Infection Control Today - 04/2004: Clinical Update

Keeping Bugs at Bay
Preventing Outbreaks

By Kathy Dix

Epidemiologists have a unique role in healthcare preventing, identifying and tracking outbreaks. ICT spoke with several todetermine how to prevent outbreaks and how to identify the diseases that aremaking the public most nervous.

Influenza

Influenza is very common; 10 percent to 20 percent of thepopulation becomes ill with influenza, emphasizes Kristin Nichol, MD, MPH,chief of medicine at the Veterans Affairs Medical Center in Minneapolis and aprofessor at the University of Minnesota. Higher attack rates are seen incertain subgroups, especially school-age children, she points out.

Typical characteristics include the acute onset of fever,sore throat, headache, dry cough, muscle aches and myalgia, Nichol says. Influenza typically is this febrile upper respiratorysyndrome that tends to be more severe than a typical cold. Of course, fever andcough tend to be hallmark symptoms, especially in adult populations. Inchildren, fever and cough are still common, but sometimes we might seegastrointestinal symptoms that we tend not to see in older populations.

When asked how clinicians might distinguish influenza fromsevere acute respiratory syndrome (SARS), Nichol says, Remember that SARS isvery rare, at least in the United States. Even though it may have a much moresevere kind of presentation with a pneumonia syndrome associated with travel toappropriate parts of the world or exposure, because influenza is so common,someone presenting with almost any kind of respiratory syndrome is still so muchmore likely to have influenza than SARS, and of course this year we really haventseen SARS activity in North America to my knowledge. I think last year, peopleunderstandably were very aware of the SARS activity, especially in other partsof the world, but remember that in this country, up to 50,000 or more people ayear will die from influenza. That really overshadows at least in thiscountry risks from many other infectious diseases. I think while itsalways appropriate to be concerned about controlling other diseases, we mustntforget that influenza is here and we havent conquered it.

The 2003-2004 flu epidemic has certainly been the subject ofmuch media coverage; Nichol, who has spent more than a decade researchinginfluenza and its prevention, is pleased that finally, the public is payingattention. Ive been saying for a long time that influenza is a veryserious disease, and its complications especially can result in hospitalizationor death among certain groups, including the elderly, so I think maybe peoplehavent been as aware of the messages that have been out there, sheobserves. Influenza has been here for a long time. All we have to do ishearken back to the 1918 so-called Spanish flu pandemic in which 20 to 40million died. More of our combat troops died from the Spanish flu than fromcombat-related injury.

The Spanish flu, now thought to be related to an avian flu,was so potent that healthy young people were affected as strongly as thosegroups considered high risk. Not infrequently, the person would reportbecoming ill in the morning, report to the doctor in the afternoon, and in thenext day or two theyd be dead, Nichol says. Thats a very extrememanifestation of influenza in the world, but we still have very seriousmanifestations every year. Again, we are very concerned about preventing thenext pandemic, or being prepared for the next pandemic, but in the meantime weshould pay a lot of attention to regular old epidemic influenza.

Nichol continues, We have safe and effective vaccines, andthis year it may be that we will not have much left over, if any, because ofthis unusual peak in demand in December, which to my knowledge weve reallynever seen in this country. In past years, we have thrown away perhaps 10percent to 20 percent of influenza vaccine thats manufactured every year.What a shame! Every one of those doses is an opportunity to prevent influenza,or to prevent a potentially very serious complication.

Asked if there are other means of prevention besides vaccine,Nichol reinforces, Prevention with immunization is always the best strategy. There are some medications for prophylaxis or prevention aswell as for treatment if started within two days of the onset of symptoms. Butespecially for people in certain high priority groups, we do recommendimmunization as the best strategy. Vaccines are safe and effective, and thisyear we now have the nasal spray vaccine for people 5 to 49 years of age.

Although certain high-priority groups are particularlysusceptible, Nichol says that national recommendations acknowledge thatimmunization can be beneficial for just about everybody. Thosehigher-priority groups include the elderly, people with underlying chronicmedical conditions, people in nursing homes, women who are pregnant or willbecome pregnant, children and adolescents on aspirin because of risk for a veryrare complication of influenza called Reye syndrome, children six to 23 monthsof age, and household contacts and healthcare providers.

