates for other purposes like planning studies, clinical trials, vaccine research! To all researchers and data nerds - the detailed technical tables should be downloaded examined (here), perhaps parsed out to our students and trainees, and used for different purposes that simply a “reporting requirement”.  I know there are many limitations to the accuracy of any one facilities reports and likely aggregate data up to the state or national level. However, as a long time national surveillance nerd all too familiar with the warts and ugliness of surveillance data, they do inform us, approximate the truth, and can help us ask the right questions and target the right populations. The more eyes using these data the more transparent the process will become, more uses of the data will be identified, patient safety should improve, and CDC will become more accountable to update (c’mon, where’s 2015 and 2016 NHSN AR data?! update the portal please!!),  maintain, and advance the public accessibility of useful data in our field.

Identifying Barriers to Hand Hygiene Audit and Feedback

This is a guest post by Daniel Livorsi MD and Heather Schacht Reisinger PhD from the University of Iowa Carver College of Medicine and the Iowa City VA Health Care System

Our research group recently published a qualitative investigation of hand hygiene in JAMA Network Open. The study describes real-life barriers encountered by 8 VA hospitals in their use of audit-and-feedback to improve hand hygiene compliance. For anyone involved in hand hygiene monitoring and improvement, the barriers we describe will probably not come as a surprise. In brief, we found that auditing hand hygiene compliance by direct observation was perceived to collect inaccurate data and created tension with frontline staff; the feedback process did not encourage positive change.

Although the importance of hand hygiene is widely acknowledged, our field’s understanding of how to improve hand hygiene compliance is still relatively primitive. All of the hospitals we visited had implemented audit-and-feedback, which was the focus of the study, but many were also using other strategies, such as environmental engineering and education. Despite these well-intentioned efforts, hand hygiene compliance rates at the participating sites were 49.8% (n = 9791) at room entry and 63.9% (n = 10 135) at room exit. It seems safe to assume that such poor compliance rates are common across all of healthcare. To meet regulatory standards (e.g. the Joint Commission), hospitals need to keep going through the motions of auditing, but wouldn’t it be great if all this effort could be directed towards interventions that actually work?

An accompanying editorial argues that all of these audit-and-feedback programs were missing one key component: immediate personalized feedback coupled to individualized action planning. In general, feedback is more effective if it is provided in real-time and is individualized, so this strategy is appealing. However, at the hospitals we describe, giving personalized feedback would likely face some logistical challenges, including limited personnel to perform these separate individualized audits and potential pushback from labor unions on the collection of individualized performance data. In addition, collecting individualized data still does not address larger questions about the accuracy of direct observations.

Like many processes in healthcare, improving hand hygiene will require both technical interventions and socio-adaptive changes. Clearly, compliance rates are not where they need to be, and the current strategies are not effective. I don’t pretend to know the answers, but as a field, let’s not give up on trying to find some solutions.

image credit: honoring University of Iowa Veterans

Allergy Emancipation

September 28, 2018 marks 90 years since Sir Alexander Fleming discovered penicillin as an effective antimicrobial which would soon save millions of lives. He warned soon afterwards that unless we used penicillin judiciously, we would see antibiotic resistance, and he was right. With decades of inappropriate antibiotic prescribing, we have dug ourselves a deep hole of antimicrobial resistance, and inaccurate penicillin allergies is but one shovel used to put us in this mess. How? Simple If/And/Then construct: IF unverified penicillin allergies lead to unnecessary/inappropriate use of broad-spectrum antibiotics which contributes to antimicrobial resistance, AND antimicrobial resistance is a public health problem, THEN unverified penicillin allergies are a public health problem.

In a single day on hospital service the Infectious Diseases consult team encountered a few patients with beta lactam allergies: one had developed significant angioedema in the last year with amoxicillin; another had developed a questionable rash on nafcillin therapy; a third recalled his mother telling him that he turned green after receiving oral penicillin as a child. Our approach: in the first case we avoided penicillin; in the second, we recommended a cephalosporin graded challenge which the patient tolerated; in the third, after detailed history we gave the patient full dose amoxicillin-clavulanate, he tolerated it well and he was able to discharge without IV antibiotics. These are fantastic cases for teaching purposes, but additionally, how exhilarating it is to liberate a patient from an irrelevant penicillin “allergy” and give them appropriate treatment upfront!



Penicillin allergies are frequently documented drug allergies in the hospital setting, with 10% of Americans reporting a penicillin allergy. Some penicillin allergies are real. However, most penicillin allergies are either inaccurate or inconsequential, with only 1% of Americans actually demonstrating true allergy upon testing. Furthermore, most patients with true penicillin allergies lose hypersensitivity over time, and by 10 years after the event, 80% of patients are no longer penicillin allergic. Can you imagine if all potential food allergies were treated the same as penicillin allergies? People wouldn’t eat at all! Most people, if they have what they think might be a reaction to a food they like, might either try the food again or get tested to know for certain they cannot eat that food. But 50 years ago, if they had a rash that coincided with penicillin administration, it would never occur to them to try it again.

