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The 20th century has seen phenomenal advances in medical research and technology, yet infectious disease is still one of the top international killers. Emerging infectious diseases can be the most worrisome since oftentimes less is known about them than their more established peers.
The official definition of an emerging disease, according to the National Institute of Allergy and Infectious Diseases (NIAID), is “an outbreak of previously unknown diseases or known diseases whose incidence in humans has significantly increased in the past two decades.”
NIAID conducts research to understand, treat, and prevent diseases that are infectious, immunologic, and allergy-associated. Such research, for obvious reasons, can be extremely useful. For instance, the discovery that chronic gastric ulcers are caused by the bacterium Helicobacter pylori, not through stress or diet as was previously believed.¹
The good news is that recently-battled diseases such as tuberculosis (TB), extremely drug resistant TB (XDR-TB), methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff), etc., are beatable, says Carolyn Gould, MD, MSc, a medical epidemiologist. Gould serves on the response team of the Prevention and Response Branch of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC).
“In general these infections continue to be a threat, but most of these infections are preventable and we need to continue to educate and put these prevention practices into place,” Gould says.
“I think there has been more awareness about the problems of healthcare-acquired infections (HAIs),” she adds. “Many hospitals are taking very proactive approaches to combat these infections. Resource limitations are a major impediment, and it is very important for hospital administrators to make infection control and antibiotic management a priority and provide the resources to do so.”
Diseases emerge for several reasons and some are unfolding rapidly. Changes in human behavior, demographics, land use, etc., alter transmission patterns and bring people in closer and more frequent contact with pathogens.¹ One factor may be increased human exposure to exotic animals for pets and food.
“For example, close contact with exotic rodents imported to the U.S. as pets was found to be the origin of the recent U.S. outbreak of monkeypox,” NIAID documents state, “and use of exotic civet cats for meat in China was found to be the route by which the SARS coronavirus made the transition from animal to human hosts.”
Re-emerging diseases are known diseases that have reappeared after a significant decline in incidence.¹ Persistent as a telemarketer and deadly as a psycho scorned, some diseases make encores through genetic variations and adaptations. Oftentimes, the human immune system does not recognize these diseases and doesn’t know how to fight them. And unfortunately, human behavior may play a negative role. For instance, overuse of antimicrobial drugs and pesticides has led to the development of resistant pathogens. Such examples are tuberculosis, malaria, nosocomial, and foodborne infections.¹ Another problem, according to NIAID, is that a lack of compliance with vaccination policies has allowed diseases such as measles and pertussis to make a dramatic re-entry after being in submission for years. Some diseases that were under control in developed nations are making a comeback, such as dengue and West Nile virus.¹ And yet one more concern: bioterrorism. Use of smallpox or anthrax is a continued possibility.
Infectious diseases are of utmost concern at many facilities, says Kenneth J. Waithe, CEH, director of environmental services (ES) for Satilla Regional Medical Center in Georgia. Waithe is employed by HHA Services, an outsourced contract provider, and serves on committees for infection control and safety. He oversees the hazardous materials protocols for the Joint Commission Environment of Care standard and says the diseases that are of biggest concern to Satilla are MSRA and C. diff. Waithe has seen a large incidence of MRSA in the last few months.
“MRSA has become the most difficult to control since it involves a diligent, multifaceted approach to cleaning/disinfecting,” Waithe says. “The medical industry has to turn a positive corner in order for us to combat the occurrence of infections, because the alternative does not bode well (with) any of us in the healthcare field.”
Tom Cayce, manager of ES at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla., agrees that MRSA is a huge problem. Moffitt recently formed a MRSA task force to address it. The program spans from patient care areas to public restrooms.
Researchers at the CDC are most concerned about MRSA, vancomycin-resistant Enterococcus (VRE), drug-resistant gram negative bacteria, as well as C. diff, according to Gould.
“These pathogens are important because they have the potential to cause severe disease, and some may be difficult to treat because of drug resistance,” Gould says.
Some people are more aware of infectious threats than others, says Libby Chinnes, an independent infection control consultant with IC Solutions, LLC, based in Mt. Pleasant, S.C. She has more than 25 years of experience in infection control and prevention.
“I think infections, in general, are more on the radar of those in the C-suite with the spotlight on (HAIs) and mandatory public reporting of these infections gaining momentum across the nation,” Chinnes says.
All infectious agents are troublesome and require a great deal of resources. “They all create work for (infection control practitioners), even simultaneously, at times,” Chinnes says. “The airborne diseases such as TB may have the capacity to expose more persons before diagnosis and initiation of isolation, yet we know that antimicrobial drug-resistant organisms like MRSA and VRE transmitted mainly through contact with the patient or environment are on the rise. Facilities are discovering more C. diff and even resistant forms of C. diff. Some interventions to control and prevent infections are labor-intensive but evidence-based, such as performing active surveillance and isolation of those found to be colonized or infected with the resistant bug and have produced exciting outcomes.”
Are Healthcare Staffs Doing Enough?
According to Cayce, healthcare staffs are doing everything they can with their given resources. “Every colleague I have ever spoken with has the passion and desire to want a clean facility and they make use of their resources to accomplish this,” Cayce says. “I will say that administrators should give a second thought before cutting their (ES) staffing budgets because these dollars spent are dollars spent on the first line of defense for infections. It would be like a football coach saying ‘Okay, we are going to cut back on expenses so let’s get rid of our right and left tackles and only play with nine players.’ What kind of nonsense is that?”
Indeed, providing adequate supplies and resources is necessary, Chinnes says. It is also necessary to put in place a handwashing and respiratory hygiene etiquette (covering one’s cough, for instance) every hour every day, all through the year. Creating this culture only during flu season is not enough.
