30 January 2009

1st Global Health Blog Carnival: The posts are in!

Readers, there has been a metric ton of new MRSA research released in the past few days, and I am slogging my way through it. (On your behalf. No, no, no need to thank me.)

So, more to come. But in the meantime, I wanted to draw your attention to the aggregated posts of the Global Health Blog Carnival, which I mentioned yesterday. They are listed at Christine Gorman's very fine blog Global Health Report. Malaria, decision-making, anti-smoking, current health v. future health ... oh, go click. I'll be back soon.

29 January 2009

Prevention v. treatment (1st Global Health Blog Carnival!)

Constant readers, about a dozen of us who are interested in global health are co-blogging today in a Global Health Blog Carnival. If you are on Twitter, search the hashtag #ghnews. If you're not, we will try to get them all linked somewhere. This was organized (to the degree that blogger organize, which as you can guess is like herding small felines) by reporter and blogger Christine Gorman, formerly of TIME Magazine.

Our theme for today is prevention v. treatment. Fortuitously, the New England Journal of Medicine today is publishing an editorial (for which they have posted the free full text) that reminds us of the full burden and cost of MRSA. Drs. Cesar A. Arias and Barbara E. Murray say:
Faced with this gloomy picture, 21st-century clinicians must turn to compounds developed decades ago and previously abandoned because of toxicity — or test everything they can think of and use whatever looks active. ...
It is more difficult than ever to eradicate infections caused by antibiotic-resistant "superbugs," and the problem is exacerbated by a dry pipeline for new antimicrobials with bactericidal activity against gram-negative bacteria and enterococci. A concerted effort on the part of academic researchers and their institutions, industry, and government is crucial if humans are to maintain the upper hand in this battle against bacteria — a fight with global consequences. (NEJM 360(5):439-443)
As we've discussed time and time again, MRSA is increasingly common worldwide and increasingly costly to treat. Moreover, what has been presented by some as the first line of prevention for hospital-acquired MRSA — active surveillance and testing programs, also called "search and destroy" — is deeply controversial.

So what's the next step? Well, in the past, when medicine has wanted to nullify an infectious disease threat, it did not rely only on surveillance or asepsis; it developed a vaccine. And there have been a few efforts to develop a MRSA vaccine, which are recapped in a new article in Infectious Disease Clinics of North America (yes, that's a journal):
The most extensively tested vaccine against S aureus, which is a capsular polysaccharide-based vaccine known as StaphVAX, showed promise in an initial phase 3 trial, but was found to be ineffective in a confirmatory trial, leading to its development being halted. Likewise, a human IgG preparation known as INH-A21 (Veronate) with elevated levels of antibodies to the staphylococcal surface adhesins ClfA and SdrG made it into phase 3 testing, where it failed to show a clinical benefit. ... Given the multiple and sometimes redundant virulence factors of S aureus that enable it to be such a crafty pathogen, if a vaccine is to prove effective, it will have to be multicomponent, incorporating several surface proteins, toxoids, and surface polysaccharides. (23 (1): 153-171)
Several longtime MRSA researchers, including Dr. Robert S. Daum of the University of Chicago, who wrote the first paper calling attention to community-associated MRSA in 1998, have called for a vaccine to be made a research priority.

Any thoughts, constant readers? In the public mind, right now, vaccines are at a low point: People are turning away from them, manufacturing problems have led to shortages, and pharma no longer finds vaccine manufacturing a lucrative business sector. If a MRSA vaccine were developed, would you take it yourself before surgery, or give one to your children?

28 January 2009

About handwashing: Here's a resource for kids

If you have young teens or younger, here's a fun resource aimed at persuading them to wash their hands. (And if you don't, it might tune you up to pre-teen culture):

Mitchel Musso, who plays the boy best friend on the Disney TV Show Hannah Montana, has filmed a public service announcement TV spot: "Clean Hands Are Cool Hands."

It's part of a campaign sponsored by the Hospital Corporation of America (HCA) and Steris Corp., which makes infection-control and surgical gear. The kid side of the site has behind-the-scenes cuteness — music, photos, video outtakes; the parent/teacher side, medical information, lesson plans, posters and stickers.

Can't hurt. May help. Cute.

