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 to determine how to prevent outbreaks and how to identify the diseases that are making the public most nervous.

Influenza

Influenza is very common; 10 percent to 20 percent of the population becomes ill with influenza, emphasizes Kristin Nichol, MD, MPH, chief of medicine at the Veterans Affairs Medical Center in Minneapolis and a professor at the University of Minnesota. Higher attack rates are seen in certain 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 respiratory syndrome that tends to be more severe than a typical cold. Of course, fever and cough tend to be hallmark symptoms, especially in adult populations. In children, fever and cough are still common, but sometimes we might see gastrointestinal symptoms that we tend not to see in older populations.

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

The 2003-2004 flu epidemic has certainly been the subject of much media coverage; Nichol, who has spent more than a decade researching influenza and its prevention, is pleased that finally, the public is paying attention. Ive been saying for a long time that influenza is a very serious disease, and its complications especially can result in hospitalization or death among certain groups, including the elderly, so I think maybe people havent been as aware of the messages that have been out there, she observes. Influenza has been here for a long time. All we have to do is hearken back to the 1918 so-called Spanish flu pandemic in which 20 to 40 million died. More of our combat troops died from the Spanish flu than from combat-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 those groups considered high risk. Not infrequently, the person would report becoming ill in the morning, report to the doctor in the afternoon, and in the next day or two theyd be dead, Nichol says. Thats a very extreme manifestation of influenza in the world, but we still have very serious manifestations every year. Again, we are very concerned about preventing the next pandemic, or being prepared for the next pandemic, but in the meantime we should pay a lot of attention to regular old epidemic influenza.

Nichol continues, We have safe and effective vaccines, and this year it may be that we will not have much left over, if any, because of this unusual peak in demand in December, which to my knowledge weve really never seen in this country. In past years, we have thrown away perhaps 10 percent 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 as well as for treatment if started within two days of the onset of symptoms. But especially for people in certain high priority groups, we do recommend immunization as the best strategy. Vaccines are safe and effective, and this year we now have the nasal spray vaccine for people 5 to 49 years of age.

Although certain high-priority groups are particularly susceptible, Nichol says that national recommendations acknowledge that immunization can be beneficial for just about everybody. Those higher-priority groups include the elderly, people with underlying chronic medical conditions, people in nursing homes, women who are pregnant or will become pregnant, children and adolescents on aspirin because of risk for a very rare complication of influenza called Reye syndrome, children six to 23 months of age, and household contacts and healthcare providers.

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

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

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

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

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

General Prevention

There are other options to prevent infectious diseases, says Paula Keller, technical director of epidemiology at William Beaumont Hospital in suburban Detroit. From what Ive seen in my career, the most effective way to prevent outbreaks is concurrent surveillance, she says. If people are looking 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 site infections (SSIs), you can miss a vent-associated pneumonia outbreak, or a cluster 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; it depends on administrative support, Keller says. Here at Beaumont, we have strong administrative support, and we do complete surveillance in our ICUs. We also do total house surveillance for bloodstream infections, all SSIs, all resistant organisms, and c. difficile. We report all infections resulting in secondary bloodstream infections. With this detailed surveillance, we are able to identify any clusters of infection. If we see two or three nosocomial MRSA 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 good administrative support, she observes. A doctor who really understands epidemiology who is committed to epidemiology as opposed to doing it as a sideline is a huge asset to any infection control program.

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

The patient response has been very positive, Keller says. The feedback Ive gotten from all of our clinics and ambulatory sites is that patients respond very well to this. They really appreciate the concern for their health. 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. this year, it is crucial for physicians in areas at high risk for SARS to be able to identify which patients have a coronavirus and which have influenza. But telling the difference is not easy. From everything Ive read, there is no rapid diagnostic test, and truly what we can best rely on is travel history, Keller says. Even before that we want to take precautions against any droplet spread, to healthcare workers, other patients or to visitors.

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

After months of being on high-alert status, it is easy for vigilance to wane somewhat thus the spread of infectious organisms from the lack of appropriate handwashing. I think that anything you do every day becomes your norm, and you can become casual about it, Keller points out. I once worked in a microbiology laboratory. All of the infected specimens from the surrounding 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 her finger to turn her work-cards.

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

Newsletters and annual education are crucial, but Keller points out that surveillance is often the most useful means of reminding staff about proper infection control. We are on the units just about every day, and we observe practice. Just being there is so valuable. Its so much easier to do surveillance in medical records, but if youre on the unit looking at charts, that gives everyone an opportunity to talk to you about any questions they have about infectious diseases.

If there is a breakdown in infection control, have the individual who failed to do the precautions do a presentation, says Frank Myers, MA, CIC, CPHQ, an epidemiologist at Scripps Mercy Hospital in San Diego. They can talk about how they felt about having transmitted an 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, its not usually as far as what their baseline was before the intervention. Youll see a spike, but youll see a continuous improvement over their baseline because people will remember.

