Let's Just Get Every Face Covered

Photo by cottonbro at pexels.com

In the over decade-long history of this blog, Dan's recent post, A Tiresome SPAT, 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.

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?

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. 

Our recent JAMA viewpoint, Moving Personal Protective Equipment into the Communnity, 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.

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). 

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. 

Guest Post: IDSA’s Take on the Match Results

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

The first annual IDWeek Mentorship Lunch, IDWeek 2014    

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

Compensation

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

Funding for Research and Public Health

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

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

Mentorship

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

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

Paul Farmer's take on the Ebola Epidemic

Click here for an excellent commentary on the Ebola epidemic by Dr. Paul Farmer in the London Review of Books. I was particulary struck by this paragraph:

I’ve been asked more than once what the formula for effective action against Ebola might be. It’s often those reluctant to invest in a comprehensive model of prevention and care for the poor who ask for ready-made solutions. What’s the ‘model’ or the ‘minimum basic package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The desire for simple solutions and for proof of a high ‘return on investment’ will be encountered by anyone aiming to deliver comprehensive services (which will necessarily include both prevention and care, all too often pitted against each other) to the poor. Anyone whose metrics or proof are judged wanting is likely to receive a cool reception, even though the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery. Without staff, stuff, space and systems, nothing can be done.

In other words, this epidemic is driven more by the lack of medical and public health infrastructure than it is by a filovirus.

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

Urine Trouble (part 2)

I recently blogged about the teenager who urinated in the Portland water reservoir and the decision made to drain 38 million gallons of water in response. Well, the latest news is that Portland officials kind of changed their minds. Instead of draining the reservoir, they will transfer the water to an empty reservoir to be used as a water feature. I'm not entirely sure I get that logic either.

Dallas Songer, the reservoir urinator, seems to have a better understanding of water contamination and its implications than the Portland water experts. Here's what he said in a recent interview:

"Yeah, it's fucking retarded dude. Like, how they can do that? How can they be like, 'Yeah, we're gonna flush all that water.' Dude, I've seen dead birds in there. During the summer time I've see hella dead animals in there. Like dead squirrels and shit. I mean, really, dude?"

Photo:  The British Gazette

Urine Trouble

You may heard about the teenager in Portland, Oregon who urinated in a water reservoir last week. The act wasn't really newsworthy, but the response sure was. Officials in Portland decided to drain the reservoir, which holds 38 million gallons of water. Could there be any reason from an infectious diseases standpoint that this would be necessary?

Let's assume that the young man had to pee really badly. That would probably amount to a 500 mL void. Converting gallons to liters, the reservoir holds 144 million liters of water. So the urine was diluted by a factor of 288 million. That's not even a drop in a bucket! Moreover, given that urinary tract infections in young men are exceedingly rare, the overwhelming odds are that his urine was sterile. But playing devil's advocate, even if he had the most raging UTI known to man, chlorine coupled with the enormous dilution factor would negate any risk. And most urinary pathogens would cause no harm even if ingested.

But a smart person might ask what could happen if the teenager had previously travelled to Africa and was infected with Schistosoma haematobium, the parasite that causes urinary tract schistosomiasis and produces eggs that are found in the urine of infected persons. Well, fortunately, the Bulinus snails required for the life cycle of S. haematobium are not found in the United States.

Lastly, I'm not a wildlife biologist but it would seem to me that nonhuman mammals, birds and reptiles probably use water reservoirs for their bathrooms far more commonly than humans, and we aren't draining reservoirs for that.

Let's hope the Portland standard doesn't become the rule. If so, we'll probably have to drain every swimming pool in the United States.

Photo: Mount Tabor Reservoir in Portland. AP Photo/The Oregonian, Benjamin Brink

Montgomery County is now in the loop!

The next time a contagion sweeps through the NIH Clinical Center, Montgomery County officials will be on it, thanks to a new agreement between NIH, Maryland and Montgomery County. The back-story is that Montgomery County officials were unhappy that they weren’t informed promptly about the deadly KPC outbreak at NIH.

This raises the question of when a hospital should communicate with public health officials (and the public generally) about fairly common SNAFUs. At any given time, 5-10% of hospitals are dealing with clusters or outbreaks of multiple-drug resistant gram negative bacteria (KPCs, ESBLs, MDR-Acinetobacter, etc.), and even more are in the midst of MRSA, VRE, fungal or other outbreaks. The population at risk during these outbreaks is pretty clearly defined, and doesn’t include the general public. General notification can generate media frenzy, free-floating panic and anxiety, and waste precious time and resources for the personnel trying to contain the outbreak (responding to media, doing damage control of various types, etc.). Furthermore, most states don’t include common healthcare associated bacterial pathogens among their legally reportable diseases.

However, as state and local public health officials become increasingly involved in HAI issues, it would be wise to establish explicit criteria for when healthcare facilities should report clusters and outbreaks. Provided they have sufficient funding (which they currently do not!), public health departments should play a critical role in coordinating responses to HAI outbreaks, which often involve multiple healthcare facilities in a region (across the spectrum of acute, long-term, and long-term acute care).

