The almighty influenza vaccine

A recent study in Clinical Infectious Disease that analyzed the effectiveness of the influenza vaccine for the 2014-15 season was sent to me by a colleague. Wow. Overall effectiveness (for influenza A and B combined) was a whopping 19%, but for influenza A was 6%. Honestly, placebo is more effective than that. For the 2015-16 season, overall effectiveness was 47%, and 55% for influenza A.

CDC used to cite that the flu vaccine was 70-90% effective, but more recently they have revised that significantly. I was quite surprised when I looked at the CDC website today and I made the graph below from their data.

In 12 consecutive flu seasons, effectiveness hit 60% just once. If you average those 12 seasons, the effectiveness was 41%. We are sorely in need of a better vaccine. The CDC analysis begs many questions: Should hospitals make this weakly effective vaccine a condition of employment? Should SHEA take another look at its guideline? Does anyone still believe that we should fire healthcare workers that are not vaccinated with a vaccine that provides such poor protection? How many hospitals fire employees who come to work sick with influenza? Would you rather be hospitalized at a hospital with a mandatory flu vaccine policy or a hospital that makes a serious attempt to minimize presenteeism?

CAUTI SCHMAUTI ! (part 4)

A new paper in Infection Control and Hospital Epidemiology takes us another step closer to reclassifying CAUTI from a healthcare associated infection to a healthcare associated myth. Tom Fraser and colleagues at the Cleveland Clinic worked with their ICUs to reach consensus to limit urine cultures in patients with fever to kidney transplant recipients, neutropenic patients, patients with recent GU surgery, and patients with evidence of urinary tract obstruction. One year later, here’s what they found:

• There was no significant change in urinary catheter utilization (approximately 70% of patient days were associated with catheter use 1 year before and after implementation of changes in ordering urine cultures).
• The number of urine cultures ordered fell by ~50%.
• The CAUTI rate fell from 3.0 to 1.9/1,000 catheter days, a significant reduction of 33%.
• There was no change in the rate of healthcare associated bloodstream infections, and no change in the subset due to Enterobacteriacae, which implies that there was no increase in bacteremic urinary tract infections. The potential for bacteremia is a major reason for treating CAUTI.

A similar study from Mayo Clinic showed similar findings (50% reduction in urine cultures ordered and a 30% reduction in CAUTI).

It would be interesting to know how many cases of C. difficile have been caused by treating this noninfection, or as the Cleveland authors call it, “an artificial construct designed to reflect clinical events for surveillance purposes.” And as we become more serious about antibiotic stewardship, “CAUTI” should be viewed as low hanging fruit.

In previous posts on this blog (here and here) there have been discussions questioning the existence of CAUTI. We now seem to be reaching a tipping point where it’s becoming increasingly clear that the opportunity cost of this medicalized artificial construct outweighs the benefit of continued focus.

Annual US Deaths from MDRO: 23,000 - Deaths from Alcohol Hand Rub Fires: Zero

I just returned from the Healthcare Epidemiology Training course in Ho Chi Minh City, Vietnam where I had a wonderful time interacting with the students and other faculty. Thanks to Professor Le Thi Anh Thu, we had the opportunity to tour an 1800-bed hospital in the city and observed many barriers to infection control including an average daily census greatly exceeding the bed capacity; many patients are forced to share beds with other patients. However, in one area Vietnam is far superior to the United States - they allow alcohol hand rub at the bedside! You can see Joost Hopman, Andreas Voss and I touring a medical ICU in Vietnam - notice the green hand rub dispensers at the end of the beds.

In the US, fire code prevents alcohol hand rub from being placed at the bedside rendering the practice of the WHO 5 moments impossible. Healthcare workers simply don't have the time to leave the room to practice hand hygiene after each contact with the environment or patient. 

