ICHE Special Issue: Antimicrobial Stewardship

Infection Control and Hospital Epidemiology has just announced that it will publish a special issue devoted to antimicrobial stewardship in conjunction with the SHEA spring meeting in Jacksonville, Florida, April 13-16, 2012. 

Topics of interest include:

• Antimicrobial stewardship for special populations, including pediatrics, oncology, hemodialysis, and critical care
• Health outcome and cost effectiveness impact of antimicrobial stewardship
• Use of diagnostic tools and role of microbiology in antimicrobial stewardship
• Effective implementation of programs in community hospitals, long-term care acute care facilities, outpatient settings and non-acute healthcare settings (e.g., dialysis, ambulatory care and ambulatory surgery centers)

Due date: October 1, 2011.

Get writing and submit your paper here.

Call for manuscripts PDF available here.

Good luck!

SHEA 2012 and ID Week 2012 - SAVE THE DATES

So there are now two new meetings to choose from if you're interested in infection prevention.  Dan and I are involved with the planning of both meetings, so as more information becomes available, I'm sure we will provide it to you, our dear readers and accidental web surfers looking for Snicker's pictures.

SHEA 2012: Advancing Healthcare Epidemiology & Antimicrobial Stewardship, April 13 - 16, 2012 in Jacksonville, FL

SHEA 2012 is not the same old SHEA.  The old scientific meeting with podium and poster presentations has merged with IDSA (see below).  This new spring meeting is newly designed for 2012 and offers both the traditional basic SHEA/CDC training course as well as a parallel advanced epidemiological methods track that focuses on designing, analyzing and presenting infection prevention research. The conference also includes meetings addressing antimicrobial stewardship.

More information when available will be posted on SHEA's website

Inaugural IDWeek 2012: October 17-21, 2012, in San Diego, CA
A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS

IDWEEK 2012 is where to go if you want to see the latest science surrounding infection prevention.  The SHEA podium, symposium and abstract presentations are expected to run parallel to the traditional IDSA-infectious disease presentations so that attendees can choose what is best for them.

For more information visit http://www.idweek.org/

Banning hands-free faucets: Is Hopkins throwing the bathwater out with the bathwater?

I hope everyone enjoyed SHEA.  Overall, a good meeting with good weather and good science.  I pinch-hit as a moderator for a hand-hygiene session on Saturday.  The original moderator (i.e. Mike Edmond, have you heard of him??) was scheduled to moderate two sessions at the same time and for some reason wasn't able to pull it off.  ;)

There were interesting studies presented in the session including an abstract highlighting iScrub, which Dan has mentioned before.  One particular abstract garnered a lot of press attention - I'm not used to hearing about data in the morning newspaper before the abstract is presented, for example. The study was conducted by Emily Snydor, Lisa Maragakis and colleagues at Johns Hopkins Hospital and aimed to determine the safety of touchless water faucets in their hospital.  They compared 20 newly installed automatic faucets with 20 old standard faucets and found that 50% of the automatic faucets had 15% of standard faucets were contaminated with Legionella. After chlorine dioxide, 29% of the automatic faucets and 7% of standard faucets were still contaminated with Legionella.  Hopkins is now removing all of the automatic faucets from their facility.

Some thoughts: 1) It appears that Legionella is a problem in their system and the automatic faucets are only part of the problem.  Removing them isn't enough.  2) The faucets in the study were not installed at the same time since the automatic faucets were new and the standard faucets were likely years old - could biofilm play a role here?  3) Not all automatic faucets would be the same, perhaps different designs would have different risks.  4) What about other pathogens?  How do you balance lower risk of C. diff or acinetobacter with touchless faucets compared to Legionella?  5) Could the faucets be "reprogrammed" or designed to allow flow of the stagnant water prior to contact with the HCW hands?  This might reduce one benefit of these automatic faucets since they do save a lot of water.

What do you guys think? Is this enough data to ban automatic faucets in hospitals? My other concern is that this study will be misinterpreted and people will become afraid of automatic faucets in places such as airports.  I doubt the Legionella risk in airports outweighs the influenza risk, for example.

