tag:blogger.com,1999:blog-80662382903705573892024-03-15T20:09:52.664-05:00Controversies in Hospital Infection PreventionPondering vexing issues in infection prevention and controlDan Diekemahttp://www.blogger.com/profile/10231929371552334184noreply@blogger.comBlogger1840125tag:blogger.com,1999:blog-8066238290370557389.post-5842985733186031702021-06-21T09:49:00.002-05:002021-06-22T06:54:15.972-05:00OSHA! OSHA! OSHA!<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-2J15UKuN7B8/YNCikSAb6MI/AAAAAAAAAfI/qGIgPQh9BCwkae4ds7xw1Omj9pmSwWAmACLcBGAsYHQ/s246/marcia.gif" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="181" data-original-width="246" src="https://1.bp.blogspot.com/-2J15UKuN7B8/YNCikSAb6MI/AAAAAAAAAfI/qGIgPQh9BCwkae4ds7xw1Omj9pmSwWAmACLcBGAsYHQ/s0/marcia.gif" /></a></div><p align="center" class="MsoNormal" style="text-align: center;"><br /></p>
<p class="MsoNormal">In many parts of the country, as rates of COVID-19 are
declining and vaccination coverage is increasing (albeit with substantial
variation across the US and the world), reopening has commenced.<span style="mso-spacerun: yes;"> </span>Masking requirements and guidelines have
relaxed, gatherings have increased, and we’re entering the post-COVID
reality.<span style="mso-spacerun: yes;"> </span>In healthcare, discussions
regarding how to safely relax various interventions put in place during the
height of the pandemic are underway:<span style="mso-spacerun: yes;">
</span>When do we (should we ever) stop active screening of healthcare workers,
patients, and visitors? Can we stop requiring admission and pre-procedural asymptomatic
screening testing? How does a fully vaccinated workforce affect this
relaxation? Can we safely gather? Do we stop social distancing? Will universal
facemask use in clinical areas be the new standard practice from here on out?<o:p></o:p></p>
<p class="MsoNormal">Last week, a massive regulatory curveball crashed into this discussion
when OSHA released the <a href="https://www.osha.gov/coronavirus/ets">Emergency Temporary Standard</a> on COVID-19. Catching many facilities
by surprise, the new Standard, which many are required to meet within 14 days
of publication in the Federal Register, harkens back to Spring of 2020 in many
ways. <span style="mso-spacerun: yes;"> </span>The requirements do not seem to
take into account the declining rates of infection and increasing vaccination
coverage and instead read as if rates were still climbing and vaccines were
still under clinical trials. As a regulatory branch of the government with “teeth,”
OSHA can cite and fine facilities for failure to comply (unlike other parts of
the federal government infection prevention experts are also used to following,
like the CDC).<span style="mso-spacerun: yes;"> </span>In many ways, this makes
OSHA’s directives and perspective on interventions the final say, even when
evidence may not fully support them. <o:p></o:p></p>
<p class="MsoNormal">OSHA’s mission is a very important one: to ensure employers
provide a safe working environment and that employees have safeguards in place
to minimize/eliminate harm from their working environment.<span style="mso-spacerun: yes;"> </span>OSHA standards have paved the way for safe,
protected workplaces, and their guidance applies to all types of industries,
from manufacturing plants to construction sites to hospitals and clinics. However,
OSHA’s approach to healthcare has been criticized for failing to
account for patients and potential patient harm in their mission to protect
healthcare workers. While at the manufacturing plant, any regulatory requirements
put in place won’t harm the widgets being produced, in healthcare, we have to work
to ensure protection of the workforce while also accounting for practices that could
result in harm to the patients that that workforce serves.<o:p></o:p></p>
<p class="MsoNormal">Enter the “ETS,” as it’s (not really) affectionately called.
With a massive preamble of 916 pages (one can only imagine how long such a
document took to go through gaining internal consensus), the ETS outlines expected
practices that must be in place for facilities who may see persons with
suspected or confirmed COVID-19.<span style="mso-spacerun: yes;"> </span>Some
key concerns about the new guidance are as follows:</p><p class="MsoNormal"></p><ul style="text-align: left;"><li><span style="text-indent: -0.25in;">I won’t rehash the mask vs N95 for the care of
COVID-19 patients debate, other than to note that this is an issue where the science
is still very much in conflict (see recent debate at SHEA and upcoming one at
IDWeek 2021 on just this topic). OSHA’s ETS has essentially made the argument
moot:</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">N95s must be worn for care of any
suspect or confirmed COVID-19 patient – not just with those undergoing an AGP.
Imagine the implications of this:</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">now,
even fully vaccinated pediatricians, seeing wave after wave of children with
URIs this fall, must wear the full COVID-19 PPE for every patient. Every day. If
such workers aren’t facing burnout now, that may tip them over the edge. It’s
one thing if such conservative use of precautions were necessary; however, that’s
unclear, especially in a fully vaccinated person.</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">Maybe a facemask and eye protection is all
that one needs, but that doesn’t matter now.</span></li><li><span style="text-indent: -0.25in;">The ETS requires employers to notify employees
if a case of COVID-19 is reported in their workspace. The notification is not
just to close contacts but to anyone working in the “well-defined” workplace
who weren’t wearing a respirator. This seems more burdensome to already stretched
occupational health programs, but what’s even more curious is if such notification
was important, it is not necessary if the COVID-19 case occurs in a patient in area where
care of suspected and confirmed COVID-19 patients occurs.</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">So if alerted to a case of COVID-19 in the
sterile processing department, all employees in that area (not just close
contacts) not wearing an N95 (why would they be??) must be notified, but if that case happens to have been on one of the
clinical units where COVID-19 patients reside, notification is not required. </span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">Hmm . . .</span></li><li><span style="text-indent: -0.25in;">Some of the ETS requirements are confusing and
vague, such as this statement: “When the employer establishes it is not
feasible for an employee to maintain a distance of at least 6 feet from all
other people, the employer must ensure that the employee is as far apart from
all other people as feasible.”</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">“Must
ensure” is very strong language yet how is this even remotely possible to monitor,
enforce, or even set expectations for?</span></li><li><span style="text-indent: -0.25in;">The ETS does allow exemptions for fully
vaccinated persons, but only in areas where “people with suspected or confirmed
COVID-19 are not permitted to enter those settings.” Unfortunately, in
healthcare settings, many such persons are coming to the facility for care for
those exact symptoms or require urgent medical interventions that cannot be
delayed, and prohibiting them from entering the location runs counter to that
mission and can result in patient harm. As a result, the fully vaccinated status of
the workforce will not matter for many of the requirements.</span></li><li><span style="text-indent: -0.25in;">Despite being the most effective interventions to
protect the workforce (which has an added benefit of protecting the widgets . .
. I mean, the patients too), OSHA does not take a firm stance on requiring COVID-19
vaccination for healthcare personnel. </span><span style="text-indent: -0.25in;"> (In fairness, they do strongly encourage vaccination and require employers to provide time off for vaccine-related symptoms).</span></li></ul><p></p><p class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><o:p></o:p></p>
<p class="MsoNormal">Despite my cynical attitude, I do think some of the ETS
requirements are very positive: the emphasis on cleaning, ventilation requirements,
use of transmission-based precautions, and a much stronger expectation around reporting
of employee respiratory illness and staying home when ill. I do, however, worry
about the overly burdensome requirements at a time when COVID rates are falling,
especially when we enter the fall and our good friends influenza, RSV, and
other viruses make a return (but maybe, given the near elimination of those
viruses last winter, that’s part of the intended impact of the Standard?).<span style="mso-spacerun: yes;"> </span>Interestingly, OSHA opted only to release an
ETS regarding COVID-19 for healthcare and not for other industries.<span style="mso-spacerun: yes;"> </span>But if COVID-19 is still an occupational risk
for workers in healthcare, isn’t it for other industry workers as well? I also realize that the emergence of variants of concern can change the epidemiology of COVID-19 rapidly, but thankfully, vaccination does still provide substantial protection against the currently circulating variants.<o:p></o:p></p>
<p class="MsoNormal">So as you scramble to unroll back/reinstitute interventions that had been in
place last year and struggle with messaging to the workforce of the new
requirements, know you are not alone.<span style="mso-spacerun: yes;">
</span>Hopefully, with public comment and more science, the positive aspects of
the Standard can be kept while eliminating or revising the more burdensome and
arguably non-protective requirements. As Marcia Brady would say, "Sure, Jan . . ."<o:p></o:p></p><p class="MsoNormal" style="text-align: center;"><i>[This document represents my individual personal views and opinions and are not necessarily the views and opinions of Vanderbilt University Medical Center]</i></p>Tom Talbothttp://www.blogger.com/profile/10606566936885428481noreply@blogger.com1tag:blogger.com,1999:blog-8066238290370557389.post-14421798949885044972021-05-18T19:54:00.000-05:002021-05-18T19:54:10.084-05:00Lifting Mask Requirements in Nonclinical Workspaces in Healthcare Facilities<i><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-8enoEkuUBx0/YKRhEV0N0SI/AAAAAAAADCg/56TjBjLU_McQjyVBnFzud4a54xIMChc9wCLcBGAsYHQ/s350/JorgeSalinas-350x233.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="233" data-original-width="350" height="266" src="https://1.bp.blogspot.com/-8enoEkuUBx0/YKRhEV0N0SI/AAAAAAAADCg/56TjBjLU_McQjyVBnFzud4a54xIMChc9wCLcBGAsYHQ/w400-h266/JorgeSalinas-350x233.jpg" width="400" /></a></div><div><i><br /></i></div><div><i><br /></i></div><div><i><br /></i></div><div><i><br /></i></div><div><i><br /></i></div><div><i><br /></i></div>This guest post was written by Jorge Salinas, MD, Hospital Epidemiologist at the University of Iowa Hospitals & Clinics. </i><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div>The COVID-19 epidemiologic situation in the United States has improved tremendously. The Centers for Disease Control and Prevention (CDC) recently <a href="https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7019e3-H.pdf">modelled </a>that the United States will continue seeing a decreasing incidence in coming months. There is also increasing recognition that vaccines are protective against infection and transmission. Because of these factors, an <a href="https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/participate-in-activities.html">updated CDC guidance</a> for settings other than healthcare facilities states that fully vaccinated people may attend indoor gatherings without wearing a mask. These indoor locations include restaurants, bars, gyms, movie theaters, and full-capacity worship services. They even allow singing in an indoor chorus. This qualitative jump has —of course— been received with skepticism by many members of the public including some public health practitioners. </div><div><br /></div><div>Some of the reasons for the criticism arise from 1) how difficult it is to determine if unmasked persons are in fact vaccinated, 2) the low vaccine uptake in some localities, and 3) the relatively high incidence in these communities. These are adequate indicators that should influence de-escalation of universal mask requirements in the community. However, confirming the vaccination status of people in public indoor spaces represents the hardest challenge to overcome. We may be able to bypass it by assuring that high vaccination levels and a low incidence have been achieved in the community.
If these principles hold true for the community, I believe they are true for some areas in healthcare settings too. Healthcare facilities (Hospitals, nursing homes, long-term care facilities) have several factors that make them special such as caring for vulnerable people: elderly, ill, or immunosuppressed patients. However, healthcare facilities have better administrative and engineering controls than community settings, namely, higher vaccination rates and air handling. Healthcare facilities also have several spaces, some of which, host only healthcare workers while other areas have visitors and patients. </div><div><br /></div><div>The latest CDC <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html">recommendation </a>for COVID-19 infection prevention and control in healthcare facilities from April 2021 states that “In general, fully vaccinated HCP should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing”. This recommendation acknowledges that the COVID-19 vaccines approved in the United States are quite good at preventing both infection and transmission. However, the same guidance states that “If unvaccinated HCP are present, everyone should wear source control and unvaccinated HCP should physically distance from others”.
Because of the astonishing protection derived from vaccination, healthcare workers may be able to have maskless meetings and lift mask requirements in shared workspaces and gatherings even if the vaccination status of each individual worker is not known. To achieve that safely, healthcare facilities will need to ensure high vaccine acceptance rates among healthcare workers (e.g., >70%), vaccination among those eligible in the public is high (e.g., >50%), and community incidence is low (e.g., <10/100,000 population). Facilities should require that healthcare
workers who were not vaccinated continue wearing masks. </div><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">As the incidence of COVID-19 continues to decline and
vaccination rates go up, further de-implementation will also need to be
considered in the future: for example, lifting mask requirements in hallways
and waiting areas for healthcare workers, visitors, and patients. Lastly, mask
wearing when providing patient care will also need to be evaluated. Many
societal milestones will need to be met before these next de-implementation
phases.<o:p></o:p></p>
<p class="MsoNormal">As with other de-implementation efforts, it will be
important to have adequate surveillance in place to detect if this change is
associated with increases in transmission. Other factors such as potential future increases
in community incidence either because of emerging variants of concern or waning
immunity are also possible but not very likely in the short term. <o:p></o:p></p>
<p class="MsoNormal">Throughout the pandemic, everyone in charge of national,
local public health, as well as healthcare epidemiologists/infection prevention
professionals have made decisions with incomplete information and risking the
possibility of being wrong. We must, however, not let our fear of being wrong
keep us from implementing —or de-implementing — measures when the epidemiologic parameters
support it.</p>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-50805233149875093542020-12-19T14:16:00.001-06:002020-12-19T14:16:48.018-06:00A Momentous Week in Our Pandemic Response<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-rEffVfzoQU4/X95aAKn_l0I/AAAAAAAAC5Q/deaoZI-ZNlQA49bCmIee4SjUFTwKz3SxwCLcBGAsYHQ/s1660/retrato%2B2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1654" data-original-width="1660" height="199" src="https://1.bp.blogspot.com/-rEffVfzoQU4/X95aAKn_l0I/AAAAAAAAC5Q/deaoZI-ZNlQA49bCmIee4SjUFTwKz3SxwCLcBGAsYHQ/w200-h199/retrato%2B2.jpg" width="200" /></a></div><i><br /><br /></i><p></p><p><i>This guest post was written by Jorge Salinas, MD, Hospital Epidemiologist at the University of Iowa Hospitals & Clinics. </i></p><p><br /></p><p>Her saturation had dropped to 89. Fever persisted. She was being
admitted. This was the telegraphic message that started a roller coaster of a
week. My mother had been symptomatic for a few days but had suddenly worsened. By
7:45 that same morning, we received confirmation—shipment was completed, 975
doses were on the dock, the vaccination deployment plan was a go.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">A quick morning huddle. Everyone knew their positions and
what to do: teams to prepare the doses, employee health nurses to administer
them, planners to manage schedules. It was nicely choreographed and rehearsed.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-BLPUPGutTa8/X95bZv7IwtI/AAAAAAAAC5g/Nq4MTR0wxtMECLaAdpWKvbaeZP3MfcQ0wCLcBGAsYHQ/s2048/14virus-briefing-emotion1-superJumbo-v2.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2048" data-original-width="2048" height="320" src="https://1.bp.blogspot.com/-BLPUPGutTa8/X95bZv7IwtI/AAAAAAAAC5g/Nq4MTR0wxtMECLaAdpWKvbaeZP3MfcQ0wCLcBGAsYHQ/s320/14virus-briefing-emotion1-superJumbo-v2.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><a href="nyti.ms/37hvMT2"><i>The New York Times</i>, 12/18/20</a></td></tr></tbody></table>ED nurse, environmental services custodian, doctor, resident.
How many people received the dose before me? Ten? Twenty? Jorge, this way. Immediately
after the shot, I was asked, on camera, how I felt now that I had received the precious
vaccine. This was undoubtedly a triumph of science. One of the greatest medical
breakthroughs in years. And I had received it. Yet, I couldn’t avoid feeling
unworthy of it. Because I am part of our system pandemic response I had more
access to the vaccine than those more at risk. I had reluctantly persuaded
myself that being a Hospital Epidemiologist and a Hispanic physician it would
be advantageous to our response. To lead by example, show my healthcare
colleagues here and abroad that I have confidence in the vaccine development
process, that these vaccines are efficacious and safe. Took a big swallow,
don’t think of mom right now, take a deep breath, go on.<span style="font-family: "Times New Roman",serif; mso-fareast-font-family: "Times New Roman"; mso-no-proof: yes;"> </span><span style="mso-spacerun: yes;"> </span> </p>
<p class="MsoNormal">I am not an ethicist. I believe that the fair allocation of
scarce resources is one of the hardest feats in medicine. We had debated
extensively: how could we allocate these first thousand doses amongst almost
20,000 healthcare workers? Who should get it? Those over the age of 65? Those
working in COVID units? Those on oncology and transplant floors? Should it be a
lottery? Should we factor in healthcare worker comorbidities? Why did they send
only 975 doses? We decided to prioritize every frontline, doctor, nurse,
respiratory therapist, trainee, environmental services worker, etc., assigned
to our inpatient and outpatient COVID units. After them, healthcare workers
across all lines in all other units would be given the vaccine. Most States have less than 20% of
doses needed for healthcare workers at the moment. </p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-5NEssk0QdSA/X95dFXNEK3I/AAAAAAAAC5s/kE8YRj7tPpkwVfJd8VNju-l5zvf4z87ggCLcBGAsYHQ/s936/Picture1.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="731" data-original-width="936" height="500" src="https://1.bp.blogspot.com/-5NEssk0QdSA/X95dFXNEK3I/AAAAAAAAC5s/kE8YRj7tPpkwVfJd8VNju-l5zvf4z87ggCLcBGAsYHQ/w640-h500/Picture1.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Source: <a href="http://Vox.com">Vox.com</a></td></tr></tbody></table><br /><p class="MsoNormal">By mid-week we had vaccinated hundreds of people across all
work lines in the first priority group. Questions of course came in: When is my
turn? Why is my unit in phase one or two? But all in all, people were gracious
and kind and most are still patiently awaiting their turn. A question arose
though that was a bit harder to answer. If there is a cancellation, who should
get that dose? Whoever can come in faster? Here again, came another simple
realization: there are barriers to vaccination, even among healthcare workers.