So when do you think a hospital should notify their state and/or local public health department? Two cases of MRSA infection in the NICU? A single serious post-operative Group A strep infection? New introduction of a carbapenemase into the ICU?

Oh, and Happy Thanksgiving!

I'm madder than a giraffe with a sore throat...

…over the CDC budget, which Eli blogged about last week. As their budget gets cut further and further, the CDC leans more heavily on the Prevention and Public Health Fund (“Prevention Fund”) to pay for core functions. The problem is that the Prevention Fund was originally designed to fund new initiatives, not to fill in for ill-advised core budget cuts. And since the fund was established as part of the Affordable Care Act, it has now become a political target (and was already cut drastically as part of the payroll tax cut extension and Medicare “doc fix” deal). If you require further evidence of the tenuous status of the Prevention Fund, know that it has been termed “an Obamacare slush fund” by the GOP (note to whoever came up with that genius terminology: you are a colossal ***).

Ezra Klein had a great post last month about why prevention funding is so vulnerable in the current climate. In it he quoted Rick Mayes from the University of Richmond, 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.

Few individuals have personal interactions with or know what epidemiologists, health program coordinators, virology trainers, and outreach specialists do. When individuals are spared from a disease because the air in their office building is clean, it is not immediately clear whom to thank or if thanks are even necessary. As a consequence, public health professionals, programs, and policies are largely invisible to the public and taken for granted.”

I agree with this, but I think the issue is even larger, and more depressing. The statement above assumes that if people were just informed of the consequences of not supporting prevention efforts, they would act differently. I don’t think so. I’m hearing more political candidates question the basic social contract, the very assumption that government has a legitimate role in providing for the common good (and that we all have an obligation to pay for it). I encourage you to listen to this podcast, entitled, “What Kind of Country”, which details some trade-offs that local governments are making when money runs out and citizens are no longer interested in paying to provide for the common good. I was particularly struck by the story of individual citizens refusing a small tax increase to keep all the streetlights on in their town, but willing to pay $300 out of pocket to keep the lights near their own house burning.

2009 H1N1 Pandemic Response: Looking backward and forward

Recently in PLoS Medicine, Gabriel M. Leung from the Food and Health Bureau, Hong Kong and Angus Nicoll from the European Centre for Disease Prevention and Control reflected on the public health response to pandemic H1N1. They discuss what went right and what should be done now to augment our future responses.

I really liked that their primary points highlighted that "public health messages...should not confuse what could happen (and should be prepared for) with what is most likely to happen" and that "decisions regarding pandemic response during the exigencies of a public health emergency must be judged according to the best evidence available at the time."  I've pasted below the list of pandemic "Firsts" which included a special shout out to the challenging "blogosphere," of which this here ye olde blogge was a member.

Box 1. A Series of “Firsts” about Pandemic (H1N1) 2009

• The first pandemic to emerge in the twenty-first century. It has been more widespread and remains ongoing, compared to SARS.
  
• The first pandemic to occur after major global investments in pandemic preparedness had been initiated.
  
• The first pandemic for which effective vaccines and antivirals were widely available in many countries, thus requiring public health authorities to earn and retain the confidence of health care providers through whom such are usually distributed.
  
• The first influenza pandemic to coincide with the ongoing HIV/AIDS pandemic and for which preliminary data do not suggest a substantial, disproportionate impact on HIV-infected patients.
  
• The first pandemic that took place within the context of a set of International Health Regulations and global governance, which had not been widely tested until the present.
  
• The first pandemic with early diagnostic tests that led to rapid diagnosis but also an early obsession in the media and of policymakers with having reports of the numbers of those infected.
  
• The first pandemic with antivirals available in many countries that led to a hopeful expectation that the pandemic might be containable, leading to the preparation for and implementation of a “containment phase” in some places.
  
• The first pandemic in which intensive care was available in many countries to treat critically ill patients, fostering an expectation that everyone could be treated and cured.
  
• The first pandemic with instant communication so that early impressions (such as the experience and response in Mexico and the Ukraine) could be shared ahead of proper scientific analysis.
  
• The first pandemic in which web-based platforms of traditional journals expedited dissemination, complemented by other innovative online resources (e.g. PLoS Currents: Influenza, http://knol.google.com/k/plos-currents-i​nfluenza#, based on Google's knol technology).
• The first pandemic with a “blogosphere” and other rapid social media messaging tools that challenged conventional public health communication.

Source: G. Leung and A. Nicoll. Reflections on Pandemic (H1N1) 2009 and the International Response. PLoS Med 2010

The Show Me State?

Here is a new twist on public reporting: how long should a state be required to keep hospital-specific data easily accessible to the public? Missouri’s Department of Public Health is taking heat for removing older data from their website (essentially, they just “write over” the old data with new data, so the older data gets purged).