NBC - Dallas article, March 31, 2011
VOA article, April 5, 2011

See you in Dallas: SHEA 2011

Safe travels to anybody heading to Dallas this week for SHEA 2011 (and everyone else too). We hope to see some of you there. If you're unable to make it to Dallas, SHEA is offering on-demand webcasts with audio AND video.  This is the last year (for the foreseeable future) for a stand-alone SHEA meeting, as the meeting will be combined with IDSA in the fall of 2012. Change is change.

15th Annual Fellows Course in Hospital Epidemiology & Infection Control

The original Washington Monument

The 15th annual Fellows Course in Infection Control & Hospital Epidemiology will be held July 6-8, 2011 in Baltimore. The course meets the ABIM requirements for ID fellows and is sponsored by SHEA. Faculty from the University of Maryland, Johns Hopkins, Brown, Wake Forest, U. Penn and Washington University are involved.  This is a really great 3-day course for anyone interested in evidence-based infection prevention  - it's not just for fellows. Discount registration is available before July 4th.

Baltimore is the largest independent city in the US.

for more info: SHEA course page, agenda, registration.

Dallas in April!

What could be better? Don’t miss the next SHEA pre-registration deadline! If you haven’t yet registered, you will save $50 by registering before February 28th.

SHEA Program Planner is now live

If you haven’t yet made plans to attend, please consider coming to Dallas on April Fool’s Day to attend the SHEA 2011 scientific meeting. You have two months to review the scientific abstracts that will be presented, as the online program planner is now up!

What's in a name? APIC Name Change 2010 Edition

O, be some other name!

What's in a name? that which we call a rose
By any other name would smell as sweet;

-Romeo and Juliet

This just in (to me at least)...for the second year running APIC members have cast ballots in favor of changing their name to "Association for the Prevention of Infections”, replacing the original “Association for Professionals in Infection Control and Epidemiology" yet they did not achieve the necessary two-thirds majority to change the name.  Thus, APIC will have the same meaning at least for another year. For some reason, I've always thought APIC stood for "Spreading knowledge Preventing infection TM," so I'm a bit relieved that it doesn't.

Despite being an APIC member, I don't have a strong opinion on the name change. However, I wonder what the reasons are behind the failure to obtain the necessary super majority?  Perhaps dropping the word "Professional" might upset members since it could suggest a movement away from career development activities towards a purely outcomes-based organization.  For me, I like that "Epidemiology" is in the current name even if it's not in the acronym - I guess it is an invisible "E" instead of the usual silent "e"

Deciding what to name your organization or meeting can be quite tricky. I've been recently involved in a similar process within our research group at the Iowa City VA and have found it interesting to see how some people really favor one name, others strongly favor a different name and all have legitimately good reasons that are hard to reconcile. 

Recently, I heard that there's been a debate as to what the 2012 combined SHEA-IDSA meeting should be called.  Someone told me that they wanted to name it "ID Week" not to be confused with "National Pet ID Week," or "Protect Your ID Week (October 17-23)" or even "ID Weak."  I suspect SHEA members will not like that name as it buries Hospital Epidemiology and not all people involved in SHEA activities see themselves as "Infectious Disease." One nice suggestion I heard was that the meeting name should incorporate SHEA, HIVMA, IDSA and the ASTMH, the tropical medicine society. Somehow that seems about right.

Another reason why mandating flu shots is stupid

I wanted to share with readers a simple, back of the envelope calculation that points out the folly of trying to control respiratory illness in healthcare workers by mandating influenza vaccine.

Here are the assumptions for the calculation:

• Our hypothetical hospital has 5,000 healthcare workers
• It’s a nonpandemic influenza season, in which 7% of the population (including healthcare workers) gets an influenza-like illness (ILI), of which 7% is due to influenza (these estimates are from the control arms of 95 influenza vaccine trials involving 1 million subjects over the course of four decades). Now of course the 7% of the 7% (those with influenza) can be reduced by influenza vaccination.
• The hospital has a baseline influenza vaccination rate of 70% without mandating the vaccine
• We’ll generously assume that influenza vaccine is 90% efficacious at preventing influenza (though it has no impact on non-influenza ILI)
• Presenteeism is 70% (i.e., 70% of healthcare workers come to work when they are sick)

Now let’s take 2 different approaches to reduce the risk of transmission of ILI to patients. In the first approach, we’ll mandate influenza vaccine and achieve a vaccination rate of 98% (we'll assume that 2% of HCWs have a contraindication). In the second approach we won’t mandate vaccination and we’ll maintain the vaccination rate at the baseline of 70%, but we undertake an educational campaign to reduce presenteeism.