Once a penicillin allergy is listed in a patient’s record, they are more likely to receive inappropriate broad-spectrum antibiotics – a practice that can be both costly and have worse clinical outcomes. Patients with methicillin-susceptible Staphylococcus aureus bacteremia treated with vancomycin instead of a beta-lactam have higher mortality rates than those receiving appropriate beta-lactam therapy. Patients undergoing surgery who receive alternative antibiotics for preoperative infection prophylaxis (due to reported penicillin allergies) have a 50% higher riskof developing a surgical site infection than those who appropriately receive beta lactam prophylaxis.

The Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiology of America (SHEA) recommend that patients with reported beta lactam allergy should undergo betalactam allergy skin testing. Allergy verification and penicillin allergy skin-testing are becoming more recognized components of antimicrobial stewardship and de-labelling allergies can have significantly improved patient outcomes. Following a simple algorithm can help to easily identify patients suitable for skin testing and could avoid almost 3 weeks hospitalization and 1000 days of second-line antibiotics. However in some situations or in low-resource settings, it may not be practical to perform skin testing on everyone who reports a penicillin allergy. In a previous blog post about beta-lactam skin testing I mused about whether better allergy histories are more bang for the buck, since a structured allergy history can potentially decrease inappropriate 2nd line antibiotic use by 26%.

There’s an age-old joke that if a team wants a detailed history on a patient, just consult ID. If our attention to detail is already expected, shouldn’t we feel empowered to take that allergy history and de-label the penicillin allergy? Inpatient allergy consultations are difficult to coordinate when those divisions may be understaffed and allergists are busy with outpatient practices. So how can we capitalize on their expertise when they can’t see the patient in the hospital? Simple: partner with them to create guidance for practice, utilize ordersets for allergy de-labelling and facilitate outpatient allergy evaluations after discharge.

In honor of Sir Alexander Fleming and National Penicillin Allergy Day, let us pledge to emancipate our patients from the fake allergies. Go on, get that detailed history! Get some penicillin skin testing! Do that graded challenge! Give that first line beta-lactam antibiotic! But for goodness’ sake when you do, please DELETE the allergy from the health record so that the ordeal does not have to be repeated!

And now for something completely different....

I always assume that in any highly intelligent, over-educated, opinionated group of people (my people!), there will be Monty Python fans...so I'd like to use John Cleese to change the subject and post a shameless plug.

As many of you (but not enough) know, the SHEA Education and Research Foundation sponsors a scholarship program for people who are interested in getting specialized training in developing, managing or improving antibiotic stewardship programs.  The funds to support the scholarships come from a campaign that was the brain child of the brilliant Dr Judy Guzman- Cottrill.  She founded the now annual "Race Against Resistance".  SHEA members sign up as fund raisers and most of them raise money around their participation in a local 5K, marathon, triathlon, or bike race between the SHEA spring meeting and IDWeek in October.   In the first two years of the program, the racers raised about $35,000 and sponsored 6 scholarship recipients to attend training courses. This year, the illustrious Dr David Calfee agreed to coordinate the program, as well as being a fundraising team member himself.

So I have three requests for the readership of this blog.
1. Be sure your trainees, junior faculty, and members of your local stewardship team KNOW about the availability of these funds.  If you are a trainee, junior faculty, on a stewardship team or thinking about starting or joining a stewardship team, apply yourself for scholarship funds and come along t0 the SHEA spring meeting or another training course, courtesy of the foundation. We are hoping to provide more scholarships this year and next so we need more people to apply for the funds!

2. Donate!  The more money raised, the more people we can sponsor.  The more people trained in antimicrobial stewardship, the better!  There is a team of 12 brave and true SHEA members who have committed to raise money for this cause.  Head on over to the website and pick your favorite, pick the underdog, pick the one who has the best picture, or no picture, and donate a few dollars to their cause. Only one month left until IDWeek, where the winning fundraiser will be recognized at the SHEA business meeting!

Here's the shameless part.  Yes, I am one of the fundraising team.  "But Hilary," you may be thinking, "I've never seen you run a step! Or swim, or bike....in fact you hate to exercise! What happened?"  Well, I'll tell you.  I asked David Calfee why this program wasn't open to a wider range of skills than just athletic abilities?  I believe I mentioned two of my best skills: drinking wine and reading books.  It seemed wrong to ask people to donate in support of my drinking more wine so.... I started a Speed Reading Race Against Resistance!  I committed to reading at least 8 books per month between the SHEA Spring Meeting and IDWeek - and to prove I'm keeping my end of the bargain, every month, I am posting short reviews of every book I read that month. You can find the reviews for May, June and July here (click on "Updates").  If you donate, the page update with book reviews is sent right to you! And I even came up with a slogan, "Let's show the runners, reading pays off!" 

Which brings me to my last request:
3. Start thinking now of what skills you have that could be leveraged into a Race Against Resistance Team. Next year I'd love to see more reading teams, walking teams, knitting teams, Pokemon Go teams, yoga teams, and cooking teams, in addition to the athletic teams, raising more money, to give more scholarships, to train more people in stewardship, to see fewer cases of C diff. 

Because really, even though we may argue about how, we're all committed to the same cause: keeping patients and providers safe and healthy. 

