Time to Review Your Hospital Tuberculosis Control Plan: Updated CDC Guidance

This is a guest post by Jorge Salinas, MD, Hospital Epidemiologist at University of Iowa Hospitals and Clinics.

The National Tuberculosis Controller Association (NTCA) and the Centers for Disease Control and Prevention (CDC) just published their updated guidance for the prevention of M. tuberculosis (TB) transmission in healthcare settings.

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).

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).

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).

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.

Working while sick

A few days ago, I learned about visual abstracts, a great way to encapsulate the essence of a paper. You can read more about visual abstracts here. Here's my first attempt using a recent paper in the American Journal of Infection Control.

This paper tells us that hospitals can't just mandate influenza vaccine for their workers and think that they have done their job. Preventing the transmission of respiratory illnesses requires a more comprehensive approach that makes a real attempt at keeping sick healthcare workers at home. Of note, the rate of vaccination in the survey participants was 45%, and vaccine effectiveness that season was only 19%.

Bottom line: Influenza like illness (ILI) has many causes, influenza vaccine is modestly to moderately effective against three of those, and healthcare workers continue to place patients at risk by coming to work when sick with ILI.

How much more stupid can it get?

Forbes.com recently reported on a psychologist at an academic medical center in New York who was fired because she didn't receive the influenza vaccine this year. Followers of this blog know how I feel about mandatory flu vaccine policies, which are not grounded in high-level evidence. But this case is worse. Much worse. The psychologist is unpaid, occasionally gives lectures, but doesn't see patients. The hospital epidemiologist defended the termination decision on the basis that the psychologist may expose other healthcare workers in the medical library. Wow! All of us come into contact with unvaccinated humans on a daily basis, and many of those contacts are likely more intense than those that occur in a library. What's next? Firing healthcare workers who have unvaccinated family members at home? Where does this end? This is what happens when you enact a misguided policy. One stupid decision just leads to the next more stupid decision. Fortunately for the poor psychologist, a more enlightened medical school offered her library privileges.

It's time to finally fix this

In 2010, the Society for Healthcare Epidemiology (SHEA) published a position paper that stated that annual influenza vaccination of healthcare workers should be a condition of employment on the basis of four studies performed in nursing homes. In other words, SHEA advised hospitals to fire HCWs who refused to get a flu shot. Other professional societies jumped on this insane bandwagon, and CMS made vaccine compliance rates publicly reportable and a metric in their hospital Star Rating program.

From the beginning, I have argued on this blog that SHEA's position was misguided for a number of reasons that I won't rehash in this post (see here, here, and here). Moreover, the Cochrane group evaluated the same four papers on which SHEA based its recommendation and determined there was no conclusive evidence that vaccinating HCWs was effective in reducing influenza in patients. But SHEA didn't back down. Another systematic review by another group came to the same conclusion. But SHEA didn't back down. CDC significantly downgraded the effectiveness of influenza vaccination to worse than placebo in some years. But SHEA didn't back down. And there's even a lack of evidence that influenza vaccine of healthcare workers reduces influenza in healthcare workers.

Now comes a 21-page paper (free full text here) in PLoS One by a group of Canadian epidemiologists that decimates those four nursing home studies. And all I can say is: SHEA better back down.

According to these investigators, all four studies violate the principle of dilution by reporting greater percentage reductions with less specific outcomes (i.e., the studies report percentage reductions in all-cause mortality > influenza-like illness (ILI) > laboratory-confirmed influenza). The principle of dilution requires that vaccine efficacy must be lower when non-targeted events (non-flu illnesses) are included in the study outcome than when only the target (confirmed influenza) contributes. The authors give the simple analogy of using an item-specific coupon at the grocery store--the percentage reduction in price on that item will always be much greater than the percentage reduction on your entire purchase that includes multiple other items. It's an irrefutable law of mathematics.

They also note several sources of bias. Depending on the study, there were differences in mortality between the control and intervention groups accrued before influenza arrived in the community, and there were issues with the definition of ILI. Estimates of numbers need to vaccinate were so flawed (off by as much as 4,000-fold) that if extrapolated to all healthcare workers in the US, more deaths would be averted than occurred in the 1918 influenza pandemic.