Those in support services and trainees even within our system would have a harder
time to stop doing what they are doing at work, arrange day care, or plan for the
possibility of a couple of days off after their shot in case of side effects.
Quickly reacting and sprinting to get into an opening could disadvantage some
groups over others. We had planned for an equal allocation to all work lines in
high-risk areas but it was clear that some employees have additional barriers
to vaccination.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">Support service workers, trainees, housekeepers. Weren’t they
also at higher risk of exposure outside of work? Our data has shown that most
exposures among healthcare workers were nonoccupational. Had my job as a
healthcare epidemiologist biased me to focus protection mostly while at work?
But what about when in the community? I realized that when deploying vaccines, we
should think of high risk of exposure at work of course, but some groups had a
higher risk of COVID outside of work, in addition to potential barriers to
getting the first doses of vaccines even if allocated to them.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">Fair allocation of vaccine doses is not easy. Aiming for fair
may not even be enough. At work and in the community, we need to work extra
hard to reach those with less resources, those who chronically have barriers to
access to care. These lessons from my own healthcare system will guide how I
think about vaccine allocation for subsequent groups. After healthcare workers
and people living in long-term care facilities are vaccinated, how are we to
prioritize the next groups? It is clear that we have to actively reach those at
an increased risk of acquisition however hard it may be.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">While it will take several months and ethical conundrums
will continue to arise locally, what about the rest of the world? Mom was a
laboratory technician before she had us. If she had still been working, when
would a dose have reached her in distant Peru? The global vaccine pipeline is
not looking very promising for resource limited countries. The same challenges
seen locally are present on a world scale. Resource limited countries may not
reach full coverage until very late in 2021 or 2022. Who looks after a fair
allocation of vaccines on a global level?</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"><span style="mso-no-proof: yes;"><span style="mso-spacerun: yes;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-0-NH_xyj6AE/X95d8dByHOI/AAAAAAAAC50/8tnWTXtd37cUraJzinY-uTIfL9tLkLrwgCLcBGAsYHQ/s936/Picture2.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="578" data-original-width="936" height="396" src="https://1.bp.blogspot.com/-0-NH_xyj6AE/X95d8dByHOI/AAAAAAAAC50/8tnWTXtd37cUraJzinY-uTIfL9tLkLrwgCLcBGAsYHQ/w640-h396/Picture2.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Source: <a href="https://launchandscalefaster.org/COVID-19">Duke Global Health Innovation Center</a></td></tr></tbody></table><br /> <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-rZ9teUHID_Q/X95eoJECaKI/AAAAAAAAC6A/nUtaOwxG75QmYrLVWjPInx6Z92B5_JKYACLcBGAsYHQ/s936/Picture3.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="658" data-original-width="936" height="450" src="https://1.bp.blogspot.com/-rZ9teUHID_Q/X95eoJECaKI/AAAAAAAAC6A/nUtaOwxG75QmYrLVWjPInx6Z92B5_JKYACLcBGAsYHQ/w640-h450/Picture3.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Source: <a href="https://www.economist.com/graphic-detail/2020/11/12/rich-countries-grab-half-of-projected-covid-19-vaccine-supply">The Economist</a></td></tr></tbody></table><br /></span></span></p>
<p class="MsoNormal">As we close this week, I feel grateful to have received the
vaccine, to work in healthcare epidemiology, to continue learning from my
mistakes, and I strive to be just in our protection efforts for healthcare
workers and our communities. I am grateful my mother is recovering, for my
colleagues taking care of her and the hundreds of thousands of people battling
COVID-19 worldwide.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">The next weeks and months will continue being challenging.
It is clear we have entered a new phase in the pandemic, but until we reach
high vaccination coverage we must continue implementing nonpharmacologic
interventions, masks, avoiding indoor crowds, and maintaining our distance. We
must also advocate for just allocation of medical resources in our local and
global societies. Hundreds of thousands of lives can still be saved.</p><p class="MsoNormal"><o:p></o:p></p>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com3tag:blogger.com,1999:blog-8066238290370557389.post-74212376465090898362020-07-17T11:36:00.002-05:002020-07-17T11:36:57.530-05:00COVID-19 Transmission: Medicine Grand Rounds at UCSF<br /><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/Cio3rh6ta3w" width="320" youtube-src-id="Cio3rh6ta3w"></iframe></div><div><br /></div>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com2tag:blogger.com,1999:blog-8066238290370557389.post-6390875613584313782020-07-07T13:13:00.010-05:002020-07-07T18:41:47.862-05:00Let's Just Get Every Face Covered<br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-anMI4qhPDbU/XwSOQ5DWfAI/AAAAAAAACvk/mkPROtNNcEUIeOzgrvc4aaDxCTHJ145cQCLcBGAsYHQ/s2048/people-wearing-diy-masks-3951628.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" height="416" src="https://1.bp.blogspot.com/-anMI4qhPDbU/XwSOQ5DWfAI/AAAAAAAACvk/mkPROtNNcEUIeOzgrvc4aaDxCTHJ145cQCLcBGAsYHQ/w625-h416/people-wearing-diy-masks-3951628.jpg" width="625" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><font size="2">Photo by cottonbro at pexels.com</font><br /></td></tr></tbody></table><br /><div>In the over decade-long history of this blog, Dan's recent post, <a href="http://haicontroversies.blogspot.com/2020/07/a-tiresome-spat.html">A Tiresome SPAT</a>, has been viewed more times than any other post we've ever written. And it's only been up 48 hours. This is a testament to Dan's ability to encapsulate the controversy regarding SARS-CoV-2 transmission in a billiant way. As I reflected on his writing, it became increasingly clear to me that the source of the controversy of whether we are dealing with droplet transmission or aerosol transmission is deeply rooted in the framework through which you're viewing the issue. These frames are associated with different values and ways of thinking, and depending on the frame utilized determines your recommmendations for mitigating transmission.</div><div><br /></div><div>The first framework I'll describe is the medical (i.e., individual patient) frame. Imagine a patient visiting their physician and asking what they can do to best avoid COVID-19 infection. In addition to social distancing and hand hygiene, the physician would likely recommend a mask and eye protection. The physician might even recommend an N95 respirator depending on the patient's underlying conditions, the context of their exposures, and the patient's risk tolerance. In general, in this framework, risk tolerance is low, and the goal is typically to reduce the individual's risk to the irreducible minimum. This approach drives the occupational health perspective. PPE is viewed from the standpoint of efficacy--how do we provide ideal protection?</div><div><br /></div><div>Now, let's look at the public health (i.e., population) framework. From this perspective, the goal is not necessarily to prevent every possible case of COVID-19, but rather to bring the outbreak to an end. This requires reducing the R0 to less than one. Thus, the interventions don't need to be perfect, and individual risk is tolerated to a somewhat greater degree. And in this framework, the PPE recommended is that which is most effective (i.e., how well does it work in the real world?), which factors in adherence. Let's say that face covering A is 90% efficacious, but only 20% of people are willing to wear it. On the other hand, face covering B is 60% efficacious, but 80% of people are willing to wear it. We're clearly better off with face covering B. The public health framework is driven by a utilitarian perspective--accomplishing the greatest good for the population, not for any given individual patient. </div><div><br /></div><div>Our recent JAMA viewpoint, <i><a href="https://jamanetwork.com/journals/jama/fullarticle/2765525?resultClick=1">Moving Personal Protective Equipment into the Communnity</a></i>, in which we argue for universal face shields in the community settting, was written from a public health framework. This was perhaps not clear to the many individuals who pointed out that in some cases there could be airborne transmission of the virus for which a face shield may not work. Yes, we get that, but the epidemiology convinces us that the airborne route is a minor mechanism of transmission.</div><div><br /></div><div>The bottom line here is that we can't let perfect be the enemy of the good. We recommend influenza vaccine every year despite an average seasonal effectiveness of approximately 40%. The best face covering is the face covering that people will wear. Though I personally favor face shields for community use, I am happy to see faces covered in almost any way possible (which is why I love the photo above). </div><div><br /></div><div>And if it's not bad enough that experts are not in agreeement, we have the additional problems of botched messaging by the CDC and political leaders who by intentionally sowing doubt and refusing to be good role models, make this work all the harder. Kudos to those leaders who are mandating face coverings. And my message to everyone is this: for community settings, let's just get everyone in a face covering now, whichever one works for them. After the pandemic is over, we can sort it out once and for all. </div><div><br /></div><div><br /></div>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com2tag:blogger.com,1999:blog-8066238290370557389.post-53776198291290292842020-07-05T12:47:00.001-05:002020-07-06T09:11:20.267-05:00A tiresome SPAT<iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/ohDB5gbtaEQ" width="560"></iframe><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">I’m surprised that we can’t stop arguing about the modes of SARS-CoV-2 transmission, despite the fact that most experts (including our friends at WHO) agree on the important issues. Our colleague Jorge Salinas very nicely summarized these issues (and their implications) in <a href="http://haicontroversies.blogspot.com/2020/06/covid-19-can-have-airborne-transmission.html">this post</a>.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The latest kerfuffle: <a href="https://www.nytimes.com/2020/07/04/health/239-experts-with-1-big-claim-the-coronavirus-is-airborne.html">media coverage</a> of 239 experts who are upset that the WHO is not acting as decisively as they’d like on an evidence base that the experts themselves admit is far from definitive.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">As we’ve outlined <a href="http://haicontroversies.blogspot.com/2020/06/covid-19-can-have-airborne-transmission.html">here</a> and <a href="http://haicontroversies.blogspot.com/2020/04/airborne-vs-droplet-turbulent-gas.html">here</a>, a major problem plaguing this discussion is the false dichotomy between “droplet” and “airborne” transmission that we use in healthcare settings (for simplicity of messaging, and because it has served us well for several decades—for reasons I’ll get back to later). This dichotomy divides application of transmission-based precautions between those pathogens spread via respiratory droplets, <i>all of which must absolutely fall to the ground within 6 feet of the source</i>, and those pathogens which become airborne, meaning they travel long distances on air currents, remain in the air for very long periods of time, and most importantly, can cause infection after their airborne sojourns if they find the right mucosal surface.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">But we know (and WHO experts know) that there is no such dichotomy—it’s more of a continuum. At the very least there is a middle category, let’s call it <u>S</u>mall <u>P</u>article <u>A</u>erosol <u>T</u>ransmission (or SPAT). Many respiratory viruses (not just SARS-CoV-2) can remain suspended in aerosols and travel distances > 6 feet. As <a href="http://haicontroversies.blogspot.com/2020/06/covid-19-can-have-airborne-transmission.html">Jorge outlined</a>, it’s probable that transmission events occur when these aerosols are concentrated in closed, poorly ventilated spaces or in very large amounts (e.g. a <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm">2+ hour choir practice</a>, a <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e1.htm">3 hour indoor birthday party</a>, a <a href="https://khn.org/news/packed-bars-serve-up-new-rounds-of-covid-contagion/">crowded bar</a>). This may explain the superspreading events that drive a lot of SARS-CoV-2 transmission.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">It’s important to distinguish SPAT from “classic airborne transmission” (let’s call it CAT). The CAT pathogens (TB, measles, VZV) have very different transmission dynamics than SPAT pathogens, as I outlined <a href="http://haicontroversies.blogspot.com/2020/04/airborne-vs-droplet-turbulent-gas.html">here</a> (R0s of >10, household transmission rates of 50-90%). The distinction is important because for most healthcare epidemiologists, using the term “airborne” implies a common set of “one-size fits all” interventions to prevent transmission, interventions that require resource-intensive engineering controls and PPE requirements. It is not at all clear that such interventions are required to prevent transmission of SPAT pathogens. In fact, most evidence (and real world experience) suggests that they are not. This is why the droplet-airborne dichotomy has served us fairly well over the years—either because droplet precautions appear to be pretty effective at preventing SPAT, or because SPAT is rare even among those viruses capable of it.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I could say more about my feelings about aerosol-scientists criticizing epidemiologists and clinicians for having an “overly medicalized view” of the evidence, but I don’t want to be CAT-ty. I just want to end the SPAT.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">So let’s redirect the discussion instead to: <b>with the limited information we have, what additional interventions should WHO and/or CDC recommend for transmission prevention during the pandemic? </b>Masks in crowded indoor spaces? Sure, but avoiding such spaces is preferred. Improved ventilation in all indoor environments? Absolutely, let’s get to work on that. N95s in the community? Don’t make me laugh, it might generate aerosols.* N95s for all patient care? Fair to consider, but by now we’ve gathered quite a lot of experience <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30527-2/fulltext">safely delivering care using existing WHO recommendations</a>. And as Jorge <a href="http://haicontroversies.blogspot.com/2020/06/covid-19-can-have-airborne-transmission.html">aptly pointed out</a>, “a debate only centered on whether respirators or medical masks are needed can distract us from the bigger challenges.” Indeed.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>*Clarification as this comment, made in jest, has been misinterpreted. N95 masks do not generate aerosols. They are unrealistic for community use, as they must be fit-tested and worn properly (even if we had an unlimited supply, which we do not). Nor are they, in my opinion, necessary for community protection. Face shields or medical/cloth masks are preferred for community use.</i></span>Dan Diekemahttp://www.blogger.com/profile/10231929371552334184noreply@blogger.com4tag:blogger.com,1999:blog-8066238290370557389.post-73058985845911069292020-06-18T07:15:00.003-05:002020-06-18T08:55:39.172-05:00COVID-19 Can Have Airborne Transmission but You Don't Need to Run for an N95<p class="MsoNormal"><i></i></p><div class="separator" style="clear: both; text-align: center;"><i><a href="https://1.bp.blogspot.com/-opwoguWXp4c/XutanM_kCpI/AAAAAAAACuE/qxK2NuoJVM86uTLaffk6j-gVhpob45ixwCK4BGAsYHg/s300/jorge.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="300" data-original-width="200" src="https://1.bp.blogspot.com/-opwoguWXp4c/XutanM_kCpI/AAAAAAAACuE/qxK2NuoJVM86uTLaffk6j-gVhpob45ixwCK4BGAsYHg/jorge.jpg" /></a></i></div><i>This is a guest post by Jorge Salinas, MD, Hospital Epidemiologist at the University of Iowa Hospitals & Clinics. </i><p></p><p class="MsoNormal">There is virtually no doubt that SARS-CoV2 is transmitted by
droplets and contact. However, the debate continues about whether SARS-CoV2 can
be transmitted through the air, in what epidemiologists call “airborne
transmission.” As with most biologic processes, unfortunately this is not a
dichotomy. Many (too many) factors play a role.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">Population density matters. As people breathe, speak, sneeze,
or cough we all produce many particles that have a continuum of sizes. These
particles are unfortunately called too many names in the literature and the lay
press (e.g., droplets, aerosols). Viruses and biologic processes don’t read
textbooks. These particles can be large (what healthcare epidemiologists call “droplets”),
medium size (no fancy name for them), and small (these are called “aerosols” by
some but “droplet nuclei” by others). If we are near only one infectious person,
the number of small particles (aerosols) expelled may not be enough to meaningfully
contribute to infection. But if we are exposed to many infectious people at
once, the number of small particles can increase. In such instances, airborne
transmission in addition to contact and droplet transmission can play a role in
outbreaks.<o:p></o:p></p>
<p class="MsoNormal">Patient characteristics are also tremendously important. Some
may extrapolate that COVID is not as contagious or rule out the possibility of
airborne transmission because of a <a href="https://covid19.colorado.gov/data/outbreak-data">paucity of hospital outbreaks</a>, even if not
following airborne precautions.
