Closely tracking occupational infections among health care workers helps Vanderbilt University Medical Center in Nashville detect clusters and prevent further transmission.
Tuberculosis remains the primary infectious disease threat to health care workers, with exposures occurring from delays in diagnosis, according to a Vanderbilt analysis. From 2006 to 2011, 1,844 employees were exposed in 62 events, resulting in nine new latent TB infections, the analysis showed. The tracking of specific exposures was possible because of Vanderbilt’s homegrown occupational health surveillance system.
The occupational health software links with the human resources database, so employee health professionals can determine who was working in a particular unit. If there is a conversion on a TB skin test, they can check to see if any other conversions occurred on the same unit.
Twice, Vanderbilt has detected increased conversions and provided additional training and personal protective equipment, says Mary Yarbrough, MD, MPH, FACOEM, associate professor of clinical medicine and executive director of Vanderbilt’s health and wellness program.
On a quarterly basis, employee health works with infection control to review cases of TB conversions and other exposure events, Yarbrough says.
“We’re so focused on prevention, which is good, but we’ve also got to look and see where the prevention didn’t work,” she says. “Where did we have our exposures? What diseases resulted from that and what can we do [to prevent the exposures]?”
The surveillance software makes it easy to look for connections. “If someone comes in and converts on a TB test, we can go back and see if they had any exposures. Were there any other people on that unit that had conversions or exposures?”
For example, when an increase in conversions was detected in the emergency department, occupational health investigated and found that employees were not always closing the door of isolation rooms and some employees were not wearing the respirators. After re-training and a switch to bi-annual TB testing, no conversions occurred the following year, says Yarbrough, who recently presented her results at the annual stakeholder meeting of the National Personal Protective Technology Laboratory of the National Institute for Occupational Safety and Health (NIOSH) in Pittsburgh.
Measles cases in the U.S. rose to the highest level in 15 years in 2011, posing a particular risk to both hospital patients and health care workers.
Last year, there were 222 reported cases and 17 outbreaks. That included four health care workers who had been exposed at work, says Jane Seward, MD, MPH, deputy director of the Division of Viral Diseases at the Centers for Disease Control and Prevention.
One was a receptionist in the emergency department who had no documented immunity. Immunization one day after the exposure did not prevent her from acquiring measles, Seward says. One health care worker had serologic evidence of immunity and one had a history of disease, but both became infected. The fourth health care worker had no record of immunization.
The risk of transmission to patients or visitors in hospitals and other health care facilities is even greater. Last year, 15 cases were transmitted in health care facilities, Seward says.
“It’s highly, highly transmissible, including through the air,” she says. “Those coughs propel thousands of droplets into the air. Some of those will aerosolize and the virus will remain suspended in the air for up to a couple of hours after someone leaves the room.”
Measles was eliminated as an endemic disease in the United States in 2000, according to the CDC. But large measles outbreaks continue to occur in other countries. There were more than 15,000 cases in France alone last year, says Seward. Almost all of last year’s U.S. cases were linked to travel abroad or foreign visitors, CDC said.
Because measles can be severe, people with measles may visit a clinic, doctor’s office or hospital – or more than one. “You can have a lot of different exposures in health care settings just from a single case,” Seward says.
If there’s an outbreak in a hospital, employee health will need to verify immunity of employees. People born before 1957 are presumed to be immune, but in an outbreak, CDC recommends that they receive two doses of MMR.
Seward advises hospitals to maintain good documentation on immunization and immune status of employees and to consider immunizing those born before 1957. It can be difficult and costly for hospitals to scramble to verify immunity of employees during an outbreak, Seward says.
“Some select studies have been done in health care workers showing that a small percent are susceptible. But that small percent, if they become exposed to a case, probably will become a case,” she says.
“The best prevention is to be vaccinated. If you’re not vaccinated then you certainly have a great chance of becoming a case if you’re exposed to measles,” she says.
1. Centers for Disease Control and Prevention. Measles – United States, 2011. MMWR 2012; 61:253-257.
“The past is not dead. In fact, it's not even past.”
Was it not so long ago in a universe strikingly similar to ours that federal regulators were calling for a comprehensive national regulation to protect health care workers from tuberculosis?
