H1N1 Draws Renewed Attention to Health Policy Issues

The global spread of a unique strain of swine-origin H1N1 influenza (SO-IV) is almost a certainty. The lethality of the SO-IV and the impact of a pandemic on an already fragile world economy has yet to be determined. However, in the early days of this pandemic we have much to be proud of. Cooperation and communication between federal agencies, state government, local health departments, hospitals, and individual clinicians appears to be unprecedented. Hopefully, the aggressive steps that are being taken by our colleagues in public health will pay off and soften the blow of SO-IV.

As was recently related by an advisor to President Obama, “Never let a crisis go to waste.” Indeed, the current pandemic illustrates the need for a robust public health system and active infection prevention programs in hospitals. For the past several months, the Society for Healthcare Epidemiology of America (SHEA), the Centers for Disease Control and Prevention (CDC), and other allied groups have been busy framing the needs for research and clinical practice to harness funding to the best possible effect. The American Recovery and Reinvestment Act, signed into law in mid-February, includes $50 million for states to carry out activities in healthcare-associated infection (HAI) reduction. Nearly $22 million in additional funds for the Department of Health and Human Services (HHS) has been included in the Omnibus Fiscal Year 2009 appropriations bill, passed by the House and Senate in early April. The total includes an increase of $7.5 million for CDC’s National Healthcare Safety Network (NHSN) and $9.3 million for the Agency for Healthcare Research and Quality (AHRQ). Although SHEA applauds these funding gestures, HAIs are a very significant problem, resulting in an estimated 100,000 deaths yearly in the United States and efforts to better understand, prevent and treat these infections are generally poorly funded and relatively neglected.

The stimulus money will be allocated through CDC to the states and SHEA is in conversations with the agency to recommend its most efficacious application. The method by which monies will be allocated has yet to be determined; however, in preparation, several tools exist for facilities and locales to assess their landscape and help inform their state’s needs.

As noted in the January ICT column of SHEA Synopsis, SHEA concurrently released in its journal Infection Control and Hospital Epidemiology the “SHEA/Infectious Diseases Society of America (IDSA) Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals,” and a position paper with CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC titled “Recommendations for Metrics for Multidrug-Resistant Organisms MDROs) in Healthcare Settings.” The MDRO position paper aims to assist facilities in standardizing the monitoring of multidrug-resistant organisms and other pathogens within their institutions so that infection prevention teams can quickly define situations and prioritize problems. The compendium complements the document, defining basic precautions and advanced, facility-specific practices to combat HAIs. Application of these two documents can greatly assist institutions in framing their needs as the contemplate expenditure of scarce resources.

SHEA supports the conclusions of last year’s GAO report on coordination among HHS agencies related to HAI prevention. We believe that coordinated action among CDC, the Centers for Medicare & Medicaid Services (CMS) and the AHRQ is critical. Early this year the HHS released its “Action Plan to Prevent Healthcare-Associated Infections.” Early signals from the Obama administration indicate support for this plan. In joint comments with the IDSA, SHEA has suggested that CMS and CDC should align with such tools as the NHSN and CMS’s Surgical Care Improvement Project (SCIP), with funding for improvements on these tools side-by-side with support for hospitals.

FY2010 spending levels are being considered. Clearly, HAI prevention should be a primary concern. SHEA urges support of at least $8.6 billion for CDC’s “core programs,” not including the mandatory funding provided for the Vaccines for Children Program (VFC), to ensure that the agency is able to carry out its prevention mission and to assure an adequate translation of new research into effective state and local programs. Within this total, SHEA recommends a FY 2010 funding level of $2.4 billion for CDC’s Infectious Diseases program budget. With respect to the National Institutes of Health (NIH) budget it must be recognized that the NIH is the single-largest funding source for infectious diseases research in the U.S. Despite the fact that HAIs are among the top 10 annual causes of death in the U.S., scientists studying these infections have received relatively less funding than colleagues in many other disciplines. This should change! NIH-funded work often lays the ground work for advancements in treatments, cures, and medical technologies. In order to determine the preventability of infections, we first need to understand how and why these infections occur. A comprehensive national research agenda on HAIs must include at least three major categories of research: pathogenesis, epidemiology, and infection prevention strategies. Carefully designed multi-center prospective clinical trials are needed to establish the effectiveness of prevention and control strategies. SHEA believes that any national effort designed to address the problem of HAIs should begin with the following principles: scrutiny of the science base; development of an aggressive, prioritized research agenda; the conduct of studies that address the identified questions; creation and deployment of guidelines based on the outcomes of these studies, followed by studies that assess the efficacy of the intervention. SHEA believes that as the magnitude of the HAI problem becomes part of the dialogue on healthcare reform, it is imperative that Congress and funding organizations put significant resources behind this momentum.

In prioritizing funding from various agencies for basic and translational research as well as improvement in the healthcare delivery system and healthcare reform, SHEA stands behind the following principles:

• SHEA strongly encourages an emphasis on implementation of evidence-based practices (EBP).

• SHEA supports investment in training and education programs in order for the next generation of healthcare professionals to learn better means to prevent and treat HAIs and further improve our healthcare delivery system.

• SHEA supports a broad context for use of dollars dedicated to combat HAIs rather than pathogen-specific targets or mandates.

• SHEA supports investment in hospital infrastructure and qualified personnel for infection prevention and control including epidemiologists, infection prevention and control professionals, NHSN implementation, and adequate microbiology/lab diagnostic capability.

• SHEA believes that funds should be used, in part, for translational research projects that can allow more rapid integration of science into practice.

• While health services research and translational research projects may provide some immediate short-term benefit, to achieve further success, a substantial investment in basic science, translational medicine, and epidemiology is needed to permit effective and precise, interventions that prevent HAIs.

Mark E. Rupp, MD, is president of the Society for Healthcare Epidemiology of America (SHEA), professor at the University of Nebraska Medical Center, and director of the Department of Healthcare Epidemiology.