Dallas Ebola Press Conference & Hospital Statement

 

# 9181

 

A clearly subdued Dallas County Judge (highest ranking county official in the state of Texas) Clay Jenkins, in a press conference this morning at Texas Health Presbyterian Hospital, provided additional details on the first nosocomial transmission of Ebola in the United States.

What we know (some details are being withheld to protect the family, and observe HIPAA regulations), is that a healthcare provider at Texas Presbyterian Hospital – who was involved in Eric Duncan’s care after he was admitted on the 28th -  was in isolation last night with a mild fever. 

 

This particular HCW was considered a `low risk’ contact of Mr. Duncan. This patient’s initial tests came back positive around midnight last night.

According to Dr. Varga, head of clinical care at Texas Presbyterian, this HCW was following all CDC recommended infection control procedures (Gloves, gown, facemask & eye shield), but a review is underway to understand what happened. 

Here is a statement from Dr. Dan Varga, released at the same time as the press conference was begun:

 

Statement from Dr. Dan Varga, Oct. 12, 7:30 a.m. CDT

10/12/2014

Ebola Virus 

Statement from Dr. Dan Varga, Chief Clinical Officer, Senior Executive Vice President

Late Saturday, a preliminary blood test on a care-giver at Texas Health Presbyterian Hospital Dallas showed positive for Ebola. The healthcare worker had been under the self-monitoring regimen prescribed by the CDC, based on involvement in caring for patient Thomas Eric Duncan during his inpatient care that started on September 28.

Individuals being monitored are required to take their temperature twice daily. As a result of that procedure, the care-giver notified the hospital of imminent arrival and was immediately admitted to the hospital in isolation. The entire process, from the patient’s self-monitoring to the admission into isolation, took less than 90 minutes. The patient’s condition is stable. A close contact has also been proactively placed in isolation. The care-giver and the family have requested total privacy, so we can’t discuss any further details of the situation.

We have known that further cases of Ebola are a possibility among those who were in contact with Mr. Duncan before he passed away last week. The system of monitoring, quarantine and isolation was established to protect those who cared for Mr. Duncan as well as the community at large by identifying any potential ebola cases as early as possible and getting those individuals into treatment immediately.

Finally, we have put the ED on “diversion” until further notice because of limitations in staffed capacity — meaning ambulances are not currently bringing patients to our emergency department. While we are on diversion we are also using this time to further expand the margin of safety by triple-checking our full compliance with updated CDC guidelines. We are also continuing to monitor all staff who had some relation to Mr. Duncan’s care even if they are not assumed to be at significant risk of infection.

All of these steps are being taken so the public and our own employees can have complete confidence in the safety and integrity of our facilities and the care we provide.

 

 

Meanwhile, the city of Dallas has sealed off this new patient’s apartment, decontaminated the common areas in the apartment complex, sealed and decontaminated the patient’s car, and has canvassed the neighborhood – knocking on doors – checking on everyone and providing information to nearby residents.

 

A close contact of this patient is also in isolation as precaution – but is not currently symptomatic.  There is also reportedly a pet in the apartment, and efforts will be made later today to check on, and provide for, this animal.

 

We will probably  be hearing later today from the CDC, the State of Texas, and Dallas County Department of Health.

 

While obviously a setback, this was not unexpected.  

 

Despite all of the reassurances over the level of precautions being taken, there is no way to reduce the risk of treating an Ebola patient to zero.  As Zach Thomas, head of Dallas County Health Department – in a TV interview (WFAA) right after the press conference – warned `Don’t be shocked if we see another case’.

Stay tuned.

Spain: MOH Statement On Ebola Infected Nurse & News Roundup

 

# 9155

 

In a follow up to yesterday’s report (see Nurse `Infected With Ebola’ In Madrid, Spain) we are seeing more details emerge, including demands from the EU for clarification on how this infection could have occurred (see AFP article EU demands explanation from Spain on Ebola case) in a modern hospital that knew they were receiving and treating an Ebola case.

 

ABC News is reporting that Spain Places Husband of Ebola Nurse in Quarantine – a reasonable precaution given his risks of exposure – and that the MOH is drawing up a list of others who may have had contact with this nurse so that they can be monitored.

 

Although we know how to protect against infection with the Ebola virus, the reality is, no system of infection control is infallible.  There are reports overnight in the media of complaints over `substandard PPEs’ provided by the Spanish hospital, although authorities are still insisting all proper infection control procedures were followed.

 

Quickly getting to the bottom of how this exposure occurred – and making adjustments to prevent it from happening again -  will be paramount to prevent a crisis of confidence in the ability of modern hospitals to take in, and care for Ebola cases,  without endangering their staff.  

 

For now, the Spanish MOH is being circumspect on releasing details of this nurse’s contacts, or travel history, during the six days after she began to feel unwell, but was not isolated.  A tactic that, unfortunately, may lead to more intense speculation online and in the media.

 

While it isn’t currently visible from the front page of Spain’s Ministry of Health website, there is now a brief press release posted under the  Actualidad (news)  banner.

 

Press Releases

Diagnosed a secondary case of Ebola virus infection

The patient was isolated at the Hospital La Paz Carlos III

The patient is a member of the medical staff who treated Manuel García Viejo

The Minister of Health, Social Services and Equality, Ana Mato, sends a message of calm and highlights the absolute coordination with health authorities both nationally and internationally

6 October 2014 The Minister of Health, Social Services and Equality, Ana Mato, today reported the detection of a secondary case of Ebola virus infection in our country. The minister, who appeared together with the Director General of Public Health, Mercedes Vinuesa, Director of Primary Care, Community of Madrid, Antonio Alemany and healthcare professionals of the Community, explained that this is a medical technician who treated the Manuel García patient Viejo. After the symptoms have been detected and confirmed infection, remains hospitalized in isolation at the La Paz Hospital Carlos III.

The minister explained that the Ministry and the public health authorities of the Community of Madrid are working in a coordinated and are taking every step to give the best care to the patient and to ensure the safety of the population and health personnel . It has also indicated that it is investigating the source of infection.

He also stressed the absolute international coordination and recalled that Spain collaborates with the World Health Organization (WHO). Finally, you have moved a message of reassurance to all citizens.