If we follow the natural history of COVID, we now know that a person is
possibly infectious 48 hours before symptom onset. Most people do not require
hospitalization, and those that require hospitalization may be in later stages
of the disease. We are learning daily that COVID, the disease caused by
SARS-CoV2, is likely a continuum. Initially, the disease is predominantly
caused by direct injury of the virus to tissues, but as days go by some
patients will have immunologic or para-infectious syndromes that may require
hospitalization. By the time a patient with COVID requires hospitalization,
their infectiousness has likely decreased. It is now clearly recognized that
presence of viral RNA does not equal risk of transmission in many cases. <o:p></o:p></p>
<p class="MsoNormal">The setting is also very important. How big is the space
where the infectious person and their potential contact are located. If
outdoors, the risk is tremendously decreased as air flows freely greatly
decreasing the possibility of breathing “the same air.” Indoors, the number of
air exchanges is very important: the more air exchanges, the lesser the
likelihood of spread. Fortunately, most hospitals have already implemented an
increased number of air exchanges likely decreasing the possibility of airborne
transmission of pathogens in hospitals.<o:p></o:p></p>
<p class="MsoNormal">If airborne transmission plays a role in SARS-CoV-2
transmission, I believe it is predominantly in the early stages of the disease,
in the viral phase. That may explain why most healthcare outbreaks have
occurred in nursing homes and long-term care facilities. Not only because of potential
infection prevention deficits but because patients are already in the facility
when they become infectious. They are at the peak of infectiousness when in the
facility. Hospitals on the other hand, will usually admit patients days or even
weeks after the beginning of the infectious period, likely attenuating the risk
of transmission in hospitals.<o:p></o:p></p>
<p class="MsoNormal">Recognizing that SARS-coV2 can also spread via small
particles should not lead to panic. It should lead us to modify our behaviors
in the community by avoiding crowded indoor settings, using universal source
control with face coverings, and maintaining physical distance. <o:p></o:p></p>
<p class="MsoNormal"></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-kmMLaythKQQ/XutYyHJawiI/AAAAAAAACtk/2truBelUoaIxxsAt8DjI9mco7_MdEAwKACK4BGAsYHg/s1430/controls.jpg" style="margin-left: auto; margin-right: auto;"><img alt="Modified from CDC." border="0" data-original-height="1026" data-original-width="1430" height="351" src="https://1.bp.blogspot.com/-kmMLaythKQQ/XutYyHJawiI/AAAAAAAACtk/2truBelUoaIxxsAt8DjI9mco7_MdEAwKACK4BGAsYHg/w489-h351/controls.jpg" width="489" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Modified from CDC.<br /></td></tr></tbody></table>In healthcare facilities, we need to continue educating
stakeholders about the hierarchy of infection controls. Administrative and engineering
controls are by far the most important measures. Decreasing population density,
protocols for early identification and isolation of potentially infectious
cases, especially those early in the disease course, and increased air
exchanges are likely the most important measures. Personal protective equipment
is also important. However, a debate only centered on whether respirators or
medical masks are needed can distract us from the bigger challenges of
administrative and engineering controls. <o:p></o:p><p></p>
<p class="MsoNormal">Reducing population density in healthcare facilities
(patient census and personnel) can lead to increased safety but has a
tremendous impact on population health (less capacity to take care of patients)
and potential economic implications if healthcare personnel numbers are
decreased. Engineering controls are also costly but fortunately most hospital
design standards already address increased air exchanges compared to regular
buildings and homes. <o:p></o:p></p>
<p class="MsoNormal">This pandemic has been challenging for all. COVID-19 keeps
me humble as what I thought I knew yesterday may not be true today. Let’s all
remain humble and nimble as we respond to COVID-19 in the community and in
healthcare facilities. <o:p></o:p></p><br /><div class="separator" style="clear: both; text-align: center;"><br /></div>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com4tag:blogger.com,1999:blog-8066238290370557389.post-54786718385856493622020-06-06T15:19:00.105-05:002020-10-15T16:32:45.579-05:00Need a Face Shield? <div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-f_D4_bRB-Mw/XtwilViD_RI/AAAAAAAACr8/2RQAc-uDBMAb0ErQDqaqUS_bl4fcRpv6ACK4BGAsYHg/s6720/engin-akyurt-4K2hE3jzt0A-unsplash.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4480" data-original-width="6720" height="426" src="https://1.bp.blogspot.com/-f_D4_bRB-Mw/XtwilViD_RI/AAAAAAAACr8/2RQAc-uDBMAb0ErQDqaqUS_bl4fcRpv6ACK4BGAsYHg/w640-h426/engin-akyurt-4K2hE3jzt0A-unsplash.jpg" width="640" /></a></div><div><br /></div><div><br /></div>Over the past few months, numerous people have contacted me to ask where they can purchase a face shield. I've assembled a list of some companies below. I'm sure there are many more, which I'm happy to add if you send me an email.<div><b><br /></b></div><div><b>Standard Shields:</b></div><ul style="text-align: left;"><li><a href="https://1800shields.com/products/face-shield?gclid=Cj0KCQjwoPL2BRDxARIsAEMm9y82AV6DgdExJRoVMWHKiRZM9WMkGVXAUgbHAhrbuES9qm8jKywuPtQaAhRzEALw_wcB">1800Shields</a><br /></li><li><a href="https://ppe3d.com/collections/frontpage/products/face-shield">3DPPE</a><br /></li><li><a href="https://vinta.co/pages/active-shield-collection?fbclid=IwAR1fYbDTe0aeHcZiLvVZphsAnccA7Nos5FNwSsrY7lyxqx40VMYgryCVz_0">Active Shield</a><br /></li><li><a href="https://www.faceshield.actuatedmedical.com/">Actuated Medical</a></li><li><a href="https://www.alisapan.com/products/transparent-isolation-anti-pollution-protective-hat-ct00041?variant=31564800983142&fbclid=IwAR38W9P_AWL9jEtqv2Hn55UrIM81OqsAjCPVX7p2iRErB7I7Y1E3HdKSb3o">Alisa Pan</a><br /></li><li><a href="https://altheacare.com/products/althea?fbclid=IwAR0fgSIRPZ_81uMBr-cyDaR0t9k_Al7Hvi333RwDYAXMMDeZTPBq3fwP-O0">AltheaCare</a><br /></li><li><a href="https://www.amazon.com/face-shields/s?k=face+shields">Amazon (multiple vendors)</a><br /></li><li><a href="https://amdalenses.com/products/washable-full-face-visor?fbclid=IwAR2jwvgiOuYn0qAAIUZlBl4XNhdZOkLKjY6y1GvZLJZhC3SH9n_ETYZKJD0">AMDA Lenses</a></li><li><a href="https://armorexpert.com/pages/fs?fbclid=IwAR3ZI9RvzcywIwS7qN41zrkbk90EuJbL8Hw4sSA9XBjA8tLRA0Seg1PyTP0">Armor Expert</a></li><li><a href="https://upyourarsenal.com/products/arsenal-face-shield">Arsenal</a></li><li><a href="https://www.arttoframe.com/adult-face-shield/clear/pack-1">ArtToFrame</a></li><li><a href="https://aspeus.com/">ASPEUS</a><br /></li><li><a href="https://www.bdisigns.com/face-shields.html">BDI Signs</a><br /></li><li><a href="https://www.beready.us/collections/face-shields">Be Ready</a><br /></li><li><a href="https://bluebearprotection.com/collections/blue-bear-protection-products-1/products/face-shields?variant=32423800242276">Blue Bear Protection</a><br /></li><li><a href="https://www.bolle-safety.com/models/face-shields">Bolle Safety</a><br /></li><li><a href="https://bk-textiles.com/products/full-face-protective-face-shields">Brooklyn Textiles</a><br /></li><li><a href="https://caregoody.com/products/facesheieldmaskusa?utm_source=facebook&utm_medium=23844858417280146%20video%20ads%201&utm_campaign=Free%20shipping&utm_content=video%20ads%201&https%3A%2F%2Fcaregoody.com%2Fproducts%2Ffacesheieldmaskusa%3Futm_source=facebook&fbclid=IwAR16wxsnE9DUI0RbhfpCJTMLh6rpEFBTt3y3XzdSEpj0vyb2h7lZO428C30">Care Goody</a><br /></li><li><a href="https://refinedoneshop.com/products/face-shield?fbclid=IwAR1h8YhgweOlGEdc4huAVNKlDKa-dLiMC7uqjEDzI_kRn5PZjfMxNpEoQrU">Counshop</a><br /></li><li><a href="https://www.debonairshop.com/?fbclid=IwAR3ijt8hD3AtmYuBC-TcialC1ij7hefV28mkN8NtV5OWOEF6cmuSBGN_M8w">DebonAIR</a><br /></li><li><a href="https://www.discmakers.com/faceshields/?utm_campaign=GOOFACESHI&utm_source=google&utm_medium=cpc&utm_content=&utm_term=faceshield&gclid=Cj0KCQjw_ez2BRCyARIsAJfg-kvYf9D9dmnQQelMZ-WCTHOzxC28mA0smsxwo37SXIyF9Mjs1r7Jp7UaAuzDEALw_wcB">Disc Makers</a><br /></li><li><a href="https://distancemasks.com/?fbclid=IwAR2ukR-iDiSL_OWhcUG-_rIUSnF-MAkycLIm0iZSn7Fu6W0iKW31a7HhnOE">Distance Masks</a><br /></li><li><a href="https://dome-shield.com/DS/o.html">Dome Shield</a><br /></li><li><a href="https://www.eagleeyes.com/products/safety-goggles-with-face-shield">Eagle Eye Optics</a><br /></li><li><a href="https://www.ebay.com/b/Safety-Face-Shield/183970/bn_7023273616">Ebay (multiple vendors)</a></li><li><a href="https://ecofaceguards.com/?fbclid=IwAR1nKckf9PsUFda8dOTsX1wV_BmCxLlK_wKML8auAggWuHT9k7M8N14Q8Xs">Eco FaceGuards</a><br /></li><li><a href="https://www.egisviso.com/">Egis Viso</a><br /></li><li><a href="https://www.fabberz.com/">FABBERZ</a><br /></li><li><a href="https://faceguardus.com/products/face-guard?fbclid=IwAR1ERI564Ebp0r6zBKiPsgH4fchOnMWHSC3uGUvu-d7WQOL3ppFTy7twEpA">FACEGUARD USA</a></li><li><a href="https://www.faceshield.com/?fbclid=IwAR3ZQaqUdYWhEMHMbtv767PKUeUh0AfGZVYqXPDwJgc4vaBLWJFXA4Q-7tE">FACESHIELD</a></li><li><a href="https://firefarmfabrication.com/shop-ppe-products">Fire Farm</a><br /></li><li><a href="https://www.flowfold.com/collections/face-shields">Flowfold</a><br /></li><li><a href="https://fusionlens.com/pages/safety-splash-goggles-eng?fbclid=IwAR0HDBhlueShKL8mUKcbPmTs9T5ax7ubNkVwvP7oza85sF97h6KdvNSQo60">Fusion Lens</a><br /></li><li><a href="https://www.garizone.com/products/protective-hat-transparent-anti-dust-proof?fbclid=IwAR3vZrEGLkE3G-Eu2SkBfW8dPfuA949370Qf1fnyWXvujQ1m6KKE2Xh8n2E">Garizone</a><br /></li><li><a href="https://geteminnovations.com/?fbclid=IwAR3GeJ7Pa3J2XULUvRZwYtm7A9ckdBtFXhs3kRSwgCqL-V_odO-rmLIoc9c">GetEm Innovations</a></li><li><a href="https://www.goodworksociety.org/goodstore.html">GoodShield</a><br /></li><li><a href="https://www.google.com/search?q=face+shield&safe=off&rlz=1C1CHBF_enUS778US778&sxsrf=ALeKk02DDLObf6BV10kLqfFzMCW8TBLllQ:1591484554699&source=lnms&tbm=shop&sa=X&ved=2ahUKEwiQjbH8pe7pAhWbAZ0JHdxXChIQ_AUoAXoECA4QAw&biw=1852&bih=977">Google shopping (multiple vendors)</a></li><li><a href="https://shop.graceport.com/products/s-100">Grace Technologies</a><br /></li><li><a href="https://hardwirellc.com/products/hardwire-face-shield">Hardwire</a><br /></li><li><a href="https://henrythehand.com/product-category/henryhealthshields/">Henry's Health Shield</a><br /></li><li><a href="https://www.rapidresponseppe.com/">Humanity Shield</a><br /></li><li><a href="https://usa.imaskplusfaceshield.com/product/imask-face-shield/">i-Mask+ Face Shield</a></li><li><a href="https://shopinspiredtrends.com/products/shield?fbclid=IwAR2Mg06MJxLuoTrezkL2iBqROIyfQQB4mcrOPxmIEOmsSenuNzms0NljsX8">Inspired Trends</a></li><li><a href="https://iowamade.org/protostudios-face-shield">Iowa Made</a><br /></li><li><a href="https://www.kitsbow.com/collections/personal-protective-equipment/products/w-n-face-shield-disposable">Kitsbow</a><br /></li><li><a href="https://laminatippe.com/product-category/face-shield/">Laminati PPE</a><br /></li><li><a href="https://liftedlenses.com/collections/anti-droplet-face-shield/products/anti-droplet-shield?fbclid=IwAR0-Zek_hPoaNL7KFc9qr4W8jAoSSP5wA4qqr3h80xLWTCqs6F7QgfsbI3U">Lifted Lenses</a><br /></li><li><a href="https://makers4medicine.org/purchase">Makers4Medicine</a><br /></li><li><a href="https://www.medspecprotect.com/?fbclid=IwAR1gROi5MAuyHQO2LViZrSqEMk3R0G5Ayv2QQjlcQGF3Hy8qIXTbJ6AN4qY">Medspec Protect</a><br /></li><li><a href="https://mifaceshields.com/?fbclid=IwAR1ig6KzlG1VOhpVT6B0GxcGqVbXm0OLkSwp06go15sphCJ8FC0AjedZAsk">MI Face Shields</a></li><li><a href="https://www.refinery29.com/en-us/shop/product/flippable-fixed-comfortable-face-shield-9905376">Moda Loom</a><br /></li><li><a href="https://msp-aviation.com/msp-face-shield-lp/">MSP Aviation</a></li><li><a href="https://www.noelasmaruniforms.com/pages/wellness-face-shield?utm_source=fb&utm_medium=cpc&utm_campaign=2%20-%20Prospecting%20%7C%20CA%20%2F%20US%20%7C%20Conversions%20%7C%20HV%2FLC%20%7C%20Mar1%20%7C&utm_term=US%20%7C%20LAL%20%7C%20LKL%201%25%20%7C%20N%2FA%20%7C%20All%20%7C%20Conversions%20%7C%207d%20Click%20%7C%20Auto%20%7C%20%20%7C%20%20%7C&utm_content=Single%20Image%20%7C%20Ad%201%20%7C%20Lifestyle%20%7C%20Shop%20Now%20%7C%20V06.12A%20%7C%20Face%20shield%20-%20Copy&site_source_name=fb&placement=Facebook_Desktop_Feed&campaign_id=23844514544520515&adset_id=23844514631240515&ad_id=23845190892870515&fb_ad_id=23845190892870515&ct=y&ctsp=yxz&fbclid=IwAR2BUIVrpXCMpu07letuuNiGKOE6BiEeJA28SQh4so8sd69nEday1bwWVm0">Noel Asmar</a></li><li><a href="https://www.noheadache.com/products/no-headache-safety-visor-shield-with-replacement-shields?fbclid=IwAR2AZEBKYNHHYkjSQhF89r0X3ailJYyTUPSI9f1sl1dKalqyQSAO-PFwiGU">No Headache</a><br /></li><li><a href="https://octplace.com/products/face-shield?fbclid=IwAR14fme_b8d8bXU9H9dQHGYjwHM3Qcf53Ha6sbMV-8OUMEbK-lw1jM2C8No">OCTPLACE</a><br /></li><li><a href="https://shield48.eu/">Shield48</a><br /></li><li><a href="https://www.sparxhockey.com/products/sparx-face-shield">Sparx</a><br /></li><li><a href="https://srpfaceshield.com/?fbclid=IwAR3wZrVe26ndWLDri1yUayELd1qBSJfhdY6QPu8grh8npW3WYkBY9ssTfpo">SRP</a></li><li><a href="https://svedaorganics.com/collections/personal-protection/products/face-shield?utm_source=facebook&utm_medium=face%20shield%20-%20lookalike&utm_campaign=conversions%2012%20june&fbclid=IwAR0k7-qu441a9JbG_n09iNZIpH3QLnXLB6jZxk0wE2VQyaRaFWNsNe4fmII">Sveda Organics</a><br /></li><li><a href="https://techniquemedical.com/products/v2-fully-reusable">Technique Medical</a><br /></li><li><a href="https://theone08.com/?fbclid=IwAR2LbU33VcBbq47KJ0pWm2s404dwxABKgG3gr4LordCZhvP4A8Q-ZsW2m0k">TheOne08</a></li><li><a href="https://trueheroshield.com/product/truehero-shield/">TrueHero</a><br /></li><li><a href="https://faceshields-usa.com/product/reusable-face-sheilds/?fbclid=IwAR0QCp7o3XCt_1LDX7DautMjry1KL5qqRrLEjbNSwtNAgF92d9ac_eiWilE">Unified</a><br /></li><li><a href="https://shop.wetdesign.com/">Wet Shield</a><br /></li><li><a href="https://zshields.zverse.com/products/protective-face-shields-2-0?variant=33631676497979">ZVerse</a><br /></li></ul><div><div><b><br /></b></div><div><b>Industrial shields:</b></div><div><ul style="text-align: left;"><li><a href="https://www.acmetools.com/shop/tools/jackson-safety-14200s">Jackson Safety Maxview</a></li><li><a href="https://utmfaceshield.com/product/utm-personal-protective-face-shield/">UTM</a><br /></li><li><a href="https://www.nationaltoolwarehouse.com/UVEX-Bionic-Shield-P115033.aspx?utm_source=criteo&utm_medium=retargeting&utm_campaign=970x250%09">Uvex Bionic</a></li></ul></div><div><br /></div><div><b>Shields that attach to baseball caps:</b></div><ul style="text-align: left;"><li><a href="https://www.armorhat.com/?fbclid=IwAR2ADT4xDdkKHvipY_u17NsbBP6Hdg8P_tCla2Kpu94lLJZKxCVFR0fzf6U">Armor Hat</a><br /></li><li><a href="https://capguard.us/collections/our-products/products/single-cap-guard-assembly?fbclid=IwAR1rMZYB6B-wW3yC4fUyWCKoPwY8oBhszhqAIwKnsjjfwj7Haj5xcU_8tVk">CapGuard</a><br /></li><li><a href="https://www.freshairfaceshields.com/?utm_source=23845231181120172&utm_medium=Facebook_Desktop_Feed&utm_campaign=23845231181160172&fbclid=IwAR0Lb9grLvXQuR8K3eVSu3ajWD3C9d-zLaAmmGkuJM-2JnsHx98L_xjt9Qc">Fresh Air Face Shields</a><br /></li><li><a href="https://instashieldusa.com/?fbclid=IwAR3M6ChnwLD3_hFFDI7VU8Rv1dtvaEu1lw9MeLmWeVpQ-B87yHakOMLuAbY">InstaShield</a></li><li><a href="https://justemporium.com/products/baseball-cap-with-removable-flip-up-visor-shield?variant=32129210253409&currency=USD&utm_medium=product_sync&utm_source=google&utm_content=sag_organic&utm_campaign=sag_organic&gclid=Cj0KCQjw_ez2BRCyARIsAJfg-kvQm9LUAbUWlCiEelLikXYh0t-KBcpJ6lQNZWOdq0STqF80EtYPQ88aAuUhEALw_wcB">Just Emporium</a><br /></li><li><a href="https://realshield.com/?gclid=CjwKCAjwxLH3BRApEiwAqX9arWUNm2iE6JSBW71NvDp1zZsmN8XUaWIi8g17Wk8UUnhRGVx-o5iGIBoClk8QAvD_BwE">RealShield</a><br /></li></ul></div><div><br /></div><div><b>Hats with built-in shields:</b></div><div><ul style="text-align: left;"><li><a href="https://www.considered-goods.com/products/sun-protection-hat-visor?fbclid=IwAR36oDiQDLpZJPQubNuBvgpe0JLo7a4H-O2aRk0Asg2jfaVb_m5AHT9Is3o">Considered Goods</a><br /></li><li><a href="https://www.ginigood.com/products/hat?fbclid=IwAR3eokYQCWAQeE0c0E7BCzBiI0Nwa8B8lxyRh-6u1EBYZtHJjpxoW0j-xss">GiniGood</a></li><li><a href="https://hairbrella.com/">Hairbrella</a><br /></li><li><a href="https://justemporium.com/products/hatscreen?variant=32136746926177&currency=USD&utm_medium=product_sync&utm_source=google&utm_content=sag_organic&utm_campaign=sag_organic&gclid=Cj0KCQjw_ez2BRCyARIsAJfg-kvYSk7S18fFA-v6a5pk9IwhN0ogfsu42SLLppRVhAh9pmkdG55kofIaAqvmEALw_wcB">Just Emporium</a></li><li><a href="https://www.thesafetyhats.com/collections/plain-hats/products/original-safety-hat?fbclid=IwAR16QtLQYQn8pMGkROXEiOhTANgQ_YyuG1Djt7BFueLKt2hj7KRQGw6Y0J8">Safety Hats</a><br /></li><li><a href="https://us.shein.com/Floral-Bucket-Hat-With-Face-Shield-p-1171362-cat-1772.html?url_from=adplaswhatglov03200430670one-size&gclid=Cj0KCQjwo6D4BRDgARIsAA6uN1_RL1rscmqQes8GBkBXWlxgrzG3w863u47T-oamQEIhcp64nebMz50aAl1PEALw_wcB">Shein</a><br /></li></ul></div><div><b><br /></b></div><div><b>Fun ones & kids' shields:</b></div><div><ul style="text-align: left;"><li><a href="https://www.arttoframe.com/kids-face-shield/bear-nose/pack-1">ArtToFrames</a></li><li><a href="https://www.bosschicklife.com/">Boss Chick Life</a><br /></li><li><a href="https://www.impactmerch.com/retail/product/devo-energy-dome-ppe-kit/">DEVO Energy Dome</a><br /></li><li><a href="http://www.discoshield.com/">Disco Shield</a><br /></li><li><a href="https://www.shieldpals.com/shield-pals">Shield Pals</a></li><li><a href="https://theanniestore.com/product/safety-transparent-full-face-limited-edition-2020/?fbclid=IwAR3_KaJy-zP576PmVcs04TY_H6AA_wxqRAAnSKpI16IrGbnr2SRRMSTFKKs">The Annie Store</a><br /></li><li><a href="https://www.zazzle.com/c/face+shields">Zazzle</a><br /></li></ul></div><div><b><br /></b></div><div><b>Shields designed to be worn with loupes:</b></div><div><ul style="text-align: left;"><li><a href="https://www.71vcompliancesigns.com/shop/dental-flex-face-shield-r6mx9-r6gtk">Dental Flex</a><br /></li><li><a href="https://makers4medicine.org/purchase/ols/products/face-shield-xl-with-foam-headrest">Loupe Lid</a><br /></li><li><a href="https://www.nelderm.com/products/face-shield-visors?utm_source=Facebook&utm_medium=cpc&utm_campaign=ohio_dental_test&fbclid=IwAR3L7JNi1BUehx-XXuN_ohTYtf7Toq2qrDBmdyplUSvW_GPEG_OM3mEmN0g">NelDerm</a><br /></li><li><a href="https://ultralightoptics.shop/collections/loupe-visors">Ultra Light Optics</a> </li></ul><div><br /></div><div><b>Shields with goggles:</b></div><div><ul style="text-align: left;"><li><a href="https://www.eagleeyes.com/products/safety-goggles-with-face-shield">Eagle Eyes</a></li></ul></div><div><b><br /></b></div><div><b>DIY Face Shields:</b></div></div><div><ul style="text-align: left;"><li><a href="https://support.apple.com/en-us/HT211142">Apple</a></li><li><a href="https://www.instructables.com/id/DIY-PPE-Face-Shield-3D-Printer-Not-Needed/">Instructables</a><br /></li><li><a href="https://www.michaels.com/diy-face-masks-and-shields/acetate-face-shield/acetate-face-shield">Michael's</a><br /></li><li><a href="https://qz.com/1839582/how-to-make-ppe-face-shields-for-healthcare-workers-at-home/">Quartz</a><br /></li><li><a href="https://www.youtube.com/watch?v=oxIOFz0kWj4">Woodbrew</a><br /></li></ul></div><div><b><br /></b></div><div><b>Shield bulk orders:</b></div><ul style="text-align: left;"><li><a href="https://www.acushield.net/products/acushield-face-protector?variant=33946271350920">AcuShield</a></li><li><a href="https://armorexpert.com/pages/fs?fbclid=IwAR0ssiYn8Y_Zuniim9Y5NGfDlteZAwjXVScNeubbZz5GpOOtVH9aGGe8L8c">Armor Expert</a><br /></li><li><a href="https://carrkit.com/collections/ultra-lightweight-face-shield">carrKIT</a><br /></li><li><a href="https://www.clevelandmenu.com/wp-content/uploads/2020/05/DuroShield-Cleveland-Menu-1.pdf">Cleveland Menu</a></li><li><a href="https://www.crosstex.com/face-shield-152">CROSSTEX</a><br /></li><li><a href="https://dentalstore123.com/shop/dr-face-shield-protective-face-shield/">Dr. Face Shield</a></li><li><a href="https://www.egisviso.com/">Egis Viso</a><br /></li><li><a href="http://www.feiereisen.com/html/other.html">Feiereisen</a></li><li><a href="https://helmyplastics.com/face-shield/?utm_source=facebook&utm_medium=feed&utm_campaign=covid19&utm_content=ladysingleimage&fbclid=IwAR2ZjYPRJl4HL5S6X1riHYK_uluPaVLxmZjrQIUEz7CSluphruBd_jrMvW0#store">Helmy</a></li><li><a href="https://safetygloves.com/products/fluid-resistant-full-face-protector">HexArmor</a><br /></li><li><a href="https://highgroundgear.com/products/safe-face-shield">High Ground Gear</a></li><li><a href="https://homefrontrosie.org/">Homefront Rosie (a nonprofit that sells face shields & also donates faces shields to hospitals)</a></li><li><a href="https://iowamade.org/protostudios-face-shield">Iowa Made</a><br /></li><li><a href="https://www.rcoeng.com/ppe-store.html?store-page=Face-Shield-p203652015">RCO Engineering</a></li><li><a href="https://www.rufshield.com/optin-375187741587657514607?fbclid=IwAR04NIThTNYn2TvYi36sx1TpKs2wh7pbS_JbJ8iM39pwk_-3b9sA3HbB4go">RUF Shield</a><br /></li><li><a href="https://trilliumnow.com/products/trishield-face-shield-9-5-x-9-5">Trillium Now</a></li><li><a href="http://www.upstaging.com/faceshields/">Upstaging</a></li><li><a href="https://store.visipak.com/face-shield.html">Visipak</a><br /></li></ul>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com1tag:blogger.com,1999:blog-8066238290370557389.post-56943329652389026302020-04-14T17:42:00.006-05:002020-04-19T07:39:08.908-05:00Lessons from a Pandemic: Part 2<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-sb7gtl8jTmE/XpODfCn3uqI/AAAAAAAACjk/vfQrHvzqD50tFDWDnm76vGQmRpor0fUvwCK4BGAsYHg/volodymyr-hryshchenko-7JAyy7jLTAk-unsplash.