Don't eliminate hand hygiene surveillance in hospitals

Yeah. Mike's correct. Hand hygiene does prevent HAI. (everyone can relax and be happy) You just can't see it or measure it and that's important. Here's why:

This past month I wrote two posts (here and here) trying to explain why you can’t link ward-level hand hygiene compliance to reduced healthcare-associated infections on the ward level. I thought the argument was pretty simple – there are so many factors in addition to hand hygiene that are important to do when preventing specific HAI (insertion checklist for CLABSI or clipping not shaving for SSI) and there are so many hand hygiene opportunities that don’t specifically impact your HAI of interest (or 30 HAI of interest) that you can’t possibly link them statistically in a study or when reporting them in your annual infection control report.

Let me be clear. I never said hand hygiene was unimportant. I said the opposite several times. Hand hygiene is critically important for infection control, particularly MDRO prevention but also HAI reduction. But for both, you can’t see the association in a graph or statistically and that’s important. Why?

In infection control, we can audit and feedback two things: process measures and outcomes.

Process measures are metrics like CLABSI checklist compliance or hand hygiene compliance. We know process measures are important for patient safety and they are easy to measure and directly remediable to education or other improvement interventions. If you see hand hygiene compliance is falling, you can educate clinicians about hand hygiene.

Outcomes measures are metrics like CLABSI rates or CAUTI rates. These are typically more difficult to measure and are delayed compared to process measures. SSI rates take a lot of person-time to track and surveillance occurs over many months for some procedures. When reviewing the literature in 2016 before giving a SHEA talk on Outcomes vs Process Measures, I found a general consensus that risk-adjusted outcomes measures are preferred to process measures because that's what the public wants to see – lower infections.

So here is why this is important. When manuscript reviewers or bloggers say ward-level hand hygiene reduces ward-level HAI, they are really saying they don’t care about hand hygiene monitoring. Specifically, they are saying – “If your intervention increases hand hygiene compliance but you can’t show me reduced HAI, I'm not interested.” We all know hand hygiene monitoring is time-consuming, costly and biased by the Hawthorne effect. So why monitor it? If hand hygiene can be linked so clearly to 30 HAI as Mike proposes, we should just go ahead and report the outcome measures (HAI rates), which will save us time and money. One less thing to do.

Let me summarize. Hand hygiene is critically important for MDRO prevention and HAI prevention. Yet, you can’t link these in clinical studies nor will you see a genuine association in your hospital’s annual report. Not seeing an association DOES NOT mean hand hygiene is unimportant.

Overcoming dogma is hard and seeing Mike’s arguments affirms my earlier trepidation. I’ll take full blame that I didn’t reference CDC and other papers like he did (although he misquoted them, to be clear). One of the things I like about blogging is that I can give you the gist without citations. But I was a bit sloppy. I’m sure I could be a better writer, but many criticisms in Mike’s post don’t hold water – perhaps I will respond in the comments or in a future post (when I am not 35,000 feet above the Pacific). For example, hand hygiene is part of the insertion bundle, but I find no mention of monthly hand hygiene compliance as being important. I'll also add that when I write these posts you are seeing my struggle to understand something. What I really appreciate about the twitter comments, both positive and negative, and Mike's post is that they make me critically determine where my ideas need more work or better explanation.

However, if we take dogma and Mike’s arguments to their logical conclusion, they suggest we can eliminate the process measure hand hygiene compliance in studies and in hospitals and replace it with HAI outcome reporting. I will say I’m surprised with this inevitable conclusion. I think that’s a huge mistake.

So there’s no misunderstanding: KEEP MONITORING HAND HYGIENE COMPLIANCE

Hand hygiene MOST CERTAINLY prevents healthcare associated infections

I’ve spent some time trying to process Eli’s last two posts on hand hygiene. It’s tough to untangle his logic and I’m not sure what he’s trying to prove. But here’s my point-by-point response:

In the first post, he notes: “if puerperal fever was a CDC HAI and clinicians didn't wear gloves, we could still say hand hygiene prevents HAI. However, that's not the current reality.” Well, puerperal fever is a CDC HAI (see here, page 23).

Next he states that CDC defines HAI as CLABSI, CAUTI, SSI and VAP. That’s a true statement, but I think he’s implying that CDC defines HAIs as only those 4 (particularly in light of the paragraph above). Actually, CDC has defined over 30 HAIs (definitions here, page 4).

He goes on to say that the WHO hand hygiene moment #2 (hand hygiene before clean and aseptic procedures) is not part of the CLABSI bundle published by Peter Pronovost. But Pronovost’s article (to which he links) states otherwise:

Per Eli, “Do we really think that interns and nurses practicing hand hygiene on the wards prevents SSIs to any measurable extent compared to pre-operative CHG bathing or peri-operative antibiotics?” Well, to Eli I would say, the next time one of your family members has a surgical procedure, tell the surgical team that they don’t need to perform hand hygiene before touching your loved one’s fresh surgical wound.

He argues that hand hygiene is not a significant component in the causal pathway for HAI, then four paragraphs later goes a step further and states that hand hygiene is not in the causal pathway. While for some HAIs hand hygiene may not be the most important risk factor, it is nonetheless a risk factor and it is indeed in the causal pathway. Then we come to twisted logic. Per Eli, hand hygiene prevents transmission of microorganisms but it doesn’t prevent HAIs. However, transmission of microorganisms is an intermediate outcome that can lead to HAI. It’s like saying: guns don’t kill people, bullets do.

He states that interventions to improve hand hygiene are not used for outbreak control. That’s contrary to my experience. We focused on hand hygiene in almost every outbreak that I managed over two decades as a hospital epidemiologist. In some cases, it was one of our first interventions while we proceeded with the investigation.