WHO: UAE Reports New MERS-CoV Case (HCW)

 

Coronavirus – Credit CDC PHIL

 

 

# 8125

 

 

The World Health Organization has just posted a GAR update  (h/t @MackayIM & @HelenBranswell)  with information on a new MERS case in the UAE – a 33 year-old Health Care Worker who was in contact with an earlier confirmed case (see WHO Coronavirus Update – December 22nd) who has since died.

. 

 

This newest case is described as being hospitalized with bilateral pneumonia, acute renal failure and thrombocytopenia on December 28th, and is currently listed in stable, but critical, condition.

 

One of the ongoing concerns over MERS is the relatively high number of hospital (nosocomial) transmissions we continue to see, despite presumed increases in infection control procedures.  Today’s WHO update once again contains a strong reminder for vigilance among medical staff to prevent transmission.

 

 

Middle East respiratory syndrome coronavirus (MERS-CoV) - update

Disease outbreak news

3 January 2014 - On 31 December 2013, WHO has been informed of an additional laboratory-confirmed case of Middle East Respiratory Syndrome coronavirus (MERS-CoV) in United Arab Emirates.

 

The case is a 33 year-old male healthcare worker in Dubai who was in contact with the confirmed MERS-CoV case reported to WHO on 20 December. He developed symptoms on 27 December, and was hospitalized on 28 December with bilateral pneumonia, acute renal failure and thrombocytopenia. The patient has underlying history of bronchial asthma and chronic kidney disease. The case was laboratory confirmed for MERS-CoV on 29 December 2013. The patient is in critical but stable condition.

 

Globally, from September 2012 to date, WHO has been informed of a total of 177 laboratory-confirmed cases of infection with MERS-CoV, including 74 deaths.

 

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.

 

Health care providers are advised to maintain vigilance. Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations.

 

Patients diagnosed and reported to date have had respiratory disease as their primary illness. Diarrhoea is commonly reported among the patients and severe complications include renal failure and acute respiratory distress syndrome (ARDS) with shock. It is possible that severely immunocompromised patients can present with atypical signs and symptoms.

 

Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC). Health care facilities that provide care for patients suspected or confirmed with MERS-CoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients, health care workers and visitors.

(Continue . . . )

Media Reports Blame Saudi nCoV Outbreak On Dialysis Equipment

 

# 7245

 

Via a pair of long, but reasonably decipherable, Arabic news items overnight (h/t Tetano on FluTrackers) we get reports attributing their current `healthcare’ related coronavirus outbreak to contaminated dialysis equipment.

 

If the bulk of these cases can be shown to be due to contaminated hospital equipment, rather than from direct human-to-human transmission, then a lot of people will breathe a little easier. 

But as we’ve also seen news reports suggesting that some H2H transmission may have taken place, this may not be as reassuring as one might hope.

 

For now, I would view these media stories cautiously, and put them all in the interesting, even plausible category. 

 

But until we see some official verification (and hopefully, details from the epidemiological investigation emerge) -  it would be premature to call this the definitive explanation for the mode of viral transmission in this outbreak.

 

First, from Almadaa.net/news.

 

"Hemodialysis" hospital because of a "Corona" Mfg

06-28-1434 03: 49

Information revealed that the main causes of the spread of "Corona" in a hospital in Al-Ahsa comes due to contamination of dialysis  "devices" in the hospital.

 

Medical sources in Al-Ahsa in accordance with home health among other reasons provided by follow-up committees investigate the circumstances of the spread of the disease non-compliance by some workers in hospital infection control systems worldwide.

 

The coronavirus had caused the death of seven people and injured six others in the last two weeks, Al-Ahsa, causing a health alert and panic and fear between the hospitals.

 

Nearby, said one of the victims of the "virus" – that the close was not suffering from a serious illness when you sleep in the hospital, but was being washed with renal dialysis "3 days per week, and suddenly, the doctors informed his family a few days before his death, that their father is in critical condition as a result of a virus.

 

In the same context, the situation of an HIV-infected, a marked improvement in his health, in custody in hypnosis at a hospital in Kuala Lumpur as a precautionary measure, and will not be allowed to get out of the hospital before making sure he recovers fully, and that at least a minimum of two weeks.

 

The sources said that with the 5 others hospitalized in Al-Ahsa and Eastern hospitals are being treated intensively in hypnosis and rooms still unstable health condition.

(Continue . . .)

 

We’ve a second report with almost identical language - this time from Alarabiya.net.

 

Kidney dialysis is contaminated beyond a "Corona" Mfg

The investigation revealed non-compliance in hospital infection control systems worldwide

Wednesday 27 Jumada II 1434-may 8, 2013

After the toll HIV-infected "SK" in Saudi Arabia, revealed information to highlight the causes of the spread of the virus at a hospital in Al-Ahsa, is contamination of dialysis "devices" in the hospital, according to Al-Watan.

 

And medical and health sources said the health of the lahsa among other reasons provided by follow-up committees investigate the circumstances of the spread of the disease non-compliance by some workers in hospital infection control systems worldwide. The coronavirus had caused the death of seven people and injured six others in the last two weeks, Al-Ahsa, which because of the State of health in the province, alert and panic and fear between the hospitals.

 

Nearby, said one of the victims of the "virus" – that the close was not suffering from a serious illness when you sleep in the hospital, but was being washed with renal dialysis "3 days per week, and suddenly, the doctors informed his family a few days before his death, that their father is in critical condition as a result of a virus. The sources said that with the 5 others hospitalized in Al-Ahsa and Eastern hospitals are being treated intensively in hypnosis, and rooms still unstable health condition.

 

(Continue . . .)

The Flight Of The Bacterial Intruder

Credit CDC PHIL

 

 

# 6625

 

HCAIs (Health care associated Infections) or HAIs (Hospital acquired infections) constitute a major threat to life, health, and the cost of medical care in this country, and around the world. This oft quoted assessment from the CDC on the burden of Hospital Acquired Infections in the United States is from 2010.

 

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

A 2009 report The Direct Medical Costs of Healthcare-associated Infections in U.S. Hospitals and the Benefits of Prevention finds:

 

Applying two different Consumer Price Index
(CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services).

 

 

As you can imagine, hospitals are engaged in a perpetual battle against the spread of infection - and while progress is being made - many pathogens continue to slip past the infection control safeguards.