Recently the CDC National Tuberculosis Surveillance System reported that the rate of new TB cases in 2011 was the lowest since reporting began in 1953. A total of 10,521 cases were reported in 2011 for an incidence of 3.4 cases per 100,000 population — a decrease of 6.4% from the previous year.
Before we start planning a public health victory parade and talk about complete TB eradication, it’s best to reread that quote above by Faulkner. TB is nothing if not patient, a great opportunist and a classic opportunistic infection that has risen time again after last rites have been administered. Thus we have that aforementioned resurgence of TB in the late 1980s and early 1990s when a series of hospital outbreaks triggered the failed rule-making attempt by OSHA.
TB remains a global problem so it remains a threat to any given country that raises the victory flag of complacency. Even in the otherwise encouraging U.S. data, 16 states and the District of Columbia actually had higher rates in 2011 than in 2010. Four states — California, Florida, New York, and Texas -- accounted for approximately one-half of all TB cases reported in 2011. Among the 81% of cases for whom their HIV status was known, 7.9% were seropositive.
A total of 109 cases of MDR TB were reported in 2010 (the most recent year for which complete results were available), representing 1.3% of those tested, a figure unchanged from the previous year. Among individuals with no past history of treatment for tuberculosis, the percentage of MDR TB has remained stable at approximately 1.0% since 1997. Among those with a previous history of TB, the proportion with MDR TB was approximately 4 times higher. Foreign-born individuals accounted for 82.6% of the total MDR TB cases in 2010 and 4 cases of XDR TB have were reported in 2011, all occurring in foreign-born. Though we are seeing only a smattering of the pan-resistant XDR-TB, it is a strain that is loose in the world and thus a possible disease in our future.
While overall TB rates are decreasing in the U.S., TB continues to be a significant problem among the foreign-born. Almost 80% of cases among the foreign-born were diagnosed two or more years after entry into the U.S., suggesting that most were the result of reactivation of latent infection that had been acquired in their native lands. The genie may be back in the bottle, but we should continue to keep a firm grip on the cork. The history of TB – sometimes called “the U-shaped curve of concern” -- is that once the disease declines and the attendant public health dollars bottom out with it, the inevitable resurgence begins.
The suddenly white-hot issue of antibiotic stewardship is not a new idea by any means, so it comes as something of a surprise to note that the first multicenter study testing a single intervention was recently published.(1)
The first of many we can only hope, as stewardship and infection control have become the last, best options against rising drug resistant pathogens. The study showed that antimicrobial stewardship expressed as a post-prescription review and feedback intervention can decrease antimicrobial use, especially when it’s part of an established antimicrobial program.1
This was the first study to look at performing the same antimicrobial stewardship intervention at multiple academic hospitals, says Sara Cosgrove, MD, MS, an associate professor of medicine in the division of infectious diseases at Johns Hopkins University School of Medicine in Baltimore, MD.
“We took five different academic medical centers and came up with standardized
data collection materials and interventions,” Cosgrove explains. “The intervention was that
at 48-72 hours we had an infectious disease physician review the use of broad spectrum
antibiotic use on some medical and surgical floors of the hospital.”
If the ID physician did not believe broad spectrum antibiotics was appropriate, the doctor would call the medical teams to recommend stopping the antibiotic. The study’s end point was to see if antibioticuse changed from the baseline, before calls were made, to the time after the intervention occurred.
“There was a mixed benefit,” Cosgrove says. “In hospitals where there was an established
antimicrobial program that included salary support and intellectual support of stewardship,
there was a decrease in antimicrobial use in the follow-up period,” she says. “In other
hospitals, where programs had just started or did not exist, we didn’t see any reduction in
For more on this story see the May issue of Hospital Infection Control & Prevention. Reference
1. Evaluation of postprescription review and feedback as a method of promoting rational antimicrobial use: a multicenter intervention. Infect Cont Hosp Epi 2012;33(4):374-380.
Antibiotic stewardship – while labeled as the last-ditch stand to stave off a post-antibiotic era – actuaully can begin on a fairly mundane level. Sort of like realizing it now costs more than a penny to make a penny, but that’s a discussion for another day that will probably never arrive in this blog.
