Maryn McKenna

Journalist and Author

What Would Keep Ebola from Spreading in the US? Investing in Simple Research Years Ago.

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Daliborlev (CC), FLickr

Daliborlev (CC), Flickr

There’s a thing you learn, when you’ve been writing about infectious diseases for a while: People love drama. They’re not so much with detail.

Drama is H5N1 avian flu killing half the people who contract it, and the enormous surge in whooping cough, and the sinister movement of almost-untreatable NDM-1 resistance from South Asia to the West.

Detail is the question of whether health care workers treating pandemic-flu patients should expect viral spread for 3 feet or 6 feet; and why immunity conferred by the current pertussis vaccine fades a few years earlier than expected; and how hospitals can encourage their janitors to clean rooms more thoroughly, when they’ve always treated them as a disposable part of the staff.

All of those details are crucial to controlling those diseases. All of them are also research questions. None of them, guaranteed, have gotten the attention or funding that would answer the questions in a way that equips us to counter the dramatic problems.
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Keys to Controlling Ebola in the US: Travel Records and Infection Control

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Daliborlev (CC), FLickr

Daliborlev (CC), Flickr

If you’re at all interested in infectious diseases, you’ve probably heard by now that a person traveled to the United States while infected with Ebola, was diagnosed and is now in a hospital in Texas. (I was on a flight without Wi-Fi yesterday from before the press conference was announced to after it concluded. Turning my phone on after arrival was… interesting.)

The Centers for Disease Control and Prevention held a press conference yesterday afternoon (transcript is here), and WIRED’s Greg Miller covered it.

The quick details:

  • The infected person flew from Liberia to the US on Sept. 19-20 to visit family members who live in Texas.*
  • He began to develop symptoms on Sept. 24 (important because victims are infectious only after symptoms develop).
  • He went to an ER in Dallas on Sept. 26 and was given antibiotics and sent home.
  • Two days later, Sept. 28, he was taken by ambulance to Texas Presbyterian Hospital in Dallas and was admitted on suspicion of Ebola and put in isolation.
  • The test results confirming the diagnosis came down yesterday, the same day as the announcement.

 

(*A quick Google will demonstrate that the patient and his family have been named by the Associated Press, with the New York Times using the name and attributing it to AP. Given the unnecessary panic around Ebola at this point, I have conflicting thoughts about whether and how the name should be used, so am passing on using it for now.)

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Can Better Bathroom Design Combat Infections?

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Evolutionary biologist and graphic-design geek Colin Purrington (author of the fantastic taxonomy of lab-notebook inks) has an issue with bathrooms. Specifically, with bathrooms so badly designed that no one washes and dries their hands adequately, and then everyone is forced to touch a door handle in order to exit. He’s sufficiently exasperated that he not only blogged his annoyance, he came up with some public-health messaging to share the spleen: a set of signs formatted for printing onto large-scale Post-It sheets, suitable for guerrilla adornment of any door or a hot-air blower.

My pet peeve: bathroom doors hinged in a way that require people to touch the handle or knob to exit. I’m sure there are fire code reasons why architects specify for this, but it’s strange (remote risk of fire vs real risk of disease)…. Compounding the above problem is the fad of equipping bathrooms with only electric hand dryers (“Saves the environment!”). Because cheap hand dryers take about 3 minutes to dry hands, many people opt to just exit the bathroom without washing their hands. Or at least guys.… I don’t hang out in women’s restrooms that often. This means that the handle or knob is going to get a lot more use from hands that are coated in microbial nasties.

Is Purrington right in his denunciation of door handles, hot-air blowers and bathroom design as an engine of infection? I took a look: There’s a lot of research on germiest hazards in public places, and a little on better design. The answers seem to be: Maybe, Yes, and Yes.

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MRSA research round-up: hospitals, vitamins, pets

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Because I’ve been so behind, there’s so much to cover! So let’s dive in:

In today’s Archives of Surgery, researchers from Seattle’s Harborview Medical Center report that one simple addition to the routine of caring for trauma patients made a significant difference to the patients’ likelihood of acquiring a hospital-associated infection:
bathing them once a day with the antiseptic chlorhexidine (in an impregnated wipe). Patients who were bathed with the antiseptic wipe, compared with patients wiped down with an inert solution, had
one-fourth the likelihood of developing a catheter-related bloodstream infection and
one-third the likelihood of ventilator-associated MRSA pneumonia. Cite: Evans HL et al. Effect of Chlorhexidine Whole-Body Bathing on Hospital-Acquired Infections Among Trauma Patients.
Arch Surg. 2010;145(3):240-246.