 

A study from the University of Leeds recently published in the Journal Building and Environment may provide a clue as to why the infection control measures being used today have failed to curb the spread of bacteria in the hospital setting.

 

 

Bioaerosol Deposition in Single and Two-Bed Hospital Rooms: A Numerical and Experimental Study

M.F. King, C.J. Noakes, P.A. Sleigh, M.A. Camargo-Valero

 

You’ll find the abstract, along with figures and tables from this article, at the link above. But the full paper is behind a pay wall. The University of Leeds website, however, has a synopsis of this research project, which is excerpted below:.

 

 

Superbugs ride air currents around hospital wards

Published Thursday 11th October 12

Hospital superbugs can float on air currents and contaminate surfaces far from infected patients’ beds, according to University of Leeds researchers.

 

The results of the study, which was funded by the Engineering and Physical Sciences Research Council (EPSRC), may explain why, despite strict cleaning regimes and hygiene controls, some hospitals still struggle to prevent bacteria moving from patient to patient.

 

It is already recognised that hospital superbugs, such as MRSA and C-difficile, can be spread through contact. Patients, visitors or even hospital staff can inadvertently touch surfaces contaminated with bacteria and then pass the infection on to others, resulting in a great stress in hospitals on keeping hands and surfaces clean.

 

But the University of Leeds research showed that coughing, sneezing or simply shaking the bedclothes can send superbugs into flight, allowing them to contaminate recently-cleaned surfaces.

 

PhD student Marco-Felipe King used a biological aerosol chamber, one of a handful in the world, to replicate conditions in one- and two-bedded hospital rooms. He released tiny aerosol droplets containing Staphyloccus aureus, a bacteria related to MRSA, from a heated mannequin simulating the heat emitted by a human body. He placed open Petri dishes where other patients’ beds, bedside tables, chairs and washbasins might be and then checked where the bacteria landed and grew.

 

The results confirmed that contamination can spread to surfaces across a ward. “The level of contamination immediately around the patient’s bed was high but you would expect that. Hospitals keep beds clean and disinfect the tables and surfaces next to beds,” said Dr Cath Noakes, from the University’s School of Civil Engineering, who supervised the work. “However, we also captured significant quantities of bacteria right across the room, up to 3.5 metres away and especially along the route of the airflows in the room.”

 

“We now need to find out whether this airborne dispersion is an important route of spreading infection,” added co-supervisor Dr Andy Sleigh.

(Continue . . .)

 

 

While we often think first of viruses when it comes to airborne transmission of illness, some types of bacteria (e.g. Legionella, Mycoplasma pneumonia, Tuberculosis) are easily aerosolized and transmitted.

 

This study is not the first to identify the airborne spread of Staphylococcus aureus, but they have developed an ingenious way to quantify it.

 

Regarding MRSA and C. Difficile the Journal of The Royal Society published a review in 2009 called:

 

Airborne transmission of disease in hospitals

I. Eames, J. W. Tang,Y. Li and P. Wilson

(EXCERPT)

MRSA can survive on surfaces or skin scales for up to 80 days and spores of Clostridium difficile may last even longer. MRSA can be transmitted in aerosol from the respiratory tract but commonly attaches to skin scales of various sizes. The distance of travel depends on the size of the scale, the larger falling to the floor within 1–2 m, the smaller travelling the entire length of the ward.

<SNIP>

Clostridium difficile spores are thought to spread in the air and can be found near a patient carrying the organism (Roberts et al. 2008). However, unlike MRSA, they are rarely isolated from air samples.

 

 

Not surprisingly, in 2010, we saw a study published in the AJIC: American Journal of Infection Control that found that the more roommates you have during a hospital stay, the greater chance you will have of contracting an HAI like MRSA or C. Diff.

 

Exposure to hospital roommates as a risk factor for health care–associated infection

Meghan Hamel, MSc, Dick Zoutman, MD, FRCPC, Chris O'Callaghan, DVM, MSc, PhD

 

The authors used this study to promote the idea  of making private (or at least, semi-private) rooms the norm in Canadian hospitals. While acknowledging that it would involve considerable up-front costs, they believe the long-term savings would be considerable.

 

All of this highlights the great challenges involved in substantially reducing the incidence of HAIs in our health care facilities.

 

Solutions must not only include stringent hand hygiene and improved cleaning methods, but engineering solutions as well.

 

For more on the prevention of Hospital Acquired Infections you may wish to visit the CDC’s HAI PAGE.

 

 

Or revisit some of these earlier blogs on hospital acquired infections.

 

HPA: Healthcare-Associated Infection (HCAI) Survey

A Barrier To Good Hand Hygiene

Study: Hospital Uniforms And Bacteria

Study: HAIs, Universal Surveillance, & MRSA

 

And finally, the subject of HAIs is often addressed by Maryn McKenna on her excellent Superbug Blog, and was a major focus of her book SUPERBUG: The Fatal Menace Of MRSA.

 

Both are highly recommended.

MMWR: NDM-1 Transmission In Rhode Island

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

 

# 6397

 

From the today’s MMWR , we’ve a report on the importation and likely nosocomial transmission of a CRE (carabapenem-resistant Enterobacteriaceae) infection containing NDM-1.

 

NMD-1, or New Delhi metallo-ß-lactamase-1 – is an enzyme which confers broad antibiotic resistance to various types of bacteria. Even more troubling, it rides on a plasmid (a snippet of portable DNA) that can be shared by different types of bacteria.

 

The good news is that NDM-1 cases in the United States are still rare enough that they merit extensive reportage in the CDC’s MMWR. The bad news is, they continue to spread around the globe and our treatment options against them are extremely limited.

 

A few excerpts from today’s MMWR report follow (slightly reparagraphed for readability). 

 

 

Carbapenem-Resistant Enterobacteriaceae Containing New Delhi Metallo-Beta-Lactamase in Two Patients — Rhode Island, March 2012

 

June 22, 2012 / 61(24);446-448

U.S. and international efforts to control carabapenem-resistant Enterobacteriaceae (CRE) are critical to protect public health. Clinicians caring for patients infected with such organisms have few, if any, therapeutic options available. CRE containing New Delhi metallo-beta-lactamase (NDM), first reported in a patient who had been hospitalized in New Delhi, India, in 2007 (1), are of particular concern because these enzymes usually are encoded on plasmids that harbor multiple resistance determinants and are transmitted easily to other Enterobacteriaceae and other genera of bacteria (2).