So, the question is this: what reduction in presenteeism would have the same impact as achieving 98% influenza vaccination in terms of the number of HCWs at work with ILI? The answer is an astonishing 1% absolute difference. Reducing presenteeism by 1 percentage point (from 70% to 69%) would have the same impact as increasing vaccination from 70% to 98%. So in our 5,000 employee workforce if we could get 4 HCWs with ILI to stay home it would have the equivalent effect of mandating influenza vaccine. 

Now one could argue with the assumptions and we could re-run the numbers using different percentages for any of the variables. But the primary and irrefutable message is this: pathogen-specific interventions (i.e., vertical approaches) for controlling transmission of infection in the hospital are inefficient when compared to multipotent, horizontal approaches. And remember that a sizable fraction of the patients are vaccinated against influenza (we don't have vaccines for the rest of the ILIs), which actually increases the differential impact of the strategies in favor of reducing presenteeism.

Unfortunately, the horizontal approach to controlling ILI won’t make any companies any money, and in our sound bite culture, the path of least resistance (which SHEA and others have fallen prey to), is to simply call for mandating flu vaccine.

Let me once again emphasize I am not anti-vaccine. I get a flu shot every year. But I think the costs of forcing resistant healthcare workers to get vaccinated in terms of unintended consequences outweigh the benefit. So I can live with 70% compliance and find other ways to protect our patients.

P.S. my calculations are below:

	Baseline	Alternative strategies
	70% vaccinated, 70% presenteeism	98% vaccinated, 70% presenteeism	70% vaccinated, 69% presenteeism
Total HCWs	5,000	5,000	5,000
Vaccinated HCWs	3,500	4,900	3,500
Unvaccinated HCWs	1,500	100	1,500
HCWs with non-flu ILI (6.5%)	325	325	325
Unvaccinated HCWs with flu (0.5%)	7.5	0.5	7.5
Vaccinated workers with flu (0.5% x 10%)	1.75	2.45	1.75
Total HCWs with ILI	334	328	334
HCWs at work with ILI	234	230	230

American Academy of Pediatrics Recommends Mandatory Influenza Immunization of all Health Care Workers

We have already posted several times in the last week regarding the SHEA Position Paper.  The AAP Policy Statement comes to a similar conclusion.  They appear to come from the position that compliance with vaccine is low, low is bad and mandatory programs can increase compliance. No good information in the document regarding financial COI, but they do include a statement that they were internally disclosed and resolved through a Board-approved process.  Not being a member of AAP, I'm not sure what that means.  Perhaps someone can enlighten us.

Interestingly, the AAP paper has 24 references vs SHEA's 63.

AAP Policy Statement

Previous SHEA Position Paper posts: here, here and here.

Conflicts of interest are not always financial. Role up your sleeves...and get your flu vaccine?

I joined this blog in December 2009.  There were several reasons for this including what I saw was a great need for conversation among hospital epidemiologists and infection preventionists around complex and important issues such as N95 masks in 2009 novel H1N1, ADI for MRSA and mandatory influenza vaccination of HCW.  That's why I was so excited to see that SHEA was finally releasing a position paper endorsing "a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges."  I was so excited in fact, that I haven't read the document.  To be fair to myself, I've been pretty busy and I've seen several talks and debates on the issue. However, I was excited because it would awaken the debate again within the medical community and, more importantly, this blog.

Dan, Mike and I have all commented on the conflict of interest issue. It is true that several authors of the SHEA position paper have financial ties to vaccine manufacturers.  I agree, as I probably said 1000 times during high school debates, that 'perception is key' and that ideally we could produce documents such as this SHEA paper free of financial conflicts.  However, given that this document has been produced, what can and should we do with it?  How will we interpret it in the light of other organizations (e.g. AAP) coming to the same conclusion? Additionally, to be fair to the document and process, this isn't purely a SHEA position paper, but rather it was "approved by the Board of the Society of Healthcare Epidemiology of America and endorsed by the Infectious Diseases Society of America."