27 January 2009

More MRSA in meat, and not just pork

In my excitement over the paper by Tara Smith and team on Friday, I failed to sufficiently emphasize an important new finding. (I included it in my story for ScientificAmerican.com, but it was toward the end.) I feel it deserves a post of its own, so here it is:

The Food and Consumer Product Safety Authority of the Netherlands has found MRSA in 12% of 2,217 samples of meat on sale in the country, including not just pork, but beef, lamb, chicken, turkey and game birds, and 85% of the bacterial isolates were the"pig strain" ST 398.

We have talked before (all posts here) about the potential risk of MRSA in meat, especially ST 398 because it seems to have found a preferred host in pigs. In this study, however, the meat most likely to carry ST 398 was not pork, but turkey, followed by chicken and then by veal, and then by pork.

So what does all this mean? It's still probably too early to tell: Recall that the first isolations of this bug were in 2004, there have still been only a few papers on it, and this finding by Smith and team is the first identification of the strain in the United States. (Though not in North America, as it was identified in Canada in 2007.) It seems likely that ST 398 may have found a niche in other food animals, and that it contaminates the meat when the animals are slaughtered.

The consensus among the Dutch, though, is that this is an effect of the use of antibiotics in food animals. The romantic image of the Netherlands is as a cute little collection of postage-stamp family farms, but the reality, especially in the southeast of the country, is that they have substantial industrial-sized farms housing thousands of animals on relatively small properties. The only way to grow animals efficiently under such conditions is to keep very close tabs on potential illness, and liberally deploy antibiotics when necessary. (NB, I am not talking here about sub-therapeutic, growth-promoting use, but rather prophylactic antibiotics, given to an entire herd when a certain percentage of the herd shows sign of illness.) Evidence for this, according to the current study's authors: Meat sold as "biologic" — that's "organic," in the US — had a much lower rate of contamination with ST 398.

There are still very few reports of human illness from ST 398, though of those reports, some are quite serious, including wound infections and endocarditis. The concern here, as the researchers interested in it have been saying from the start, is that someone will inadvertently colonize themselves with the organism by touching their eyes or nose while handling meat contaminated with ST 398. Colonization does not necessarily lead to disease, but it does lead to a far greater pool of organism potentially spreading unmonitored through human and animal populations, swapping resistance and virulence factors as it goes.

So, you know what I'm going to say: Wash your hands, wash your hands, wash your hands.

24 January 2009

The havoc resistant bugs can wreak: Mariana Bridi, RIP

Constant readers, you may not have seen this story: It has been moving very fast over the past few days, has now concluded, and is very sad.

Mariana Bridi, a 20-year-old Brazilian who was twice a finalist in her country's preliminaries of the Miss World competition, died this morning of severe sepsis after a brutal battle that included amputations of her hands and feet.

The bug that caused her death: drug-resistant Pseudomonas aeruginosa. Pseudomonas is a Gram-negative bacterium, and there is a great deal of concern in the infectious disease world about the lack of drugs in the pipeline for Gram negatives.

Bridi apparently had a urinary tract infection. She was initially diagnosed with kidney stones, which she apparently did not have; but the diagnosis suggests she was having sharp pains around the areas of her kidneys or in her lower back, which a UTI can cause if it spreads upward from the bladder. Ascending UTIs are more likely to spill over into the bloodstream, causing bacteremia and triggering sepsis, in which the immune system goes into overdrive in response to the overload of bacteria in the blood. One of the hallmarks of severe sepsis is DIC, disseminated intravascular coagulation, in which micro-clots form in small blood vessels and block circulation, killing the tissue downstream. Sepsis is an extreme emergency; in the past, one-third of people who developed sepsis died, though new modes of treatment have improved those numbers.

What a sad story.

UPDATE: KevinMD.com has an excellent analysis of the case, with contributions from other physicians in the comments. Important point: Pseudomonas is usually a nosocomial organism. If it is correct that Bridi picked up the bug out in her daily life, as opposed to during a prior hospital admission, that would be a very troubling development.

23 January 2009

Appearing tonight at SciAm.com

Folks, last summer I told you about the very exciting though disturbing development of ST 398 MRSA — the "untypable" Dutch strain that originated in pigs and spread to humans — being found in pigs in the US for the first time.

But here's the brand-new second half of that story: It was found in pig handlers as well, on a set of linked farms — a closed production system that takes pigs from birth to just before slaughter — in Iowa and Illinois.

The full study has just been published, in the online Public Library of Science journal PLoS One.

And I have a story describing the research and the background — and the alarming spread of ST 398 in Europe — up tonight at ScientificAmerican.com.

