Infection Control Today - 04/2004: Clinical Update

April 1, 2004

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 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

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
, 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

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.


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

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.