The data still exists at the department...as the state’s data manager says, “it just isn’t handy”. To get it you have to formally request it, a programmer must be available, and you have to pay the cost of retrieval.

An interesting side note—the 2004 Missouri statute mandating public reporting came with no appropriation, even though the state’s health department spends over 240K each year to implement it. It’s true that you get what you pay for—if public reporting is important, it needs to be appropriately funded. And doing it correctly (including independent validation) is expensive!

Addendum: Never mind, the older data will be restored. By the time Iowa starts public reporting of HAI data, we'll have all these lessons to draw on!

New Year's Resolutions, Procrastination and Public Health

I suspect we've all made resolutions at some point, but studies show most of us fail to accomplish our goals. I mean, is Lindsay Lohan really going to stick to this? I give her until St. Patrick's Day, but I digress.

In a recent article, The Economist suggests that a major reason for our failure to accomplish our goals is that we have a tendency to procrastinate; no surprise there. We tend to put off unpleasant or costly things into the future. That would be OK if we would stick to a single delay, but it turns out that we are time-inconsistent or “present-biased” and will always put off tough or costly things to the next day. Tomorrow really is always a day away. They reference a paper by O’Donoghue and Rabin.

I suspect this tendency is at the heart of the public health problems we have in the US. When you build a road you have immediate gratification, but the gratification of a well-funded state health department is uncertain and certainly in the future. Perhaps a better example is one I suspect many of us in infection control will soon face: should we push our administration to restock our N95 mask cache that we used to meet the OSHA/CDC/IOM requirement to care for suspected H1N1 cases? Avian flu is still out there and is just as likely to become a pandemic as it was last year.

This issue really concerns me. Even in this mild pandemic, we all saw how quickly the supply chains dried up for critical supplies. However, I suspect that hospital administrators will assume that the next pandemic will be this mild or forget the supply chain difficulties we had. Even more of a concern for me is procrastination. Will they assume that they can delay purchasing N95s for a cache because we just had a pandemic so the next one won't happen soon? They can "wait 'til next year" just like our favorite Cubs fan. The problem is that next year they will wait until next year.

Fortunately, the Economist and authors Duflo, Kremer and Robinson offer a potential solution using an example of why so few African farmers use fertilizer and how this can be improved. The quick answer is that the tendency to procrastinate can be overcome by small upfront time-limited subsidies. This small investment ends up being far less costly than doing nothing or offering a larger subsidy later in the year. What this suggests is that public officials should offer a grant to hospitals who invest in their pandemic cache (mask, antivirals etc) in the next year, but remove the subsidy quickly. This could overcome the inertia to do nothing because of pandemic fatigue or procrastination. Of course, how can we overcome our public officials' tendency to procrastinate? They do have bridges to fix. Thoughts?

The revolving door syndrome

For the second time in a week, I'll refer you to an interesting piece in the blog Effect Measure.

What is happening to public health departments?

There's an excellent piece in the Effect Measure blog on the shrinking resources in state public health departments. It's sad and scary...

Public health vs. clinical medicine

It’s a typical mid-summer day in Richmond—really hot and very humid. It’s my favorite time of the year (I must have been a plant in a previous life!). So I went to soak up the weather by washing my car. This is a mindless activity that I enjoy because it gives me time to think. I began to think some more about the issue of giving camp kids Tamiflu that I blogged about this morning. It’s a good example of the tension that exists between public health and clinical medicine. As an epidemiologist and a clinician, I can appreciate both arguments. But I have often found myself at odds with public health practitioners over issues like post-exposure prophylaxis. It seems to me that a lot of people in public health have a purist approach and a willingness to play the odds with risk that makes the clinician uncomfortable. Moreover, there’s a detachment that those of us who see patients can’t accept. Don’t get me wrong—I have great admiration for public health practitioners and the important work they do for little money or recognition.

As an example, following a case of meningococcal meningitis, my approach to who should receive postexposure prophylaxis is typically more lenient than my public health colleagues. Given the severity of the disease, the ease of giving a single dose of ciprofloxacin, and the comfort this provides to the contact and family members (a placebo effect of sorts), it doesn’t seem appropriate to me to make a big production of “the rules” about who should receive prophylaxis, especially since the rules are relatively arbitrary anyway. A death from an infectious disease may be viewed as a case by the public health community. To the clinician, it’s a patient—someone’s child, mother, father, brother or sister. A few years ago, I attended a conference about a rabies case given by a public health colleague. It was technically an excellent presentation, but what I remember most was how proud she was about how few doses of rabies prophylaxis were given to contacts of the case. All I could think about was how would she have felt if one of those contacts developed rabies? In the New York Times article from this morning we see the tension between Dr. Marc Siegel (the parent and clinician) and Dr. Anne Schuchat (the public health official), who seems to be applying the rigid rules in a not too empathic way. Maybe public health doctors should spend some time in the clinical setting to be reminded that behind every case of a reportable disease is a real human being and that decisions at the bedside are rarely so black and white.