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="3648" data-original-width="6692" src="https://1.bp.blogspot.com/-sb7gtl8jTmE/XpODfCn3uqI/AAAAAAAACjk/vfQrHvzqD50tFDWDnm76vGQmRpor0fUvwCK4BGAsYHg/volodymyr-hryshchenko-7JAyy7jLTAk-unsplash.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><font size="1">Photo by Volodymyr Hryshchenko on <a href="https://unsplash.com/photos/7JAyy7jLTAk" target="_blank">Unsplash</a></font></td></tr></tbody></table><br /><div>Three weeks ago, I wrote a piece on the lessons I learned from the beginning weeks of the COVID-19 pandemic in Iowa. You can see that <a href="http://haicontroversies.blogspot.com/2020/03/lessons-from-pandemic.html">here</a>. If any of you feel like I do, three weeks in COVID time seems like a year. It has the feeling of a chapter from <a href="https://www.amazon.com/Einsteins-Dreams-Vintage-Contemporaries-Lightman-ebook/dp/B004JHYS4E/ref=sr_1_1?crid=175EQER8TBZV1&dchild=1&keywords=einsteins+dreams&qid=1586727381&s=books&sprefix=einsteins+%2Caps%2C195&sr=1-1"><i>Einstein's Dreams</i></a>. In ordinary time my week has a rhythm to it, with different meetings and activities on different days. Certain nights we go out for dinner. Now, every day is nearly the same at work and after work. It's all COVID, all the time. I sometimes wonder what normal life will be like but it seems so distant that I find it hard to imagine. I know that at some point this will end but it doesn't seem near enough to be real. It's like being in a surreal time warp that could have been an episode from the <i><a href="https://en.wikipedia.org/wiki/The_Twilight_Zone" target="_blank">Twilight Zone</a></i>. OK, enough weirdness. Here are my latest lessons:</div><div><ol style="text-align: left;"><li><b>Working at home truly increases efficiency.</b> For the first time ever, I worked at home for an entire week. Previously, I had never worked at home for more than a day, and only if I had a project that required intense focus or a need to get it completed quickly. I had multiple Zoom meetings every day and gave four lectures by Zoom. What I now realize is that the many interruptions in my work day, with all the starting and stopping and the re-start after every interruption really reduce efficiency. At the hospital most of my meetings involve a 5-10 minute walk each way and when you have numerous meetings that adds up. And along the way you stop for unplanned chats that increase walking time. I also feel the need to check in with people that I work with and discuss current work issues. That's a good thing, but I now have a better view of how all of this impacts my workflow. <br /><br /></li><li><b>Medical care doesn't necessarily need to be face-to-face. </b>Last week I had my first telemedicine clinic. I had done telemedicine inpatient infectious diseases consults for small community hospitals in the past but never outpatient clinic. It worked very smoothly. For most patients, particularly those with known problems, auscultation, palpation, and percussion don't add all that much. Once the outbreak is over, it will be interesting to see how many clinic visits return onsite. With advances in technology, patients can have BP cuffs that transmit readings, pulse oximieters, and even wireless stethoscopes at relatively low cost, making good assessment in the patient's home much more achievable.<br /><br /></li><li><b>Determining what is and is not an aerosol-generating procedure (AGP) needs to be thoroughly explored in future research.</b> See these two excellent posts by Tom Talbot <a href="http://haicontroversies.blogspot.com/2020/03/agpitation.html">here</a> and <a href="http://haicontroversies.blogspot.com/2020/04/agpitation-part-deux.html">here</a> to read more about AGPs. <br /><br /></li><li><b>In times of crisis, healthcare workers' risk tolerance is greatly reduced and risk perception is not always rational.</b> This is natural given all of the information on the outbreak, much of it scary, that comes at us 24/7. There is a cry for zero risk, even though that is likely not achievable. In an effort to advocate for their constituencies, professional societies have added to the anxiety and created more demand for resources that are already scarce, such as testing supplies and personal protective equipment. <br /><br /></li><li><b>Once and for all, we need to determine the utility of every item of personal protective equipment for various types of pathogens. </b>This will require federal funding to do the needed research. New designs should be evaluated and current PPE improved. <br /><br /></li><li><b>The focus of infection control and prevention research has been too focused on bacterial pathogens. </b>Looking at journals from the last decade, one can see that most of the papers are focused on drug-resistant bacterial pathogens. These organisms pose little risk to healthcare workers. As above, federal funding will be needed to accomplish the needed work.<br /><br /></li><li><b>CDC has not been helpful by producing confusing information that is not practical, and SHEA and APIC have offered little to no guidance at a time when it is most needed. </b>In contrast, the World Health Organization has produced guidance that is based on sound logic and written in a very clear manner. <br /><br /></li><li><b>Anthony Fauci is a hero. </b>Where would we be without him? Don't think about the answer to that question. <br /></li></ol><div>More to come. Stay safe, everyone!</div><div><br /></div><div>Mike</div><div><br /></div></div><div><br /></div><div><br /></div><div> </div><div><br /></div><div><br /></div>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-88315677750404810592020-04-11T17:40:00.009-05:002020-07-08T06:23:30.131-05:00The Face Shield Strategy: Moving to the Community<br /><div><div class="separator" style="clear: both; text-align: center;"><br /></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-RPWD6YXrAyQ/XpIm7k2h0cI/AAAAAAAACjE/YwqUqIgZvBwhdah9QkVv2Mx4KuasSg-PgCK4BGAsYHg/dos-recien-nacidos-bangkok-protegidos-mascaras-avance-pandemia-coronavirus-1914821.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2629" data-original-width="3943" src="https://1.bp.blogspot.com/-RPWD6YXrAyQ/XpIm7k2h0cI/AAAAAAAACjE/YwqUqIgZvBwhdah9QkVv2Mx4KuasSg-PgCK4BGAsYHg/dos-recien-nacidos-bangkok-protegidos-mascaras-avance-pandemia-coronavirus-1914821.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><font size="1">REUTERS/Athit Perawongmetha</font></td></tr></tbody></table><br /><div><br /></div><div>With the assistance of a great supply management team, we have been able to outfit all of our clinical staff with face shields. See <a href="http://haicontroversies.blogspot.com/2020/03/the-iowa-face-shield-strategy.html" target="_blank">here</a> for our rationale and implementation. Acceptance by healthcare workers has been good and compliance is easy to visually monitor. Our message is that the shields are to be worn at all times except when eating or when in a room alone. Shields alone are worn for non-COVID care. For the care of COVID patients, masks are added beneath the shield, except in the instance of aerosol-generating procedures, when N95 respirators are worn beneath the shield. </div></div><div><br /></div><div>This week <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html" target="_blank">CDC recommended</a> the use of cloth masks for all persons in public settings. Although cloth masks are better than nothing, depending on the material, the filtration efficiency varies, and they can become contaminated. Moreover, adjusting the mask increases the frequency of touching the face, which can lead to autoinoculation if the hands are contaminated. We're not very excited about this strategy. However, we believe that face shields offer a better solution for the public. Dan and I laid out the case for this in an <a href="https://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2020/04/07/coronavirus-covid-19-ppe-iowa-doctors-mass-produce-face-shields/2952532001/" target="_blank">OpEd</a> in the Des Moines Register this week. </div><div><br /></div><div>The advantages of face shields are their durability allowing them to be worn an indefinite number of times, the ability to easily clean them after use, their comfort, and they prevent the wearer from touching their face. Importantly, they cover all the portals of entry for this virus--the eyes, the nose, and the mouth. Moreover, the supply chain is significantly more diversified than that of face masks, so availability is much greater. Large companies, such as <a href="https://www.dezeen.com/2020/04/09/apple-coronavirus-face-shield/" target="_blank">Apple</a>, <a href="https://www.dezeen.com/2020/04/08/nike-ppe-face-shield-coronavirus/" target="_blank">Nike</a> and <a href="https://www.deere.com/en/our-company/news-and-announcements/news-releases/2020/corporate/2020apr09-deere-face-shield-production-health-care-workers/" target="_blank">John Deere</a>, have converted production lines to make face shields. Smaller companies, such as <a href="http://www.upstaging.com/faceshields/" target="_blank">Upstaging</a>, have as well. Upstaging is selling shields to consumers as well as hospitals. (I ordered some from them and received them in less than 24 hours.) Because the design of face shields is simple, massive production should not be difficult. Individuals and groups are making them via 3-D printing, and they can even be made from materials that are readily available from stores that sell office or <a href="https://www.michaels.com/diy-face-masks-and-shields/acetate-face-shield/acetate-face-shield">craft</a> supplies. <b>Our goal should be to have a face shield for every person in the country. </b>It should be worn anytime a person leaves their home, while in any public place, and even at work. From news reports, it appears that face shields are already being more commonly worn in other nations, particularly in some Asian countries. </div><div><br /></div><div>Some argue that face shields may not prevent infectious aerosols that could be propelled around the edge of the shield. However, it appears that with this virus, <a href="http://haicontroversies.blogspot.com/2020/04/airborne-vs-droplet-turbulent-gas.html" target="_blank">transmission occurs mostly via droplets</a> that do not have the ability to move in air currents and waft around the shield edges. But importantly, if everyone is shielded, these aerosols would need to move around the shield of the infected person and then waft around the shield of the uninfected person for infectious droplet nuceli to land on their face. The probability of this happening seems low, particularly since persons who are symptomatic and coughing should not be leaving their homes anyway. And hand hygiene still needs to be stressed to prevent autoinoculation. </div><div><br /></div><div>Some are critical of any strategy that isn't perfect. But let's think about the influenza vaccine. Although the effectiveness varies from year to year, on average it's 40%. We push this vaccine hard in the hospital and in the community. Could we expect that face shields are at least 40% effective in reducing the transmission of COVID-19? I think so. Universal shielding would bend the curve more quickly and accelerate the ability to reduce social distancing and restrictions on movement. </div><div><br /></div><div>Face shields are a simple solution that if implemented universally would have a major impact on public health. Until we have a vaccine, this may be our best intervention for preventing transmission in the community.</div><div><br /></div><div><br /></div><div>Addendum: See our viewpoint, <a href="https://jamanetwork.com/journals/jama/fullarticle/2765525?resultClick=1">Moving Personal Protective Equipment into the Community</a>, on this topic in JAMA.</div><div><br /></div>Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com7tag:blogger.com,1999:blog-8066238290370557389.post-37871701217511003102020-04-05T17:40:00.002-05:002020-04-05T17:40:36.573-05:00Airborne vs Droplet: Turbulent Gas Clouds of Opinion!<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Arial, Helvetica, sans-serif;"><br />There’s much about the COVID-19 pandemic that is unprecedented, at least in my lifetime. One aspect is very familiar, though: arguments about the primary mode(s) of transmission of a newly emerging respiratory virus.</span><div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Much of the problem stems from our need to divide transmission modes into simple categories in order to apply prevention measures effectively. When someone calls the infection prevention program to ask about precautions recommended for virus X on the respiratory viral panel, it's not helpful to begin the conversation by saying, </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">“<i>well, you know, droplet and airborne transmission is not really a dichotomy, it’s more like a continuum, and there are a lot of factors at play—can we talk in more detail about the patient’s condition, what procedures they might be undergoing, and whether they might break out in song during routine patient care activities?</i>”</span></blockquote>
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<span style="font-family: Arial, Helvetica, sans-serif;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/31259864">One recent review</a> you may find useful was published in Current Opinions in Infectious Diseases in August of 2019 by Shiu, Leung and Cowling (talk about great timing…). A very important point made in this piece is that viral nucleic acids and (less often) viable virus can be found in air samples--including from healthcare environments--for influenza, RSV, adenovirus, rhinovirus, and other coronaviruses. So <a href="https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2">reports</a> about airborne SARS-CoV-2 (which <u>will</u> keep coming out in both pre-print and peer-reviewed literature) are not surprising. Nor do they answer the most important practical question about SARS-CoV-2 transmission:</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><b>Is airborne transmission a major mode of COVID-19 spread in community and in routine (i.e. no aerosol-generating procedure (AGP)) clinical settings?</b></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">My view is that we should consider the epidemiology of COVID-19 thus far in the pandemic, to determine if transmission patterns are more consistent with that of other common respiratory viral pathogens, <i>or</i> more consistent with that of the agents we classically consider to be transmitted by the airborne route (measles, VZV and <i>M. tuberculosis</i>). We could compare, for example, attack rates in various settings (household, healthcare, public), and the infamous R0 (expected ‘average’ number of secondary cases from a single infected individual in a susceptible population).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">For COVID I’ll point to two careful contact investigations—<a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6909e1.htm">this one of the over 400 close contacts</a> of the first 10 travel-related COVID-19 cases in the US, and <a href="https://www.medrxiv.org/content/10.1101/2020.03.24.20042606v1">this study from Guangzhou, China</a>, which was ten-fold larger (4950 close contacts to confirmed cases). The US study examined symptomatic secondary attack rates, and the study in China did serial RT-PCR on all contacts in addition to monitoring for symptoms. The findings are remarkably similar: highest attack rates are among household contacts (10.5% in US, 10.2% in Guangzhou), with extremely low rates of transmission among healthcare or community contacts (zero in US study, 1% among healthcare contacts and 0.1% among public transport contacts in Guangzhou). As for the R0, which of course varies as a population begins prevention approaches, the best estimate in my opinion is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/32097725">tragic natural experiment</a> performed on the unfortunate passengers of the Diamond Princess: during the early stage of the outbreak the R0 was 2.3.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">For <a href="https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/measles-rubeola">measles</a>, the R0 is 12-18 and the secondary household attack rates are >= 90%. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">For <a href="https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/varicella-chickenpox">VZV</a>, the R0 is ~10 and the secondary household attack rate is 85%.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">For TB, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583136/">R0 for smear-positive untreated TB</a> is up to 10 (per year) and the secondary household attack rate has been <a href="https://www.ncbi.nlm.nih.gov/pubmed/18450516">reported</a> to be >50%.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Based upon the above, I’m confident that SARS-CoV-2 transmission is similar to that of other respiratory viruses we are used to encountering—for which experience suggests droplet + contact spread to be the primary route of transmission. The trick is determining under what conditions a higher-risk aerosol might be produced (i.e. what is our list of AGPs? See <a href="https://haicontroversies.blogspot.com/2020/03/agpitation.html">here</a> and <a href="https://haicontroversies.blogspot.com/2020/04/agpitation-part-deux.html">here</a>, if you dare!).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Does this mean that every respiratory droplet falls to the ground immediately and within 6 feet of a coughing patient? No. Dr. Lydia Bourouiba</span><span style="font-family: Arial, Helvetica, sans-serif;"> has an <a href="https://jamanetwork.com/journals/jama/fullarticle/2763852">excellent piece in JAMA</a> about the role of “turbulent gas clouds” in allowing droplets to travel further, and to remain in the air longer, than our traditional “droplet-airborne” dichotomy considers. In my view, this kind of droplet + "gas cloud" production mostly contributes to the extensive surface contamination that results in the highest risk of transmission being among close household contacts.</span></div>