You could argue that we should post or even eliminate all of the potential "financial" conflicts of all of the board members of these societies and I would, at first pass, agree with you.  So now, in the future, we might have all board members and all guideline writers be free of all financial conflicts of interest. That may be theoretically possible for one subject, but all subjects? I doubt it.  I also don't think that "financial" conflicts of interest are the most important or result in the most bias.  I think it's not even close; but more on that in a minute.

Now if you think I've gone off my rocker (again), well, I was lead author on a SHEA guideline back in 2007 titled "Raising standards while watching the bottom line : Making a business case for infection control," and that guideline was conceived of, supported, edited, modified and approved by many members of the SHEA board.  In my opinion, a majority of those on the SHEA board must have pushed for this new flu vax position paper knowing what the outcome would be.  In fact, didn't SHEA produce a 2005 position paper containing a different recommendation? So why go through the effort to produce another document so soon, if they didn't know it would produce a different or this exact recommendation? Importantly, the SHEA position paper adheres to all current guidelines and lists financial conflicts of the authors. Nothing is perfect, but I don't think we should discount the recommendations for that reason.

On to another subject.  In April and June of this year I wrote posts discussing what I see is the most important bias in science and in life. That bias is confirmation bias.  My first post on the subject discussed how all of us that have pre-specified opinions, especially ones that are well known to others, root for results of new trials to support our pre-existing beliefs. It's just natural. This tendency for people to favor information that confirms preconceptions regardless of whether the information is true can influence our search for information, how we interpret information and even our memory.  Now, I'm not sure a definitive study has been done, but I suspect that if you have stated a strong public opinion for or against a certain "thing" it would take a lot of money to get you to change your mind and I haven't even mentioned status quo bias. Cognitive biases....if only the solution was so simple as listing or eliminating financial relationships!

While I'm on the subject of definitive studies, I will first state that I have great respect for the Cochrane reviewers and the SHEA position paper authors (and of course my co-bloggers).  However, no amount of genius can overcome the lack of studies/data/funding that exists for the evaluation of infection prevention interventions. So, again, even though I've not read the SHEA paper or the Cochrane reviews, I can definitively say that they are both wrong. Why? No one has completed the necessary cluster-randomized trial in 50-100 hospitals during different influenza seasons with different vaccine-virus matches in different countries with different acuity levels of the hospitalized patient populations etc, etc, etc.  No one will.

To me, the key issue around mandatory vaccine for HCW is not whether the vaccine works, as Mike discussed on Saturday. Rather, it is how much better HCW compliance would be under a mandate. I think most can agree that mandates greatly increase vaccine compliance, but if the data suggests that the vaccine doesn't work, then the question shouldn't be whether or not to mandate the vaccine. The question should really be whether we even offer it to HCW at all, or less seriously, even bother tracking compliance.  I think Mike's post or rather the Cochrane reviews have far more serious implications that stretch way beyond HCW mandates. To me though, there is enough data to support the efficacy and safety of influenza vaccine both in direct protection and also herd immunity. Thus, I think the key issue is compliance; but again, I haven't read it (yet).

So, what would I have done if asked to determine the benefits of mandatory influenza vaccine in HCW?  I might have completed a different type of research synthesis, altogether. I could have taken data like Mark Loeb's 2010 JAMA paper showing the benefits of herd immunity imparted on the unvaccinated by vaccinating children in small rural communities in Canada. Then, I'd have built a decision-analytic type model accounting for the non-linearity of influenza transmission in hospitals, adjusted for various levels of HCW vaccination compliance, completed numerous sensitivity analyses and then reported in which hospitals, in which countries and in which influenza seasons (H3 vs H1) we would expect influenza mandates to be most effective. Too bad that's not gonna happen.  Oh, and people wouldn't believe the model anyway.  It's just math for goodness sake and nobody trusts equations. No, most of us would much rather put our faith in conflicted human beings.  Go figure.

No links today; gotta spend time reading SHEA's new position paper

More on SHEA's Flu Vaccine Mandate for Healthcare Workers

Last week, Dan blogged about SHEA’s new position paper, which calls for annual influenza vaccination as a condition of initial and continued employment for healthcare workers (HCWs). Simply put, SHEA is recommending that HCWs without a contraindication to influenza vaccine be fired if they refuse to be vaccinated. That’s a strong stance coming from an organization that typically avoids strong stances. I’ve blogged before about why I think that mandating influenza vaccination is a bad idea, but in this posting I want to focus on the evidence behind the recommendation.

