This isn’t about MRSA, but it’s such a jaw-dropping example of infection control failure that I thought it was worth passing along.

A team from the Centers for Disease Control report today in the Annals of Internal Medicine that, in the past 10 years, infection control has failed so significantly that 448 people have become infected with hepatitis B or C and more than 60,000 had to be tested for potential infection. (And that is almost certainly an underestimate, since the team counted only previously recognized outbreaks of two or more infections, not single ones.)

Three are known to have died, though that again is probably an underestimate.

From the CDC press release (not yet online, I’ll link when it is):

In the United States, transmission of HBV and HCV while receiving health care has been considered uncommon. However, a review of CDC outbreak information revealed a total of 33 identified outbreaks outside of hospitals in 15 states, during the past decade: 12 in outpatient clinics, six in hemodialysis centers and 15 in long-term care facilities.

Here are some of the actions that caused these infections:

• reusing syringes
• contaminating multi-dose vials with unclean syringes
• using single-dose vials for multiple patients
• re-using end-caps from single-use syringes
• using fingerstick devices on multiple patients without cleaning
• using blood-sugar measuring devices on multiple patients without cleaning

Just jaw-dropping. Because let’s be clear: Hep B and C are potentially life-threatening diseases. These actions weren’t just careless: They were life-endangering. And really, how hard is this? None of these actions should have been difficult or foreign; They represent the most basic steps in Standard Precautions (what used to be called Universal Precautions), which any health care worker ought to know from the beginning of his or her career, but which every health care worker ought to have by heart in the age of AIDS.

And, infuriatingly, there are probably many more such infections that remain undetected. From the paper:

…the viral hepatitis outbreaks reported here probably represent only a portion of the true burden of infection attributable to the receipt of health care in the United States. First, we included only nonhospital health care settings. … Second, under-ascertainment of health care–associated viral hepatitis outbreaks is likely. Linking an outbreak to a single health care venue responsible for transmission is complicated by the long incubation period of HCV and HBV infection (up to 6 months)… Furthermore, many patients with HBV or HCV infection will be asymptomatic or have mild or nonspecific symptoms, resulting in infections that go undetected for many years. Finally, outbreak detection relies on thorough case investigation and successful identification of health care as a risk. Few health departments currently have the time, funds, personnel resources, or ability to address legal impediments to investigate viral hepatitis that may be health care–associated.

The cite is: Nicola D. Thompson, PhD, MS; Joseph F. Perz, DrPH, MA; Anne C. Moorman, BSN, MPH; and Scott D. Holmberg, MD, MPH. Nonhospital Health Care–Associated Hepatitis B and C Virus Transmission: United States, 1998–2008. Ann Intern Med. 2009;150:33-39.

We’ve been talking the past few days about hospital infection control: Is it as simple as Sir Richard Branson suggests? Or as complex as Paul Levy’s commenters make it appear?

The National Health Service of Scotland comes down on the side of simple. It is poised to enact a new, no-tolerance policy: Wash your hands or lose your job.

It is important to add that the Scottish health service (a subset of the National Health Service of the entire UK) has actually done a good job of promoting hand hygiene in its hospitals. A year ago, an audit showed that Scottish hospitals were at 79% compliance, and so the service set a 12-month goal of 90% compliance.

(All of these numbers, by the way, are better than in the United States, where even intensive attention to hand-washing gets even caring hospitals only to about 70%. And yes, it is true that hand hygiene alone does not equal infection control — but it is the basic building block. If you can’t establish hand hygiene, what are your odds of accomplishing more complex interventions?)

But now they’ve decided to go for 100%. In Scotland the move is being applauded. The Glasgow Evening Times editorialized:

If it takes the threat of the sack to make medical staff wash their hands then it is a justified action. It is scarcely credible that up to 10% of doctors, dentists and nurses do not practice this basic hygiene measure.

Anyone want to disagree?

I have a long story in the new (October) SELF Magazine: Morgellons mystery.

It is not about MRSA; it’s about Morgellons, a syndrome which approximately 12,000 sufferers claim is a new, unrecognized disease, but which medical authorities say is a delusion. The story is a look at the experience of several people who identify themselves as having the disease, contrasted with the efforts of several researchers — including the head of a new CDC investigation — to figure out what exactly is going on.

It’s a medical mystery story, and a meditation on the nature of evidence and belief.

And it raises the question: When something arises that fits no past pattern, how do we recognize it, describe it and prove its existence to others? It’s a question that should resonate with advocates for MRSA – especially community MRSA infection.

Lotrs more MRSA news coming this week.

I’m on the road reporting for two weeks, which makes keeping up with MRSA news fairly challenging. (Hangs head in shame, promises to do better in August when I will be chaining myself to my computer in vain hope of meeting a manuscript deadline.)

Meanwhile, here is a tidbit of news on the MRSA front, from the UK. As our international readers will know (oh yes, we have them, Google Analytics makes a very nice map – hi, London! say hello, Rotherham!), MRSA has been a ferocious hospital pathogen in the UK, but community strains have been less problematic there until recently.

The National Institute for Health and Clinical Excellence, an agency that does cost-benefit analysis on behalf of the National Health System, has asked doctors to limit prescribing antibiotics for most of the upper-respiratory infections they see in private practice on the assumption that most URIs will be viral and therefore not helped by antibiotics anyway.

…Doctors in the state’s health system should not prescribe antibiotics for most cases of sore throats, colds, bronchitis or other types of respiratory infections, the National Institute for Health and Clinical Excellence, or NICE, said.
They should also delay writing such prescriptions and reassure people the drugs are not needed immediately and would make little difference because most respiratory infections are viral, the new guidelines said. …
The drugs watchdog said a quarter of people in England and Wales visit the doctor because of respiratory tract infections, which account for 60 percent of all antibiotic prescriptions in general practice. (Reuters, byline Michael Kahn)

Note that this is a guideline, which is to say voluntary — though because it is promulgated by a regulatory body within a single-payer health system, may well have more force than similar guidelines that have been promulgated in the US by professional societies such as the Infectious Diseases Society of America. This article from IDSA from last April captures how effective guidelines have been here. Answer: Overall, not much, because they are a matter of asking, not compelling.

I’m interested in hearing from any readers who have experience with antibiotic stewardship programs at the society level or in institutions: Do they work, what does it take to implement them, how draconian do you have to be? If anyone can offer thoughts, please comment or send me a private email to the address in the right-hand column.

On to North Carolina.