His next post focused on how you cannot correlate ward-level hand hygiene compliance with HAIs. Given the relatively small number of observations collected, and the relatively small range of compliance, I agree.

He shows an Ishikawa diagram of factors leading to CLABSI, but it and his subsequent logic ignore the fact that CLABSIs are not just associated with catheter insertion. In fact, we rarely see insertion-related CLABSIs anymore because the CLABSI bundle (which includes hand hygiene!) is so effective. The typical CLABSI now occurs in patients who have had a central line for weeks to months. So, the important factors now are associated with line maintenance (e.g., the line dressing, skin hygiene, minimization of entry into the line for lab draws, etc).

He next estimates how many months of hand hygiene observations are necessary to witness one opportunity where the HCW touches a CVC? But his focus is on how many observations are performed not on how many opportunities exist. I’ve previously estimated that in a 700-bed hospital there are 15 million hand hygiene opportunities per year. Using Eli’s estimates (which I have no reason to doubt), that translates to 30,000 direct manipulations of a central venous catheter yearly. I sincerely hope that every one of those was preceded by hand hygiene, and I suspect almost every hospital epidemiologist and every patient hopes so, too.

I get Eli’s point that trying to precisely measure hand hygiene compliance is dumb. But I think there is value in the process of monitoring hand hygiene because it keeps hand hygiene top of mind. It’s the Hawthorne effect in action. And the past decade or so of all this measurement has made a difference. If I compare the present to when I was a house officer 30 years ago, it’s amazingly different. There was zero focus on hand hygiene in the 1980s. There were many fewer sinks and no alcohol-based products available. We have made enormous progress.

My thoughts on hand hygiene are simple: It’s important. It’s really important. Keep doing it. Keep measuring it. It eventually becomes a habit. And someday, it will be so ingrained we won’t need to talk about it anymore.

Trying to link ward-level hand hygiene compliance and healthcare-associated infections

I've spent 15 years studying hand hygiene, so I obviously think it is critical to safe healthcare delivery. As I mentioned in my prior post on hand hygiene and HAI, sometimes these posts are difficult to write. The difficulty stems from the inertia required to confront dogma, while simultaneously bracing for the inevitable criticism. And of course, I could be completely wrong. Often times, dogma is correct.

But as I've gazed out of my office in the old Singapore CDC (soon to be replaced by a shiny new NCID), I've had moments to consider various causal diagrams linking hand hygiene to various outcomes, like CLABSI. (see below or source) If you carefully examine (click to expand) this or other causal models you see that hand hygiene is there, but it is only one of many possible causes of CLABSI. So, strictly speaking hand hygiene is in the causal pathway to CLABSI development. That's the dogma and it's true, to a point.

But let's move on to my contention: ward-level or ICU-level hand hygiene compliance changes can't be linked to reductions in HAI. For example, no amount of raising hand hygiene from 0% to 100% can be associated with reductions in HAI, such as CLABSI. It's just not mathematically possible. Sure, some study might show such an association, but I wouldn't believe it.

So to borrow a strategy used often by fellow blogger Mike, I'll use math(s).

Most facilities monitor hand hygiene compliance with direct observation. On the ward level, we reported that less than 30 opportunities/ward/month are collected. That was in 2012, so let's say things are much better and we observe 100 opportunities. This actually doesn't matter - you could observe 10,000 per month with an automated system, but let's stick with 100 opportunities.

Now, let's estimate how many opportunities are related to HH moment #2 (before aseptic procedure). Most estimates that I've seen are close to 10%. And how many of HH moment #2 involve directly manipulating a central venous catheter - let's go with 2%. You can estimate a lower or higher rate depending on ward acuity, but I'm going to stick with 2% since the vast majority involve peripheral lines. So, 2% of 10% is 0.2% or 0.002.

So, how many months of 100 observations/month are required before we witness one opportunity where the HCW touches a CVC? Answer: 5 months.

Now over those 5 months, let's assume we have observed a hand hygiene compliance of 50%, so 250/500. Let's also assume the worst and say that HCW were 0% complaint with CVC-related moment #2 in those 5 months. Now, let's assume they were 100% compliant over the next 5 months after we targeted a hand hygiene education program to moment #2. Our compliance would increase to 251/500 or 50.2%. Any other increases in hand hygiene would not be in the causal pathway for CLABSI, so even if compliance shot up to 80%, we would only care about the 0.2% increase.  In fact, this highlights why it's difficult to link ward-level hand hygiene compliance to reduced CLABSI, since most of the increase does not involve CVC-related moment #2. It's almost all noise.

And if you still want to install the automated monitoring system, you can multiply the numerator and denominator by 100, and still have 25000/50000 (50%) with an increase to 25100/50000 (50.2%). And if your hand hygiene education was super successful and compliance increased to 80% (40000/50000), it would still be true that only 100 of the 15000 additional compliant opportunities would be CVC related. 100/15000 is 0.67%. Thus, CVC related hand hygiene opportunities are a needle in a haystack.

I encourage you to check my math, choose different rates or numbers and correct me in the comments below or on Twitter. Sadly, it's hard to link ward (or ICU) level hand hygiene compliance to ward-level CLABSI rates. But as I've said before, keep washing your hands and monitoring hand hygiene compliance in your hospital. No one wants a CRE outbreak.