 

A urine specimen collected on March 4, 2012, from a patient who recently had been hospitalized in Viet Nam, but who was receiving care at a hospital in Rhode Island, was found to have a Klebsiella pneumoniae isolate containing NDM.

 

The isolate was susceptible only to tigecycline, colistin, and polymyxin B. Point-prevalence surveys of epidemiologically linked patients revealed transmission to a second patient on the hematology/oncology unit.

 

These two cases bring to 13 the number of cases of NDM reported in the United States. After contact precautions were reinforced and environmental cleaning was implemented, no further cases were identified.

 

<SNIP Lengthy Narrative On Patients, Lab Tests, and Isolation Methods>

 

Reported by

Erica E. Hardy, MD, Leonard A. Mermel, DO, Dept of Medicine, Kimberle C. Chapin, MD, Dept of Pathology, Warren Alpert Medical School of Brown Univ; Cindy Vanner, Rhode Island Dept of Health. Ekta Gupta, MD, Dept of Medicine, Boston Univ School of Medicine, Massachusetts. Corresponding contributor: Leonard A. Mermel, lmermel@lifespan.org, 401-444-2608.

Editorial Note

Since the first report in 2009, cases involving NDM-producing Enterobacteriaceae have been reported in every continent except South America and Antarctica (7). Among 29 cases in the United Kingdom, at least 17 involved patients who had traveled to India or Pakistan, among whom 14 had been hospitalized in one of those countries (8).

 

Although medical care in the Indian subcontinent was associated with many early reports, recent cases have been described involving persons who traveled to endemic regions* but were not hospitalized (7). The plasmid-carrying NDM is highly transmissible to other bacteria, and bacteria carrying NDM can colonize the gastrointestinal systems of humans for prolonged periods and can spread through contamination of water sources and environmental surfaces (7).

 

Not surprisingly, nosocomial spread also has been documented outside of the Indian subcontinent. Of 77 cases of infection or colonization with CRE containing NDM in Europe, 13 might have been hospital-acquired in Europe (9). Spread of NDM in other parts of Asia also has been reported, including four patients in South Korea without travel history (10), similar to recent reports elsewhere (7).

 

(Continue . . . )

 

 

In summary, the report offers the following:

 

What is already known on this topic?

New Delhi metallo-beta-lactamase (NDM)–producing Klebsiella pneumoniae are resistant to extended-spectrum antimicrobials, including carbapenems. The resistance mechanism is highly transmissible and its presence substantially limits treatment options. NDM-producing Enterobacteriaceae have been identified in the United States, primarily among patients with exposure to health care in endemic countries.

 

What is added by this report?

An NDM-producing organism was isolated from a patient being treated in the United States after having been hospitalized in Vietnam. Implementation of CDC-recommended carbapenem-resistant Enterobacteriaceae (CRE) control practices, including surveillance cultures of epidemiologically linked contacts, identified likely transmission to one other patient on the same ward of the U.S. hospital. Additional control measures were applied and additional surveillance and clinical cultures have not identified further transmission.

 

What are the implications for public health practice?

An aggressive approach to control of CRE, including highly transmissible carbapenemase-producing organisms, is essential to slow the spread of these organisms in the United States. In an outbreak, use of surveillance cultures to identify asymptomatic transmission potentially is an important part of these efforts.

 

 

I  wrote about this emerging public health threat less than a week ago, in NDM-1: A Matter Of Import. The following link will provide a list of some of my past blogs on the NDM-1 enzyme.

 

Without a doubt  the `go to’ blogger on all things antibiotic resistant is Maryn McKenna, author of Superbug: The Fatal Menace of MRSA. If you aren’t a regular visitor to her Superbug Blog, you should be.

 

Last March, Director-General of the World Health Organization Margaret Chan warned that the World Faces A `Post-Antibiotic Era’.

 

One where even common infections may become untreatable.

 

While we aren’t there yet, reports such as this one add to the growing concern that someday, that fear may become a reality.

Study: Hospital Uniforms And Bacteria

 

 

Photo Credit CDC PHIL 

 

# 5798

 

 

HAIs, or Hospital Acquired Infections, take an incredible toll on patient’s health and our health care system every year. 

 

According to the HHS, they rank among the top ten leading causes of death in the United States, and accounted for an estimated 1.7 million infections and 99,000 associated deaths in 2002.

 

While hospitals are constantly working to reduce the incidence of HAIs, it is a daunting task.  We live in a  germy world, and the opportunities to spread bacteria in a healthcare setting are abundant.

 

Studies have shown that while compliance rates are improving, up to 50% of health care workers in the United States may fail to consistently wash their hands between patients (cite).

 

This year, the World Health Organization designated May 5th as global  CLEAN YOUR HANDS DAY - to encourage HCWs (Healthcare workers) to improve and sustain hand hygiene practices around the world (see A Movement With Five Moments).

 

 

One of the ongoing concerns regarding nosocomial transmission of pathogens has been that lab coats, neckties, and long sleeves might help to spread harmful bacteria from patient to patient in a healthcare facility.

 

In response, in 2007 the NHS banned the wearing of long-sleeved white coats, wristwatches, and neckties by HCWs in hospital wards, and in 2009 the AMA (American Medical Assoc.) considered a “bare below the elbows” dress code during their annual meeting, but decided the issue needed more study (see Lab Coat Legislation).

 

The rap against lab coats and neckties has primarily been that they are not usually freshly laundered every day.

 

One recent study showed that 62% of doctors surveyed waited 2-weeks or longer to launder their coats. 

 

 

While that sounds like a bit of a red flag, earlier this year we saw a study (see The Long And The Short Of It) that found no statistical difference between the amount of bacteria of freshly laundered short sleeve uniforms versus infrequently laundered white coats after only 8 hours wear.

 

And what isn’t known is how well pathogens transfer from contaminated uniforms to the surrounding environment, or on to patients.

 

Today, another study appears in APIC’s American Journal of Infection Control, that looks at the prevalence of harmful bacteria on uniforms worn in a university-affiliated hospital in Israel.

 

The areas of each uniform tested were the abdominal zone, sleeves' ends and pockets.

 

Potentially pathogenic bacteria were isolated from the uniforms of 85 participants (63%) and were detected in half the samples taken.