Dan Diekemahttp://www.blogger.com/profile/10231929371552334184noreply@blogger.com2tag:blogger.com,1999:blog-8066238290370557389.post-88489452095024559362020-04-01T13:05:00.002-05:002020-04-07T06:11:41.550-05:00AG(P)itation, Part Deux<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-SKJB74IaXSo/XoMvdad0AZI/AAAAAAAAAWE/W0YwOX8qd0QBw3-FYBI42D2nmtMQ4a1cwCLcBGAsYHQ/s1600/SeparateWaryBudgie-size_restricted.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="252" data-original-width="278" src="https://1.bp.blogspot.com/-SKJB74IaXSo/XoMvdad0AZI/AAAAAAAAAWE/W0YwOX8qd0QBw3-FYBI42D2nmtMQ4a1cwCLcBGAsYHQ/s1600/SeparateWaryBudgie-size_restricted.gif" /></a></div>
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<span style="font-family: "verdana" , sans-serif;">Since my post last weekend, I now have found the term that, once this is all over (and it will be over someday, my friends), will send me into flashbacks and result in me sitting in the corner</span><span style="font-family: "verdana" , sans-serif;">, rocking back-and-forth, saying "Please, Mommy, make it stop." "Aerosol-generating procedure." AGP for short. </span><br />
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<span style="font-family: "verdana" , sans-serif;">In the last few weeks, the items that healthcare teams across the U.S. and professional societies have insisted are AGPs have included, but are not limited to, the following:</span><br />
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<li><span style="font-family: "verdana" , sans-serif;">Laboring patients in second or third stage of delivery </span></li>
<li><span style="font-family: "verdana" , sans-serif;">All TEEs ("because might accidentally enter the airway like a bronch")</span></li>
<li><span style="font-family: "verdana" , sans-serif;">EGDs (The new AGA guidance states: "</span>To estimate the risk of viral transmission in endoscopic procedures, we examined data evaluating non-GI aerosolizing-generating procedures such as bronchoscopy and tracheal intubation. Our search strategy did not yield comparative studies on the degree of aerosolization with upper or lower GI endoscopy compared with bronchoscopy or tracheal intubation. However, we assume that insertion of the endoscope into the pharynx and esophagus is likely to be associated with a similar risk of aerosolization of respiratory droplets to that of bronchoscopy.") </li>
<li><span style="font-family: "verdana" , sans-serif;">Orthopedic procedures with drilling of intramedullary bone</span></li>
<li><span style="font-family: "verdana" , sans-serif;">Any surgery that goes anywhere near a sinus (All ophthalmologic procedures, any craniotomy, etc)</span></li>
<li><span style="font-family: "verdana" , sans-serif;">Any dental procedure</span></li>
<li><span style="font-family: "verdana" , sans-serif;">Cardiac cath lab procedures where the patient is "found down" (their MI might have been brought on by COVID-19)</span></li>
<li><span style="font-family: "verdana" , sans-serif;">All neurosurgery because the patient's face is right in the surgical field</span></li>
<li><span style="font-family: "verdana" , sans-serif;">All electrocautery (guidance that was courtesy of the American College of Surgeons that has now been removed from their guidance page)</span></li>
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<span style="font-family: "verdana" , sans-serif;">Some such requests are based primarily on concerning yet truly anecdotal stories from other countries that claim a specific specialty is at "highest risk of contracting COVID." Often these are extended to all patients due to the possibility that an asymptomatic patient could be a source of spread, drawing the thread from detection of SARS-CoV-2 at high levels in the upper airways in asymptomatic patients to detection of viral RNAemia in a minority of hospitalized highly symptomatic patients to note theoretical risks. In many of these instances, the proposed risk of "aerosol" exposure is due to facets of the procedure that would have existed long before COVID-19 and, if true, <u>should have warranted use of N95 respirators as part of Standard Precautions for these procedures for years</u>. The added interjection of professional society guidance that understandably advocates for the healthcare workers in their field but doesn't contain any evidence base to support claims that x or y is an AGP that leads to increased risk of pathogen transmission requiring an N95 also creates marked discomfort for infection prevention and operational teams on the front line, when faced to assess risk and allot precious PPE. As a colleague told me last week, "No society is going to say, 'Hey, we're cool. We'll just take the masks.'" I imagine, if we had unlimited PPE, this wouldn't be an issue, as we all want our colleagues to be protected and feel safe. The reality is PPE is a scarce resource, and one that we have to use our science to guide decisions.</span><br />
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<span style="font-family: "verdana" , sans-serif;">The best thing about this issue is that hopefully Dr. Babcock will get more funding for her research to help address these questions. When all this is over, I guarantee you that the term "AGP" will cause me, and I imagine many of you, to run the other direction . . . Stay healthy and sane everyone!!</span></div>
Tom Talbothttp://www.blogger.com/profile/10606566936885428481noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-51838864948524760122020-03-28T11:55:00.005-05:002020-04-28T11:56:16.208-05:00A Face Shield Strategy to Reduce COVID-19 Nosocomial Transmission<div class="separator" style="clear: both; text-align: center;">
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In previous blog posts, I mentioned the implementation of face shields to prevent nosocomial COVID-19 infection. Over the past few days, I have received many questions from people across the country, so I thought it would be useful to pull everything together in a single post and add some details.<br />
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<b>Rationale</b><br />
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As we began to prepare for the pandemic, we assessed our inventory of personal protective equipment (PPE). However, knowing current inventory levels alone is not useful. It's deceiving when you see PPE inventory levels of several hundred thousand items. How could we ever run out, right? This is why your inventory levels must be evaluated in the context of normal demand. Your supply chain folks should be able to tell you how many PPE items are normally used on a daily or weekly basis. Next, you need to determine your expected demand for the outbreak. There is no right answer here as there are too many unknowns. You'll just need to make an educated guess. We determined that our critical level of each PPE item was 12 weeks (84 days) at four times normal demand*, although you could argue that this is an underestimate. Next our supply chain group developed an interactive spreadsheet with each row being a PPE item, and columns showing current inventory; normal demand per day; and days of stock at normal demand, two times normal demand, and four times normal demand. The final column (days of stock at four times normal demand) is color coded as follows: red <u><</u>84 days, yellow 85-111 days, green <u>></u>112 days (16 weeks). Once this is done, you will likely be surprised to find that what seemed like an abundance is really not so. When evaluating your levels, you also need to consider that some items are on allocation and you can expect to receive periodic shipments, while others are simply stocked out with no promise of future deliveries.<br />
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After reviewing all of the above, the most worrisome thing for us was an inadequate supply of face masks (<84 days at four times normal usage). My biggest fear was that we would overuse them early in the outbreak when few COVID patients are hospitalized, then have none after the surge of COVID inpatients arrived. Many hospitals had extended the use of face masks beyond a single patient encounter, which is a reasonable decision in this time of shortage, but we know that face masks lose their effectiveness when they get wet. Some began to use cloth masks, which is also a problem. So I began to wonder whether face masks could be replaced by face shields.<br />
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Why face shields?<br />
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<li>They provide greater facial surface area coverage than face masks by protecting all the facial mucosal surfaces from infectious droplets. </li>
<li>Given that the eyes are protected, we can eliminate the need for goggles when a face mask is worn. And we know that healthcare workers are really bad at wearing eye protection.</li>
<li>They prevent you from touching your face. One of the major drawbacks of face masks is that some people will touch their faces even more to adjust the mask and this poses a risk for autoinoculation by contaminated hands. </li>
<li>Face shields are durable, can be cleaned after use, and reused repeatedly.</li>
<li>Many people (myself included) find face shields more comfortable than face masks.</li><li>Communication is better with shields than with face masks as your face is visible to patients and coworkers. </li>
<li>If all of your healthcare workers are shielded, social distancing becomes less important.</li>
<li>And importantly, this is a device that is diversified across other industries. There is greater availability since the medical supply chain is so stressed at this time. </li>
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Are there any disadvantages compared to face masks? The only one I can think of is the possiblity of a droplet coming in an upward trajectory going under the bottom edge of the shield. Although the probability of this is small, this can be minimized by having the shielded healthcare worker flex their neck when standing over the patient (for example, when performing a physical exam), bringing the bottom edge of the shield closer to the HCW's torso. Moreover, when doing a procedure that normally requires a face mask, we recommend that a mask be worn under the shield anyway. </div>
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A few people have asked what is the evidence that face shields can replace face masks, and those particularly inclined toward <a href="https://scienceblogs.com/effectmeasure/2009/10/24/journalists-sink-in-the-atlant">methodolatry</a> (the profane worship of the randomized clinical trial as the only valid method of investigation) continue to demand that face shields not replace face masks. Do I have evidence? No. To me, this is just plain common sense--we have a product that is reusable, cleanable, covers more of your face, decreases the risk of autoinoculation, and keeps us from burning through our mask supply. We have hospitals in the US where nurses are using bandanas to protect themselves. In this extraordinary time, I can live without a clinical trial.</div>
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<b>Implementation</b></div>
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We quickly found that face shields marketed for medical uses were stocked out. One of our pharmacists went to a local hardware store and found shields used for grinding. We then explored vendors that supply hardware and agricultural products (see more <a href="https://now.uiowa.edu/2020/03/supplying-those-front-line-pandemic">here</a> on the purchasing process). In addition, the University of Wisconsin has a great <a href="https://making.engr.wisc.edu/shield/">website</a> that includes diagrams for construction of shields, and Johns Hopkins has a <a href="https://twitter.com/ErinHerstine/status/1241238704624107521?s=20">"recipe"</a> available that can be used to create 50,000 shields. We placed the Wisconsin diagrams on the hospital website and several manufacturing firms responded that they could fabricate them for us. In addition, we have had some designed and produced by people interested in 3-D printing. One of our physicians, modified the Johns Hopkins' information and has her kids at home making shields. We also placed on our hospital's website a request for donation of face shields that people have at home, and we received many donations. It has really been a community effort. As our supply of shields grows daily, we deploy them throughout the medical center. At this point, the shields are handed off from one worker to the next as their shift ends, but our ultimate goal is for every person to have one for their personal use. </div>
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Here are the instructions we give to our staff on when to use face shields:</div>
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<li>Wear the face shield with every patient encounter (COVID and non-COVID patients) over a medical mask. Think of it as a new component of standard precautions--every patient, every time.</li>
<li>For COVID patients (confirmed or suspect), if an aerosol generating procedure is being performed, wear the face shield over an N95 respirator.</li>
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<div>To help introduce the concept to our workforce, we produced this video:<br />
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We still have some details to iron out, such as the best product to clean the shield, since some products damage polycarbonate. We have had some of the shields break, so fabricating replacement shields to repair them is ongoing. </div>
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Lastly, I have had a number of people who want to purchase their own shield ask me which one I recommend. Over the past two weeks, I have tried many models and have become a face shield connaisseur. If you want to buy your own, I think the best is the Uvex Bionic S8510 made by Honeywell (shown in the photo to the right). It is more sturdy than many other models, provides greater facial coverage (extends laterally on the face to your ears), and is comfortable. What really sets it apart is the V-shaped, downward projecting bottom border of the shield. This allows it to sit close to your upper torso, minimizing the risk of upward trajectory droplets. As an added bonus, from a sartorial standpoint, you'll look top-notch in this one! It's the kingdaddy!<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-2GH9W6B6mYY/XqhgKPxuKfI/AAAAAAAAClY/lGEgg1cPoqQWm417jcYp9L5ZCRyjOlAoACK4BGAsYHg/unnamed.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="560" data-original-width="524" height="320" src="https://1.bp.blogspot.com/-2GH9W6B6mYY/XqhgKPxuKfI/AAAAAAAAClY/lGEgg1cPoqQWm417jcYp9L5ZCRyjOlAoACK4BGAsYHg/s320/unnamed.png" /></a></div></div>
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This is probably more than you ever wanted to know about face shields. But it's a crazy time and we hospital epidemiologists are doing things I could have never imagined just a month ago. The bottom line is that by employing face shields we are able to protect our workforce while extending the duration of time that we will have face masks available.<br />
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Stay safe and be well!</div>
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Mike Edmond</div>
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*<a href="https://www.nytimes.com/2020/03/29/us/politics/trump-coronavirus-guidelines.html">Addendum:</a> A hospital in New York reported 15-30 times normal demand for face masks.<br />
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Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com6tag:blogger.com,1999:blog-8066238290370557389.post-76029115796171504242020-03-22T14:22:00.002-05:002020-04-07T06:11:56.494-05:00AG(P)itation<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;"><i>(Apologies to Mike - we usually don't like to step on each other on the blog, but I missed he'd just published another great post! So don't miss it <a href="http://haicontroversies.blogspot.com/2020/03/lessons-from-pandemic.html">here</a>!)</i></span><br />
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">So this week, the reality of what's coming started to dawn on many at the medical center. As we start moving from the preparation to the treatment phase of the pandemic, more people have been pulled into the realities of caring for suspected and confirmed COVID patients . . . and stories abound from around the U.S. about how a lot of them have some very strong opinions about PPE: A healthcare worker who showed up to work in full Ebola gear (no, I'm sure the co-workers felt safe in their "flimsy" masks). Entire units who mandated masking of everyone after a co-worker was diagnosed with COVID (and had not worked with symptoms). The sudden interest in and expertise about asymptomatic transmission by folks who never worried about coming to work sick with other viruses before. Adding to the confusion are the contradicting images (full Tyvek suits in China), messages (a Power Point describing Wuhan experiences that notes SARS-CoV-2 can spread "through eyelashes and hair"), and, sadly, guidance from various authorities:</span><br />
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<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;"><b>OSHA:</b> "Those who work closely with (either in contact with or within 6 feet of) patients known to be, or suspected of being, infected with SARS-CoV-2, the virus that causes COVID-19, should wear respirators."</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;"><b>CDC:</b> First, the recommended protection included a respirator for all types of patient care. Then this was revised to: "Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure. . .When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19."</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;"><b>WHO, Canadian Health Authority, and an increasing number of state health departments, including Tennessee: </b> Gown, gloves, facemask, eye protection (goggles or face shield) unless performing an aerosol-generating procedure, and then use a respirator or PAPR instead of the mask.</span></li>
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">I definitely understand and support the need to be cautious, especially when it's early in a new pathogen outbreak, and the protection and safety of healthcare personnel (HCP) has been a major concern of mine and the focus of my career. But one can easily see how the seeds of confusion have been sown among our HCPs regarding PPE.</span><br />
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">No issue has been the bane of my work this week than "aerosol-generating procedures" or AGPs, and as I tried to dive into the science behind these recs, I came away even more confused. A few quick learnings and thoughts on this issue:</span><br />
<ul>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The term "aerosol" means a very different thing to a true aerosol scientist (whom I imagine I will offend with much of my own ignorance here) and most lay medical people: To the former, an aerosol is a smaller particle (smaller than a droplet), the smallest of which require a higher level of filtration to protect HCP (as in a respirator). To the latter, any visible drop of fluid, liquid, spit, etc. is an "aerosol" ("I can see it flying through the air!!"), and as such their perception is that the official lists (more on those in a bit) of AGPs are lacking. </span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The various lists of what might be an AGP vary by organization and even changes within a single organization's guidance. Some include nebulized medications. Some, like WHO, had nebs on one version of the list in 2007 but removed them in 2009. A brief summary below:</span></li>