Hand hygiene doesn't prevent healthcare associated infections

Not all transmission leads to infection and not all infections are preceded by transmission. Hand hygiene prevents transmission, not infection.

....some posts are just hard to write.

One of the persistent beliefs in infectious diseases and infection prevention is that hand hygiene compliance prevents healthcare associated infections. Perhaps this harkens back to Semmelweis and the prevention of puerperal fever through hand disinfection. Of course, if puerperal fever was a CDC HAI and clinicians didn't wear gloves, we could still say hand hygiene prevents HAI. However, that's not the current reality.

CDC defines HAI as CLABSI, CAUTI, SSI and VAP. We can even consider hospital-onset BSI and almost any other infection we can track using CMS or EMR data and monthly aggregate hand hygiene compliance is not a significant component in the causal pathway for the development of an HAI.

Sure, hand hygiene/sterile gloves before catheter insertion and hand antisepsis prior to invasive surgical procedures are standard practice. However, when I talk about hand hygiene compliance, I mean monthly hand hygiene on room entry/exit or following the WHO 5 My 5 Moments during care on medical wards and in ICUs. And yes, there are instances where Moment #2 - before clean/aseptic procedure could potentially reduce CLABSI, but the proportion of CLABSI caused by such breaks in moment #2 pale that occur outside of the insertion bundle pale in comparison to those prevented with the highly effective CLABSI bundle. Otherwise, monthly aggregate hand hygiene compliance would have been included in the CLABSI bundle. It wasn't.

Let's discuss SSI prevention. Do we really think that interns and nurses practicing hand hygiene on the wards prevents SSIs to any measurable extent compared to pre-operative CHG bathing or peri-operative antibiotics?  No, I didn't think so.

How about we look at this another way. If you were called by a CT surgeon because of an outbreak of SSI in CABG patients or an outbreak of CLABSI in her ICU, would you first (or second or third) start a hand hygiene campaign? I assume no and thus, you don't think hand hygiene prevents SSI or CLABSI. 

Thus, for all practical purposes, we won't be able to do studies associating improved hand hygiene compliance on the wards or ICUs with reduced infections. Even when such studies are done and do show an association, they have minimal basis in causal reality. Requiring hand hygiene bundles and intervention studies to show reduced HAI is incorrect and counterproductive. Since hand hygiene on wards and ICUs is not in the causal pathway for HAI incidence, we shouldn't expect hand hygiene to prevent them.

But all is not lost. Hand hygiene does prevent MDRO transmission (and indeed transmission of susceptible pathogens) in healthcare settings. Hand hygiene is critical to tackling the MDRO crisis but these benefits aren't currently captured by CMS and most EMR systems. To document the benefits of hand hygiene, we would need to complete surveillance for important pathogens on admission and discharge and document acquisition or transmission. This is expensive and likely not necessary nor feasible.

Keep your heads up and continue to drive hand hygiene compliance. Continue to do hand hygiene surveillance and improvement studies! Hand hygiene is critical to MDRO prevention and likely the future of healthcare. Just stop it with the HAI target.

Addendum: This post was written in response to the question: "Do you care about increases in monthly hand hygiene compliance if you can't document reduced HAI?" I would answer yes. Hand hygiene is an important clinical outcome in itself and requiring HAI reductions is a trap. Don't fall into that trap. I've attempted to explain why here.

Addendum 2: In response to this post, others have mentioned CDI as an HAI that could be targeted with hand hygiene interventions. As Dan mentioned back in 2013, CDI might not be the optimal target since a minority of cases appear to be related to in-hospital transmission. This was shown back in 1994. Stewardship might be a more appropriate intervention for CDI prevention.

Is the CLABSI metric now doing more harm than good?

It’s a good news, bad news situation. 

The good news is that we’ve got an effective bundle of practices that can prevent most central line associated bloodstream infections (CLABSIs). Public reporting and pay-for-performance have added to the incentive for hospitals to implement these practices, leading to a dramatic nationwide decline in CLABSI rates. 

The bad news for most hospitals is that the remaining events that meet the NHSN CLABSI definition represent a motley assortment of “one-offs” that aren’t clearly preventable (see this great post from Scott Fridkin for more detail, and to share your “one-offs”). Given how low the CLABSI baseline now is, just a slight “blip” in these one-offs can push a hospital’s SIR above 1 and contribute to financial penalties (for some perspective, the post-intervention CLABSI rate in the widely cited Keystone ICU project (1.4 per 1K line days) now translates to an SIR of >1 at many hospitals). 

These blips result in a tremendous amount of effort by unit leadership and infection prevention programs, as they examine each event for preventability or for common themes—often concluding that the events are either secondary or mucosal-barrier injury (MBI) attributable, but don’t meet the requisite NHSN definition (so must be reported as primary CLABSIs).

HAI definitions, like lab diagnostics, perform best when applied to individuals with moderate-to-high pretest likelihood of disease (or, populations in which the disease is prevalent). This leads to a paradox for HAI surveillance—as prevention approaches improve and HAI rates fall, the positive predictive value of surveillance definitions also declines (if one defines a “true positive” as an event that meets an intuitive clinical definition of the HAI in question—e.g. an old-fashioned primary CLABSI likely to be due to breaches in the process of line insertion and care).

