They will never stop...

....trying to kill the Prevention and Public Health fund. We’ve blogged about this before, here, here, here, here, here, and sadly, again today.

The House of Representatives just voted to reauthorize the Children’s Health Insurance Program (CHIP), which is a good thing—but decided to pay for it with cuts to Medicare and with a huge slash to the Prevention and Public Health fund, which is a very bad thing that will harm many effective prevention efforts. Here is a list of what this fund supports, including expansion of laboratory capacity to detect and respond to emerging infections and antimicrobial resistance, and improvement of state public health infrastructure to detect and prevent healthcare-associated infections across all health care settings.

Meanwhile, our Congress is also planning a massive reduction in corporate taxes with no plan to pay for it (besides adding to the deficit).

Priorities!

21st Century Cures (But Doesn't Prevent) Act

---

Soy un perdedor
I'm a loser baby, so why don't you kill me?

-Beck (Loser)
---

There was a lot of excitement yesterday when the US Senate approved the 21st Century Cures Act, which would increase NIH funding, address issues with the mental health delivery and alter the approval process for pharmaceuticals and devices. Unfortunately, along with the winners there are several losers in this legislation.

And the big loser is?  - The Prevention and Public Health Fund. Dan has written often (here, here, and here) about how this fund is a frequent target for cuts. And this time, it seems even worse. Per reports, "[the bill] also cuts $3.5 billion, or about 30%, from Obamacare’s Prevention and Public Health Fund, which fosters work to prevent Alzheimer’s disease, hospital-acquired infections and other conditions."

So apart from the Cubs win, we can all agree that 2016 was a real loser for the HAI and public health communities.

Ebola: What can we learn from an N of 1?

Most of us woke up to the very unsettling news that a health care worker had acquired Ebola during the care of the index patient in Dallas. Those following the blog know that we've been worried about just this type of event since July, when Mike provided an Ebola primer. Specifically, we've been worried about the complexity of the PPE required and how this could paradoxically increase risks to health care workers. We've also highlighted the massive WHO budget cuts, CDC cuts and Prevention and Public Health Fund cuts since at least 2012.

In addition to the national cuts, individual hospitals have seen reduced support for infection control programs just as more and more is being asked of them. It used to be that hospital epidemiologists and infection preventionists could do surveillance rounds on the wards and educate from-line staff. Now, many hospitals have barely enough staff to complete their surveillance and public reporting duties leaving many trapped at their desks analyzing data. There is zero excess capacity to educate clinical staff on basic infection prevention practices like contact precautions. At many hospitals there is no capacity to add additional training in Ebola PPE protocols. As Marc-Oliver Wright said to me once: "You can't fight and prepare for the maybe (insert scary virus) when the required was due yesterday." Yet many hospitals are managing by shifting staff away from MRSA, away from CLABSI and away from influenza, which leaves our patients vulnerable to these more likely threats. If this were the military, there would be claims about fighting with one hand behind our back. That's the case here - we are fighting a war against Ebola and we've got an un-gloved hand behind our back.

So what are the lesson's from Dallas?

First, PPE is not 100% effective with current technology and training protocols. If health care workers auto-contaminate their hands when removing gloves 11% of the time when they caring for VRE colonized patients and 4.5% of the time when caring for patients with Acinetobacter, there is little room for error in PPE removal and hand hygiene when caring for patients infected with Ebola, particularly near the end of their disease course.

Second, the focus of Ebola preparedness in the US has to be 100% directed towards hospitals, initially the ICU settings. It's a simple fact that patients aren't infectious until after they develop symptoms and they are highly infectious once they are in shock in the ICU. Each and every hospital must walk through PPE donning and doffing and plans for Ebola patient care. They must train a cohort of doctors, nurses and environmental services staff now. Practice, Practice, Practice. Once the ICU staff are trained, the net should be widened to include the emergency department and other clinical settings. Work backwards from the highest risk settings where patients are most infectious (e.g. ICU) to the least.

Third, we need to demand funding for infection control in our hospitals. Double the number of infection preventionists and make sure each hospital has an Infectious Disease trained physician responsible for ensuring that all infection prevention protocols are followed. If we aren't even prepared for Ebola, how will we ever be prepared for a far more infectious avian influenza or MERS?