The cite is: Smith, TC, Male, MJ, Harper, AL et al. Methicillin-Resistant Staphylococcus aureus (MRSA) Strain ST398 Is Present in Midwestern U.S. Swine and Swine Workers. PLoS ONE 4(1): e4258 doi:10.1371/journal.pone.0004258

UPDATE: Lead author Tara Smith talks about the paper at her own blog, Aetiology. And for good measure, her Science Blogs sibling (AKA "scibling") Ed Yong discusses the paper at Not Exactly Rocket Science.

Well, this is bad news.

Hi again, constant readers - yes, eye-deep again in a chapter, and sinking. About which: Is there anyone there who remembers staph 80/81 and would like to talk about it? Email me, address in the right-hand bar.

And now to the bad news. I am coming to this story late, but truthfully I am not even sure how late, as it seems to have trickled out without fanfare, and different media have covered it at different times over the past month. At any rate: The FDA has quietly reversed a decision it took last summer, and will allow cephalosporins, a human medicine, to be used without restriction in food animals.

What's a cephalosporin? The best-known one is the very commonly used drug Keflex (cephalexin), which you might take for tonsillitis or bronchitis - not a drug that you want to stop working because bacteria have developed resistance to it. (Yes, MRSA already has.)

Supporting material, tracking backward: A notice from the National Academies of Science news office from two days ago is here. An NPR story from Dec. 29 is here. A lengthy essay hosted by food-safety expert/attorney Bill Marler is here. A statement from the Pew Charitable Trusts' Campaign on Human Health and Industrial Farming, dated Dec. 12, is here. A short story from the Wall Street Journal, dated Dec. 9, is here.

Here's where I think this all ends up: On Nov. 25, the FDA put a note in the Federal Register announcing that it was reversing its earlier, July 3 decision to put curbs on the "extra-label" — anything not specifically allowed by the label — use of cephalosporins in animals. (Here's a July 16 Q and A explaining what it was prohibiting.)

The reason for the revocation of the ban/permission to use without restrictions, the FDA said in the Nov. 25 notice, was that it had gotten so many public comments on the ban — which was supposed to take effect Nov. 30 — that it decided the only appropriate action was to lift the ban until it could fully consider whether to reimpose it. And, because it was a revocation of a previous order and not a new order, it did not have to give advance notice.

As to what this means, consider this stinging op-ed from John Carling, former governor of the very agricultural state of Kansas, and chairman of the Pew Commission, which produced a mammoth report last year on industrial-scale agriculture:
The rest of the world has leapt ahead of us on this issue. In Europe, antibiotics have long been eliminated from food production. South Korea followed suit this summer. Our refusal to turn away from this practice could cost us markets for our food products overseas and, by extension, precious jobs here at home.
The Pew Commission was composed of farmers, doctors, veterinarians, economists and other talented professionals who took on the challenge of finding a model that would allow U.S. farmers and ranchers the freedom to pursue their livelihoods in a way that does not adversely impact public health, the environment and the economies of their communities.
We believe we found such a model, and it included phasing out the indiscriminate overuse of antibiotics.
Changing the way agriculture works in this country will likely prove challenging, and involve many difficult decisions.
It's a tragedy that on this occasion the FDA took the easy — and more dangerous — way out.

19 January 2009

US Air 1549 and the relevance of checklists

Constant readers, when we discussed the importance of surgical checklists last week, I mentioned parenthetically that I am a licensed pilot. (For av geeks: single engine, taildragger, VFR. And, just to complete the geekery, married to an avionics engineer.) So I've been particularly fascinated by the story and back-story of US Air flight 1549, which — as I am sure most of you know — bellied into the Hudson last week after losing both its engines to bird ingestion and landed beautifully, with no injuries to its passengers or crew.

The landing is being called a miracle, but to a pilot, it's no miracle: It's a testament to excellent performance under pressure by pilot-in-command Chesley “Sully” Sullenberger III and his first officer and crew. How did they perform so well? They ran down a checklist. Why did they reach for the checklist immediately, almost instinctively, and perform so well as a group? Because they trained many, many, many times to do exactly that.

Last week's New England Journal of Medicine article made clear the value of checklists to medicine. But patient-safety analyst Bob Wachter asks an additional vital question: Even when medicine has such measures, how often do we train to implement them? The answer, he finds, is not often:
We need to continue to work, as aviation has for the past generation, to train our "pilots" to become Sullys. Because we in healthcare are flying over some pretty cold rivers, each and every day.
(Hat tip to KevinMD.com for calling attention to Wachter's post.)