 

They found 21 cultures from the nurses uniforms and 6 from physician uniforms grew multi-drug resistant pathogens, including 8 that grew MRSA.

 

While a bit disconcerting, given the environment in which these uniforms are worn, and previous studies we’ve seen, these results are not all that surprising.

 

The abstract can be read at:

 

AJIC: American Journal of Infection Control
Volume 39, Issue 7 , Pages 555-559, September 2011

Nursing and physician attire as possible source of nosocomial infections

Conclusion

Up to 60% of hospital staff’s uniforms are colonized with potentially pathogenic bacteria, including drug-resistant organisms. It remains to be determined whether these bacteria can be transferred to patients and cause clinically relevant infection.

In an Elsevier Health Services Press Release (Doctors' and nurses' hospital uniforms contain dangerous bacteria majority of the time, study shows), APIC President Russell Olmsted, MPH, CIC is quoted as saying:

 

"It is important to put these study results into perspective. Any clothing that is worn by humans will become contaminated with microorganisms. The cornerstone of infection prevention remains the use of hand hygiene to prevent the movement of microbes from these surfaces to patients.

 

New evidence such as this study by Dr. Wiener-Well is helpful to improve the understanding of potential sources of contamination but, as is true for many studies, it raises additional questions that need to be investigated."

 

 

Last year, according to Infection Control Today, the American Medical Association (AMA)  announced plans to begin formal research on "textile transmission of infections" singling out the "physician's white lab coat as a primary concern associated with textile transmission of infections."

 

Promising new technologies, including bacteria-resistant fabrics, are being developed in hopes that they will reduce HAIs.

 

But for now, more research is needed to determine just how much of a role contaminated uniforms really play in the spread of harmful pathogens to patients in the hospital.

Netherlands: Large Nosocomial KPC Outbreak

 

 

K. pneumoniae on a MacConkey agar plate.

# 5717

 

For nearly two months a hospital in Rotterdam in the Netherlands has been battling an outbreak of CRKP - Carbapenem-Resistant Klebsiella pneumoniae – which may have been linked to as many as 27 deaths.

 

The exact cause of death has yet to be determined in all of these cases.

 

Klebsiella pneumoniae is a Gram negative, rod shaped bacterium commonly found in the flora of the human intestinal tract. Most of the time, it resides harmlessly in the intestines.

 

But when K. pneumoniae moves beyond the intestinal tract – particularly in people with weakened immune systems – it can cause cause severe pneumonia, urinary tract infections (UTI), septicemia, and soft tissue infections.

 

Complicating matters, over the past decade doctors have seen the emergence of antibiotic resistant forms of K. pneumoniae – known as CRKP or  KPC (K. pneumoniae carbapenemase).

 

Bacteria resistant to the Carbapenem class of antibiotics – called carbapenemases – are of particular concern since Carbapenems are often used as the drug of last resort for treating difficult bacterial infections

 

K. Pneumoniae’s opportunistic qualities – attacking those with weakened immune systems - makes it an important, and difficult to control, hospital acquired (nosocomial) infection.

 

First a report from Xinhua News, and then I’ll return with more, including a press release from the hospital.

 

Multiple-resistant bacteria likely cause 27 deaths in Netherlands: hospital

2011-07-27 02:26:27

THE HAGUE, July 26 (Xinhua) -- Klebsiella bacterie Oxa-48, a kind of multi-resistant bacteria, may have caused 27 deaths in the Netherlands since June 1, a hospital source said Tuesday.

 

Though the 27 people died have all been infected with the bacteria, it didn't mean that all the deceased have died as a result of the bacteria, added the Maastad hospital in Rotterdam.

 

Research is under way to show the link between the deaths and the multiple resistant bacteria.

 

The hospital announced the first two death cases on June 1, while the latest report said 78 people are carrier of the bacteria and another 1,967 people are suspected carriers for the time being.

(Continue . . .)

 

 

According to the following (machine translated) press release from the Maastad hospital, there have been no new infections detected since July 18th, and while more infections may be discovered, the situations is `under control’.

 

Press Release: Update multi-resistant bacteria in Rotterdam Hospital: July 26, 2011

On July 26, 2011, the Hospital Rotterdam the next situation that: 78 carriers of multiresistant bacteria, 27 in 1967 and deceased persons suspected patients.

 

Compared to July 21 this represents an increase of 8 carriers, two deceased persons and 143 suspected patients.

 

An increase of carriers automatically means more suspected patients, as they have been in the vicinity of the carriers.  Given the current culture tests and examinations will increase the numbers in the near future.

 

At present, the Hospital Rotterdam, since July 18, no infections in patients receiving for the first time hospitalized. On this basis we can conclude that the outbreak is still under control.

 

This is the current state of affairs until July 26, 2011:

• The number of carriers of the bacteria increased from 70 to 78 patients
• • Of these 78 patients, a total of 27 deceased patients.
  • It does not mean these 27 patients were deceased by the bacterium.
  • Investigated the role of bacteria in the death of patients.
  • -Of the 78 patients are currently only 8 patients in the hospital, which cared isolated.

• The number of people in a room located in the 78 carriers of the bacterium has increased from 1824 to 1967 people.
  • The 143 additional people receive today a culture test by mail.
  • At present there are 43 patients included isolated and tested.
  • If it appears that more patients are infected, should be monitored in any patient with whom they have been in contact. This allows the number of infections is increasing.

 

 

While this is an unusually large nosocomial outbreak, it is by no means an isolated incident.

 

In 2010, a survey presented at the IDSA  conference in Vancouver showed that Chicago was reporting a 42% rise in the number of hospitals and long-term care facilities reporting cases of KPC over last year.

 

Similarly, Brazil reported a substantial outbreak of KPC in 2010, which has been identified in more than 200 patients, and blamed for 22 deaths last year.

 

There have been outbreaks in many other countries, including Italy, Israel, France, Germany, the United Kingdom, Argentina, Lebanon, Israel, Morocco and Tunisia, and Ireland.

 

The gene that gives K. Pneumoniae its carbapenem resistance resides on a plasmid — a snippet of transferable DNA – that has the potential to jump to other strains of bacteria.