Aside from the time and energy spent chasing one-offs, the continued pressure on the CLABSI metric is going to result in some counterproductive approaches to reach “zero”. After all, there are really only two ways to eliminate CLABSI as it is currently defined: (1) stop using central lines, and/or (2) stop obtaining blood cultures in patients who have central lines.

Hope ya' don't mind if I pay ya' in change!

Many of you may have heard that CMS is proposing to change the payment rates for outpatient care, including that provided by ID physicians. A detailed explanation of the proposal can be found here, but for a simple illustration please see the short video below:

Yes, it’s almost that bad. How many hours do you invest in seeing a new outpatient with a complicated problem, including review of voluminous records, the clinic appointment itself, the follow up calls, the time spent obtaining authorization for various tests or scans, and the EMR time to document it all? Now divide $135 by that number.

So yea, please submit comments directly to CMS and contact your congressperson!

The Presenteeism Problem: "It's My Allergies . . . Honestly!"

As we discuss HAI prevention, there are the "Big 6" HAIs (CLABSI, CAUTI, SSI, C. diff, MDROs, and VAP [although that one has been put on probation]) that get all the attention and resources.  However, other infections acquired in healthcare settings have less visibility but cause substantial harm.  One such HAI is healthcare-acquired respiratory viral infections (HARVI).  HARVI due to influenza has gotten increasing attention, especially in light of healthcare personnel (HCP) vaccination discussions (no worries, friends, I'm not stoking that debate again), but other viruses are increasingly recognized as causes of harm among our patients and colleagues (especially in light of better diagnostic tests).

In the current issue of ICHE, Len Mermel and Eric Chow provide an interesting perspective on one key aspect of HARVI transmission - HCP working while ill/symptomatic.  In their commentary, they argue that sick leave and work restriction policies that use fever as the parameter to keep HCP at home is too lenient, as infections due to many respiratory viruses may not cause fever but can still pose a substantial transmission risk.  They also call for a culture change surrounding presenteeism/working while ill, as too often the pressures to stay at work (limited sick leave especially with vacation days bundled into sick days in a single allocation, desire not to burden colleagues, importance of not handing over care to patients and maintaining the doctor-patient relationship) outweigh the push to stay home.  Policies, they appropriately argue, should be non-punitive with redundancy to allow coverage more readily.  Thanks to them both for raising some very important and provocative questions.

As I read their commentary, however, I kept going down various rabbit holes focused on implementation: 

• How do you assess HCP with resp. symptoms for infection vs. non-infectious entities like allergies (there's no POC test to rule out allergic rhinitis)?  This would be a huge issue at my hospital, as we sit in the allergy belt of the country where spring leads to a chorus of runny noses.
• What are the untended consequences of broader "stay at home" policies?  In units with highly-specific patient populations, you may run out of the experienced, skilled HCP and rely on coverage HCP, who may not be as comfortable or familiar with protocols, treatment regimens (e.g. a non-trauma nurse covering in the trauma unit).  Does that lead to unintended harm (arguably yes, if HCP shortages occur)?
• What about the utility of masking those with respiratory symptoms and no fever (not mentioned in the paper)?  Does that reduce transmission as effectively?  As part of the broader culture change, should expectations for masking to improve acceptance be part of the conversation?

Finally, such discussions and debates highlight the need for more implementation guidance and research on HARVI prevention. Hey, SHEA, time for a new Compendium chapter?

A semi-terrible, semi-no good, semi-very bad week in a semi-private room

A close family member became ill while traveling, and required emergent hospitalization. So I boarded a flight to provide support during what ended up being a weeklong hospitalization: the first two days at a small (~50 bed) local hospital, the rest at a large (>500 bed) tertiary care hospital. 

Overall, we were pleased with the care, and will likely rate the large hospital favorably (which I presume is common, given that this facility has a 5-star CMS rating). However, as others have pointed out, it would be very instructive for every health care worker to spend time each year as a patient or family member. Despite spending much of our professional lives in hospitals and seeking empathy with patients and their loved ones, nothing can replace being thrust into the patient/family role. So here are a few observations from the experience: 

There is nothing private about semi-private rooms. Multiple patient rooms are inimical not just to infection prevention, but also to privacy, confidentiality and basic human dignity. We learned much more than we ought to about the person in the neighboring bed, and vice versa. Add to that the additional interruptions, alarms (see below), and frequency with which HCWs moved from one bed to the other without performing hand hygiene, and I am more convinced than ever that single patient rooms should be the standard in all health care facilities. And “semi-private” should be replaced by “non-private” or “multi-patient” as a descriptor of hospital rooms.

Hospitals are aural assault zones. Most hospitals now have “quiet” or “hush” campaigns, laudable efforts to reduce noise. But noise from the hallways is a very small part of the problem. Seemingly everything in the hospital room makes noise! The IV pump (even when it isn’t alarming, in some cases), the NG suction, the various alarms (IV pump alarms, bed alarms), compression devices, intercom messages, code announcements… I’ve long had a pet peeve about IV pump alarms, but my concerns now encompass many additional noise sources—a long overdue solution is to re-route the pump alarm elsewhere (nurses’ station, pager), which also obviates the ridiculous step of requiring the patient (or family member) to press their call button to inform their caregiver that their IV pump is alarming. Engineering solutions to reduce noisy interruptions are essential.