Are *you* a germophobe?

I have a feature in the new February edition of SELF Magazine. (For readers outside the US, SELF is one of the largest magazines aimed at women 18-40 — and it has a ton of international editions, so it may well be on your newsstands too.)

It's titled "Germophobia," and it's a light-hearted but also serious look at how we can live without paranoia in a microbial world.

16 January 2009

A timely reminder on using antibiotics well (and badly)

The Infectious Diseases Society of America, the professional organization for ID physicians, is criticizing large grocery store and pharmacy chains for giving antibiotics away for free. (Yes, you read that right: Not generic, not cheap, free. Here is a Wall Street Journal Health blog post explaining the practice, which has become quite common over the past two years.)

IDSA is concerned of course that these antibiotics will be used inappropriately because, being free, they will have a perceived lesser value. The Centers for Disease Control and Prevention has been campaigning for years against inappropriate antibiotic use, via its Get Smart: Keep Antibiotics Working campaign.

(Why is it important to use antibiotics only for the things they work against? All together now: Because if used inappropriately — in too-low doses, too-short courses, or against an illness where they are not useful — they will encourage the development of resistant bacteria, and also may kill your own commensal bacteria, clearing a niche that resistant ones can then occupy. Very good, class, early dismissal today.)

There's an additional, interesting twist to these campaigns, though, which IDSA very rightly raises: They are taking place now, in flu season. One of the most common inappropriate uses of antibiotics is against viral diseases such as flu; the CDC says:
Tens of millions of antibiotics prescribed in doctors' offices each year are for viral infections, which cannot effectively be treated with antibiotics. Doctors cite diagnostic uncertainty, time pressure on physicians, and patient demand as the primary reasons why antibiotics are over-prescribed.
IDSA is quite rightly concerned that the launch of these free-pill programs in flu season will reinforce the association between flu and antibiotics, which is precisely the association that causes antibiotics to be most overused. An excellent point.

15 January 2009

This is what hand hygiene looks like

Contant reader Robyn pointed out an amazing image in the New England Journal of Medicine issue I discussed below. I missed it (thanks, Robyn!), so I went back and retrieved it. Here's what you're looking at:

The Cleveland Veterans Affairs Medical Center discovered via a routine nasal swab that a quadriplegic patient was colonized with MRSA; the patient had not had any signs that would have indicated an infection. To satisfy their curiosity over how much MRSA a healthcare worker might pick up from a patient whom they did not know was colonized, they had a health care worker do an abdominal exam of the patient — let's underline that: abdominal; nowhere near his nose. Then they pressed the worker's hand onto a growth medium that had been tuned with antibiotics so that it would allow MRSA to grow but suppress other bacteria.

That's what you're looking at above. All of that red is MRSA. The image on the right is what grew after the same worker did hand-sanitizing with alcohol foam and then pressed the same hand onto an identical culture plate. What's growing? Nothing at all.

Here's the back story, quoted from NEJM (re-paragraphed):
A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found on routine surveillance cultures to have methicillin-resistant Staphylococcus aureus (MRSA) colonization of his anterior nares. He had no history of MRSA infection or colonization.
To assess the potential implications of the patient's MRSA carriage for infection control, an imprint of a health care worker's ungloved hand was obtained for culture after the worker had performed an abdominal examination of the patient. The MRSA colonies grown from this handprint on the plate (CHROMagar Staph aureus), which contained 6 µg of cefoxitin per milliliter to inhibit methicillin-susceptible S. aureus, are pink and show the outline of the worker's fingers and thumb (Panel A).
With the use of a polymerase-chain-reaction assay, the mecA gene, which confers methicillin resistance, was amplified from nares and imprint isolates. After the worker's hand had been cleaned with alcohol foam, another hand imprint was obtained, and the resulting culture was negative for MRSA (Panel B).
These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant pathogens.
The cite is: Donskey, Curtis J., Eckstein, Brittany C. IMAGES IN CLINICAL MEDICINE: The Hands Give It Away. N Engl J Med 2009 360: e3

UPDATE: The tireless and too-seldom-thanked crew at ZoneGrippeAviare, who provide pandemic news for the Francophone community, have translated this post into French. Mes mercis respectueuses!