As for those who protest that they fear the shot, or those whohave reported reactions to the shot in the past, Nichol says, Its alwayshard to know how to interpret reports like that. She explains that illnessassociated with a flu shot may actually have been from an illness alreadypresent that would have caused symptoms even without the shot.

You might think your immune system didnt like it, shesays. But placebo control trials have demonstrated with flu shots that thereare no differences in systemic symptoms, but we do see a difference in mild tomoderate arm soreness, she continues. With the nasal spray vaccine,children and adults who receive that vaccine do tend to have some mild upperrespiratory symptoms for a few days; thats to be expected, though, becausethis is an attenuated or weakened virus. Those very weak but live viruses thenstimulate the immune system of the individual through that route ofadministration, so some people have a mild stuffy nose, or a minor sore throatfor a couple of days, but again, fever tends not to be a significant findingwith either vaccine in large groups.

Nichol adds, I would focus on the enemy thats here everyyear. Influenza is making tens of millions of people in this countrysick every year and causing hundreds of thousands of hospitalizations, and tensof thousands of deaths, and we should really be concerned about this enemy inour backyard.

And, Nichol continues, Hands down, vaccination is the mostcost effective way to prevent and control influenza. Some antiviral medicationshave been approved by the FDA not only for treatment but also for prevention. Ofcourse, one has to take the medication throughout the outbreak period.

Nichol points out that even for people who do not developcomplications, the flu is a really miserable experience. People are sick fiveto six days, but 20 percent are sick 10 days or longer. People miss on averagetwo to three days of work or school. Influenza is the most common cause ofschool and work absenteeism due to acute conditions in this country. Its a huge disease burden. But, she says, Things canchange. We have a lot we can do for humankind if we do a better job ofcontrolling influenza.

General Prevention

There are other options to prevent infectious diseases, saysPaula Keller, technical director of epidemiology at William Beaumont Hospital insuburban Detroit. From what Ive seen in my career, the most effective wayto prevent outbreaks is concurrent surveillance, she says. If people arelooking at infections within the hospital in real time, not two months later,you can identify a cluster, and you can initiate control measures immediately.If youre doing targeted surveillance and looking, say, only at surgical siteinfections (SSIs), you can miss a vent-associated pneumonia outbreak, or acluster of clostridium difficile, or other types of outbreaks. The best way to prevent an outbreak is administrative support,and to provide adequate staffing of the infection control department, she says.

Some facilities do not have enough surveillance staff; itdepends on administrative support, Keller says. Here at Beaumont, we havestrong administrative support, and we do complete surveillance in our ICUs. Wealso do total house surveillance for bloodstream infections, all SSIs, allresistant organisms, and c. difficile. We report all infections resultingin secondary bloodstream infections. With this detailed surveillance, we areable to identify any clusters of infection. If we see two or three nosocomialMRSA infections on a single unit, we can initiate control measures right away,and as a result, and we havent seen any outbreaks in years.

Kellers medical director is a CDC-trained epidemiologist.I think that a strong medical director is a big predictor of goodadministrative support, she observes. A doctor who really understands epidemiology who is committed to epidemiology as opposed to doing it as a sideline isa huge asset to any infection control program.

Kellers facility initiated a respiratory etiquette orrespiratory hygiene program as recommended by the CDC. It is quite simple,merely reinforcing what your mother always said, Cover your mouth when youcough, wash your hands, throw used tissues in the trash, she says. Wehave placed signs at all of our registration and information desks. We havetissues, surgical masks and alcohol gel available at these desks, so people cancover the nose and mouth with a tissue when they cough, discard the tissues, andthen use the alcohol gel to cleanse their hands. If they cant reliably cover the nose and mouth when theycough, well give them a surgical mask. This process can not only reduce therisk of transmission of the flu, it should also reduce the risk of spreading anyairborne or droplet-spread disease in our waiting rooms.

The patient response has been very positive, Keller says. Thefeedback Ive gotten from all of our clinics and ambulatory sites is thatpatients respond very well to this. They really appreciate the concern for theirhealth. Most people want to do whats best for the greater good. Very few people are interested in infecting others.

Although SARS has not been much of a problem for the U.S. thisyear, it is crucial for physicians in areas at high risk for SARS to be able toidentify which patients have a coronavirus and which have influenza. But tellingthe difference is not easy. From everything Ive read, there is no rapiddiagnostic test, and truly what we can best rely on is travel history, Keller says. Even before that we want to take precautionsagainst any droplet spread, to healthcare workers, other patients or tovisitors.