Expecting patients to “speak up” and advocate for themselves is unrealistic. Acute care hospitalization is a traumatic experience, and once admitted the focus of the patient (and family) is simply on surviving the hospitalization and getting home. The default approach is often passive acceptance and deference to the treating caregiver. It’s not just that you don’t want to upset your doctors and nurses, but you also strongly want to believe that they are doing the right thing(s). We hesitated on more than one occasion when, in retrospect, it would have been better to speak up sooner, or more directly (on two occasions it might have prevented a complication). If even physicians are slow to point out problems or ask questions, how can we expect others to do so?

Finally, a kind word, a smile, and some ice chips can make a massive difference! Kindness may not be the only thing that matters (the right diagnosis and treatment is also kind of important), but it goes a long way.

Speaking of smiles, this sticker on our IV pump provided one during the first hospitalization, and helped explain why the pump was so noisy...it was Y2K non-compliant! A real confidence-booster!

Dear Stewardship People: Can't We All Just Get Along?

The following post is by Dr. Jasmine Marcelin from University of Nebraska Medical Center.

Teams should work together, not compete

I am an Antimicrobial Stewardship Leader. As the Associate Medical Director of Antimicrobial Stewardship at my institution, I work with another physician (Antimicrobial Stewardship Medical Director) and an ID-trained Antimicrobial Stewardship PharmD. We have a great setup, share audit and feedback responsibilities, and have different interests clinically and for research, which makes it great to divide tasks for initiatives. I focus on outpatient ASP and SSI prophylaxis, PharmD on AU initiatives and cost, and other MD on CDI. We cover for each other, review and co-author each other’s grants, papers and presentations, and present education to various hospital groups together. We work well as a TEAM.

Teams are great things. Nothing meaningful can be accomplished when working alone and in silos. Some ASP teams also include nurses, infection preventionists, advanced practice providers and laboratory personnel, and the specific ASP leadership model will depend on the resources at an individual hospital. Each of these groups bring a very specific and unique skillset to the ASP team. Why is it then, that we seem to find ourselves in the midst of an MD-PharmD power struggle?

In February 2018, the IDSA, SHEA and PIDS released a statement that ID physicians should be leading the way in Antimicrobial Stewardship. This statement shared the unique skillset that ID doctors bring to the ASP table, including years of clinical training in the diagnosis and management of infections. This position paper reads as a statement of support from our societies demonstrating our value to hospital leadership. “Hey C-suite, we have these requirements for ASP, and it says you need a leader that has ID expertise. We literally went to school for ID, and we already work for you, so here are these reasons why you should actually PAY us for what we know how to do well, instead of asking us to do it for free while we are on hospital consults?” The position paper did not say, “ID physicians are better than Pharmacists at ASP”. In fact, the document went on to state, “An ASP should also include at least 1 pharmacist, ideally with subspecialty training in ID. While ID physicians and pharmacists may often have the most central roles in an ASP, all members of the ASP team, including microbiologists and infection preventionists, provide distinct skills of great value.”

Notwithstanding the explicit acknowledgement of the value of the team model of ASP, perhaps the conclusion “ID physicians are well equipped to lead multidisciplinary ASPs given their training, expertise, and experience” offended some of our pharmacist colleagues. The publication was followed by a letter to the editor in May 2018 that stated, “In identifying ID physicians as uniquely qualified for these functions, the paper fails to acknowledge the essential leadership and skill set of ID pharmacists in stewardship”. The letter then concludes, “Best care for patients is achieved through multi-disciplinary stewardship where pharmacist leaders are key to success”. This letter led to a flurry of social media posts misguidedly comparing the “value” of ASP physicians vs pharmacists. A real world study of ID fellow experiences with ASP shared that fellows looked to “pharmacists, not ID physician leaders as primary resources for antibiotic teaching”, and there was a social media frenzy that pharmacists should lead ASP, not ID physicians.

Seriously?

People, this is not a competition! Pharmacists are uniquely equipped to lead ASP because of their special training in the PK/PD of antibiotics, adverse drug effects, drug-drug interactions, and costs. ID physicians are uniquely equipped to lead ASP because of their special training in direct patient care, being boots on the ground as well as eyes in the sky, and can always use the “peer” card when approaching rogue prescribers. The thing is, we are BOTH essential for a successful ASP, and organizations should strive to fund BOTH, because we complement each other. The thing is, we ID physicians have had a long struggle for institutional acknowledgement and respect of our invaluable contribution to patient care. In our fight for recognition, perhaps we have failed to let our pharmacist colleagues know that we appreciate what they do, and that our work is enriched by their contributions. Perhaps we should be intentional to thank our pharmacists for this contribution so that they do not feel we are trying to usurp them and dismiss their value.

Physicians acknowledge and applaud pharmacists’ tireless contribution and value added to the ASP team. We support you in leadership roles. When we say we as physicians are suited to be ASP leaders, it is because we are. It does not diminish your role as co-leaders in a multidisciplinary team; neither does your teaching of antibiotics to ID fellows diminish our role as clinical experts to trainees. Can’t we all just get along? Time to put this superfluous competition to rest and support each other’s value, for the patients’ sake!