Here's the bottom line per the authors: Each of the four cluster RCTs used to champion compulsory HCW influenza vaccination policies reports benefits that are mathematically impossible under any reasonable hypothesis of indirect vaccine effect. It's hard to imagine a stronger conclusion.

If you don't read the entire paper, please read the discussion. Here's the concluding paragraph:

Through this detailed critique and quantification of the evidence we conclude that policies of enforced influenza vaccination of HCWs to reduce patient risk lack a sound empirical basis. In that context, an intuitive sense that there may be some evidence in support of some patient benefit is insufficient scientific basis to ethically override individual HCW rights. While HCWs have an ethical and professional duty not to place their patients at increased risk, so also have advocates for compulsory vaccination a duty to ensure that the evidence they cite is valid and reliable, particularly in the absence of good scientific estimates of patient impact. The diversion of resources from more evidence-based efforts and other important but less tangible costs related to loss of trust and credibility also need to be considered, including the implications for other immunization programs and workplace policies. Although current data are inadequate to support enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices such as staying home or masking when acutely ill.

And if that's not enough, there's a commentary in the same journal, responding to the Canadian study written by the lead author of one of the nursing home studies. He defends his study, but importantly he states that the findings should not be extrapolated beyond the nursing home setting.

As I see it, unless SHEA cites alternative facts, it has three choices: change its position to recommending (not mandating) annual influenza vaccine for healthcare workers, articulate a damn good reason to support its current policy despite the evidence (hard to imagine what that would be), or simply retire the guideline (as it has quietly done for the 2003 highly controversial MRSA/VRE search and destroy recommendation). Given the assault on science that we are likely to see over the next four years in the US, SHEA must lead by ensuring that all of its recommendations are solidly based in evidence and that expectations for compliance with interventions correlate with the strength of the evidence. Just as we must defend vaccines from false claims of adverse effects, we must also truthfully acknowledge their limitations and shape our policy on science not opinion.

Seek and ye shall find? Not so much...

Our understanding of the epidemiology of C. difficile infections continues to evolve. Dan recently blogged on a new paper that shows that a high proportion of healthcare associated cases are not due to transmission in the hospital. Another new paper in BMC Infectious Diseases (full text here) takes a look at an important question: are colonized healthcare workers involved in the transmission of Clostridium difficile in the hospital setting? At a large hospital in Australia a convenience sample of 128 healthcare workers (mostly nurses) had stool samples tested for C. difficile. Over 40% had known contact with C. difficile infected patients. Specimens were tested by ELISA and culture. No carriers were found. Given how difficult it is to get stool samples from HCWs, the authors should be commended.

Two other similar studies have been performed in the last 5 years. One found no colonized HCWs out of 112 tested, and the other found 4 of 30 (13% positive). So based on limited data it appears that colonization of healthcare workers probably does not play a major role in the transmission dynamics of C. difficile, though larger studies are needed.

Photo: Maddie Meyer/The Washington Post

Shocking: Another review of the evidence finds flu vaccine has no miracle powers

The Science section of the New York Times this week had an article on a new report regarding influenza vaccination. This report (free full text here) from the University of Minnesota is the kingdaddy of all analyses on influenza vaccination--a 3-year project funded by the Alfred P. Sloan Foundation that reviewed 12,000 papers back to 1936 and involved interviewing 88 influenza experts. The report is 123 pages without appendices and includes over 500 references. 

Here's my summary of the chapter on vaccine performance of the two major vaccines (trivalent inactivated influenza vaccine [TIV] and live attenuated influenza vaccine [LAIV]):

Population	TIV	LAIV
Children	Inconsistent evidence of protection	High level of protection (83%)
Healthy adults	Moderate protection (59%)	Lack of evidence of protection
Elderly	Paucity of evidence for protection	Inconsistent evidence of protection

What about use of the vaccine in healthcare workers? This can be found on pages 57-58 of the report and I have pasted below the important discussion of the HICPAC recommendation regarding offering influenza vaccine to healthcare workers):