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<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The actual science on what is an AGP and, more importantly, whether they confer a higher risk of transmission of infectious agents is a) very difficult to illustrate (often relying on retrospective recall of patient care activities in infected and non-infected HCP), b) involves some logistically challenging studies (ask Dr. Babcock), and c) has many confounding factors (individual patient issues, use of PPE, etc.). I refer you to a few excellent papers on the topic <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035797">HERE</a> and <a href="https://academic.oup.com/cid/article/65/8/1342/4056661?searchresult=1">HERE</a> (shout out to our favorite blogger!). Also see this nice summary in the lay press <a href="https://www.statnews.com/2020/03/16/coronavirus-can-become-aerosol-doesnt-mean-doomed/">HERE</a>. </span></li>
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">I imagine, if we all shared our lists of AGPs, there'd be wide disagreement (which is why I didn't tell you mine). Some will have nebulized medications (which always throws the peds clinics into a frenzy). Some don't. CPAP/Bipap? Maybe, but the few studies that have examined this often just say "non-invasive ventilation," and 1 study in SARS had a single patient infect 22 HCPs as a driver of that risk. Is nighttime Bipap setting on the vent the same as rescue Bipap in impending respiratory failure (where there may be more suctioning and bagging of the airway?). Open suctioning of the airway? Just try to find any further description of that generic and broad term in any of the guidelines or evidence base. Is a brief (few seconds), pharyngeal suction an AGP? Is it really similar in risk to a deep, persistent need to suction copious lower airway secretions? Clearly no, but they're all "open suction of the airways." I think what we're seeing is that a simple term or list of procedures that is provided in guidance without strong evidence or out of an abundance of caution can have major logistic and psychological impact when trying to implement on the front line. Also, without more clarity (and more funded science on this topic!), we end up potentially using valuable PPE that was not warranted if no risk exists. </span><br />
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">I'll end by saying, sadly, this is not the first time we've dealt with this issue. For those of us who were hosp epis during the H1N1 pandemic, this exact conversation occurred, albeit with less intensity as the wave of illness didn’t flood the hospitals as much as expected. Our frontline healthcare workers are putting themselves at potential risk by caring for these patients, and they are understandably anxious and scared. Conflicted and confusing PPE recs do them no service, and guidance not rooted in science that leads to inappropriate use of PPE may lead to shortages down the road and more exposed HCP. This pandemic has already started, but perhaps we can finally learn and have more funded science to provide clarity and consistency on these issues that account for the real world nuances of delivery of healthcare. Failure to do so merely puts our HCP at greater risk for the next new pathogen.</span><br />
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Tom Talbothttp://www.blogger.com/profile/10606566936885428481noreply@blogger.com1tag:blogger.com,1999:blog-8066238290370557389.post-79394133375027733802020-03-21T09:21:00.008-05:002020-04-16T06:05:46.369-05:00Lessons from a Pandemic<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-cDZtNWUOTuc/XnZrZylSA2I/AAAAAAAACdM/zo3sLtX5xfEeXw8J9eAF7rSwIiFSMW3RACLcBGAsYHQ/s1600/martin-sanchez-LNYdatC3znA-unsplash.jpg" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1067" data-original-width="1600" height="265" src="https://1.bp.blogspot.com/-cDZtNWUOTuc/XnZrZylSA2I/AAAAAAAACdM/zo3sLtX5xfEeXw8J9eAF7rSwIiFSMW3RACLcBGAsYHQ/s400/martin-sanchez-LNYdatC3znA-unsplash.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><font size="1">Photo by <a href="https://draft.blogger.com/#">Martin Sanchez</a> on </font><a href="https://draft.blogger.com/#"><font size="1">Unsplash</font></a></td></tr>
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We are in the early stages of the COVID-19 pandemic, but it's already very clear that the Infection Prevention community in the US has never faced such an enormous challenge. Reflecting back on the past two weeks, we have learned many things that will make us better prepared for the long term. My goal is to keep track of these in this blog. So here we go:<br />
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<ol style="text-align: left;"><li>We are far too reliant on single-use disposable products. Having a large supply of cloth surgical gowns and isolation gowns that can be laundered is essential. I'll comment on disposable face masks below. Less reliance on disposables will also be better for the environment.<br /><br /></li><li>The supply chain for medical products needs geographic diversification. It wasn't all that long ago that we had numerous shortages of medications and IV fluids due to the hurricane in Puerto Rico, and now we have this crisis due to concentration of manufacturing in China.<br /><br /></li><li>Just-in-time inventory management is not a great idea in healthcare, particularly when the supply chain is rooted in a single geographic area. Most hospitals, especially larger ones, have some strategic stockpile of products, but it's unlikely that any have inventory levels to manage an outbreak that lasts for many months. Hospitals and government (both at the state and federal levels) have a lot of work to do in this area.<br /><br /></li><li>We have a new standard for evaluating personal protective equipment (PPE). In the old days (like last year), the standard for evaluating a new PPE product was: is the new product better than currently available products? Today's standard is: is the new product (let's say a bandana to cover your nose and mouth) better than nothing? I'll push that a little further and argue that the new standard should be: is the bandana no worse than nothing? Healthcare workers are very afraid, and I'll freely admit that I'm one of them. We all want to proactively protect ourselves. Even if the bandana is minimally protective, if it provides some level of psychological safety, we need to respect that and allow our workers to wear "homemade" PPE.<br /><br /></li><li>Going forward, the new attire standard for healthcare workers should be hospital-laundered scrubs. These should be donned after hospital entry and doffed prior to leaving. This will require that hospitals construct adequate changing and shower facilities. And scrubs should be coupled with a bare-below-the-elbows approach to patient care.<br /><br /></li><li>To the greatest extent possible, no-touch technology should be built into hospital design. Sensors that detect a hand wave for door opening are a great advance.<br /><br /></li><li>Face shields should and will replace face masks. They provide greater facial coverage and make it physicially impossible to touch your face. And I find them more comfortable than face masks. Sturdier models can be wiped down and reused. I suspect that every healthcare worker will purchase one, just like they purchase a stethoscope. For this outbreak, I am advocating that face shields be worn for every patient encounter since many patients with COVID-19 are minimally symptomatic. It should become a new component of standard precautions.<br /><br /></li><li>The community really wants to help us. I have recieved numerous forwarded emails from colleauges who have friends and relatives who want to sew masks or isolation gowns, donate their face shields and N95s, or whatever they can do to play a part in making things better. This is beautiful.<br /><br /></li><li>Infection Preventionists are true heroes. They are working around the clock to keep hospitals functioning. These people are the salt of the earth. They work in the background with little recognition and are some of the most committed people I have ever met. Thank you, thank you, thank you!</li></ol>
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These are my initial thoughts. More to come. Get some rest and stay well!<br />
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Mike Edmond<br />
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<br />Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com8tag:blogger.com,1999:blog-8066238290370557389.post-81791015986141306032020-03-18T08:20:00.000-05:002020-03-19T07:21:10.334-05:00Practical Strategies for Physicians to Avoid COVID-19 Infection at Work<div class="separator" style="clear: both; text-align: center;">
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The physician workforce is one of the most valuable resources of any hospital, and in the midst of the COVID-19 outbreak we need to do everything possible to ensure that physicians stay healthy. Like other hospital epidemiologists, I spend a lot of time thinking about practical ways to reduce the risk of infection. So to that end, I want to offer some suggestions for reducing your risk of acquiring COVID-19 at work.<br />
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<li><b>Personal infection prevention: </b>I strongly recommend that everyone in clinical areas follow bare below the elbows. This means that there should be nothing on your forearms, including wrist jewelry and wrist watches. This prevents contamination of sleeves and allows you to perform good hand hygiene. Hospital-laundered scrubs, doffed before going home, is optimal. We want to minimize clothing contamination, so I recommend not wearing white coats, cover jackets, or fleece jackets. Neckties are problematic because they frequently touch the patient/patient surroundings and are rarely cleaned. If you feel the need to wear a necktie, tuck it into your shirt. If you wear a long sleeve shirt, roll up the sleeves. Perform hand hygiene like never before (at least before and after every patient contact), and remember to wipe down your stethoscope after each use. Lastly, avoid touching your face.</li>
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<li><b>Work rooms:</b> Physician work rooms are often small, so we need to think about how to achieve social distancing in these small spaces. One way to do this is to bring your laptop to work and do your documentation in another site to reduce the number of people in the work room. Also, it’s important to declutter these rooms so that housekeeping can come in to clean all the surfaces. It’s very difficult for them to do this when there is clutter everywhere. You should also wipe down your workspace before you use it. Avoid shared foods in work spaces.</li>
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<li><b>Conservation of personal protective equipment: </b>Supplies of PPE are tight because many of these products are manufactured in China and factories are closed. This means we really need to conserve these items so that we can safely care for COVID patients for what may be an extended duration. At my hospital, we have modified contact precautions for non-COVID patients to not include gowns, since gowns are particularly in short supply. We continue to wear gloves for patients in contact precautions. If you anticipate a splash or spray, wear a gown for any patient. One way to think about this is to ask yourself: would I rather have this gown to care for a C diff patient today, or this gown to care for a COVID patient 6 weeks from now? I think this question puts the issue into perspective. Face masks and face shields marketed for medical use are in short supply, so consider purchasing a face shield from a hardware store. Here is an <a href="https://www.amazon.com/SAS-Safety-5145-Deluxe-protection/dp/B000RFSLZ4">example</a> of one. This particular model completely covers your face even laterally, and I think provides good protection and is comfortable. If you are a physician in an area such as urgent care or the emergency department, where there are many patients with respiratory symptoms, I would consider wearing the shield the entire shift. Avoid touching the shield, and wipe it down after use. To reduce supplies used, reduce the number of persons entering the patient room to the minimum necessary.</li>
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<li><b>Workflow: </b>Again, we need to think about social distancing. In teaching hospitals, we tend to travel in packs, and this needs to stop. Consider asynchronous rounding (attending rounds with each intern separately) to avoid congregating in the hallways on rounds. You might also consider batching your duties to the degree that you can and doing more of your documentation at home. Avoid elevators.</li>
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<li><b>What to do if you become ill: </b>The most important thing is to not come to work if you have fever or new onset respiratory symptoms. If you begin to feel sick at work, remove yourself from patient care as soon as possible. If you don’t have a thermometer (I didn’t have one until a few days ago), please get one, so that you can check your temp at home should you feel febrile. You might also consider purchasing a pulse oximeter to keep at home for self-monitoring in case you become ill.</li>
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Please take care of yourself during this difficult time. Patients need us, so let’s do everything we can to stay healthy! <br />
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Mike EdmondMike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-38480293793444129432020-03-15T10:49:00.002-05:002020-03-16T15:43:52.300-05:00COVID-19: Deep Thoughts and a Little Therapy<br />
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<span style="font-family: "trebuchet ms" , sans-serif;">I’m not really a crier. I mean, sure, there are moments in life that
make me a bit misty.<span style="mso-spacerun: yes;"> </span>Turn on those first
10 minutes of the movie <i>Up</i> and on go the tears (curse you, Pixar!).<span style="mso-spacerun: yes;"> </span>But something happened Friday that made me
realize how unusual and stressful these weeks have and will be for those of us
in medicine and, in particular, hospital epidemiology.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">I have worked out with a bunch of dudes early mornings, outside (rain
or shine) for the past 2 1/2 years. At the end of every workout, there’s a
Circle of Trust where the group leader gives thanks to someone or something higher
than himself (be he Christian, Muslim, Buddhist, whatever).<span style="mso-spacerun: yes;"> </span>On Friday, to celebrate my impending 50<sup>th</sup>
birthday, I led the workout.<span style="mso-spacerun: yes;"> </span>At the
end, as we gathered, I started to give thanks but had to stop.<span style="mso-spacerun: yes;"> </span>I could feel this deep ball of tears and emotion
well up inside.<span style="mso-spacerun: yes;"> </span>Couldn’t speak. Tears
flowed. In front of these dudes.<span style="mso-spacerun: yes;"> </span>And
that’s when I realized, I wasn’t crying because I was turning 50 . . . this was
a massive release with people I trust, and it showed me how much the past 2
weeks in particular have affected me (and I imagine many, if not all, of you).<o:p></o:p></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">As Mike (see also his <a href="http://haicontroversies.blogspot.com/2020/03/conserving-ppe-in-covid-19-era.html">excellent post</a> from yesterday) has noted in an email chain, this is likely the most stressful
time many of us (save maybe the HIV epidemic in the early ‘80s) have
experienced in our hosp epi careers. I
told a friend that it feels like I’m strapped into a massive roller coaster
ride (which I hate), climbing up that hill, sensing what lies ahead from the
screams of people ahead of us (China, South Korea, Italy, Seattle, San Fran, etc.),
and wanting desperately to get off the ride, realizing we cannot. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">This week, as Vanderbilt started testing, the variety of emotions hit
hard. Patient #1 is a close friend, a physician, whom I didn’t know had been tested.<span style="mso-spacerun: yes;"> </span>He attended a school fundraiser, and by the
middle of the week, 10 people from that event were positive. <span style="mso-spacerun: yes;"> </span>But I also saw resilience.<span style="mso-spacerun: yes;"> </span>Two weeks ago, Nashville and middle Tennessee
had the added hit of a massive tornado, affecting many in the area. One of which, my colleague who is the hosp
epi at an affiliated community hospital, had to leave his apartment and move to
a hotel, most of his and his wife’s belongings locked in a damaged
building.<span style="mso-spacerun: yes;"> </span>The next day, his hospital
diagnosed the first COVID-19 case in TN.<span style="mso-spacerun: yes;">
</span>New to the job, he handled this with grace and professionalism, even
when he had to borrow a tie for the press conference because his were all locked
in the damaged apartment.<o:p></o:p></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">This will be a marathon, and I offer some simple advice as this gears
up (and I am sure others have more to offer):<o:p></o:p></span></div>
<ul>
<li><span style="font-family: "trebuchet ms" , sans-serif;"><b>Delegate:</b><span style="mso-spacerun: yes;">
</span>At first, I was hit with every question about this outbreak, from
patient education, to clinical management, to employee furlough questions.<span style="mso-spacerun: yes;"> </span>As the weeks progressed, more people joined in
the fray who could help.<span style="mso-spacerun: yes;"> </span>I quickly
learned what is under my expertise (IP) and what others can handle.<span style="mso-spacerun: yes;"> </span>No need to micromanage. You simply can’t. <span style="mso-spacerun: yes;"> </span>While there’s a core group working tirelessly
on COVID prep, there are also many in our medical center wanting to help.<span style="mso-spacerun: yes;"> </span>We’ve used our quality abstractors to assess
if clinicians are correctly ordering COVID testing per our guidance.<span style="mso-spacerun: yes;"> </span>Our stewardship team to work on treatment
options.<span style="mso-spacerun: yes;"> </span>And even though many of us are
ID physicians, delegate the clinical management of these patients to your ID
peers.<span style="mso-spacerun: yes;"> </span>Focus on the IP stuff.</span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;"><b>Be decisive:</b><span style="mso-spacerun: yes;"> </span>ID docs are known for their ability to opine,
think, review data, which is great.<span style="mso-spacerun: yes;"> </span>But
right now, the questions and decisions are coming so quickly, we have to make
quick decisions.<span style="mso-spacerun: yes;"> </span>Some may be wrong; some
may change as you learn more. We’re building an assembly line as the cars have
already started rolling down the track. Some might fall off, some might not run
well, but we have to keep building quickly. Don’t overthink things.<span style="mso-spacerun: yes;"> </span>Use the science but avoid the margins.<span style="mso-spacerun: yes;"> </span>We won’t find solutions that fit every
scenario, as overthinking things can be paralyzing.<span style="mso-spacerun: yes;"> </span></span></li>
<li><b style="font-family: "Trebuchet MS", sans-serif; text-indent: -0.25in;">Develop a bench</b><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">:</span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">If you’re the only hosp epi around, figure
out who you can train up quickly.</span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">Another
ID faculty member. </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">Ideally one who is
even keeled, can know when they don’t know the answer and ask for help.</span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span></li>
<li><b style="font-family: "Trebuchet MS", sans-serif; text-indent: -0.25in;">Take time out:</b><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> It’s imperative that we
all take breaks from this work, to refresh mentally, spiritually, and physically.