 

A trait that was recently demonstrated in an EID Journal dispatch (Transfer of Carbapenem-Resistant Plasmid from Klebsiella pneumoniae ST258 to Escherichia coli in Patient) in June, 2010.

 

One of the big concerns is that that we will see a transfer of carbapenem drug-resistance into a highly fit E. coli clone that could spread widely around the world. 

 

From EID Journal Dispatch I referenced above, the authors write:

 

Such an event may have severe public health consequences, leading to elimination of any effective antimicrobial drug treatment against the most common human bacterial pathogens.

 

Ominous words.

 

Which is why such an emphasis is being placed on the proper stewardship over our dwindling arsenal of effective antibiotics.

 

Some recent blogs on this subject include:

 

Going, Going, Gonorrhea

The Path Of Increased Resistance

Carbapenemases Rising

WHO: The Threat Of Antimicrobial Resistance

 

Perhaps the single best place I can direct you to learn about the dangers and impact of antimicrobial resistance is our favorite `scary disease girl’ Maryn McKenna’s SUPERBUG BLOG  and her terrific book on the subject  SUPERBUG: The Fatal Menace Of MRSA.

Lab Coat Legislation

 

# 5544

 

 

In recent years lab coats, long sleeves, neckties, and jewelry in the healthcare setting have all come under increased scrutiny as concerns over HAIs (Hospital Acquired Infections) – including MRSA – have escalated.

 

Long sleeves, many fear, could facilitate the transfer of bacteria from one patient to the next. 

 

In 2007, Britain’s NHS decided to ban the wearing of long-sleeved white coats, wristwatches, and neckties by healthcare providers in hospital wards.

 

In the United States, the AMA (American Medical Assoc.) considered a “bare below the elbows” dress code during their annual meeting in 2009, but decided the issue needed more study. 

 

Some healthcare facilities – like the Mayo Clinic – have pushed ahead with their own dress codes to address the issue.  

 

Today UPI is reporting that New York State legislators are considering mandating a `hygienic dress code for medical professionals’ – one that may eventually prohibit the wearing of jewelry, wristwatches, neckties, long sleeves, and the iconic white lab coat.

 

N.Y. may ban germy doctor ties, lab coats

Published: May 8, 2011 at 2:04 AM

 

 

The article goes on to say that if passed, a 25-person advisory council – to be appointed by the commissioner of health – would provide recommendations for a new medical dress code.

 

While `textile transfer’ of bacteria in the healthcare setting makes sense, the scientific evidence linking sleeve cuffs and neckties to actual HAIs is scant, mostly anecdotal, and sometimes even contradictory.

 

While not exactly a smoking gun, in 2009 researchers at the Virginia Commonwealth University Medical Center in Richmond demonstrated that large inoculums of MRSA,vancomycin-resistant enterococci (VRE), and pan–resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin.

 

The rap against lab coats and neckties has primarily been that they are not usually freshly laundered every day.

 

One study showed that 62% of doctors surveyed waited 2-weeks or longer to launder their coats. 

 

But earlier this year, a study (see The Long And The Short Of It) found no statistical difference between the amount of bacteria of freshly laundered short sleeve uniforms versus infrequently laundered white coats after only 8 hours wear.

 

The argument can still be made, however, that long sleeve cuffs (and neckties) are more likely to come in contact with a series of patients than the fabric of short sleeved shirts.

 

With an estimated 99 thousand deaths each year in the United States from nosocomial (hospital acquired) infections each year, the stakes are enormous. 

 

Yet the science proving the supposed benefits of a dress code change is sparse. 

 

So, for now at least, the the debate over the fate of lab coats, long sleeves, and neckties in the United States continues with no resolution in sight.

The Long And The Short Of It

 

 

# 5304

 

 

Admittedly, I can’t help but think about MRSA (and other pathogenic nasties) every time a nurse slips a well worn BP cuff around my arm, or a doctor places the bell of his trusty stethoscope against my bare chest. 

 

How long, I wonder, has it been since they’ve been sanitized for my protection?

 

Just as quickly, I decide I don’t really want to know as I surreptitiously reach for my bottle of alcohol hand sanitizer.

 

But it does explain why my B/P is always 10 points higher at the doctor’s office.

 

While I’ve long been germ-averse, my visceral reaction has grown stronger ever since I read Maryn McKenna’s vivid account of growing antimicrobial resistance in her book Superbug: The Fatal Menace of MRSA, which I reviewed last year here.  

 

 

 

Luckily, awareness of the dangers of MRSA and other pathogens has improved in the health care industry – and while serious infection control gaps remain – policies are being introduced to try to reduce the risks.

In recent years, physician’s ties, long coats, and long sleeves have all been pointed to as potential carriers of pathogens as doctors  make their rounds from one patient to the next.

 

While the science behind these suspicions has been scant, some hospitals have invoked a `no-tie’ policy, while others have barred the wearing of long sleeved coats. 

 

Today, in the Journal of Hospital Medicine, we get a study that looks at the level of bacterial contamination (including MRSA) on long sleeve coats compared with newly laundered short-sleeved uniforms worn by 100 physicians, and bacterial counts on their wrists wearing either garment.

 

The good news is, after 8 hours of wear, no difference was observed in the degree of bacterial contamination of freshly laundered short sleeve uniforms versus infrequently laundered white coats.

 

The slightly less reassuring flip side to this finding was that after 8 hours of wear, both groups were equally colonized with bacteria. 

 

Exactly how contaminated both cohorts were, unfortunately, was not revealed in the study’s abstract.

 

 

Original Research

Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial

Marisha Burden MD,Lilia Cervantes MD, Diane Weed MA, MT, Angela Keniston, Connie S. Price MD, Richard K. Albert MD

 

As this study is in a pay-to-view journal, we are lucky to have more details available from the press release.

 

 

Contact: Jennifer Beal
healthnews@wiley.com
44-012-437-70633
Wiley-Blackwell

Long- and short-sleeved physician workwear receive same amount of bacterial and MRSA contamination

Governmental agencies in the United Kingdom recently instituted guidelines banning physicians' white coats and the wearing of long-sleeved garments to decrease the transmission of bacteria within hospitals due to the belief that cuffs of long-sleeved shirts carry more bacteria. However, a new study published today in the Journal of Hospital Medicine shows that after an eight-hour day, there is no difference in contamination of long- and short-sleeved shirts, or on the skin at the wearers' wrists.