How important are hospital-acquired infections? Here’s a piece of research from a few weeks ago that I sadly failed to blog at the time: Just
two categories of HAIs, sepsis and pneumonia, account for 48,000 deaths and $8.1 billion in health care costs in a single year. Writing in the Archives of Internal Medicine, researchers from the nonprofit project Extending the Cure analyzed 69 million hospital-discharge records issued in 40 states between 1998 and 2006. Hospital charges and number of days that patients had to stay in the hospital were
40% higher because of those infections, many of which are caused by MRSA — and all of which are completely preventable. Cite: Eber, MR et al. Clinical and Economic Outcomes Attributable to Health care-Associated Sepsis and Pneumonia.
Arch Intern Med. 2010; 170(4): 347-53.

 What else could reduce the rate of MRSA infections? How about Vitamin D? South Carolina scientists analyze data from the NHANES (National Health and Nutrition Examination Survey 2001-2004), a massive database overseen by the CDC, and find
an association between low blood levels of Vit. D and the likelihood of MRSA colonization. More than 28% of the population is Vitamin D deficient. MRSA colonization is increasing in the US. Can giving Vit. D decrease MRSA carriage? More research needed. Cite: Matheson EM et al. Vitamin D and methicillin-resistant Staphylococcus aureus nasal carriage.
Scand J Infect Dis
. 2010 Mar 8. [Epub ahead of print]

And finally: Who else carries MRSA? Some unlucky pet owners have found that animals can harbor human strains, long enough at least to pass the strain back to a human whose colonization has been cleared. So it makes sense to ask whether humans who spend time with pets are carrying the bug. Last month’s Veterinary Surgery reports that the answer is Yes.
Veterinarians are carrying MRSA in very significant numbers: 17% of vets and 18% of vet technicians at an international veterinary symposium held in San Diego in 2008. Cite: Burstiner, LC et al. Methicillin-Resistant Staphylococcus aureus Colonization in Personnel Attending a Veterinary Surgery Conference.
Vet Surg. 2010 Feb;39(2):150-7.

MRSA in the journal Science – spread, outbreaks and an argument for active surveillance

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I have a story tonight at CIDRAP about a paper published this evening in the journal Science. To respect fair use and make sure my colleagues get clicks, I just quote the story here — but then I want to talk about why I think it’s such an important study.

   A multi-national team of researchers has applied a new genomic tool to a 50-year-old bacterial foe, using minute mutations to track the spread of drug-resistant staph both across continents and within a single hospital.
On a global scale, their sleuthing tracked the movement of one clone of methicillin-resistant Staphylococcus aureus (MRSA) back and forth across the planet, pinpointing when individual cases transported infections across national borders to spark new outbreaks. Separately, their method demonstrated that what appeared to be a hospital epidemic of MRSA was not a single outbreak, but rather a mixed event of patient-to-patient transmission of one strain that was accompanied by multiple importations from outside the hospital of similar but unrelated strains. …
In a briefing yesterday for the press, the authors emphasized the latter finding, pointing out that the traditional infection control measures usually applied to hospital outbreaks would not curb the spread of infections that were carried in undetected from outside. Their method, they said, provides a proof of concept for using cutting-edge genomics to uncover the precise pathways by which MRSA spreads within hospitals—not only tracing its path from patient to patient, but also identifying the bug in patients whose undetected bacterial carriage could spark outbreaks but have not yet.

If you’d like more, here’s a very good story at Scientific American, one at BBC Health and one by the Associated Press; and Science Daily‘s version.

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One surgical infection with MRSA: $61,000

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From a multi-state, public-private research team — Duke University, Wayne State University, and the Durham, NC VA — comes a precise and alarming calculation of MRSA’s costs in hospitals: For one post-surgery infection, $61,681.

The group compared the course, costs and final outcome of three matched groups of patients from one tertiary-care center and six community hospitals in one infection-control network run by Duke. The three groups were: patients with a MRSA surgical-site infection; patients with a surgical-site infection (SSI) due to MSSA, drug-sensitive staph; and surgery patients who did not experience infections, matched to the other two groups by hospital, type of procedure, and year when the procedure took place. (This same cohort has been described in an earlier prospective study that looked at risks for MRSA SSIs.) Altogether, there were 150 patients with MRSA SSIs, 128 with MSSA SSIs, and 231 uninfected surgery patients to serve as controls.