Of course, the basic, most effective method of infectioncontrol is handwashing. Keller references a Chicago Tribune article fromsummer 2003, which focused on handwashing. It was very sensationalized, butroutine handwashing between every patient is just so important, Keller says.I find it interesting that many actions considered good manners arealso good infection control measures: covering your nose and mouth when youcough, washing your hands after going to the bathroom.

After months of being on high-alert status, it is easy forvigilance to wane somewhat thus the spread of infectious organisms from thelack of appropriate handwashing. I think that anything you do every daybecomes your norm, and you can become casual about it, Keller points out. Ionce worked in a microbiology laboratory. All of the infected specimens from thesurrounding community came to the lab, and we worked with them on open benches.I remember one of the techs working with bacterial cultures would lick herfinger to turn her work-cards.

When confronted, she said, Well, I never got sick; no one Iknow ever got sick. Most people cant live in a heightened alert theycant maintain a level of high concern or they would not be able to workinfectious items or people. Thats where infection control, the annualinservice, routine infection control education is so vital to help us allremember what we need to do to protect ourselves and our patients. Our patientsare, of course, what were here for.

Newsletters and annual education are crucial, but Kellerpoints out that surveillance is often the most useful means of reminding staffabout proper infection control. We are on the units just about every day, andwe observe practice. Just being there is so valuable. Its so much easier todo surveillance in medical records, but if youre on the unit looking atcharts, that gives everyone an opportunity to talk to you about any questionsthey have about infectious diseases.

If there is a breakdown in infection control, have theindividual who failed to do the precautions do a presentation, says FrankMyers, MA, CIC, CPHQ, an epidemiologist at Scripps Mercy Hospital in San Diego. They can talk about how they felt about having transmittedan organism to a patient. Those can be very motivational to staff.

Although the half-life of those talks isnt very long,Myers says, that also raises the bar, because even if they slip back, itsnot usually as far as what their baseline was before the intervention. Youllsee a spike, but youll see a continuous improvement over their baselinebecause people will remember.

To prevent outbreaks, Myers says that early detection of thosewith upper respiratory infections that can be transmitted in a hospital settingis one of the key requirements. With the flu, we use droplet precautions, andone of the big ways to prevent nosocomial transmission of the flu is certainlyvaccination, he stresses. And for those who are averse to vaccination, Myerssays, Offer rewards! Offer education whenever people say no, and if you canmake it the norm so that most people around an individual get the flu shot, youcan use positive peer pressure to encourage that individual to get it.Certainly, there are people who are medically contraindicated, and in thosecases you dont want positive peer pressure. Oftentimes, having units competeagainst each other for the highest vaccination rate has been effective. If youremaking rewards a free lunch for the floor, that can very quickly motivate thestaff to positively influence their peers behavior.

However, techniques that work at one facility will not work atanother. Some institutions have high profile individuals who beginthe campaign by getting the flu shot. At my institution, they have a picture ofme on a monkey. The monkey climbs a coconut tree, so we set a goal at thebeginning of the year that the monkey will get the coconuts. At anotherinstitution, that would be an utter failure, Myers laughs.

Creating such a campaign is usually collaborative among theemployee health nurse, the infection control practitioner, the leaders of theinstitution and frontline workers. Myers facility gets feedback fromemployees asking if they received the flu shot and how and where. Theyre asked what they did and did not like about theexperience and how it might be improved. That way, we get ideas we wouldnthave otherwise thought of, Myers says, because we get locked into what wedo as the correct way. The nurse asks, Why do you bring the mobile carts whenyou could have us give it? Can you have a nurse give the vaccination toanother nurse? Is that allowable under state law and hospital policy?

Also critical to preventing outbreaks is having staff whorecognize pathogens that are transmitted in ways other than whats preventedby standard precautions. Are you doing a doing good job screening patientsfor TB? For meningococcal meningitis? Another element is better communicationbetween nurse and physician as to what diseases are potentially on thedifferential. And certainly in some settings, some data exists that suggestsincreased environmental cleaning, especially for particular pathogens like clostridiumdifficile, he says.