Of note, there are 3 Cochrane reviews on influenza vaccination published this year that are worth reading. If you’re not familiar with Cochrane Reviews, you can read more about them here. These reviews are generally thought of as the highest quality, most rigorous reviews of the medical literature, and the reviews are developed free of any commercial funding.

The first Cochrane review, Influenza Vaccination for Healthcare Workers Who Work with the Elderly, is most applicable to the SHEA position statement. SHEA’s position on the utility of vaccinating HCWs to prevent influenza transmission to patients is based on 4 studies in long-term care facilities (LTCFs). And of note, those 4 studies are part of the Cochrane review, which comes to the following conclusion: “We conclude there is no evidence that vaccinating HCWs prevents influenza in elderly residents in LTCFs.”

Another recent Cochrane review evaluated the utility of influenza vaccination of healthy adults, which presumably represents the majority of HCWs. The authors concluded: “Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.”

The last Cochrane review is least applicable to our current discussion, but interesting nonetheless. In reviewing the effect of influenza vaccine for the elderly, the authors conclude “The available evidence is of poor quality and provides no guidance regarding the safety, efficacy or effectiveness of influenza vaccines for people aged 65 years or older.”

So given the lack of rigorous evidence supporting the utility of vaccinating HCWs to prevent transmission to patients, I find it astonishing that the Society for Healthcare Epidemiology would adopt such a position. I certainly would have no problem with a position statement that strongly encourages vaccination, but to recommend that HCWs be fired for noncompliance with vaccination is over the top and undermines SHEA’s credibility. The level of compliance with any intervention to improve the quality or safety of patient care must be correlated to the strength of the evidence, and in this case, the evidence for a mandate is lacking.

As I was looking at the Cochrane reviews, I wondered aloud how the SHEA guideline writers could have come to their conclusion. My good friend and colleague, Gonzalo Bearman, quickly responded, “they were blinded by dogma.” Amen, Gonzalo!

SHEA endorses mandatory flu vaccine for healthcare workers

Here is the position paper, and here is SHEA’s press release. We have blogged on this issue often, so you can read some of these posts here, here, here, here, here, here and here. More can be had by linking to related topics in our “labels” section to the right.

One of my posts makes reference to the conflict of interest issue. I know it is complicated. But in an ideal world, “official” position papers such as this would be written by those who have no financial ties to vaccine makers. This is not meant to sound snarky or holier-than-thou (I have my own industry ties, related to research funding). I also know that this means many future position papers and guidelines will be written by professionals who have a lower profile, since almost all opinion leaders have some conflicts in their area(s) of expertise.

I will make no further comment, though perhaps others who read this blog regularly (including one or more of the authors of the position paper) wish to comment!

Should a hospital epidemiologist buy an iPad?

Perhaps some of you have already purchased an iPad. I suspect many of you think that getting another device is completely ridiculous since you already have a BlackBerry or iPhone, laptop and a desktop computer. If that is the case, you should check out Dropbox, which allows you to keep all of your documents synced across all devices and safely backed-up. If you are still on the fence, you may have been searching the interwebs for advice only to be faced with >1,000,000 google hits for "should I buy and iPad" with various humorously handy decision trees. None, I suspect, were actually helpful to you, the daring hospital epidemiologist or fearless infection preventionist. That's why CHIP exists, to serve our loyal readers.

First and foremost, I don't think you should purchase iPads for tracking hand hygiene compliance and various other in-hospital surveillance activities. There are several reasons for this including cost, size (Hawthorne effect people!) and you aren't supposed to clean the screen with solvents since they can damage the oleophobic-coated screen, oh, and the cost. As Dan has stated, there are Apps for that, but stick with an iPhone or iPod Touch.

Beyond that, I think there are 3 basic types of hospital epidemiologists and IPs, each with different needs and lives. I'm sure I will leave some or most of you out, but perhaps reading between the lines will get you the answers you need. If you still have questions, we offer open comment posting and we will try to answer your questions.