 

A group of researchers from the University of Colorado, USA, decided to assess the accuracy of the assumption that longer sleeves lead to more contamination by testing the uniforms of 100 physicians at Denver Health randomly assigned to wearing a freshly washed, short-sleeved uniform or their usual long-sleeved white coat. "We were surprised to find no statistical difference in contamination between the short- and long-sleeved workwear," said lead researcher Marisha Burden, MD. "We also found bacterial contamination of newly laundered uniforms occurs within hours of putting them on."

 

50 physicians were asked to start the day of the trial in a standard, freshly washed, short-sleeved uniform, and the 50 physicians wearing their usual long-sleeved white coats were not made aware of the trial date until shortly before the cultures were obtained, to ensure that they did not change or wash their coats. Cultures were taken from the physicians' wrists, cuffs and pockets. No significant differences were found in bacteria colony counts between each style.

 

The researchers also found that although the newly laundered uniforms were nearly sterile prior to putting them on, by three hours of wear nearly 50% of the bacteria counted at eight hours were already present.

 

"By the end of an eight-hour work day, we found no data supporting the contention that long-sleeved white coats were more heavily contaminated than short-sleeved uniforms. Our data do not support discarding white coats for uniforms that are changed on a daily basis, or for requiring health care workers to avoid long-sleeved garments," concluded Burden.

 

 

While I’m somewhat placated by these results, I doubt that I’ll be completely comfortable until I’m able to  retrofit the shower at my place to dispense 62% alcohol gel.

 

Not that I’m germ phobic, or anything.

EID Journal: Nosocomial Transmission Of 2009 H1N1

 

 

 

# 5301

 

 

From an expedited report in the CDC’s  EID Journal we get further evidence that a hospital is really no place for a sick person; a review of nosocomial (in-hospital) transmission of the 2009 pandemic virus in the United Kingdom.

 

First the link and abstract (reformatted), and then some discussion.

 

 

Nosocomial Pandemic (H1N1) 2009, United Kingdom, 2009–2010

J.E. Enstone et al.  (170 KB, 14 pages)

DOI: 10.3201/eid1704.101679 
Enstone JE, Myles PR, Openshaw PJM, Gadd EM, Lim WS, Semple MS, et al.  Emerg Infect Dis. 2011 Apr

To determine the effect of nosocomial infections on health in the United Kingdom, we studied 1,520 patients in 75 National Health Service hospitals. We identified and characterized patients who acquired influenza in hospitals during the pandemic (H1N1) 2009 outbreak.

 

Of 30 patients, 12 (80%) of 15 adults and 14 (93%) of 15 children had serious underlying illnesses. Only 12 (57%) of 21 patients who received antiviral therapy did so within 48 hours after symptom onset, but 53% needed escalated care or mechanical ventilation; 8 (27%) of 30 died.

 

Despite national guidelines and standardized infection control procedures, nosocomial transmission remains a problem when influenza is prevalent. Health care workers should be routinely offered influenza vaccine, and vaccination should be prioritized for all patients at high risk. Staff should remain alert to the possibility of influenza in patients with complex clinical problems and be ready to institute antiviral therapy while awaiting diagnosis during influenza outbreaks.

(Continue . . .)

 

While only 30 nosocomial flu infections were identified and analyzed in this study, the authors were quick to point out that they were unlikely to detect all cases among the patient cohort studied.   

The definition of a `nosocomial’ infection adopted for this study was very strict, so as to exclude any potential community acquired infections.

 

Additionally, patients already compromised by serious illness were most likely to be identified, mild cases were likely overlooked, and some patients may have been infected in the hospital, but were discharged before becoming symptomatic.

 

As far as the route of infection, the authors had this to say:

 

On the basis of information obtained in the study, we cannot determine where and from whom patients acquired influenza. However, 3 routes are possible.

 

First, infection could have been acquired from other patients; 1 patient shared a bay with a patient who was presymptomatic at the time but for whom influenza was diagnosed 1 day later.

 

Second, transmission from visitors of patients cannot be ruled out. Although national guidelines strongly discourage persons with influenza-like symptoms from visiting patients (29), this recommendation may have been difficult to implement, particularly for parents of sick children who often provide most hands-on care in a hospital.

 

Third, transmission may have occurred from an infectious health care worker (because staff continue to work when infected with influenza [33]) or from contaminated hands of a health care worker.

 

Transmission from asymptomatic persons might occur in all 3 instances

 

The authors conclude:

 

Nosocomial infections with pandemic (H1N1) 2009 in this case series were associated with high rates of illness and death. This finding highlights the need for adherence to infection control guidelines for staff and visitors (including the need to urge visitors not to visit when they are ill, particularly when providing hands-on care for vulnerable children), staff vaccination, maintenance of clinical suspicion for influenza in areas of high risk, prompt (empirical) antiviral treatment for vulnerable patients in whom influenza is possible or likely, and consideration of postponing nonurgent procedures for hematology patients during periods of known high influenza activity.

 

This report demonstrates that nosocomial transmission is a recurrent problem when the prevalence of influenza is high and the total effect of nosocomial influenza is underestimated by outbreak reports alone.

 

 

Concerns over the spread of influenza in healthcare facilities have been the driving force behind the repeated calls for mandatory yearly vaccination of HCWs (Health Care Workers) against the flu.

 

A few recent blogs on that contentious subject include:

 

APIC Calls For Mandatory Flu Vaccination For HCWs

AAP: Recommends Mandatory Flu Vaccinations For HCWs

SHEA: Mandatory Vaccination Of Health Care Workers

IDSA Urges Mandatory Flu Vaccinations For Healthcare Workers

 

While strongly advocating HCW influenza vaccination, the CDC has stopped short of mandating them. I blogged on this back on June 23rd, 2010  in  CDC: Proposed Influenza Infection Control Guidance.

 

Similarly, a UK Department of Health report issued in June 2010 called Learning The Lessons From the H1N1 Vaccination Campaign For Healthcare Workers  – while not mandating vaccination – stresses the `professional duty’ of all HCWs to get the vaccine.

 

While many infection control experts see this as a long overdue step in patient and co-worker protection, the obstacles that lay before these sorts of policies are substantial.

 

This is a hugely divisive issue, with many HCWs believing that it is an infringement of their rights to decide what will be injected into their bodies.