With c. difficile, one of the things people forgetis its a spore-forming organism. So alcohol-based handrub doesnt work.Therefore, when you have a case of clostridium difficile in the hospital,you have to remind the staff, Dont use alcohol based handrub. It wontwork against c. difficile. How often do people forget that? heemphasizes.

In its recommendations for hand hygiene, even the CDC forgotto include c. difficile with anthrax among the organisms against whichalcohol handrub will be ineffective. C. difficile was included in thediscussion document, but not in the final list of recommendations.

Finally, Myers says, Whenever people are writing policiesand trying to prevent outbreaks, remember that best practice is never a bestpractice when its not practical practice. If your staff isnt going to beable to do it, writing the best policy that cant be used by your staff is nothelpful. If you describe best practice but it could only exist in anideal world and it cant be implemented in your hospital, that shouldnt bein your policy.

He continues, First of all, you lose credibility withstaff, when you come in with a pie-in-the-sky, cant be appliedintervention, you immediately lose credibility. Base your interventions on thebest science and what can work at your institution. If its notindividualized, if youre just writing best science but not specific to yourinstitution, thats not going to help you prevent disease transmission.

SARS

The standard infectious disease control procedures arequite effective. Outbreaks usually occur when something breaks down, saysStephen O. Cunnion, MD, PhD, MPH, president of International Consultants inHealth, Inc. No one is checking that the procedures are being carried out correctly. Hands might not be washed betweenpatients. Even such mundane things such as cleaning your stethoscope betweenuses can cause an outbreak. If you follow the rules that are laid down thereshould be minimum outbreaks. Rare outbreaks will occur since control procedurescant cover every possible way an outbreak can occur. Multi-resistantorganisms make it ever so much harder.

SARS was one example of how diligence might have prevented awidespread epidemic. SARS was interesting because we started going one way,and kept going that way even when the information came out that it was somethingdifferent, Cunnion says. When it first appeared, virtually all of usthought it was going to be a bird flu. That had been the pattern in SoutheastAsia. We were waiting for an outbreak because were long overdue for a majorhuman flu epidemic. So when SARS first hit, flu was our first thought. Everybodyput on their masks. Flu is mostly transmitted by wet particles and coughing.Once SARS was found to be in the cold virus family, the emphasis was still onface masks. Colds are usually spread from mouth or nose to hand and thenpossibly an inanimate object, be it doorknobs or elevator buttons orcountertops. Someone elses hand picks up the virus and they touch theireyes, nose or mouth, thus completing the transmission. If more attention werepaid to this type of control rather than face masks, we probably would have beenable to keep SARS from going as far as it did.

When asked about super-carriers, Cunnion says, I stilldont really subscribe to the idea of a SARS supercarrier; Im not asconvinced as many experts are. Im not saying that there isnt such a thing;obviously certain people can get sicker than others, and some people seem to bebetter at spreading disease than others Typhoid Mary being a good example but you can account for much of the transmission by the gross contaminationof a common object that many people touched, like the same elevator buttons ordoorknobs. If somebody wiped his nose and contaminated a doorknob, how manypeople touch that doorknob and get contaminated?

Cunnion was the first to bring the problem of SARS to theattention of the American health community. A teacher in China posted a messageto an Internet bulletin board, which was seen by an ex-neighbor of Cunnions,who immediately forwarded it to him. After a fruitless search for news aboutthis strange illness that had caused the local hospitals to close their doors,Cunnion posted a message on the ProMed Web site, asking for information.

He was reporting that the hospitals were locked down,people were dying on the streets and people were rioting. As I placed the piecestogether, I then knew that something was drastically wrong, Cunnion recalls.And there was nothing being reported.

Even more than a year later, identifying SARS in a patient isdifficult, because its definition was clinical since we had no laboratorytest, he observes. Our first clinical definition was quite strict; itsactually respiratory failure. I think youll find that the mortality rate forSARS will go down tremendously once we find a good, reliable laboratory test.Then we can count all the asymptomatics and milder cases.

Cunnion is eager for a decent laboratory test to identifySARS. For me as a medical epidemiologist, Im more interested in anFDA-approved standardized test that can be done at any laboratory. Thats thekey to surveillance. You really dont have surveillance unless you have a testlike that available. That doesnt mean you cant have surveillance of anoutbreak if you dont have a test. You can, but its a lot harder, becauseyou have a definition based on symptoms and when you do that, you have to startwith a restrictive definition.