1) I attend SHEA/APIC: This one's the easiest. If you want to travel lightly, and as of now TSA allows iPads to be kept in your bag when passing through security, then the iPad is for you. The key benefits of the iPad are light weight, long battery life - I used it for 11 hours Sunday and still had 25% battery life left - and access to any content you want to read. That includes .doc, .ppt and .pdf files. There is a 99 cent app called GoodReader that will meet 99% of your needs. You can use it to read almost any document, download any file, grab any email attachment from the iPad Safari web browser, save most webpages for later viewing, AND wireless sync with your laptop even if wifi is not available. That last one is cool, and more information on how to do that is available (here) on the GoodReader site. If you get a 3G iPad, you can surf, check email and even control your home or work computer all without paying crazy hotel wifi fees. Apple charges $15 or $30/month but you can cancel anytime. Thus, only pay when you attend SHEA/APIC.

The iPad is the best email device I've used and will get better when the 4.0 OS comes out in the fall when it will allow a single in-box for your half-dozen email addresses. Even now it's fantastic and typing is more than adequate. Enter your passwords once and never have to log-in again. It works with gmail, yahoo, mobileme, aol and outlook along with others. You can also probably log into your VPN and check labs and other hospital-specific data unless you work at the VA. Either way, you should check with your IT support staff if your require that type of access.

2) I submit abstracts to SHEA/APIC: Above, I described some reasons why I think the iPad is the single best media consumption (documents, email) device there is. It is also wonderful for PubMed searches and other web-based searches including uploading your abstracts. Creating abstracts is a bit tougher. They can be started or edited using Apple's Pages (for .doc) and Keynote (for .ppt) but these applications have their limitations, which hopefully will be remedied in a future update. First, you must email the documents to yourself to get them on/off the device (or sync with iTunes). Second, track changes is not available and all previous changes are accepted once the document reaches the iPad. Third, some formatting is lost. It is likely that none of the abstract, poster or slide presentations will need to be completed while you're traveling, however. Hopefully.

3) I submit manuscripts to ICHE/AJIC. This is a bit more complicated. I would still say the iPad is for you, but the reasons are more subtle. You can create a draft document in Pages while you travel, but you can't really do track changes, insert endnotes etc. There is a PDF work-around since you can modify PDF documents using iAnnotate, but I suspect that is too much for most. However, the iPad is the single best PDF reader. Reading on a laptop or computer is sub-optimal since you can never get the screen set to the proper distance or are forced to read at a desk or table. With iPad, you can read PDFs as you would a book or magazine. No more printing and carrying PDFs! That will save your back and your eyes. This is why I purchased the iPad (the work reason, I also stream MLB games). It is fantastic to have all of your PDFs and MS Word files via Dropbox and GoodReader in one device that you can place next to your laptop when writing a paper or take to your reading chair when you finally make it home.

Final note: I also recommend Papers if you own a Mac/iPad/iPhone. This software is great for organizing the 1000's of PDFs you have scattered around devices. It pulls them all together and allows searching using metadata like you can in iTunes - search by author, title, date, journal. You can also dump PDFs in a folder and then create an Endnote library.

Final, final note: You don't need to get the expensive 64GB model if you have easy access to wifi, or get the 3G iPad, since you can always access your files in the cloud with services such as Dropbox and MobileMe. If you want to have 20 movies available as you fly back and forth from the WHO, then maybe you need the 64GB. Most of what I described, apart from iWork (Pages/Keynote) can also be done on the iPhone, but reading PDFs for long periods can be tough.

This healthcare quality report is excellent....for us to poop on!

So SHEA, APIC and IDSA have released a joint statement that echoes (and expands upon) Mike's concerns about the recent, highly publicized AHRQ report. The statement and accompanying set of talking points speak for themselves. I will quote one small section, and let you read the rest.

"We are concerned that any report coming from a government agency based solely on the use of administrative data, commonly referred to as billing/coding data, paints an inaccurate picture of healthcare-associated infections for the public. In contrast, another Department of Health and Human Services agency -- the Centers for Disease Control and Prevention (CDC) – is preparing to release epidemiologically sound, surveillance data based on the National Healthcare Safety Network (NHSN). Multiple studies have concluded that administrative coding data appears to be a poor tool for accurately identifying infections. This may create greater confusion among consumers."