 

I’ve covered HCW’s objections to forced flu shots in the past, including:

 

HCWs: Refusing To Bare Arms

HCWs: Developing a Different Kind Of Resistance

 

Complicating matters, HCWs are often pressured into working when they are sick – simply because of the difficulty in finding someone to cover their shifts.

 

This is a subject I wrote about at some length back in September of 2009 (see A Hospital Is No Place For A Sick Person).

 

Between the spread of flu via asymptomatic individuals, and the less-than-100% immunity conveyed by the yearly flu vaccine, it is no doubt impossible to completely eliminate the nosocomial spread of influenza in healthcare settings.

 

But hospitalized individuals are at particular risk of complications, and even death, from the flu. Which makes it not only morally incumbent, but economically imperative, that healthcare facilities do what they can to prevent infection.

 

Reasonable measures that can reduce the spread of the virus – such as improved vaccination rates and better infection control measures - are vital areas that many healthcare facilities need to review and improve.

Study: Aerosolized Transmission Of Influenza

 

 

# 5084

 

 

Remarkably, even as we approach the end of the first year of the second decade of the 21st century, there remains a good deal of basic information about how influenza is transmitted that scientists haven’t completely nailed down.

 

The easy answer is via coughs and sneezes, but we actually need something a little more definitive than that.

 

The three commonly cited routes are large-droplets, aerosols, and  direct contact with secretions and fomites (inanimate objects contaminated with the influenza virus).

 

Most scientists concede that all three probably play a role in transmission, but how much each method contributes is far less certain.

 

Coughing and sneezing produces virus laden large-droplets that remain airborne for a very short period of time, and then settle to the ground (or other surfaces).

 

The `range’ of these droplets is assumed to be 6 to 10 feet, and has traditionally been considered the primary route of transmission.

 

Photo Credit PHIL (Public Health Image Library)

 

Virus particles may also end up deposited on fomites – like phone receivers, computer keyboards, and shopping cart handles – and end up transferred to others that come in contact with them.

 

Coughs and sneezes – and certain medical procedures (like nebulizers) -  can also produce fine aerosolized particles that can conceivably remain airborne for extended periods and travel much further than large droplets.  

 

But how often, and under what conditions, aerosolized transmission of the influenza virus actually takes place remains a subject of considerable debate.   

 

Since those answers could affect infection control policies and recommendations, particularly in heath care settings, determining the actual mechanisms of influenza transmission is more than just an academic exercise.

 

While it doesn’t come close to definitively answering the question, today we’ve a new study that appears in IDSA’s journal Clinical Infectious Diseases that adds some more data to the mix.

 

A few excerpts from the Abstract (follow the link to read it in its entirety), followed by a little more discussion.

 

Clinical Infectious Diseases 2010;51:1176–1183

DOI: 10.1086/656743

Possible Role of Aerosol Transmission in a Hospital Outbreak of Influenza

Bonnie C. K. Wong,Nelson Lee,Yuguo Li,Paul K. S. Chan,Hong Qiu,Zhiwen Luo,Raymond W. M. Lai,Karry L. K. Ngai,David S. C. Hui,K. W. Choi,and Ignatius T. S. Yu

Background. We examined the role of aerosol transmission of influenza in an acute ward setting.

Methods. We investigated a seasonal influenza A outbreak that occurred in our general medical ward (with open bay ward layout) in 2008. Clinical and epidemiological information was collected in real time during the outbreak. Spatiotemporal analysis was performed to estimate the infection risk among patients. Airflow measurements were conducted, and concentrations of hypothetical virus‐laden aerosols at different ward locations were estimated using computational fluid dynamics modeling.

Results.Nine inpatients were infected with an identical strain of influenza A/H3N2 virus. With reference to the index patient’s location, the attack rate was 20.0% and 22.2% in the “same” and “adjacent” bays, respectively, but 0% in the “distant” bay (P=.04).

<SNIP>

 

Conclusions. Our findings suggest a possible role of aerosol transmission of influenza in an acute ward setting. Source and engineering controls, such as avoiding aerosol generation and improving ventilation design, may warrant consideration to prevent nosocomial outbreaks.

 

 

Although the article isn’t open access, we can glean a few more details from the IDSA press release.

 

703-299-0412
Infectious Diseases Society of America

Hong Kong hospital reports possible airborne influenza transmission

Direct contact and droplets are the primary ways influenza spreads. Under certain conditions, however, aerosol transmission is possible. In a study published in the current issue of Clinical Infectious Diseases, available online, the authors examined such an outbreak in their own hospital in Hong Kong.

 

On April 4, 2008, seven inpatients in the hospital's general medical ward developed fever and respiratory symptoms. Ultimately, nine inpatients exhibited influenza-like symptoms and tested positive for influenza A. The cause of the outbreak was believed to be an influenza patient who was admitted on March 27. He received a form of non-invasive ventilation on March 31, and was then moved to the intensive care unit after 16 hours. During that time, he was located right beside the outflow jet of an air purifier, which created an unopposed air current across the ward.

 

"We showed that infectious aerosols generated by a respiratory device applied to an influenza patient might have been blown across the hospital ward by an imbalanced indoor airflow, causing a major nosocomial outbreak," said study author Nelson Lee, MD, of the Chinese University of Hong Kong. "The spatial distribution of affected patients was highly consistent with an aerosol mode of transmission, as opposed to that expected from droplet transmission.

 

"Suitable personal protective equipment, including the use of N95 respirators, will need to be considered when aerosol-generating procedures are performed on influenza patients," Dr. Lee added. "Avoiding such procedures in open wards and improving ventilation design in health care facilities may also help to reduce the risk of nosocomial transmission of influenza."

 

 

In this case, it took the combination of an influenza patient receiving a ventilation treatment in an open ward next to another air current producing device to lead to the apparent aerosolized spread of the virus.

 

A fairly complex (but not altogether unusual) set of circumstances found in this particular emergency department.  

 

Under what other conditions influenza (and other respiratory viruses) might spread via aerosolized particles remains an open question.  

 

A few blogs (and conflicting studies) on this subject include:

 

Ferreting Out The Transmissibility Of Aerosolized H5N1

Study: H5N1 - A Very Persistent Virus

Good To The Last Droplet

Referral: Influenza and airborne transmission