Fourth and finally, we must increase national funding for infection prevention. We must develop new PPE technologies and new methods to improve compliance and education. Right now we are using ancient technology - gloves, gowns, masks. We must also fund local and regional public health departments, as well as CDC, WHO and the PHEP, whose funding has been cut if half since 2006 (see below). We might get lucky with Ebola in the US (sadly it continues to get worse in Africa), but I doubt we'll be so lucky with the next virus.

***And for reading beyond the events of today, I suggest reading Judy Stone's excellent post on the problems with politics and public health mixing. She's covered many of the same topics that I've mentioned but with a broader scope.

Ebola and WHO budget cuts

Anthony Harris used to (and may still) include this New Yorker cartoon in his antibiotic resistance talks. I've always thought it summed up the resistance crisis quite well. We don't have effective antibiotics, so we must resort to the ridiculous. One of the major reasons we lack new classes of antibiotics is the lack of public funding for basic research of bacterial pathogens. It's pretty simple really. Years of ignoring the problem have us in this situation and it will take many years of reinvestment to build up the laboratory and professional resources needed to be fully engaged in antibiotic discovery.

A similar situation has played out in public health preparedness. I encourage you to read Dan's posts (here and here) covering the Prevention and Public Health Fund. And it's not just the US. In the Guardian today, Peter Piot - the discover of Ebola, expressed his fears that the outbreak is out of control. It's an amazing account of how he discovered and named the virus. It also highlights the almost tragic accidents that occurred in his lab, yet no one caught the virus. When asked why the WHO responded so late to the Ebola outbreak in Africa, he responded:

"On the one hand, it was because their African regional office isn't staffed with the most capable people but with political appointees. And the headquarters in Geneva suffered large budget cuts that had been agreed to by member states. The department for haemorrhagic fever and the one responsible for the management of epidemic emergencies were hit hard...I think it is what people call a perfect storm: when every individual circumstance is a bit worse than normal and they then combine to create a disaster. And with this epidemic there were many factors that were disadvantageous from the very beginning."

I'm not a military historian, but this situation seems terribly similar to what I've read about simultaneous wars on two fronts. Although in public health, it can be four or five fronts. We have Ebola, MERS, avian influenza and Enterovirus D68 knocking on our doors (and I'm sure I left out a few.) These are all on top of the CDC and WHO's "day jobs" fighting foodborne outbreaks, antibacterial resistant bacteria, TB, HIV and malaria (and I'm sure I left out many). Long term cuts to public health infrastructure can't be repaired in one month or one year. You can't go buy extra diseases detectives quickly off the shelf much like you can't quickly buy an extra aircraft carrier. We can already see how outbreaks respond to intensive budget cuts.

image source: Conde Naste

Prevention Fund love (finally!)

At long last, someone is showing a little backbone in trying to protect the Prevention and Public Health Fund.  The fact that it's the Senator from Iowa makes it all the sweeter.  Go Tom!  The money quote from Senator Harkin:

"I am greatly disappointed that the administration chose to help pay for the Affordable Care Act in fiscal year 2013 by raiding the Public Health and Prevention Fund. The Prevention Fund works. Thanks to this funding, more children are being immunized. More people are quitting smoking. More communities are fighting chronic disease. More people are being screened for hepatitis C. Robbing prevention when we know these efforts can improve people's health and lower healthcare costs goes against the very mission of healthcare reform."

h/t to Mike for e-mailing me the link.

Prevention: Who needs it?

We’ve been blogging for some time about threats to the Prevention and Public Health Fund, a fund that supports many critical prevention efforts, including funding state health departments to coordinate healthcare-associated infection (HAI) prevention and enhancing laboratory capacity to detect infectious diseases threats.

As Sarah Kliff points out in the WaPo wonkblog, congressional gridlock has led to a “good news, bad news” situation with this fund. The good news is that Republicans haven’t been able to eliminate the fund entirely, as is their wont. The bad news is that funding for implementation of the Affordable Care Act is also being held up, so the fund is now being raided to pay for those activities (in 2013, nearly half of the funds will be used to set up the federal health exchanges).

To quote Rick Mayes and Thomas Oliver again on the “prevention paradox”:

“If public health measures are effective, the problems they are aimed at are often solved or never even materialize, thereby making them virtually invisible.”

If we continue to starve prevention efforts, those problems won’t remain invisible for long…