14 January 2009

Reducing errors: Worldwide proof that it's not so hard

There's an encouraging joint announcement coming this afternoon from the World Health Organization and the New England Journal of Medicine. (I've set the timer on this post to publish when the embargo lifts.)

Using a simple but detailed checklist, eight hospitals in a mix of high-income and resource-poor areas were able to reduce their rates of surgical complications by one-third and their rate of death due to surgical complications by almost one-half.

The checklist study was sponsored by the WHO's Safe Surgery Saves Lives campaign. It was headed by surgeon and author Atul Gawande, MD, who is lead author of the NEJM paper and has spoken passionately about checklists as a simple, reliable, reproducible, low-cost intervention that can return extraordinary improvements.

The checklist idea originates in medicine with Dr. Peter Provonost, Johns Hopkins University critical-care researcher and MacArthur "genius" fellow. Gawande wrote a profile of Provonost, and plea for checklist implementation, in the New Yorker in Dec. 2007, and followed that article two weeks later with a New York Times op-ed piece.

The checklist idea has been borrowed from other tech-intensive fields, notably aviation. As a licensed pilot, I can testify that no pilot or crew, no matter how experienced, would ever dare take off without running through a checklist. To believe that you can keep everything you need to do in your head without reference to an external reminder is, in aviation, simply not a credible position. It is considered an absurd display of ego that puts others at unnecessary risk. (For a taste of how aviation looks at medicine's resistance to improvement, see Sir Richard Branson's comments last month.)

In the current study, one hospital in each of eight cities — Toronto, New Delhi, Amman, Auckland, Manila, London, Seattle and Ifakara, Tanzania — agreed to follow a pre-, during- and post-surgery checklist for every noncardiac surgery on patients older than 16. The study group collected data before implementation of the checklist on 3,733 consecutively enrolled patients, and during the checklist implementation, on 3,955 patients.

The checklist is on the WHO website (.pdf in English) along with toolkits for implementation. If you look, you'll see it is very simple. For instance, before anesthesia:
  • Patient has confirmed: identity, site, procedure, consent
  • Site marked (or marking confirmed not applicable)
  • Anaesthesia safety check completed
  • Pulse oximeter on patient and functioning
  • Does patient have a known allergy? (No/Yes)
  • Does patient have a difficult airway/aspiration risk? (No/Yes, and equipment/assistance available)
  • Is there a risk of >500ml blood loss (7ml/kg in children)? (No/Yes, and adequate intravenous access and fluids planned)
There are similar short, thorough and noncomplex checklists for before skin incision and before patient leaves the operating room. Amazingly — or not, for those of you who follow the struggle against medical errors — these interventions, simple as they are, were new to most of the study hospitals.

Now, the research team is careful to point out the possible confounders to this study: It introduced changes in systems at the hospitals that may have created independent effects. It may suffer from the Hawthorne effect ("Observation changes the behavior of the observed.") Given that it used consecutively enrolled patients, it may be affected by secular trends at the individual institutions. And it does not track complications post-discharge.

All that being said, I think we can take this as a very potent argument for the adoption of surgical checklists as a component of campaigns to reduce medical errors. And, as Gawande says in the press release that WHO put out this afternoon, a pointer to possible improvements in other specialties as well:
These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields... [I]n specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope.
The cite on the study is: Haynes, AB, Weiser, TG, Berry, WR et al. Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Eng J Med 2009: 260: 491-9. Published ahead of print Jan. 14, 2009.

UPDATE: The full text has been placed online for free.

13 January 2009

Seriously, a global problem

Serendipitously, as I was preparing the previous post (an intro to GlobalPost.com, which will be featuring posts from SUPERBUG), an auto-push email from the National Library of Medicine's PubMed service landed in my inbox.

For those of you whose bedtime reading is not obscure medical journals (I know: This is what you have me for), PubMed is a search interface that allows you to pull articles for medical journals wordwide. It also offers a push option: Set a search term, fill in your email, and links to the latest articles on your term of choice are delivered. I have my search set to "MRSA" and have the results pushed once a week; there are never fewer than 25 new papers, which is a great gauge of how active an area of research — and how important a topic — MRSA is.

The latest push — 26 articles — vividly reminded me that, as NIAID Diretor Dr. Anthony Fauci said a few months ago, we are in the midst of "a global pandemic."