The 2006 statement on influenza vaccination of healthcare personnel (HCP) from the Healthcare Infection Control Practices Advisory Committee (HICPAC) and ACIP illustrates potential concerns with using a grading scale.[63] This recommendation used the HICPAC grading scale, which is similar to the GRADE criteria in that it provides a structure for ranking the evidence. All recommendations were approved by the HICPAC and the ACIP. This document has been used widely as evidence to support HCP vaccination policies, including mandating vaccination. It offers six recommendations, and one was deemed to have the highest possible evidence, category IA. Category IA recommendations are “strongly supported by well-designed experimental, clinical, or epidemiological studies.”[63] The recommendation in the HICPAC document that received a category IA rating states:  “Offer influenza vaccine annually to all eligible HCP to protect staff, patients, and family members and to decrease HCP absenteeism. Use of either available vaccine (inactivated and live, attenuated influenza vaccine [LAIV]) is recommended for eligible persons. During periods when inactivated vaccine is in short supply, use of LAIV is especially encouraged when feasible for eligible HCP.”[63]

This recommendation is supported in part by this key summary statement in the HICPAC document: “Vaccination of HCP reduces transmission of influenza in healthcare settings, staff illness and absenteeism, and influenza-related morbidity and mortality among persons at increased risk for severe influenza illness.[64-67]” In the first study cited, the authors did
not find a statistically significant reduction in patient mortality associated with HCP vaccination, after adjusting for covariates.[64] In the second study, the authors concluded that “we do not have any direct evidence that the reductions in rates of patient mortality and influenza-like illness that were associated with HCW vaccination were due to prevention of influenza.”[65] In the third study, vaccination did not reduce the episodes of self-reported respiratory infection or the number of days ill with a respiratory infection, but it did reduce the time employees were 58 unable to work because of a respiratory infection.[66] In the fourth study, the authors reported reductions in absenteeism and illness among HCP that were not statistically significant.[67] The authors did, however, report serologically confirmed vaccine effectiveness of 88% for H3N2 and 89% for influenza B across three influenza seasons.[67] Since only two of the four studies cited provide some support for the HICPAC statement and the others no support, it is unclear how the quality of evidence in these studies received a category IA evidence grade. Another review conducted in the same time frame by the Cochrane Collaboration noted that the two RCTs cited in this recommendation were at “moderate risk of bias.”[68] They concluded that “both elderly people in institutions and the healthcare workers who care for them could be vaccinated for their own protection, but an incremental benefit of vaccinating healthcare workers for elderly people has yet to be proven in well-controlled clinical trials.”[68]

So this report questions the evidence base for even recommending influenza vaccination to healthcare workers. Yet, SHEA's position is so over-reaching that it calls for mandating vaccination and firing noncompliant healthcare workers. This is now the fourth independent analysis that does not support the SHEA position statement (read about the others here, here and here).

I continue to be fascinated by the post-modern disdain for evidence. A marvelous example from this week is the shock and utter disbelief suffered by Mitt Romney and his staff on learning that Barack Obama won the presidential election, despite nearly every poll indicating that Romney would lose. I guess I naively thought that somehow epidemiologists were immune to such bias but SHEA's flu vaccine position suggests otherwise.

One of the recommendations in the Minnesota report is that "scientifically sound estimates of influenza vaccines’ efficacy and effectiveness must become the cornerstone of policy recommendations." Amen. And it's time for SHEA to retract its policy!

Hmmmm...should we follow evidence or dogma?

So there's another systematic review of the literature on influenza vaccination of healthcare workers in the August issue of Emerging Infectious Diseases (full text here). Guess what? The results are quite similar to those of the Cochrane Group. The authors of the new study write:

"HCWs would be justified in claiming that the current evidence base is not especially strong and heavily weighted toward the benefits to patients receiving care in long-term care facilities, although limited evidence would not necessarily legitimize nonacceptance."

The authors go on to state that vaccination seems reasonable since there is likely some protection of high-risk patients.

On the basis of this new analysis, I haven't changed my mind. I still think HCWs should get vaccinated against influenza. I even think that we should make it hard for them to not get vaccinated (require signed declination, mandate educational sessions, etc). But I continue to believe that you can't fire HCWs who are not vaccinated based on the current state of evidence. To do so makes a mockery of what epidemiologists are supposed to espouse above all--decisions made on evidence, not dogma.