Here is the WHO's take on the fire risk of alcohol hand rubs: The benefits of the alcohol in terms of infection prevention far outweigh the fire risks . A study in Infection Control and Hospital Epidemiology (Kramer et al 2007) found that hand rubs have been used in many hospitals for decades, representing an estimated total of 25,038 hospital years of use. The median consumption was between 31 L/month (smallest hospitals) and 450 L/month (largest hospitals), resulting in an overall consumption of 35 million L for all hospitals. A total of 7 non-severe fire incidents were reported. No reports of fire caused by static electricity or other factors were received, nor were any related to storage areas.

So let's review the US situation:

Deaths from resistant bacteria? 23,000

Deaths from alcohol hand rub fires? 0

Changing state fire codes to allow alcohol hand rubs at the patient bedside? Priceless

108 years

This one is for Steve Goodman:

A few more videos of this iconic Cubs fan who died too young:

The M. chimaera How-to Guide

A few cases at a time, the M. chimaera outbreak associated with heater cooler units continues to grow. For reasons unclear to me, the response from CDC and FDA to this train wreck in slow motion has been underwhelming. We continue to field calls from hospitals struggling to deal with an approach to the outbreak. On today’s IDSA list-serv (IDea Exchange) Dr. Luther Rhodes wrote: “The silence is deafening. I call on those physicians with hands on experience in evaluating post open heart patients referred to ID for evaluation of concerns, signs or symptoms of possible NTM infection to speak up loudly and clearly. Lessons learned, protocols developed, evaluation and testing tools learned dealing with large scale regional patient notification should in my opinion be shared…”

We have posted several times on this topic, but I thought it might be useful to summarize how a hospital could approach this problem in a single post. To view older posts, type chimaera in the search box in the top right hand corner of your display.

Step 1: Determination of risk
Whether you have seen a case or not, the first question is whether your hospital has used the LivaNova Sorin T3 heater cooler unit (HCU) in the last six years. If the answer is no, there is no immediate action you need to take. If yes, then the investigation begins, as you must assume the units are contaminated, regardless of the manufacturing date.

Step 2: Risk mitigation
If you are currently using the LivaNova (Sorin) T3 unit, the most important risk mitigation strategy is to get the units out of the operating room. The molecular epidemiology clearly points to contamination of the HCUs at the manufacturing facility, which allows the units to produce an infectious bioaerosol that contaminates the operative field. Separation of this bioaerosol from the operative field is the key to eliminating the risk. Why the FDA won’t clearly state this is very puzzling.

At the University of Iowa Hospitals and Clinics our engineers were able to quickly (within a few days) devise a solution by creating a 6” x 6” hole (see photos) through the operating room wall on the semi-restricted side of the room. The area identified for creation of this portal was determined by hose access to the OR table with minimal interference with staff and equipment; access to power; and the ability to leave proper corridor width per life safety code. Testing demonstrated that positive pressure was able to be maintained in the OR after creation of the portal. The portal itself with a sliding door was constructed of Corian in some cases and stainless steel in others. A hose protection mat was placed in the ORs to protect the HCU hoses and to provide a ramp effect for equipment to be relocated as needed during the cases. One advantage of the T3 HCU is that remotes can be purchased that allow the perfusionist in the OR to control the HCU located outside of the room. Once the HCUs were moved out of the OR, we demonstrated no difficulty with appropriate heating or cooling. Remember, given the long incubation and detection period of these infections (maximum 6 years to date), if you do not eliminate the risk now, you will likely be chasing cases for many years with no end in sight.

Outcome bias

I grew up in Wheaton, Illinois, one of Chicago’s western suburbs, and became a Cubs fan by default. All my friends were Cubs fans, my dad took us to Wrigley for games (never Comiskey!), and the Cubs games were televised on channel 9 while the White Sox were usually on a UHF channel (44) that was hard to tune in (if you remember wiggling a dial to get your grainy local UHF signals, you are old like me). The photo above is from a game I attended in 1969 with my family. That year, and every year since 1945, ended the same way: with the Cubs failing to win the NL pennant. 

So last night’s victory is a gigantic step forward for the Cubs, who will now play Cleveland in the World Series. By now you’re asking, “yes, but that’s a game and this blog is about infection prevention, what’s the connection”?

