Good Intentions Does not Always Mean Good Policy

How often do negative studies influence our behavior, or better yet our policies? For those of you that are familiar with the work I have published, you know that I published a lot of material focused on MRSA; emerging resistance, community-emergence, burden of disease, attributable cost, risk factors, and on.  I was in a position at CDC to access and synthesize a lot of data, with a goal of putting the problem in perspective and ideally affect policy. Well intended as it was, I remember very clearly in mid-2007 when policy got way ahead of the science. Two independent (but related) events occurred on October 16-17, 2007 that led to several years of a watershed of policy developments. Although I give a huge amount of credit to the very passionate and important patient advocates and consumers that built momentum for the policies – but with hindsight the policy inertia was really overcome when a senior student at Staunton River High School died on October 16 from MRSA sepsis—MRSA he acquired in the community. The press linked that death to Dr. Elizabeth Bancroft’s editorial that same week stating “…more people die of MRSA in the U.S. than of AIDS” published on October 17. Many of us see much of the public reporting and mandatory reporting policies have opened up real pathways for additional hospital resources to invest in HAI prevention. However all of us should recognize some policies of that era are likely in place that really should be re-examined. 

One of these is the Illinois 210 ILCS 83/ legislation requiring all patients admitted to intensive care units be screened for MRSA by nasal active surveillance testing (AST). Lin and colleges just published a negative study with a lot of important findings. To many, the findings will not be a surprise (CID May 15 2018, pp 1535-1539)

• Lin worked with 51 intensive care units at 25 hospitals over 5 years starting within months of enactment of this mandate to evaluate any changes in ICU MRSA prevalence through periodic point prevalence surveys performed by trained study staff during the time of this mandate. The study was a quasi-experimental time series evaluation but without a real before observation group and no control group. However, I believe that any impact would have been additive over time – the first year would have been a sort of wash in period for an intervention as broad in participation as this.  They sampled 3909 patients having the power to even detect an absolute difference in carriage as small as a 1.9% change in prevalence (eg, 10% vs 8.1%) – but they detected none. No change in prevalence of MRSA on these patients. 
  

• Compliance was high overall (93%), admission prevalence was comparable to other studies (9.7%), and overall, at any given survey of known positive patients and unknown, 11.1% were positive in any given month, in any given year of this study.  Sure, time to placement of contact precautions lagged from test turnaround time or from time to test result to actual placement of precautions, but most notably the mandated testing was only 84% sensitive compared to best testing methods  employed by the study investigators. This is the real world after all.

• While these ICUs have invested time, effort, and money into these admission swabbing and targeted placement of contact precautions, the prevalence of MRSA carriage has not budged in these intensive care unit patients.

There may be many reasons the hospitals in Illinois overall are seeing an estimated 30% decrease in their hospital-onset MRSA BSI (as most states are) since the 2010 NHSN baseline, but admission screening isn’t one of them. Maybe its CLABSI prevention, or that uptake of the percentage of study patients receiving CHG baths. However, this study suggests it was not the mandated AST for all ICU patients admitted to the ICU. These patients are bringing their MRSA in with them, let’s free up staff time to prevent the infections.

I know there are many major federal policies we all can be passionate about changing or starting, these are crazy days. But when the scientific evidence is so strong illustrating that a very well-intended policy regarding use of nursing and infection control resources does not have the intended impact – change it. Nursing care can better be spent caring for patients, practicing best infection control for all patients in these intensive care units. 

Prevention and Public Health Fund, still a political football

We’ve blogged before about threats to the Prevention and Public Health Fund. Lest anyone think that a silly election would keep prevention funding safe from the axe, this piece, citing “GOP sources”, outlines the three most likely cuts to the Affordable Care Act that lawmakers hope to secure as part of a debt-reduction deal. You guessed it, the Prevention and Public Health Fund remains a prime target. From the article:

The Prevention And Public Health Fund
The prevention fund was designed to help local communities combat disease and promote wellness. Republicans deride it as a “slush fund.” 

Initially set at $15 billion, GOP leaders convinced the president and Democratic leaders to chop it by $6.25 billion in the payroll tax cut deal early this year. Having sensed that Democrats are willing to reduce its size, they’ll hope to continue chipping away at it.

Check out Eli’s post from earlier this year, as a reminder of how much of the CDC’s budget would be at risk if prevention funds are further slashed without a commensurate boost to the CDC's core budget. 

Addendum: I forgot to link to this list of the foolishness funded by this crazy slush fund. "Improving capacity to to detect and respond to infectious diseases threats", "enhancing the ability of state and local authorities to detect outbreaks", what kind of fool thinks these activities might be important?!

Photo from Wikipedia Commons

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

Public Policy as Human Experimentation?

I found this article in today’s NY Times to be fascinating. Although it is about salt restriction, it could easily be applied to legislative and other public policy approaches to infection control interventions.

An obvious example? Legislative mandates for active MRSA screening, and the Veterans Affairs system-wide directive to screen all admissions for MRSA. Given the lack of scientific consensus on the effectiveness of active MRSA screening approaches, these mandates amount to a huge natural experiment, with every patient admitted to the involved hospitals becoming a study subject. Worse yet, the conclusion is foregone—as invasive MRSA infection rates fall for other reasons, those states or healthcare systems that enforced screening mandates will claim that this intervention was key to their success.

This would all be fine if active screening for MDROs such as MRSA, combined with increased use of isolation precautions for asymptomatic carriers, had no associated risks. Alas, this is certainly not the case. It’s not just bad public policy, it’s harmful and wrong.

Prevention Strategery....

There was a congressional hearing yesterday on the "HHS Action Plan to Prevent Healthcare Associated Infections". Witnesses included the acting director of the CDC, director of AHRQ, Peter Pronovost, Rachel Stricof, and others. I haven't had a chance yet to read through it, but if you want some bedtime reading, you can access all of the testimony here:

http://appropriations.house.gov/Subcommittees/sub_lhhse.shtml