Spend some time with your loved ones, even if just for an hour.</span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">Step away from Twitter/Facebook/etc. Go for a
run. </span></li>
<li><b style="font-family: "Trebuchet MS", sans-serif; text-indent: -0.25in;">Deal with your emotions:</b><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">Cry in front of people you trust.</span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;"> </span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -0.25in;">Meditate. Write. This is why I’m back on this
blog – this is my therapy.</span> </li>
</ul>
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<span style="font-family: "trebuchet ms" , sans-serif;">I’m glad people pushed us to reignite this blog, as the collective
insights can help the whole.<span style="mso-spacerun: yes;"> </span>As always,
we’re open for guest bloggers.<span style="mso-spacerun: yes;"> </span>Stay
healthy, stay grounded, and, of course, wash your damn hands.</span></div>
<br />Tom Talbothttp://www.blogger.com/profile/10606566936885428481noreply@blogger.com8tag:blogger.com,1999:blog-8066238290370557389.post-75703189447029311022020-03-14T12:49:00.002-05:002020-03-17T05:20:08.210-05:00Conserving PPE in the COVID-19 Era<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-JEbLv1t3mYY/Xm0XM1vLHfI/AAAAAAAACcA/vmazAR7bnQk742kmj23Hr6TccGCsP7mWQCLcBGAsYHQ/s1600/ashkan-forouzani-DPEPYPBZpB8-unsplash%2B%25281%2529.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1600" data-original-width="1217" height="320" src="https://1.bp.blogspot.com/-JEbLv1t3mYY/Xm0XM1vLHfI/AAAAAAAACcA/vmazAR7bnQk742kmj23Hr6TccGCsP7mWQCLcBGAsYHQ/s320/ashkan-forouzani-DPEPYPBZpB8-unsplash%2B%25281%2529.jpg" width="241" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Photo by <a href="https://unsplash.com/@ashkfor121?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText">Ashkan Forouzani</a> on <a href="https://unsplash.com/s/photos/doctor-mask?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText">Unsplash</a></td></tr>
</tbody></table>
In my 25 years as a hospital epidemiologist, this week was the hardest yet. Last Sunday, we learned of 3 COVID-19 cases in the Iowa City area. As of today, there are 14--that we know of. Because testing is still quite limited, these 14 patients likely represent just the tip of the iceberg. As all of this unfolds, it is like watching a train wreck in slow motion. And looking at the situations in Northern Italy and Seattle, we see that what lies ahead for us is quite scary.<br />
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One of the things I have focused on this week is personal protective equipment (PPE). It seems clear that, sooner or later, most hospitals will be in trouble. The PPE supply chain is deeply rooted in China and those factories have closed. That coupled with the just-in-time inventory concept has put all of us in a tough spot. For those of you not yet in the thick of this, I will offer some thoughts that may be of use to you.<br />
<br />
Here is my practical strategy:<br />
<br />
<ol>
<li>Know your inventory. Have your supply chain folks produce a tabular report of all PPE products used in your institution. In this table, ask them to also include the numbers of each item used in an average week so that you know your baseline utilization.</li>
<li>Develop an inventory target that includes projected usage and duration. We decided to set our critical target at 300% of normal usage for 12 weeks duration. This can be calculated from your baseline utilization for each item. On the table, any item's total inventory that is less than 300% normal usage over 12 weeks is coded red. Yellow is set at 12-16 weeks at 300% normal usage, and green is set at >16 weeks at 300% normal usage. We review the PPE inventory table daily at our Hospital Incident Command System meeting. The color coding of the table allows quick interpretation of inventory levels.</li>
<li>Critically evaluate your current usage and limit usage of PPE. Remember that we are not in normal times. Once you see how far away your current inventory is from your target inventory, you will rapidly begin to think of things that can conserve PPE. Here are several:</li>
<ul>
<li>If you use contact precautions for patients colonized with VRE or MRSA, <b>PLEASE STOP!</b> At best, the utility of this practice is questionable. Ask yourself this question: would you rather have PPE to care for a VRE colonized patient today, or that PPE for a COVID patient 6 weeks from now. </li>
<li>If you use contact precautions to isolate patients infected with VRE or MRSA, consider stopping. Numerous hospitals have done that with no ill effect. Ask yourself the same question as in the previous bullet.</li>
<li>We made the decision this week that for non-COVID contact precautions we would stop the use of gowns, but continue gloves, and stress hand hygiene and bare below the elbows (to minimize clothing contamination).</li>
<li>Begin re-using items such as face shields (after disinfection) and N95 masks.</li>
<li>Stop annual N95 fit-testing to avoid the use of masks in the fit testing process.</li>
<li>Limit the number of visitors.</li>
<li>For patients in isolation precautions, avoid taking the entire rounding team into the patient room. </li>
<li>Limit care of the COVID patient to one nurse and one physician.</li>
</ul>
<li>Send your supply chain staff on a scavenger hunt throughout the hospital to identify PPE that can be reclaimed. There are hoarders out there! In addition, secure your inventory to avoid theft.</li>
<li>Dispense PPE to individual hospital/clinic units in smaller increments.</li>
<li>Investigate alternative products. For example, we have a supply of old cloth surgical gowns that could be used as isolation gowns if needed. </li>
</ol>
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I'm sure others have ideas that we have not thought of. If so, please place them in the comment section. </div>
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To my colleagues in the infection prevention community: This is hard. We are tired. And it's only the beginning. But our work is more important than ever. Stay strong! </div>
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Namaste.</div>
Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-53939475939395151182020-03-07T12:35:00.000-06:002020-03-14T14:37:54.728-05:00What scares you?<iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/ZXRfnIfFYFI" width="560"></iframe><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I’m on a quick weekend trip for a wedding—a trip made possible only because we have a high concentration of hospital epidemiologists in Iowa City, and we haven’t yet diagnosed* a case of COVID-19 (*like much of the country, we’re behind in testing).</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">It’s disorienting to go from non-stop response planning questions to connecting with old friends. But of course the questions still came, the most common being: “are you scared by this?” My response was “yes”. Here are the three reasons I gave for my concern (before trying to turn the conversation to other things!), in no particular order:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Our healthcare system lacks surge capacity, and is already overstretched</b>. Large tertiary care centers commonly run at capacity with overflowing emergency departments and patients “orbiting” (awaiting transfer from smaller hospitals for a higher level of care). The proportion of COVID-19 patients requiring admission and ICU-level care will quickly overwhelm US hospitals if spread continues at plausible estimated rates. This will cripple our ability to care not only for COVID-19 patients for all others requiring hospital care.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Residents of long term care facilities (LTCF, including long term acute care, rehabilitation centers, etc.) are extraordinarily vulnerable</b>. We know from experience that once a transmissible pathogen enters a LTCF it spreads quickly, and the experience at the Life Care Center in Washington is <a href="https://www.nytimes.com/2020/03/06/us/coronavirus-washington-state.html">terrifying</a>.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>The social and economic disruption caused by COVID-19 may kill more than the virus does directly</b>—particularly in countries that have frayed or nonexistent social safety nets (I include the US in the “frayed” category). Job loss, loss of health coverage, homelessness, all carry with them additional morbidity and mortality that will continue long after the COVID-19 pandemic is over.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">What do my fears imply for response planning?</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>Lack of surge capacity</u> requires aggressive approaches to keep all but the sickest patients out of the hospital (telehealth, home health), and developing plans for conversion of some general hospital units to ICU-level care if needed. No surge capacity also strengthens the argument for aggressive social distancing approaches in an attempt to “flatten the curve” of the epidemic (amazingly helpful graphic below, and great Twitter thread <a href="https://twitter.com/CT_Bergstrom/status/1235865328074153986">here</a>), while admittedly worsening the social/economic disruption problems.</span></div>
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<a href="https://1.bp.blogspot.com/-rG6tkTpbsPI/XmPorUd0cSI/AAAAAAAABoQ/0RsK-Hyl0skhobKes-NSFhsMQC3CBkGCQCLcBGAsYHQ/s1600/ESas8tHVAAAhr_I.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="282" data-original-width="680" height="264" src="https://1.bp.blogspot.com/-rG6tkTpbsPI/XmPorUd0cSI/AAAAAAAABoQ/0RsK-Hyl0skhobKes-NSFhsMQC3CBkGCQCLcBGAsYHQ/s640/ESas8tHVAAAhr_I.jpg" width="640" /></a></div>
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<u style="font-family: Arial, Helvetica, sans-serif;">The vulnerability of LTCF residents</u><span style="font-family: "arial" , "helvetica" , sans-serif;"> requires drastic measures to protect these facilities—limiting facility access, screening employees for URI/ILI daily, and reducing social contact in ways that could still allow interaction (computer/tablet visits, etc.). Some may even wish to investigate temporary relocation of some residents (e.g. to family with visiting nurse assistance). LTCFs look more and more like the highest risk environments for COVID-19 (combining transmissibility with case fatality rate).</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>The social and economic disruptions</u> are the most difficult to address. In the near term, it requires recognizing when some of the more disruptive control strategies are no longer providing a benefit that overrides the ongoing damage to society. As one example, I think we’re reaching a point at which travel restrictions will have diminishing returns. This <a href="https://science.sciencemag.org/content/early/2020/03/05/science.aba9757">excellent modeling paper</a> demonstrates the likely benefit of travel bans from China before extensive international spread had occurred. The impact of travel restrictions is likely to be much less now that the virus is so widespread globally. In fact, I think the motivation for many current travel restrictions being implemented in the US is out of fear that the traveler will be subject to home quarantine upon return (and unable to work or contribute to response efforts)—once community spread is documented across the US, the use of home quarantine after travel becomes illogical. Moreover, the whole idea of quarantining healthcare personnel after exposures needs to be abandoned if we hope to have any work force for patient care. CDC recognizes this in <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html">recent updated guidance</a>.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">OK, now that I’ve revived this recently moribund blog, we’ll have to address some more COVID-19 controversies soon. Or you could just search the site for our 10 year old posts about the H1N1 N95 mask fiasco?</span></div>
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Dan Diekemahttp://www.blogger.com/profile/10231929371552334184noreply@blogger.com1tag:blogger.com,1999:blog-8066238290370557389.post-6771785230574503252019-09-24T20:46:00.001-05:002019-09-24T20:46:48.373-05:00The resistance continues...and you can help!