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

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

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

Also critical to preventing outbreaks is having staff who recognize pathogens that are transmitted in ways other than whats prevented by standard precautions. Are you doing a doing good job screening patients for TB? For meningococcal meningitis? Another element is better communication between nurse and physician as to what diseases are potentially on the differential. And certainly in some settings, some data exists that suggests increased environmental cleaning, especially for particular pathogens like clostridium difficile, he says.

With c. difficile, one of the things people forget is 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 wont work against c. difficile. How often do people forget that? he emphasizes.

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

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

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

SARS

The standard infectious disease control procedures are quite effective. Outbreaks usually occur when something breaks down, says Stephen O. Cunnion, MD, PhD, MPH, president of International Consultants in Health, Inc. No one is checking that the procedures are being carried out correctly. Hands might not be washed between patients. Even such mundane things such as cleaning your stethoscope between uses can cause an outbreak. If you follow the rules that are laid down there should be minimum outbreaks. Rare outbreaks will occur since control procedures cant cover every possible way an outbreak can occur. Multi-resistant organisms make it ever so much harder.

SARS was one example of how diligence might have prevented a widespread epidemic. SARS was interesting because we started going one way, and kept going that way even when the information came out that it was something different, Cunnion says. When it first appeared, virtually all of us thought it was going to be a bird flu. That had been the pattern in Southeast Asia. We were waiting for an outbreak because were long overdue for a major human flu epidemic. So when SARS first hit, flu was our first thought. Everybody put 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 on face masks. Colds are usually spread from mouth or nose to hand and then possibly an inanimate object, be it doorknobs or elevator buttons or countertops. Someone elses hand picks up the virus and they touch their eyes, nose or mouth, thus completing the transmission. If more attention were paid to this type of control rather than face masks, we probably would have been able to keep SARS from going as far as it did.

When asked about super-carriers, Cunnion says, I still dont really subscribe to the idea of a SARS supercarrier; Im not as convinced 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 be better at spreading disease than others Typhoid Mary being a good example but you can account for much of the transmission by the gross contamination of a common object that many people touched, like the same elevator buttons or doorknobs. If somebody wiped his nose and contaminated a doorknob, how many people touch that doorknob and get contaminated?

Cunnion was the first to bring the problem of SARS to the attention of the American health community. A teacher in China posted a message to 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 about this 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 pieces together, 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 is difficult, because its definition was clinical since we had no laboratory test, he observes. Our first clinical definition was quite strict; its actually respiratory failure. I think youll find that the mortality rate for SARS 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 identify SARS. For me as a medical epidemiologist, Im more interested in an FDA-approved standardized test that can be done at any laboratory. Thats the key to surveillance. You really dont have surveillance unless you have a test like that available. That doesnt mean you cant have surveillance of an outbreak if you dont have a test. You can, but its a lot harder, because you have a definition based on symptoms and when you do that, you have to start with 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. Virtually all of them were brought down to somebody violating infectious control regulations whether it was coming to work sick or not being careful with their own nasal excretions, not tending to a cut on their arm, or just not abiding by washing their hands or changing gloves between procedures.

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

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

Its a horrible way to practice medicine, but it seems to be really personality- driven. A lot of infectious disease people stay in their offices looking for infection trends and waiting for the next outbreak. They dont do enough floor-walking at least in my experience as they should. They should be talking with the staff, being friends with them. Its a lot easier to make suggestions when youre friends and 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 criticisms rather 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 those surveillances have to be in place before you can really get a picture of whats happening.

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

Cunnion adds that oftentimes, people get into medicine and then discover that they prefer office work to dealing with patients. This, he says, is the problem with preventive medicine: We have some very active people who go out and do real prevention. Then we have people who hide in rooms and play with statistics and do numbers. Im not saying we dont need those people, but you tend to attract the latter more than the former. So if your preventive staff is only five or six people and four or five are in it because theyd rather play 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 keen graphs and charts, but you wont have a good proactive prevention program that prevents outbreaks from occurring in the first place.

But it is possible to prevent outbreaks, as long as the infection control practitioner (ICP) is determined. I have dents on many a wall and door, trying to work out angles so that my bosses would sign off on a new program or support an old one when budgets were tight, Cunnion says. How to work inside a hospital and develop programs for prevention is looking at the dynamics of the place. You can be all righteous and say This is the way it is written, and people will look at you 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 people interested in following the correct procedures. If hospitals are trying to keep infection rates down, most put up donts; they have negative reward systems. They need to put up positive reward programs, whether it be personality or financial or some other benefit, some goal employees will work towards. Why not offer incentives, either financial or vacation days?

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

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

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