Pee first, then think!

Photo: Run On!

At the gym today I was reading the Chronicle of Higher Education while riding the bike and came across an article on the Ig Nobel awards. These awards are for research papers that first make people laugh, then make them think. One of the winners in the Medicine category went to the investigators who did a study published in Neurourology and Urodynamics on the effect of acute increase in urge to void on cognitive function (full text here). The study subjects drank 250 mL of water every 15 minutes until they could no longer inhibit voiding. Cognitive tests were performed hourly from baseline through extreme urge to void and then postmicturition. The investigators found that the extreme urge to void state was associated with significant declines in cognitive function that reversed after voiding.

Very interesting study, isn't it? So it got me to wonder whether Tom Talbot had to pee really badly when he drafted the SHEA position paper on flu vaccine for healthcare workers. Fess up, Tom!

Disclaimer:  Tom's a great epidemiologist and regular reader of our blog, so this is all in fun. 

Flu shot: Just take it on faith

Photo: Media dis&dat

The Journal of Hospital Infection has just published a systematic review on the effectiveness of seasonal influenza vaccination in healthcare workers. Here's the money quote from the abstract:

No evidence can be found of influenza vaccinations significantly reducing the incidence of influenza, number of ILI (influenza like illness) episodes, days with ILI symptoms, or amount of sick leave taken among vaccinated HCWs.

It's important to remember, however, that absence of evidence for the vaccine's effect, is NOT evidence of absence of an effect. I'm getting my flu shot this week, but I'm taking it on faith.

Joint Commission and Influenza Vaccination: IC.02.04.01

This seal in no way suggests that the
Joint Commission approves of this blog

The Joint Commission has just released proposed requirements addressing influenza vaccination of staff and licensed independent practitioners. Revisions to current requirements are proposed for Hospital, Critical Access Hospital, and Long Term Care accreditation programs with new requirements proposed for Ambulatory Care, Behavioral Health Care, Home Care, Laboratory, Medicare Based Long Term Care, and Office-Based Surgery accreditation programs.  Comments will be gathered until May 17, 2011.

You can review the proposed standards and leave comments on the JC site here.

For the Hospital Accreditation Program IC.02.04.01, elements 1-3 remain the same, elements 4 and 5 have been revised and elements 6-9 have been added. The new text is bolded below and the revised elements are:

1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff

2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)

3. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff.

4. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.

4. The hospital includes in its infection control plan the goal of improving influenza vaccination rates. (For more information, refer to Standard IC.01.04.01)

5. The hospital takes steps to increase influenza vaccination rates.

5. The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.

6. The hospital develops a written description of the methodology used to determine influenza vaccination rates. All hospital staff and licensed independent practitioners are to be included in the methodology for determining the influenza vaccination rates. (See also IC.02.04.01, EP 1)

7. The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination at least annually.

8. The hospital improves its vaccination rates according to its established goals and at least annually. (For more information, refer to Standards PI.02.01.01 and PI.03.01.01)

9. The hospital provides influenza vaccination rate data to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other staff at least annually.

More on SHEA's Flu Vaccine Mandate for Healthcare Workers

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

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

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

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

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

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

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

My surgeon has S. aureus!

Don't panic! Just based on probability a surgeon would have a 30% chance of being colonized with MSSA and perhaps a 1% chance of being colonized with MRSA. Researchers at NYU Hospital for Joint Diseases recently screened a total of 135 orthopedic surgeons for MRSA and MSSA nasal colonization. In the 74 attendings, 2.7% were MRSA+ and 23.3% were MSSA+. The story was a bit more interesting in the 61 residents with 59% MSSA+ and none MRSA colonized. Overall, 36% were MSSA+ and 1.5% were MRSA+, which is about what we would have guessed before the study.

These results are similar to Cecilia Johnston's report of healthcare worker colonization at Johns Hopkins a few years ago. She reported 28% S. aureus colonization (95% confidence interval [CI], 22%‐34%) and 2% MRSA colonization (95% CI, 0.04%‐4.0%). I pasted in Cecilia's results to highlight the fact that she calculated confidence intervals for each proportion. The NYU researchers were surprised by the high proportion of residents with MSSA colonization. Sure, the level was high, but if they would have calculated the 95% CI, which was 46%-71%, they might have been less excited.