In terms of long-hanging fruit in the antibiotic stewardship game, consider the results of a recent research identifying a systemic problem involving the unnecessary use of IV fluoroquinolones in the acute care wards of hospitals. While the data came from 128 Veterans Administration (VA) hospitals, the research suggests this is a trend that all health care systems should address through antimicrobial stewardship programs.1
“For antibiotic stewardship, we wanted to pick a topic where we could get a sense of how things were going in the VA and probably elsewhere, as well,” says Makoto Jones, MD, research investigator and staff physician at the VA Salt Lake City Health Care System in Salt Lake City, UT.
Investigators found that avoidable IV fluoroquinolone use overall was 46.8% of all fluoroquinolone days. The percentage of IV fluoroquinolone days that was avoidable was 90.9%.1 Astounding, yes, but parenteral to oral conversion of fluoroquinolones is a relatively easy stewardship step to take, he notes.
“It may be a marker of how well an antibiotic stewardship program is doing,” Jones adds.
The 152-bed VA hospital system uses a barcode medication administration to make sure that the right patient gets the right medication. The VA electronic health record collects these and other data, including admission/discharge/transfer data, which tells where a patient is at any given time in the hospital.
“We were able to look at whether an antibiotic was given intravenously or by mouth,” Jones says. “We set up the rules so if somebody was given IV antibiotics for two days in a row, we took that as their intention to give IV antibiotics.”
Barcode medication administration data were used because medication orders often can change within the first day – sometimes even before a single dose is administered, he explains.
Researchers focused on fluoroquinolones because the drug’s bioavailability is the same whether it’s given intravenously or orally. So if the patient’s gastrointestinal tract could handle the oral medication then many patients could be switched from IV to oral antibiotics, he adds.
“It’s an easy switch, and we have randomized control trials saying it appears to get people out the door faster and in a safe manner,” Jones says. “If we continue to give patients IV antibiotics they probably stay in the hospital longer than they need to.”
1. Jones M, Huttner B, Madaras-Kelly K, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Cont & Hosp Epid. 2012;33(4):362-367.
For more on this story see the May 2012 issue of Hospital Infection Control and Prevention.
In yet another sign that infection control is becoming a national priority across a wide range of accreditors, regulators and state and federal agencies, the Joint Commission has created a new web portal to combine its full array of initiatives to prevent health care associated infections (HAIs).
“[We] have many moving parts that affect many aspects of health care,” says Jerod M. Loeb, PhD executive vice president for healthcare quality evaluation at the Oakbrook Terrace, IL-based accrediting agency. “We have standards, performance measures, our center for transforming health care. The problem has been that they have all been located in silos.”
The “HAI Portal” enterprise includes the Joint Commission Center for Transforming Healthcare, Joint Commission Resources, and Joint Commission International. The goal of the HAI Portal is to provide an integrated “kiosk” of HAI resources – including those that are free and for purchase – in one web view that is accessible through any of the Joint Commission related websites.
Yes, there are Joint Commission related products for sale on the site, but Loeb says that was not the primary driver of the project.
“It was not built to be a marketing site,” he says. “But just knowing a standard and knowing the elements by which a hospital might be surveyed doesn’t give them all the other answers. So we have created a variety of tools and things that are available -- many of which are free. If you are an accredited organization, for example, you can turn to our leading-practice library. If you have issues related to getting house staff to wash hands prior to central line insertion, for example, you can find dozens of things that other organizations that we accredit have identified as good solutions.”
Indeed, in the shadow of an increasingly active Center for Medicare and Medicaid Services (CMS) – the federal agency that gives it deeming authority to grant accreditation – the Joint Commission is not likely to become less aggressive in the survey process. (As we previously reported, the CMS will begin unannounced inspections of infection prevention and hospital employee health programs later this year.)
“We certainly have worked closely with them and we will continue to work closely with CMS as part of our deemed status relationship,” Loeb says. “People and professional societies can preach it, but if nobody is validating whether [infection control] is done or not, things often don’t change. We have an interesting perspective here because we have both carrots and sticks. This portal is, we believe, a large carrot.”
The Joint Commission HAI portal can be accessed at http://www.jointcommission.org/hai.aspx.
Infectious disease societies frustrated at watching antimicrobial resistance increase for decades are taking the unusual step of asking for federal regulation and oversight of clinical practice, imploring the Centers for Medicare & Medicaid Services (CMS) to require hospitals to implement antimicrobial stewardship programs.