Here is a sampling of those latest papers, from, again, a single week:

No question, constant readers: What we are talking about here is an international problem, a truly global bug.

12 January 2009

"Pig MRSA" in New York City - via the Dominican Republic?

Folks: Back in October, I broke the news for you of an intriguing poster presentation at the ICAAC meeting. It revealed the discovery of ST 398, the anomalous staph strain found in pigs, pig farmers and health care workers in Europe, in residents of a Dominican-immigrant neighborhood in northern Manhattan, and also in the Dominican Republic.

Because there is so much traffic back and forth between those neighborhoods, the authors theorized that people are providing an "air bridge" for the bacterium — though they were unable to say whether the bug is moving from the Dominican Republic to the United States, or vice versa.

I was unable to link to that presentation at the time, because it was a meeting poster - yes, literally a poster, the authors stand by it to discuss it with anyone who wanders by. However, now it has been published as a paper, in the CDC journal Emerging Infectious Diseases; and because it is a CDC journal, the full text is available free online here.

Just to underline, despite my headline above, the strain found in NYC was not MRSA: It actually is MSSA, drug-sensitive staph. The ST 398 found in Europe, Canada and the American Midwest is MRSA. The authors hypothesize that the NYC strain is at risk of becoming MRSA also.

To see the multiple posts in this blog about MRSA ST 398 and other strains in the food chain, food animals, and pets, go to the labels under the time stamp on this post, and click "animals" or "food."

The cite for the paper is: Bhat M, Dumortier C, Taylor B, Miller M, Vasquez G, Yunen J, et al. Staphylococcus aureus ST398, New York City and Dominican Republic. Emerg Infect Dis. 2009 Feb; [Epub ahead of print]

GlobalPost launches and SUPERBUG is there

Constant readers, I am thrilled to let you know that SUPERBUG is among a select list of blogs invited to be featured on GlobalPost, a gutsy and innovative new online news site that launches today.

GlobalPost is the creation of Charles M. Sennott, formerly an award-winning foreign correspondent and bureau chief for the Boston Globe, and Philip Balboni, founder and former president of New England Cable News. The service links 65 foreign correspondents living in 46 countries. The founders say in their introductory note that they are:
...acutely aware of the fact that quality journalism in America is threatened more profoundly today than at any time in our history from an unprecedented combination of forces: the transformational power of technology and the internet, the dramatic erosion in the economic underpinnings of the traditional media, and a steady migration of the most devoted consumers of news as well as younger people to new content platforms, most importantly the web.
GlobalPost is a direct response to these forces. Our mission is to provide Americans, and all English-language readers around the world, with a depth, breadth and quality of original international reporting that has been steadily diminished in too many American newspapers and television networks. GlobalPost is at the leading edge of what we hope and believe will become a new flowering of journalism in the digital age, built around new models of financial support.

The site has a number of pages and options, and a notable commitment to transparency in its reporting. Sennott takes new visitors through the details in his editor's blog. For an outside take on why GlobalPost is worth reading and supporting, read editor and digital consultant Ken Doctor's thoughtful take.

I know that all of you who gather here regularly already understand the irrelevance of borders to infectious disease control. (For just a few recent examples, see the MRSA outbreak in a Prince Edward Island hospital, the astonishing lack of hand-washing in British health care, and the movement of the pig strain of MRSA from the Dominican Republic to New York City.)

And therefore I know you understand the crucial importance of reliable journalism from abroad. So please welcome this intriguing effort and visit the new site. I've placed a GlobalPost button in the right-hand column.

(And just to add, because it's important to say such things: No money is changing hands here. I don't get paid for being featured there, and there are no revenues accruing anywhere else. Also, nothing about being featured on GlobalPost changes anything we do or say here: The site remains on Blogger, and your comments stay within this community and continue to be moderated by me.)

06 January 2009

Hepatitis infection (lack of) control: Epic stupidity

This isn't about MRSA, but it's such a jaw-dropping example of infection control failure that I thought it was worth passing along.

A team from the Centers for Disease Control report today in the Annals of Internal Medicine that, in the past 10 years, infection control has failed so significantly that 448 people have become infected with hepatitis B or C and more than 60,000 had to be tested for potential infection. (And that is almost certainly an underestimate, since the team counted only previously recognized outbreaks of two or more infections, not single ones.)

Three are known to have died, though that again is probably an underestimate.