It's possible that the long hours spent in direct patient care might be risk factors for MSSA colonization, as would frequently performing dressing changes, but these would not be unique to ortho residents. Perhaps they should repeat the study in the same residents at a later point to determine what proportion is transient vs persistent colonization. Of course, it would be nice to repeat the study in other cohorts of ortho residents and ortho nurses.

They also reported that patients screened prior to THR, TKR and major spine surgery at their hospital had 2% MRSA and only 18% MSSA colonization. It would have been nice to read more information about these patients, such as recent antibiotic exposure.

Schwarzkopf et al. in Journal of Bone and Joint Surgery (America): PubMed or JBJS
Johnston et al. in December 2007 ICHE
Easy confidence interval for proportion calculator: link

MRSA active surveillance: It just doesn't make sense

A study in the June issue of Infection Control and Hospital Epidemiology takes a look at staphylococcal colonization in healthcare workers. Over 250 HCWs were cultured and nearly half (44%) were colonized with S. aureus. MRSA colonization was found in 7% overall and was highest in nurses (10.5%). If the findings of this study are generalizable to other hospitals, this study has two important implications. First, given that nearly half of HCWs were colonized with S. aureus, hand hygiene practiced at very high levels of compliance is warranted. It seems that in the hysteria surrounding MRSA it's been forgotten that MSSA is also a pathogen. Second, why should hospitals engage in active detection and isolation (ADI) when non-patients are a significant reservoir for MRSA in the hospital setting? For those who continue to truly believe in ADI it seems that to me that their logic should dictate that MRSA colonized HCWs be removed from practice. And then there are visitors who may be colonized. The solution there could be to ban all visitors to the hospital. Of course, all of this assumes that the ADI zealots are driven by logic. Here's my recommendation: let's stop focusing on who has what organism (see Eli's posting from a few days ago), and just get everyone to wash their hands before and after every patient contact. The key word here is every. And maybe if that happened, we wouldn't need contact precautions any more. Now here's an interesting thought experiment: what could we do with all the money that's been spent on MRSA surveillance cultures over the last 5 years?

Save the masks!

In our flu planning meeting yesterday I learned from our materials management director that we are having difficulty obtaining surgical masks and that our in-house supply is being depleted. Whether this is a local problem or whether it's more widespread I don't know. But it concerns me that hospitals are implementing policies requiring asymptomatic healthcare workers to wear surgical masks at all times, in some cases those refusing to get vaccinated, in other cases universally in high-risk areas of the hospital. Perhaps we all need to take a step back and think through the long-term implications of such policies.

It seems to me that we are seeing an exceptionalism applied to H1N1 much like that applied to MRSA--that is, we are singling out certain diseases to focus attention and apply interventions while other diseases or organisms, perhaps of equal risk and impact, are not given the same attention. With regard to H1N1, the two major differences from seasonal influenza being observed are a larger population of susceptible individuals due to the antigenic shift the virus has undergone and the overall milder disease course (though there are certainly severe cases being reported). So if you think that all healthcare workers, or even just the unvaccinated fraction, should wear masks at all times during H1N1 season, are you prepared to do the same in all subsequent influenza seasons? Even if the flu season is prolonged? Even if the vaccine and circulating strains are mismatched, meaning in essence that all healthcare workers are unvaccinated? What are the triggers for starting and stopping masking? Is prolonged mask use a practical strategy? I could go on, but you get the point, I'm sure. I think a lot of policy is being driven by the media's attention on certain diseases and organisms with a short-term focus, rather than on priorities that are grounded in the magnitude of risk and impact and the long-term implications. Perhaps key questions to ask are: How many patients died in your hospital in the last month from a catheter-related bloodstream infection? How many died from ventilator-associated pneumonia? How many died from a surgical site infection? And how many died of nosocomial H1N1?

I long for the post-H1N1 era......

Killing the live vaccine?