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<tr><td class="tr-caption" style="text-align: center;">Billions & Billions (Eric Daigh) Each of the 34,800 pills in the picture represents 1 million doses of antibiotics, totalling 34.8 billion doses given each year around the world. </td><td class="tr-caption" style="text-align: center;"> </td><td class="tr-caption" style="text-align: center;"> </td></tr>
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As SHEA president this year,<span style="mso-spacerun: yes;"> </span>I have not been doing much blogging but I have been
traveling and learning and representing SHEA in many different places.<span style="mso-spacerun: yes;"> </span>In the last few weeks, I was able to
attend the International Conference for Prevention and Infection Control
(<a href="https://www.conference.icpic.com/" target="_blank">ICPIC</a>) in Geneva and also attend a ‘side event’ at the United Nations General
Assembly focused on antimicrobial resistance.<span style="mso-spacerun: yes;"> </span></div>
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In Geneva, I heard about efforts to combat and contain
multi-drug resistant infections in many different countries.<span style="mso-spacerun: yes;"> </span>(I also realized that many European
countries are still struggling to raise their healthcare worker influenza
vaccination rates over 40 or 50%!)<span style="mso-spacerun: yes;">
</span>In addition, Kristy Weinshel, SHEA executive director, and I met with
leaders from WHO to discuss how SHEA can best support <a href="https://www.who.int/antimicrobial-resistance/en/" target="_blank">WHO efforts </a>to improve
infection prevention and antimicrobial usage around the world.<span style="mso-spacerun: yes;"> </span>We discussed training courses to
develop local expertise in resource limited countries, continued engagement of
past participants in SHEA’s International Ambassador program, and adaptation of
infection prevention guidance for these challenging settings. </div>
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In New York city, at an event sponsored by CDC, ASM, the
Gates Foundation and Wellcome Trust, we heard from DHHS Secretary Azar, a young
man who survived a multi-drug resistant infection after a train accident in
India, “England’s CMO” Dame Sally Davies and others about the risks of
continued antimicrobial overuse in agriculture and in medicine.<span style="mso-spacerun: yes;"> </span>The night also included multi-media
artworks including comic books about a post-antibiotic apocalyptic future,
‘petri dish’ microbial art including a street map of NYC and Van Gogh’s
sunflowers, textiles stained with bacterial growth and the picture above<span style="mso-spacerun: yes;"> </span>Many countries, individuals, companies
and organizations were there to celebrate progress since last year’s commitment
in <a href="https://www.cdc.gov/drugresistance/intl-activities/amr-challenge.html" target="_blank">The AMR Challenge</a> and to re-commit to continued progress.<span style="mso-spacerun: yes;"> </span></div>
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One of SHEA’s commitments is to expand scholarships in order
to continue to grow the community of experts that can improve the appropriate
use of antimicrobials in human populations.<span style="mso-spacerun: yes;"> </span>These scholarships are used to support education for
physicians, pharmacists and other providers who are involved in stewardship
research or practice.<span style="mso-spacerun: yes;"> </span>Since 2015,
SHEA members have raised over $30,000 through our annual <a href="https://www.crowdrise.com/o/en/campaign/race-against-resistance-2019" target="_blank">Race AgainstResistance</a>, originally conceived by Judy Guzman-Cottrill and carried forward by
David Calfee.<span style="mso-spacerun: yes;"> </span>Due in part to
support from all of you, last year I was the leading fundraiser, without
running a step!<span style="mso-spacerun: yes;"> </span>This year my speed
reading team of 1 (me!) is in 4<sup>th</sup> place behind some stiff
competition from actual athletes. </div>
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Now’s your chance to help!<span style="mso-spacerun: yes;"> </span>Donate to the <a href="https://www.crowdrise.com/o/en/campaign/race-against-resistance-2019" target="_blank">Race Against Resistance</a> (<a href="https://www.crowdrise.com/o/en/campaign/race-against-resistance-2019" target="_blank">pick any team</a>)! Help fight the spread of antimicrobial resistance!<span style="mso-spacerun: yes;"> </span>Help SHEA fund colleagues building
skills in antimicrobial stewardship research and clinical practice!<span style="mso-spacerun: yes;"> </span>Help prove that you don’t have to be an
athlete to raise money <a href="https://www.crowdrise.com/o/en/campaign/race-against-resistance-2019/hilarybabcock1" target="_blank">(look for the team picture that is a book and a cocktail)! </a></div>
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Hope to see many of you at IDWeek next week!<span style="mso-spacerun: yes;"> </span></div>
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</style>Hilary Babcockhttp://www.blogger.com/profile/15049394108692518949noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-73650417835202862092019-05-16T13:32:00.001-05:002019-05-16T13:43:18.233-05:00Time to Review Your Hospital Tuberculosis Control Plan: Updated CDC Guidance<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-WrHvbwgirGY/XN2snyM1ebI/AAAAAAAACUY/oNsAZl7hKaggLyRPZWrSeeTK5Gzp2_VkwCLcBGAs/s1600/JLS.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="266" data-original-width="190" src="https://1.bp.blogspot.com/-WrHvbwgirGY/XN2snyM1ebI/AAAAAAAACUY/oNsAZl7hKaggLyRPZWrSeeTK5Gzp2_VkwCLcBGAs/s1600/JLS.jpg" /></a></div>
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<i>This is a guest post by Jorge Salinas, MD, Hospital Epidemiologist at University of Iowa Hospitals and Clinics.</i></div>
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The National Tuberculosis Controller Association (NTCA) and the Centers for Disease Control and Prevention (CDC) just published their <a href="https://bit.ly/2VtBnwp">updated guidance</a> for the prevention of M. tuberculosis (TB) transmission in healthcare settings. <br />
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The previous guidelines (2005) called for tuberculosis screening for all healthcare workers upon hire and yearly if working in medium-risk settings. The setting risk was calculated based on the number of TB cases seen in the previous year. While most United States Hospitals were considered low risk, many large academic medical centers and hospitals in states with a higher incidence of TB were considered medium-risk. Fortunately, a number of studies performed in developed settings show that the rate of latent TB infection among healthcare workers is not different than the general population. In the updated guidance, hospitals previously considered medium-risk would continue testing upon hire but discontinue yearly TB screening (tuberculin skin testing or interferon gamma-release essay). This recommendation is welcomed as employee health resources can then be allocated to other emerging concerns (e.g., maximizing immunizations among healthcare workers). <br />
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The new guidance does not reduce the requirement for fit testing likely because the current TB infection prevention measures (administrative and environmental controls and personal protective equipment use) are likely the reason for such low levels of TB transmission among healthcare workers. As more data is gathered, next research steps could involve studying the necessary frequency of fit testing or the best method used (qualitative or quantitative methods). <br />
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These new recommendations will need to be accompanied by adequate contact investigations in healthcare settings. In the past, even if some contacts were not identified, the routine yearly screening would detect those patients within one year of the exposure. Now, an unidentified contact could go unnoticed until TB disease occurs. This increases the importance of training and knowledge of TB contact investigations in healthcare settings. However, TB contact investigations in healthcare settings are not straightforward: healthcare workers may have baseline positive skin testing and it is difficult to quantify the exposure risk (there is no standard recommended threshold for distance from patient or duration of exposure). Even if there was a recommended threshold, it would likely vary depending on other factors such as patient infectiousness (cavities, smear positivity) and healthcare worker immune status. Out of caution, healthcare workers may also tend to overreport exposures potentially overwhelming infection prevention programs. Another unique aspect of TB in healthcare settings involves extrapulmonary TB. Although in public health settings extrapulmonary TB is deemed likely not transmissible, it may lead to exposures in healthcare settings, especially during wound care, or procedures that may generate aerosols or splashes (irrigation, or bone surgery). <br />
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Congratulations and thank you to NTCA and CDC for their updated recommendations in light of new evidence. Those on the frontlines (Employee Health and Infection Prevention programs) will be able to reallocate resources and put their TB contact investigations skills to test.Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-11807771773554752712019-04-28T13:50:00.000-05:002019-04-28T13:50:02.765-05:00SENTRY at 20: So many bugs!<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Arial, Helvetica, sans-serif;">The <a href="https://www.jmilabs.com/sentry-surveillance-program/">SENTRY Antimicrobial Surveillance Program</a> was begun at the University of Iowa in 1997, moving a few years later to JMI Laboratories (also in Iowa!). Since inception, it’s been an industry-funded platform that performs central laboratory testing of clinical isolates of bacteria and fungi from centers around the world. The isolate submission process has been consistent over time, involving submission of organisms from consecutive episodes of infection at specified body sites (more information <a href="https://www.jmilabs.com/sentry-surveillance-program/">here</a> and in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=SENTRY+Jones+RN">many publications that have come from SENTRY</a>). </span><div>
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<span style="font-family: Arial, Helvetica, sans-serif;">So SENTRY has been operating for >20 years, and there are hundreds of thousands of isolates characterized. The major trends are reported in an <a href="https://academic.oup.com/ofid/issue/6/Supplement_1">OFID supplement</a> and in recent publications in <a href="https://www.ncbi.nlm.nih.gov/pubmed/30843070">JAC</a> and <a href="https://aac.asm.org/content/aac/early/2019/04/16/AAC.00355-19.full.pdf">AAC</a>. The supplement articles and the AAC report on trends in 20 years of bloodstream infection (BSI) isolates are open access—take a look if interested! </span><div>
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<span style="font-family: Arial, Helvetica, sans-serif;">I’ll focus briefly just on the AAC report (which I first-authored, so that’s shameless self-promotion right there)—two major points, each of which confirms on a large scale what regional surveillance programs have reported: <br /><br /><ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;"><i>S. aureus</i> and <i>E. coli</i> dominate the BSI landscape—together account for >40% of all episodes reported to SENTRY. Continued focus on prevention, detection and treatment of these two bad actors is critical, and IMO should include vaccine approaches, despite the disappointments to date.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">There’s an interesting divergence in proportion of BSI caused by important resistance phenotypes among Gram-positives (MRSA, VRE, DRE, etc.) versus Gram-negatives (ESBL, CRE) over the second decade of surveillance (2005-2016). The Gram-positive resistance phenotypes are stable-to-declining, whereas Gram-negative phenotypes steadily increase (as proportion of BSI episodes) over the entire surveillance period. </span></li>
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The decline in MRSA as a proportion of all SA BSI is particularly striking, occurring as it does at the same time worldwide (and at all body sites, both healthcare- and community-onset, as more detail in the OFID report of <a href="https://academic.oup.com/ofid/article/6/Supplement_1/S47/5381623">all SENTRY <i>S. aureus</i></a> confirms). As Eli and I discussed in this <a href="https://www.ncbi.nlm.nih.gov/pubmed/20699464">JAMA editorial</a> almost 10 years ago*, this is not easily explained by hospital-based infection control interventions. The waxing and waning of epidemic clones of MRSA is more likely to be informative. There is <b>so</b> much we still don’t understand about an organism (<i>S. aureus</i>) that lives in relative harmony with 20-30% of the human population when it isn’t causing horrendous, <a href="https://blogs.jwatch.org/hiv-id-observations/index.php/two-new-trials-of-combination-therapy-for-mrsa-bacteremia-answer-some-questions-and-raise-several-new-ones/2019/04/22/">difficult-to-treat</a> infections. <br /><br />Finally, the scope and number of isolates collected by SENTRY and similar programs represent an underutilized public health resource. Regulatory requirements for drug development and approval mandate surveillance for AMR. Better partnerships between public health authorities and the industry sponsors of such surveillance programs could enhance surveillance and response, particularly in the genomic era when ready access to large isolate collections can be so powerful. Some of this is already happening, but more could be done. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">*still behind a paywall after 10 years? What gives?</span></div>
Dan Diekemahttp://www.blogger.com/profile/10231929371552334184noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-2685650161014031062019-03-30T14:10:00.000-05:002019-03-30T14:10:41.072-05:00HAI Controversies at 10 years<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Arial, Helvetica, sans-serif;">It’s been a decade since we started this infection prevention blog. So I was planning to write a reflective post on whether it was still relevant, why I'm blogging less frequently, perhaps expand upon </span><a href="http://haicontroversies.blogspot.com/2018/12/final-thoughts.html" style="font-family: Arial, Helvetica, sans-serif;">Eli’s post</a><span style="font-family: Arial, Helvetica, sans-serif;"> about why he stopped blogging, and maybe even add my voice to all those proclaiming that “blogs are dead”. </span></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><br />So I went to our blogger stats page to get some data, and found a few interesting tidbits: this blog has had over 3 million page views since its inception, and is still getting over 10,000 page views monthly! Is this accurate? I have no idea, but it persuades me to hold off, at least for a while, on predicting the demise of the blog. </span><div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Arial, Helvetica, sans-serif;"><br />A few other fun observations from the stats page: see the huge spike of page views in late 2013? That resulted from an almost 2-year old post being picked up in a Reddit thread (a <a href="http://haicontroversies.blogspot.com/2012/02/dont-tie-one-on.html">post by Mike about neckties</a>). The next four most-viewed posts in the blog’s history are about <a href="http://haicontroversies.blogspot.com/2014/12/toilet-lids-for-infection-prevention.html">toilet lids for infection prevention</a>, <a href="http://haicontroversies.blogspot.com/2011/12/what-do-sinks-contact-lenses-have-in.html">contact lenses, sinks and <i>Fusarium</i></a>, the <a href="http://haicontroversies.blogspot.com/2016/10/the-ineradicable-mycobacterium-chimaera.html">inability to eradicate <i>M. chimaera</i> from heater-cooler devices</a>, and the <a href="http://haicontroversies.blogspot.com/2016/08/the-skullcap-feud.html">epic Skullcap Feud</a> still raging between surgeons and AORN. With topics like these, who needs cat videos?<br /><br />We started the blog to have a forum for freewheeling, even hyperbolic, discussions of controversial infection prevention topics. I think much of that back-and-forth has moved to Twitter. I’ve now come to believe that the blog is at its best during the early stages of outbreaks/crises that impact hospital infection prevention programs—to provide updates, opinions, suggestions for colleagues struggling with the same issues. The best recent example is the global <i>M. chimaera</i> outbreak, <a href="http://haicontroversies.blogspot.com/search?q=chimaera">posting our thoughts</a> as we navigated our own hospital response. For these complex situations--especially in the early, evidence-free phase--a blog post may allow for more nuanced discussions of the pros or cons of different approaches. Though I've been pretty impressed with some of the amazing twitter threads I find on med Twitter, a great example being <a href="https://twitter.com/MerinoTrial/status/1042027638137614336">this discussion of the Merino Trial</a>.<br /><br />I guess we should definitely have a larger discussion about the relevance of medical blogging. Maybe on Twitter....</span></div>
Dan Diekemahttp://www.blogger.com/profile/10231929371552334184noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-92168290715532583222019-02-17T09:27:00.000-06:002019-02-19T07:26:03.100-06:00Yes we can!<div class="separator" style="clear: both; text-align: center;">
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In early 2009, I bought three North Face <a href="http://haicontroversies.blogspot.com/2013/02/my-new-white-coat-is-cool-black-vest.html?q=bare+below+the+elbows">black vests</a> for myself and my colleagues Gonzalo Bearman and Mike Stevens at VCU Medical Center. Our Infection Control Committee had recently recommended that all healthcare workers adopt a bare below the elbows approach when providing care in the inpatient setting. The vests were good at providing some additional warmth on winter days. We avoided fleece and opted for vests that were nylon on the external surface so that they could be easily cleaned with a disinfectant wipe. We started bare below the elbows with just three people in a hospital with a workforce of 10,000.<br />
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We didn’t mandate bare below the elbows and we didn’t aggressively push it. We rolled out an educational campaign with a personal infection prevention bundle that had three components: bare below the elbows, hand hygiene before and after patient contact, and stethoscope wipe down after every patient exam. We talked about it in new employee and new housestaff orientation sessions, always noting that this was a recommendation. We had no support from hospital administration, though no one tried to obstruct us. Importantly, we gave doctors permission to not wear white coats and neckties, and continued to role model the approach as we saw patients. Given how attached some physicians are to their white coats, we knew that a mandate would produce a backlash and doom our plans. Still we got some pushback, but our response to the naysayers was consistent, “You’re not required to do this. It’s just a recommendation.” It's hard for anyone to argue with that.<br />
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Here we are a decade later, and this week saw the <a href="https://www.ncbi.nlm.nih.gov/pubmed/30638675">publication</a> of our results with this experiment in the American Journal of Infection Control. Across 40,000 observed encounters in calendar year 2017, overall compliance with bare below the elbows was 84%. Probably not too surprising, physicians were the laggards at 67%, with most other groups in the high 80s or even 90s. But having two-thirds of doctor-patient encounters occur without the <a href="http://haicontroversies.blogspot.com/search?q=microbiological+zoo">20-square-foot microbiological zoo</a> (AKA white coat), is pretty damn astounding. <br />
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What’s also interesting is that in the prior year, overall compliance was only 40%. In hindsight, we can see that 2016 appears to have been the tipping point as compliance doubled in the ensuing year. Now, bare below the elbows is part of the institutional culture. I have given many talks in the past decade on this topic where I’ve been told repeatedly that doctors will never give up their white coats, but Gonzalo tells me that it is now unusual to see a doctor in a white coat on the wards.<br />
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There are a couple of lessons here. We’ve again confirmed that changing behavior in health-related interventions is a slow process (probably even slower when the person whose health is impacted isn’t the person whose behavior must be changed). But more importantly, you don’t have to beat people over the head to make it happen. Provide encouraging messaging, role model the behavior, and let uptake diffuse. Patience is key. <br />
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Kudos to Gonzalo and Mike for persisting, and to everyone at VCU in the 84% who stepped forward. When I start service tomorrow it will be 10°F here in Iowa, and though this poikilotherm would like to be bundled in 20 layers, you can bet your bottom dollar that I’ll be bare below the elbows.
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<br />Mike Edmondhttp://www.blogger.com/profile/03722011490008008883noreply@blogger.com0tag:blogger.com,1999:blog-8066238290370557389.post-25233947873307281272019-02-14T12:10:00.003-06:002019-02-14T12:10:52.922-06:00A Blogger's Return: Relishing the Wave of Infection Prevention Science<div style="text-align: center;">
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Apologies, Faithful Readers (who do I think I am, Stan Lee (R.I.P.)?). The day-to-day life of a hospital epidemiologist, IDWeek planner, dad and spouse have pulled me away from contributions to the blog. But, like a bad rash, I'm back! I was prompted to post not because of a single study or bit of news but because of a thought I had when I received the TOC for the<a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/latest-issue"> latest issue of Infection Control and Hospital Epidemiology</a> (Disclaimer: I am a member of the editorial board but did not review any of the articles in this issue including those noted below). I was struck once again at the diversity of topics and the increasingly strong science that's being performed in our field. Makes me happy to be a hospital epidemiologist for sure! A few highlights:<br />
<ul>
<li>A <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/cefazolin-as-surgical-antimicrobial-prophylaxis-in-hysterectomy-a-systematic-review-and-metaanalysis-of-randomized-controlled-trials/4E4262A2F057CA96636BE0532A0CEFBD">systematic review/meta-analysis</a> examining whether evidence supports use of cefazolin for surgical prophylaxis in hysterectomy. The authors noted a significantly higher SSI risk with cefazolin vs. cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04–2.77; p = 0.03) and highlighted numerous limitations with the existing clinical studies.</li>
<li>A <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/human-factorsbased-risk-analysis-to-improve-the-safety-of-doffing-enhanced-personal-protective-equipment/EEC0D060D200F1A78DB2E0C86443EC98">human factors analysis of PPE doffing</a> that identified 103 failure modes with PPE removal (including issues related to the person, the place, the equipment, and the training).</li>
<li>An <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/patient-isolation-for-infection-control-and-patient-experience/89055F54116450B3F5FE29C16B07C751">analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data</a> to examine if placement in isolation adversely affected the patient experience (while isolation patients noted worse experience in the general ranking of overall care and in aspects of staff responsiveness, experience was similar in all other domains).</li>
<li>A <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/it-is-time-to-define-antimicrobial-never-events/CA198D720E26E6CDE112A8258FCFBFF2">thoughtful commentary on defining antimicrobial never events</a> that include inappropriate surgical prophylaxis, use of antibiotics for viral URI, and use of antibiotics for asymptomatic bacteriuria (as my hospital uses a Patient Harm Index of raw events for our quality goals, I love this concept, as it gives antibiotic stewardship some clear measures that fall into that framework).</li>
<li>Another <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/comparison-of-hospital-surgical-site-infection-rates-and-rankings-using-claims-versus-national-healthcare-safety-network-surveillance-data/BB0C447783700752A99A82BC212E075D">nice analysis</a> illustrating that claims-based billing code data are not useful to assess infection rates (this time: SSI) when compared to NHSN surveillance gold standard. Use to rank hospital quality is even stickier, as illustrated by the finding that 65% of hospitals in the best quartile by claims data were ranked in worse quartiles by NHSN data.</li>
</ul>
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And there are so many more excellent studies and manuscripts, so check it out (and keep pushing the IP evidence base forward)!</div>
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Tom Talbothttp://www.blogger.com/profile/10606566936885428481noreply@blogger.com0