Another aid? “Empowering patients to remind healthcare workers to perform hand hygiene before caring for the patient,” Chinnes says. “Other common sense measures like not going to work when one is sick with a fever, cold, or diarrhea are also ways in which to avoid transmitting infection to others.
“As we know, even the basics of good hand hygiene can be laborious to implement successfully and maintain,” Chinnes says. “Yet we cannot always put a cost on prevention of infections to the patients or caregivers or staff. Think of the cost of a pertussis exposure in the healthcare setting for many patients, staff, and visitors, as only one example.”
Rate of Transmission
Fighting emerging diseases is a tall order, especially in this world of high-paced frequent travel. The people who fly most often usually travel for business where they mix with other business travelers, who are also frequent fliers. A dangerous combination ensues.
“This form of assortative (like with like) mixing means a respiratory infection could potentially spread quickly within this group and thus be disseminated rapidly between countries,” the CDC states. “This rapid spread was illustrated early in the severe acute respiratory syndrome (SARS) outbreak of 2003. The index SARS case in Hong Kong Special Administrative Region, People’s Republic of China, stayed in a hotel and infected 16 persons there. Of these patients with secondary cases, six took international flights to Australia, Canada, Singapore, the Philippines and Vietnam. The arrival of these infected persons subsequently led to SARS outbreaks in Hanoi, Singapore, and Toronto within a few days of the first case in Hong Kong.”
According to one study, more research should be done on whether interventions should specifically target frequent travelers in order to slow the international spread of pathogens. The likelihood that an infected person will make an international flight when their infection is incubating and non-symptomatic is higher for a high-frequency flier than for lowfrequency fliers.²
What the Average Person Can Do
A lot more education is needed for the general public in regards to preventative medicine and lifestyle choices when it comes to avoiding infections, Waithe says.
Chinnes believes that more Americans are learning about infectious diseases and the way they are spread. Such information is particularly poignant for people who have lost a loved one to an infection, she says.
“Basic common sense measures which we learned at our moms’ knees still suffice today with preventing the spread of illness,” she adds. “Measures such as hand hygiene — soap and water — or alcohol hand rubs are the most effective. Americans can even notice provision of and use of these basic supplies in their child’s day care site or school. If the dispensers are there but they are empty, how can children wash their hands? Or if there are no dispensers or paper towels or they are mounted too high for the children to reach, hand hygiene will be neglected. Adults also need to role model for their young children so that they will begin to learn the importance of hand hygiene at an early age.”
Cayce agrees with this simple but overlooked message.
“Wash your hands!” he says. “This would be an excellent start. I can’t believe it’s 2007 and some people act like they have never heard of this concept. I’m shocked at how many times I’ve observed men leaving the mens’ room without washing their hands. Yuck!”
People should also dispose of used tissues quickly and should cover open wounds, Gould says.
The Role of Environmental Services
Waithe’s facility recently endured a $1.5 million reduction in Medicaid reimbursement, and that’s only making the battle against emerging illnesses more challenging.
“It will be increasingly difficult to combat the spread of pathogens without adequate staffing,” Waithe says. “Also, hospital staffs must do a better job of handwashing, which is the best way to stop the spread of germs. All of the media attention about infection rates and the associated reimbursement models certainly have every administrator’s attention.”
In order to stay on the cutting edge, ES staffs need the support of their facilities, and also, “a firm commitment by our vendor/suppliers to step up to the plate with financial resources,” Waithe says. “We are just now becoming noticed as an important component of healthcare, not a ‘necessary evil.’ But much more has to be done, not only by hospital administrators but by clinical staff to champion the work we do and the care we provide. Nurses take care of patients; we take care of the building. As I tell the staff ‘we don’t give direct patient care, but what we do directly affects the care of the patient.’
At Cayce’s facility, a careful protocol has been devised against emerging infectious diseases.
“Standardize, standardize and standardize,” Cayce says. “You must have the staff well versed in cleaning methods and they must be cross-trained. If they all know how to perform the functions and they know multiple areas there shouldn’t be any opportunities to skip over minor items.”
Moffitt staff members treat XDR-TB, TB, MRSA and C. diff in much the same fashion. The main difference is that they use sodium hypochlorite products for C. diff, as is recommended by the CDC.
“Our clinical staff will notify environmental services of rooms that need a terminal clean for C. diff,” Cayce says. “This will be done by calling the department and by leaving a pink isolation sign on the door of the room.”
When asked whether the danger of emerging infections is going to increase, Chinnes says there will always be new and re-emerging infectious diseases.
“New technology and devices as well as global travel may bring infectious diseases to our doorsteps,” Chinnes says. “Yet through remaining alert to new threats and diseases and collaboration with each other in facilities, communities and regions, ICPs can lead the way to partner with others to make a difference in the lives of patients and their families.”
According to Gould, more tools are needed to combat emerging infection diseases.
“From the standpoint of healthcare, one concern is that we don’t have many new antimicrobials coming down the pipeline to treat multi-drug resistant organisms, and these bacteria have shown us time after time that they can quickly develop resistance to new agents,” Gould says. “This makes it even more important that we focus on infection prevention and more appropriate antibiotic use.”
The medical industry may be able to turn a positive corner, Cayce believes.
He says, “I think if healthcare facilities continue to educate all of their staff and encourage strong working relationships between infection control and environmental services then positive results will be forthcoming.”
1. The National Institute of Allergy and Infectious Diseases (NIAID): www3.niaid.nih.gov/about/overview
2. Hollingsworth TD, Ferguson NM, Anderson RM. Frequent travelers and rate of spread of epidemics. Emerg Infect Dis. Sept. 2007. http://www.cdc.gov/EID/content/13/9/1288.htm