The world is dangerously close to the initial phases of a "post-antibiotic era," where drug resistant pathogens cause infections that cannot be treated. Antimicrobial stewardship is one of the best ways to head off the crisis, as overused and misused drugs select out resistant organisms and perpetuate the cycle.
While multidrug-resistant pneumococci, gonococci, Salmonella spp, and tuberculosis have developed over the past 30 years, there has been a dramatic drop in the development of new antibacterial agents in the past decade, says the policy statement on antibacterial stewardship, produced by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). (http://bit.ly/HLMJVP)
The major problems are the lack of new antibiotic drugs and the annual increase in antibiotic resistance to organisms found in the community, as well as in intensive care units, and hospitals,.
The chief roadblock to new antibiotic development is financial. An immediate stewardship step to reign in the widespread unnecessary use of antibiotics is roughly equivalent to the first rule of holes: When finding one’s self in one, stop digging.
“Our position is that clearly unless hospitals are forced to participate in antimicrobial stewardship and the government is forced to support new antibiotic drug development, then we will only be in a worse hole and a world of hurt,” says Thomas G. Slama, MD, FIDSA, president, IDSA, and clinical professor of medicine at the Indiana University School of Medicine in Indianapolis, IN.
For more on this important story see the May 2012 issue of Hospital Infection Control & Prevention
In a “call to action,” sharps safety experts are targeting gaps in needlestick prevention and seeking to spur a new commitment to make improvements.
“Over the past 25 years, there’s been such tremendous success in reducing health care workers’ risk of bloodborne pathogens,” says Janine Jagger, Ph.D., director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville and a pioneer in sharps safety. “It’s a question of finding gaps [in compliance] and trying to plug up those gaps.”
Sharps safety experts cite several remaining barriers and arising new challenges, including reducing the risks of injuries and blood exposures in the surgical setting:
1. Improve sharps safety in the surgical setting. Sharps injuries in the OR actually rose during the time that injuries from needles and syringes were declining dramatically. Surgeons have been reluctant to use blunt suture needles or safety scalpels, Jagger says. “It all comes down to getting surgeons on board. If they’re not onboard nothing’s going to happen,” she says.
Still, hospitals and surgery centers should adopt policies that mandate safety. “Most of the injuries in the OR occur to the OR staff and not to the surgeon,” says Jagger. “The surgical equipment that the surgeon chooses has the major effect on the risk of everyone else in the room.”
Surgeons should work with nurses and other OR personnel “to develop sharps safety standards and practices that are consistently implemented and followed in all surgical environments,” according to the consensus statement. The experts also called on OSHA to monitor compliance in ORs.
The American College of Surgeons has issued statements encouraging safer practices, including double-gloving, passing instruments in a neutral zone, and using blunt suture needles. The consensus statement gives OR personnel some additional leverage, says Jagger. ”It gives them a new opportunity to raise the issue and to focus on its importance,” she says.
2. Increase use of safety devices in non-hospital settings. The use of sharps safety devices is commonplace in hospitals, but not as consistent in non-hospital settings, such as clinics, physician offices and home health. In fact, the needlestick surveillance programs focus on hospitals; much less is known about compliance elsewhere. Market data from device manufacturers indicates less use of safety needles in non-hospital settings. The sharps safety experts recommended more research from the National Institute for Occupational Safety and Health and special enforcement programs from OSHA. “There’s less compliance because there’s less enforcement [in smaller settings],” Jagger says.
3. Ensure that frontline workers are involved in selection of safety devices. The Bloodborne Pathogen Standard requires employers to solicit the input from frontline workers when they select sharps safety devices. Yet it is hard to keep tabs on the compliance with this provision. The experts note that it is “not consistently” followed. “At a time when the pressure to reduce healthcare costs is intense, it is important to keep these user-oriented questions at the forefront of device selection,” the experts said in the consensus statement.
4. Continue innovation in safety design. When needle safety became law in the United States, device manufacturers responded quickly and developed more effective and innovative designs. “It’s really quite amazing. The technology they’ve brought forward is really good technology,” says Jagger. But even 11 years after the revised Bloodborne Pathogen Standard was released, there are devices for which there is no safety version. “I think that as we bring new information forward about gaps we have, the medical device industry is likely to respond very well again,” she says.
