Monday, December 05, 2011

Our First Line Of Defense



Photo Credit PHIL (Public Health Image Library)



# 5992


One of the concepts well illustrated during the initial outbreak of the H1N1 `swine flu virus’ in 2009 was that – until a vaccine could be developed, produced, and deployed – our only real defenses against any emerging infectious disease are NPIs; non pharmaceutical interventions.


Which is why flu hygiene (covering coughs/sneezes, disposing of tissues, washing hands often, and staying home when sick) was heavily promoted to the public during the pandemic.


Healthcare settings, where large numbers of vulnerable people are gathered in close proximity, are also the place that those infected with a new virus are likely to show up first.


Making the use of NPIs all the more important, to protect not only the staff, but other patients as well.


This morning we’ve a couple of studies that look at attitudes towards, and actually implementation of, NPIs and basic infection control procedures by both medical students and healthcare providers.


The most basic of NPIs is handwashing, and despite it having been more than 160 years since Ignaz Semmelweis published his work on the importance of hand hygiene, compliance rates in healthcare settings remain disturbingly low.


This is a subject we’ve visited many times before, including:


Giving Germs A Helping Hand 
Hand Hygiene Among Doctors Exposed
A Movement With Five Moments

Despite increased awareness and concern over HAIs (Hospital Acquired Infections), global handwashing campaigns, and the proliferation of hand sanitizing dispensers there remain serious gaps in this most basic infection control practice.


In the American Journal of Infection Control we’ve a study that surveyed beliefs of 1st year medical students over when it was appropriate to wash you hands when interacting with a patient.

Beliefs about hand hygiene: A survey in medical students in their first clinical year

Karolin Graf, MD, Iris F. Chaberny, MD, Ralf-Peter Vonberg, MD

Medical students were asked regarding knowledge and beliefs on hand hygiene before entering the clinical phase of education. By this, we noticed a lack of knowledge concerning the correct indications for hand disinfection. Regardless of previous experience in hospitals, the medical students expected that the compliance towards hand hygiene would be worse in more experienced physicians and senior consultants—who are often considered to be role models for medical students.


While this study is behind a pay wall, we do get additional details from a press release from Elsevier Health Services.


Elsevier Health Sciences

2 out of 3 medical students do not know when to wash their hands

Washington, DC, December 1, 2011 -- Only 21 percent of surveyed medical students could identify five true and two false indications of when and when not to wash their hands in the clinical setting, according to a study published in the December issue of the American Journal of Infection Control, the official publication of APIC - the Association for Professionals in Infection Control and Epidemiology.


Three researchers from the Institute for Medical Microbiology and Hospital Epidemiology at Hannover Medical School in Hannover, Germany collected surveys from 85 medical students in their third year of study during a lecture class that all students must pass before bedside training and contact with patients commences. Students were given seven scenarios, of which five ("before contact to a patient," "before preparation of intravenous fluids," "after removal of gloves," "after contact to the patient's bed," and "after contact to vomit") were correct hand hygiene (HH) indications. Only 33 percent of the students correctly identified all five true indications, and only 21 percent correctly identified all true and false indications.

(Continue . . . )



The next stop is a study that appears in the SHEA journal Infection Control and Hospital Epidemiology that shows that the inadequate use of masks by healthcare workers during the opening days of the 2009 pandemic put them at greater risk of contracting the virus.



Transmission of 2009 Pandemic Influenza A (H1N1) Virus among Healthcare Personnel-Southern California, 2009.

Jaeger JL, Patel M, Dharan N, Hancock K, Meites E, Mattson C, Gladden M, Sugerman D, Doshi S, Blau D, Harriman K, Whaley M, Sun H, Ginsberg M, Kao AS, Kriner P, Lindstrom S, Jain S, Katz J, Finelli L, Olsen SJ, Kallen AJ.


Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

We’ve a press release from SHEA with the details.


Study finds inadequate mask use among health care workers early in 2009 H1N1 outbreak

Inadequate use of masks or respirators put health care workers at risk of 2009 H1N1 infection during the earliest stages of the 2009 pandemic in the U.S., according to a study published in the December issue of Infection Control and Hospital Epidemiology, the journal of the Society of Healthcare Epidemiology of America.


The study, led by the Centers for Disease Control and Prevention (CDC), tracked 63 Southern California health care workers who had contact with six of the first eight laboratory-confirmed 2009 H1N1 cases in the U.S. Because these contacts happened before the 2009 H1N1 outbreak had been widely reported, the cases shed light on how well health care workers protect themselves before a direct epidemiological threat becomes evident.


The investigation found that 9 of the health care workers tracked became infected with the 2009 H1N1 virus, likely from contact with infected patients. Twenty of the 63 health care workers reported that they had worn a mask or respirator at least once when in contact with patients, and no one from that group became infected with 2009 H1N1. Meanwhile, 43 workers reported never using a mask around patients, and all 9 infections occurred in workers from this group.


Overall, mask and respirator use was disappointingly low, the researchers report. Only 19 percent reported using a mask during every patient encounter. Use was especially low among outpatient workers, who also made up the majority of those who became infected with 2009 H1N1.


"The findings highlight the challenge of getting health care personnel to routinely wear Personal Protective Equipment," Jenifer Jaeger, MD, MPH, Associate Pediatrician, Massachusetts General Hospital, said. "The study also suggests that greater attention to infection control and preparedness, particularly among outpatient workers, is needed."



The irony here is that once the threat of a new viral threat became apparent, there were difficulties in providing enough PPEs (Personal Protective Equipment) - including masks and respirators - to healthcare workers in some parts of the country.


In June of 2009  the CDC’s MMWR (Morbidity and Mortality Weekly Report) (Volume 58, No. 23) reported hospitals weren’t doing enough to identify potential influenza cases, to isolate them, and to protect their staff (see HCPs At Risk).


A month later the California Nurses Association/ National Nurses Organizing Committee (CNA/NNOC) filed a complaint against one hospital, which I reported on in California Nurses Association Statement On Lack Of PPE and Report: Nurses File Complaint Over Lack Of PPE.


In August 2009 I reported on Nurses Protest Lack Of PPE’s in San Francisco.  And in October, I wrote CNA/NNOC Plan Protest Over Inadequate H1N1 Protection.


And to this, we must also add the ongoing debate over what constitutes adequate PPE protection.



Ideally, the well-protected HCW (Health Care Worker) working in an infectious environment would be wearing an N95 respirator, gloves, gown and eye protection.



But during the opening months of the 2009 pandemic, it became obvious that our world faced a shortage of N95 respirators, and so strategies were adopted to maximize their use.


In some cases nurses were issued only one N95 mask to be used for an entire 8 hour shift, and told to don it only when in direct contact with a potentially infected patient.


In other venues, HCWs were issued surgical masks in lieu of N95s, despite the recommendation at the time from the CDC that N95 masks were the preferred level of protection.


Over the past two years we’ve seen dueling studies that alternately show surgical masks to be a reasonable protective barrier against respiratory viruses  . . . or pretty much useless.


Take your pick.


Which is why last January the IOM (Institute of Medicine) released, through the National Academies Press, an extensive, 200+ page update on the use of PPEs  that essentially calls for better science on which to base our decisions regarding the right kind of protection for HCWs.


We were very lucky that the 2009 pandemic virus wasn’t any more transmissible, or virulent, than it turned out to be. 


While instilling good infection control practices is imperative in normal times, the less talked about side to this story is that during a serious global pandemic threat sometime in the future, providing adequate PPEs to healthcare workers may prove to be a major challenge.

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