Work Attire

I'm a creature of habit. My first activity every day is to read the New York Times. Depending on my schedule, some days I read more articles than others. This week I was away at a conference and found myself with some early morning extra time before the first meeting session, so I delved into the Arts section. I began to read the first article: Women of the Philharmonic Can Play It All. Just Not in Pants. It begins:

Women can wear pants at the Oscars, the Tony Awards and state dinners. They can wear pants while graduating from the Naval Academy, figure skating at the Olympics and running for president. They can wear them at just about any workplace in America.

But when the women of the New York Philharmonic walked on stage at David Geffen Hall recently to play Mozart and Tchaikovsky, they all wore floor-length black skirts or gowns. And they’re required to: The Philharmonic, alone among the nation’s 20 largest orchestras, does not allow women to wear pants for formal evening concerts.

The article goes on to discuss some of the unique problems that this dress code presents for musicians, such as the difficulties encountered when playing large stringed instruments, and one woman who plays the English horn recounted how the folds of her long dress got caught in the keys of her instrument during a critical passage.

I found the article interesting, but as an outsider to the music world simply thought that it's another example of how the frivolous often eclipses the big issues in life. Then I came to this quote from a female violinist, “One thing is really clear: People in the orchestra want to remain dressy. It’s important that we look like we care. That is sending a message. We put so much into the preparation of our programs that, yes, we need to look good as well.” At this point the light bulb turned on and all of the dots connected for me: here is the musical equivalent of the judgmental doctors who think that all doctors must wear white coats. And then I knew that the pathologic manifestations of professionalism are not limited to medicine.

Well at least in medicine our clothing police aren't sexist, I thought. But then I remembered that it was only three years ago that Mayo Clinic dropped its pantyhose requirement for women physicians. And in a recent essay, Roshini Pinto-Powell, the Associate Dean of Student Affairs at the Geisel School of Medicine at Dartmouth, writes about how professionalism forces nearly every woman interviewing for medical school or residency to follow rigid rules of dress that makes her look like a penguin. Maybe we aren't ahead of the New York Philharmonic after all.

You might think that in medicine we've overcome ageism and classism in our sartorial expectations. However, it's worth pointing out that the Department of Medicine at Johns Hopkins is just now dropping the requirement of short white coats for interns. In the video attached to this article about that in the Baltimore Sun, the Internal Medicine Chief Residents express their sorrow at the loss of the short coat. Really? In 2018? Yet almost everywhere medical students are still relegated to the short coat. How about we just get rid of them all given that hierarchy with its associated authority gradient in medicine makes it much less likely that a short-coated person will speak up when she sees a long-coated person about to make an error?

On a happy note, there are always positive deviants, and I want to point out two of them. In the musical world, there is Seiji Ozawa, who was the conductor of the Boston Symphony for three decades. Instead of wearing the customary white tie and tails, he boldly wore a white turtleneck and tails, a look that became his trademark. The other is Jorge Mario Bergolio. As he was about to step out onto the balcony in St. Peter's Square to be introduced to the world as Francis, he was handed the mozzetta, a short red velvet cape trimmed in ermine worn only by the pope. He declined this heirarchical symbol despite the professionalistic expectations of his peers in the College of Cardinals.

I remain convinced that we need to assess work attire using simple humanistic criteria. Your clothes should be clean, comfortable, functional, and safe. No need for white coats. No long gowns. No mozzetta. No penguin suits. And the only people that will care are those who remain blinded by professionalism.

Safer.

AHRQ.

Pushing the Needle on Influenza Vaccination

Despite continued debates about the use of influenza vaccination mandates in healthcare settings (see prior discussions just on this blog here, here, here, here, and here), facilities continue to move toward implementing some form of ‘mandatory’ program to ensure sustained high levels of influenza vaccination coverage among their staff.  A new article published in JAMA Network Open documents this increase with an update to a multi-year survey project asking about facility infection prevention practices.  I use the word ‘mandatory’ in quotes above on purpose because, as I detailed in an accompanying editorial, the definition of a mandate, when it comes to vaccination policy, is not standardized.

“…Most importantly, it does not appear that mandate was defined. Among respondents who reported having a vaccination mandate, only 74% reported having penalties for noncompliance and 13% allowed declination without a specified reason. Of those reporting no mandate, 21% reported penalties for noncompliance with hospital policy on influenza vaccination and 41% reported requirements for wearing masks if unvaccinated. An article in a bioethics journal⁵ offers the following criteria for using the term mandate in this setting: limiting acceptable reasons for refusal, penalizing nonparticipation, and enforcing these expectations. By these criteria, it is not clear how many programs described in this survey should appropriately be referred to as mandatory—the number may be higher or lower than that reported, although an increase over time seems likely.”

The authors of the survey article also note that the VA is moving to a mandatory vaccine or mask policy this year, which will again increase the number of facilities using some type of mandate.  Hopefully, the VHA will take advantage of their more comprehensive healthcare delivery system to evaluate the impact of the program on both inpatient AND outpatient influenza among their patients, something that has been a persistent gap in prior reports.

ALSO, did you appreciate how easy it was to click the link and access the whole article?  Note that the article and the accompanying editorial are in JAMA Network Open, a new, fully open access journal “in which all content is made freely available to all readers immediately on publication. ….[they] will publish online only, every Friday.” Read more here.