A Denver television station is reporting that some hospitals there are refusing to administer the intranasal (live) H1N1 vaccine because of concerns of transmission of the virus to immunosuppressed patients. While CDC recommends that the vaccine should not be administered to healthcare workers in contact with severely immunocompromised patients (e.g., bone marrow transplant patients), I have heard from a number of clinicians who are expressing concerns regarding whether workers in contact with other immunosuppressed patients (e.g., solid organ transplant patients) should be vaccinated.

More on mandatory influenza vaccination

I just ran across this essay by George Annas on mandatory vaccination of healthcare workers. He outlines other reasons for not mandating immunization that I had not noted in my piece.

Taking the long view...

This week there was a flurry of emails amongst hospital epidemiologists about approaches to influenza vaccination of healthcare workers. I was surprised at the number of hospitals mandating the vaccine. Another approach being implemented at some hospitals is to require that unvaccinated healthcare workers wear a surgical mask at all times (how practical is that?). In addition to masking, one hospital is also requiring unvaccinated healthcare workers to wear some type of tag noting their noncompliance. While the tough tactics might be useful PR tools, I think it's a punitive, petty and mean-spirited approach to your hospital's most precious asset. I also think it's dangerous, because the ill will that will be created by such tactics is likely to have impacts on other infection control outcomes. While an effective infection prevention program requires creativity, good policies, and sound interventions, infection rates are ultimately determined by what happens at the bedside. Most interventions are wholly or partially behaviorally based, so we need healthcare workers to cooperate in implementation. Thus, infection control programs need to be forging healthy, trusting relationships with their healthcare workers. Strong arming is short-sighted, adversarial, likely to backfire, and infection control in general will be undermined. And if there's a serious adverse vaccine related event in a healthcare worker who was forced to be vaccinated, I suspect that will not only be the end of mandates, but compliance with vaccination in future campaigns will plummet, and the responsible infection control program will lose credibility. So plead, cajole, beg, sing songs, do whatever it takes to get them vaccinated, but stop short of issuing mandates or stigmatizing providers.

Mandating flu shots for healthcare workers

Today's Washington Post has an article on hospitals, health systems and states that are mandating flu shots for healthcare workers. While I certainly support the vaccination of healthcare workers, mandating it makes me uncomfortable. What I find grossly unfair is when hospitals exempt physicians from the mandates. While in many hospitals physicians are not employees, they are credentialed by the hospital. So hospitals that believe that all healthcare workers should be vaccinated should make this a requirement of the credentialing process. Otherwise, it creates a double standard that further undermines employee buy-in.

IOM & face masks: Efficacy vs effectiveness

Yesterday's report from the IOM on respiratory protection for healthcare workers against H1N1 was quite disappointing. Unfortunately, IOM evaluated the question from the standpoint of efficacy (how well an intervention works in an ideal setting) rather than one of effectiveness (how well an intervention works under real world conditions). Effectiveness takes into account compliance, which is likely to be an issue when levels of disease activity rise and healthcare workers spend more of their day wearing a mask. But more importantly, the current supply of N95 masks appears to be insufficient for them to be used when encountering all patients with suspected swine flu. I don't disagree with IOM's conclusion that N95 masks are more protective then standard masks, but to ignore logistics and practicality when making a recommendation is of little help to those of us in the trenches. I received several emails yesterday from hospital epidemiologists at academic medical centers who stated they would not follow the IOM recommendation but continue with SHEA's recommendation (i.e., use of a standard mask except for aerosol generating procedures).

Refusal to care for H1N1 patients?

I hope this doesn't become a trend. A recent entry on the Emerging Infections Network listserve describes ICU nurses refusing to care for very sick H1N1 patients, requesting reassignment for fear of contracting the virus. From the listserve responses so far, this appears to be a rare phenomenon, fortunately.

This is an interesting counterpoint to the finding Mike previously highlighted, of healthcare workers suggesting that they would refuse the vaccine! It is often interesting how people perceive risk, and what behaviors they choose to reduce that risk. Education will be key throughout this respiratory virus season—provide healthcare workers with the information and tools they need to protect themselves, and support them fully after any documented exposure. For those with valid concerns about the consequences of H1N1 acquisition (e.g. pregnancy, other high-risk condition), I believe counseling about risk, and case-by-case accommodation (including potential reassignment) is the correct approach.