Asked what, besides not handwashing, can lead to an outbreak,Cunnion responds, People taking shortcuts. I started out as a pediatrician,and in nursery outbreaks, staph and strep were usually the big thing. Virtuallyall of them were brought down to somebody violating infectious controlregulations whether it was coming to work sick or not being careful withtheir own nasal excretions, not tending to a cut on their arm, or just notabiding by washing their hands or changing gloves between procedures.

Were still not being good about following all theprocedures we put down, Cunnion says. Its easy to forget. Im notcondoning it; people are rushed; things happen; you get distracted. You need aninfection control person who moves around a lot, observes and keeps track of howthings are done. You really cant rely on people to govern themselves; you have to have a person who will tell them when things arentbeing done right. You have to find the right type of personality or youllhave problems, because it has to be done in a nice way.

Finding that personality can be difficult, Cunnion says. Itssomebody whos well-liked but respected and who has a knack of telling peoplewhat theyre doing wrong without offending them. Find a hospital with lowinfection rates, and youll probably find one of those persons, he says.

Its a horrible way to practice medicine, but it seems tobe really personality- driven. A lot of infectious disease people stay in theiroffices looking for infection trends and waiting for the next outbreak. They dontdo enough floor-walking at least in my experience as they should. Theyshould be talking with the staff, being friends with them. Its a lot easier to make suggestions when youre friendsand you can do it off the record. You dont want to burn the person in public;you want to be able to get these suggestions across as constructive criticismsrather than hand-slappings and public embarrassments, he adds.

Keeping a potential outbreak from spreading, Cunnion says,requires surveillance. Surveillance comes at many levels, at hospital,community, city, state, national and worldwide levels, and all thosesurveillances have to be in place before you can really get a picture of whatshappening.

However, funding is not always in place for propersurveillance. The problem with preventive medicine is that youre damned ifyou do and damned if you dont. Youve got to be a bit of masochist to be inpreventive medicine. You stop a disease and they take your funding away fromyou. Then when the disease comes back, they yell at you for not preventing it,Cunnion quips.

Cunnion adds that oftentimes, people get into medicine andthen discover that they prefer office work to dealing with patients. This, hesays, is the problem with preventive medicine: We have some very activepeople who go out and do real prevention. Then we have people who hide in roomsand play with statistics and do numbers. Im not saying we dont need those people, butyou tend to attract the latter more than the former. So if your preventive staffis only five or six people and four or five are in it because theyd ratherplay with a statistics package, youre not going to have a very good program.You might have what looks like a good infectious disease database with keengraphs and charts, but you wont have a good proactive prevention program thatprevents outbreaks from occurring in the first place.

But it is possible to prevent outbreaks, as long as theinfection control practitioner (ICP) is determined. I have dents on many awall and door, trying to work out angles so that my bosses would sign off on anew program or support an old one when budgets were tight, Cunnion says. How to work inside a hospital and developprograms for prevention is looking at the dynamics of the place. You can be allrighteous and say This is the way it is written, and people will look atyou and say, So are a million other things I cant do, and kiss you off.The trick is to find the right personality (or another tactic) to get peopleinterested in following the correct procedures. If hospitals are trying to keepinfection rates down, most put up donts; they have negative rewardsystems. They need to put up positive reward programs, whether it bepersonality or financial or some other benefit, some goal employees will worktowards. Why not offer incentives, either financial or vacation days?

Such a program requires investment of resources by uppermanagement. You have to have a program that the boss will buy into. This is where it becomes a little bit tricky, since manyinternal politics come to bear. Go back through your database and find how manyoutbreaks the hospital has had, and how much did it cost in legal payments andmedical costs? You figure that out over a ten year time span, and say, Overten years time span, it has cost us umpteen million dollars. If we cut it byhalf, we can save half of umpteen million dollars. You give them a costsheet. A lot of times, the bottom line will sell itself, he adds.

Outbreak investigations themselves are a fascinating art. Ilike to use this comparison: Solving an outbreak is like doing jigsaw puzzles. Every puzzle is different, and every outbreak has differentparts missing. So you cant use a standard mindset; you have to look at theproblem and get a feeling of how to progress. You get that feeling by doingenough outbreaks. Is an odd case important or not? That odd case can solve thepuzzle or just waste your time while the outbreak spreads, Cunnion concludes.