See Cub manager Joe Maddon’s quote in this piece, about how he approaches challenges:

“When you get to this particular moment, to try to avoid being outcome-biased, just . . . continue to work on the process, which is inning by inning — score first, win the inning. Those are the kind of thoughts that get you beyond this moment.”

I think you can interpret this quote in two ways, each of which applies to infection prevention. 

First, he may have meant to say “avoid being outcome-focused”. In other words, stop wasting energy worrying about your outcomes, instead put your energy into the processes that you know will, eventually, move the outcome in a favorable direction. This is becoming increasingly difficult in infection prevention as CMS PFP programs put more and more pressure on rates. The temptation is to put time and energy into activities that might impact the outcome quickly but without doing anything to improve the safety of patients (gaming the definitions, empiric treatment approaches, changing lab practice). Counterproductive, and in many cases also bad for patients.

Alternatively, he could have been literally referring to “outcome bias”, which is an error in evaluating the quality of a decision, or the effectiveness of a practice, when the outcome is already known. This might lead one to deviate from an effective practice because a bad outcome occurred in the past when the practice was in place, or to institute a dubious practice because prior implementation was coincident with a favorable outcome. This ignores the fact that outcomes are often influenced by a myriad of factors, many of which are not understood or not under the decision-maker’s control.

The infection prevention take-home from either interpretation? Focus on those practices that have been demonstrated to improve outcomes--keep your eye on the process and the outcomes will follow. Avoid gimmicks that might move the outcome needle but for which no evidence exists that patients will benefit.

P.S. I hope to see you at IDWeek in New Orleans!  I'll be joining Debbie Goff on Saturday morning to talk about social media, and Thursday will be facing off with Cliff McDonald about the C. difficile screening issue!  We will also be presenting four-center data on the ongoing M. chimaera outbreak on Saturday afternoon. If I am mysteriously absent from any of the above, it's because I'm on a plane headed to Cleveland or Chicago, to try to sneak in to a World Series game!

Time, Power and Infection Prevention

With the increased attention to infection prevention and antimicrobial resistance globally, we now have more seats at the table. In fact, many of us are or will soon be at the table in positions of leadership (power) in our hospitals or organizations. We can include our colleagues at CDC, who are being asked to do more and manage larger research portfolios. The time we imagined 10-20 years ago, where our clinical and research roles would be appreciated is now, but with the now comes an overwhelming urgency - we are overworked.

With that in mind, I read a very interesting post by Maria Popova on UC Berkeley psychologist Dacher Keltner's book, The Power Paradox: How We Gain and Lose Influence. Two quotes in particular struck me as they applied to our current situation as hospital epidemiologists and infection preventionists:

"The power paradox is this: we rise in power and make a difference in the world due to what is best about human nature, but we fall from power due to what is worst. We gain a capacity to make a difference in the world by enhancing the lives of others, but the very experience of having power and privilege leads us to behave, in our worst moments, like impulsive, out-of-control sociopaths"

"But in reading these alarmingly consistent studies, I had to wonder about one crucial confound(er) that remains unaddressed: People in positions of power also tend to be busier — that is, they tend to have greater demands on their time. We know from the now-iconic 1970s Good Samaritan study that the single greatest predictor of uncaring, unkind, and uncompassionate behavior, even among people who have devoted their lives to the welfare of others, is a perceived lack of time — a feeling of being rushed. The sense of urgency seems to consume all of our other concerns — it is the razor’s blade that severs our connection to anything outside ourselves, anything beyond the task at hand, and turns our laser-sharp focus of concern onto the the immediacy of the self alone."

I encourage you to read her full post and ponder how the Power Paradox might (or might not) apply to our new and larger roles in infection prevention. For example, I've noticed during discussions at national meetings and in peer-reviewed publications that we're blaming healthcare workers if they don't wash their hands or criticizing physicians if they overprescribe antibiotics. Keltner suggests that the Paradox can be handled by putting our focus on other people including empathizing, giving, expressing gratitude, and telling stories. It might seem that our focus on others (patients) might protect hospital epi folks, but what about the people we need to work with if we're to be successful - other healthcare workers?