From the CDC press release (not yet online, I'll link when it is):
In the United States, transmission of HBV and HCV while receiving health care has been considered uncommon. However, a review of CDC outbreak information revealed a total of 33 identified outbreaks outside of hospitals in 15 states, during the past decade: 12 in outpatient clinics, six in hemodialysis centers and 15 in long-term care facilities.
Here are some of the actions that caused these infections:
  • reusing syringes
  • contaminating multi-dose vials with unclean syringes
  • using single-dose vials for multiple patients
  • re-using end-caps from single-use syringes
  • using fingerstick devices on multiple patients without cleaning
  • using blood-sugar measuring devices on multiple patients without cleaning
Just jaw-dropping. Because let's be clear: Hep B and C are potentially life-threatening diseases. These actions weren't just careless: They were life-endangering. And really, how hard is this? None of these actions should have been difficult or foreign; They represent the most basic steps in Standard Precautions (what used to be called Universal Precautions), which any health care worker ought to know from the beginning of his or her career, but which every health care worker ought to have by heart in the age of AIDS.

And, infuriatingly, there are probably many more such infections that remain undetected. From the paper:
...the viral hepatitis outbreaks reported here probably represent only a portion of the true burden of infection attributable to the receipt of health care in the United States. First, we included only nonhospital health care settings. ... Second, under-ascertainment of health care–associated viral hepatitis outbreaks is likely. Linking an outbreak to a single health care venue responsible for transmission is complicated by the long incubation period of HCV and HBV infection (up to 6 months)... Furthermore, many patients with HBV or HCV infection will be asymptomatic or have mild or nonspecific symptoms, resulting in infections that go undetected for many years. Finally, outbreak detection relies on thorough case investigation and successful identification of health care as a risk. Few health departments currently have the time, funds, personnel resources, or ability to address legal impediments to investigate viral hepatitis that may be health care–associated.
The cite is: Nicola D. Thompson, PhD, MS; Joseph F. Perz, DrPH, MA; Anne C. Moorman, BSN, MPH; and Scott D. Holmberg, MD, MPH. Nonhospital Health Care–Associated Hepatitis B and C Virus Transmission: United States, 1998–2008. Ann Intern Med. 2009;150:33-39.

Reporting MRSA - a few places see results

Happy New Year, constant readers. I hope you had relaxing holidays; I myself have been pounding the keyboard, forging through a chapter. (I hope to post pieces at some point, but I need to talk to my editor about when is the right time in the process.)

While I was out, there were a few interesting developments on mandatory reporting of MRSA infections, which we have talked about here, among other posts.

First, the Canadian province of Ontario has launched an amazing website that reports MRSA rates for all its hospitals and allows you to search all its hospitals by name or map location. This is part of an initiative launched last May by the provincial Ministry of Health and Long-term Care that created mandatory reporting for eight indicators of patient safety: C. difficile, MRSA, VRE, standardized mortality rates, ventilator-associated pneumonia, central line infections, surgical site infections, and hand-hygiene compliance. C. diff reporting began in September; MRSA, VRE and mortality rates rolled out on Dec. 30; and the other four will be reported from April 30.

When I look at the very incomplete patchwork of reporting we have achieved state by state in this country, I find the Ontario achievement just stunning.

But, some good news from the US also: Over the holidays, Virginia made its first report of invasive MRSA infections, acting on an emergency order written by Gov. Timothy Kaine following the death of a teen named Ashton Bond in 2007. Strangely, there is no sign of the report on the website of the Virginia Department of Health (if anyone knows where it has been posted, please let me know).[UPDATE: The Virginia DOH very kindly got in touch to say that the numbers are drawn from a set of spreadsheets that are hosted here.] The Virginian-Pilot said:
There were 1,380 invasive MRSA cases reported from Dec. 1, 2007, through the end of this November. The rate for this region of Virginia was 15 per 100,000 people, slightly less than the state rate of 18.
People 60 and older had the highest rate of incidence, and blacks had higher rates than whites. ...
Only about 30 percent of the cases reported to the Virginia Health Department listed a known outcome. Of those, there were 35 deaths.
The data do not distinguish between whether MRSA was acquired in a hospital or in the community. The state also doesn't require reporting of the less serious forms of MRSA that involve skin and tissue infections. (Byline: Elizabeth Simpson)
I especially applaud this caution, attributed to Dr. Christopher Novak, an epidemiologist with the Virginia DOH:
"Just because you're reporting it doesn't mean it's under control."