5. Enhance education and training. Teaching hospitals have higher needlestick rates than non-teaching hospitals. That indicates a need to improve training, the safety experts said. Failure to activate a safety device also may reflect a lack of training in how to use the device. The Bloodborne Pathogen Standard requires annual training that includes “an opportunity for interactive questions and answers with the person conducting the training session.”
The world has dirty hands, but who is trying to do anything about? Well, the World Health Organization for one, which has designated May 5, 2012 an international day of hand hygiene observance. The 5th day of the 5th month leads us to another five: The 5 Moments that hand hygiene is recommended for health-care workers clean their hands:
• before touching a patient;
• before aseptic procedures;
• after being exposed to a patient's body fluids;
• after touching a patient; and
• after touching the patient's surroundings.
As part of a major global effort to improve hand hygiene in health care, led by WHO to support health-care workers, the “SAVE LIVES: Clean Your Hands” annual global campaign was launched in 2009 and is a natural extension of the WHO “First Global Patient Safety Challenge: Clean Care is Safer Care work.”
The campaign is designed to galvanise action at the point of care to demonstrate that hand hygiene is the entrance door for reducing health care-associated infection and patient safety. It also aims to demonstrate the world's commitment to this priority area of health care.
WHO's role includes encouraging engagement and action to maintain this global movement. Numbers are a great awareness-raising mechanism, as demonstrated by the growing number of health-care facilities registered for “SAVE LIVES: Clean Your Hands” after two years of a call to action, but they are not the end point. Sustaining the efforts to improve patient safety requires dedicated action and innovation both of which are now more crucial than ever. WHO have appreciated receiving communications about country and health-care facility activities. Action must continue; use the WHO tools to support your actions. For more information go to:
For those infection preventionists who also work in employee health, the National Institute for Occupational Safety and Health (NIOSH) is forming a new electronic, voluntary, and secure surveillance system to track occupational injuries to health care workers.
The Occupational Health and Safety Network (OHSN) will integrate a wide variety of ongoing occupational health surveillance activities and make it easier to identify effective prevention strategies, NIOSH says.
This first version of OHSN deals with work-related injuries to healthcare personnel. Modules addressing other industry sectors may be added in the future.
How might OHSN benefit healthc are facilities?
Well, OHSN lets you:
• Benchmark your facility’s rates and trends against data from similar facilities, letting you see how your facility is doing.
• Compare patterns of injuries (e.g., risk factors, types of healthcare personnel involved, circumstances leading to injuries)
• Identify effective intervention approaches shared by NIOSH and other OHSN participating facilities – and add your own facility’s best practices
• Assess the impact of your prevention efforts on traumatic injuries over time
• Track your own data to meet the requirements of OSHA and The Joint Commission
→NIOSH will work with you on integrating the collection of data required for OHSN into your current process to minimize your effort.
[Exhibit 2 about here]
Who can get involved in OHSN?
• Occupational health professionals in the healthcare industry – the intended users of OHSN
• Other organizations and groups interested in the health and safety of healthcare personnel – Please pass along this information and the OHSN website to your contacts!
• Beginning the end of 2012/early 2013, all types of ambulatory and inpatient healthcare facilities in the U.S. can enroll, including acute care hospitals, long-term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, outpatient clinics, and long-term care facilities.
How can you get involved?
Learn more about OHSN at strong>/
Open enrollment for OHSN begins soon (end of 2012/beginning of 2013))
Right now, NIOSH is seeking facilities to test the data transmission process.
To be considered as a testing facility, or to ask questions, contact:
Ahmed Gomaa, MD, ScD, MSPH: AGomaa@cdc.gov
Sara Luckhaupt, MD, MPH: SLuckhaupt@cdc.gov
OHSN Team: NIOSHOHSN@cdc.gov
Hospital Infection Control & Prevention has been the leading source for news and comment on health care epidemiology for 38 years. With the HICprevent blog site we extend our coverage and commentary on this dynamic field, opening a new dialogue with infection preventionists, health care epidemiologists and others seeking solutions to one of the most vexing problems in patient safety: health care associated infections. HICprevent welcomes your comments, questions, tips and strategies for infection prevention.