Here’s what they found. Patients with post-surgical MRSA infections:

  • stayed in the hospital 23 days longer
  • incurred an average extra cost of $61,681
  • were more likely to be readmitted to the hospital within 90 days
  • were more likely to die before 90 days had passed.

The authors write:

Our study represents the largest study to date of outcomes due to SSI due to MRSA. Our findings confirm that SSIs due to MRSA lead to significant patient suffering and provide quantitative estimates of the staggering costs of these infections. SSI due to MRSA led to a 7-fold increased risk of death, a 35-fold increased risk of hospital readmission, more than 3 weeks of additional hospitalization, and more than $60,000 of additional charges compared to uninfected controls.

For just the patients in this study, the excess costs (across 7 hospitals) totalled $19 million.

This is a highly useful study on several axes. First, remarkably, there has not been agreement over whether and how much of a problem MRSA poses in post-surgical settings, particularly when compared to drug-sensitive staph. This study provides careful, thoughtful, well-documented proof that combating MRSA infection is worthwhile. (NB, MRSA infections did not increase the risk of death relative to MSSA infections, which should remind us both of the often-forgotten virulence of MSSA, and also that MRSA’s perils can lie in extended illness and disability as much or more as in early death.) Second, by putting a very specific number on the cost of a post-surgical MRSA infection, it gives healthcare administrators a benchmark against which they can judge the cost of a prevention program. We’ve all heard complaints that prevention programs can be costly and their benefit is hard to measure in a bottom-line way. With this very specific number, that complaint should no longer be valid.

There’s a final point that is implied in the paper but not called out, so let me call it out on the authors’ behalf. These results are very likely an under-estimate of MRSA’s costs. That’s because, first, the specific procedures the patients underwent were cardiothoracic and orthopedic; those are not the surgical procedures most likely to be followed by a MRSA infection. And second, data collection for this study ceased in 2003, about a year after the first emergence of USA300 and several years before that very successful community strain began its current move into hospitals. However much MRSA was extant in 2003, there is more now.

The cite is: Anderson DJ, Kaye KS, Chen LF, Schmader KE, Choi Y, et al. 2009 Clinical and Financial Outcomes Due to Methicillin Resistant Staphylococcus aureus Surgical Site Infection: A Multi-Center Matched Outcomes Study. PLoS ONE 4(12): e8305. doi:10.1371/journal.pone.0008305

Infections rise, but hospital budgets – and infection control – shrink

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Bad news from the Association of Professionals in Infection Control and Epidemiology (APIC): In a survey of almost 2,000 of their 12,000 members, 41% say that their hospitals’ infection-prevention budgets have been cut due to the down economy.

According to the survey, conducted March 2009 and released Tuesday morning:

Three-quarters of those whose budgets were cut experienced decreases for the necessary education that trains healthcare personnel in preventing the transmission of healthcare-associated infections (HAIs) such as MRSA and C. difficile.
Half saw reductions in overall budgets for infection prevention, including money for technology, staff, education, products, equipment and updated resources.
Nearly 40 percent had layoffs or reduced hours, and a third experienced hiring freezes.

As we know here, there are (by CDC estimate) 1.7 million hospital-acquired infections and 99,000 deaths as a result of them, each year. These are numbers we are supposed to be trying to reduce. That is going to be less likely if less money flows toward what may already be an underfunded goal:

A third of survey respondents say that cuts in staffing and resources have reduced their capacity to focus on infection prevention activities.
A quarter of respondents have had to reduce surveillance activities to detect, track and monitor HAIs.

Disturbingly, at a time when electronic health records are such an important part of the health-reform debate, “Only one in five respondents have data-mining programs – electronic surveillance systems that allow infection preventionists to identify and investigate potential infections in real time.”(APIC press release)

The full report is here.

While taking a flu break, a MRSA round-up

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Constant readers, the H1N1 (Virus Formerly Known as Swine) Flu story remains a bit intense. I’ve missed a few MRSA stories over the past few days, so here is a round-up.

First, though, if you’re curious about what the swine flu reaction says about our ability to handle a pandemic, you might take a look at this story I wrote Friday at CIDRAP. Quick version: Over-reaction on the part of the “worried well” — and people seeking testing and not knowing where to get it — put ERs into meltdown nationwide. If we were facing a virus that was not only fast-spreading but virulent, we could be in serious trouble.

On to MRSA:

  • Therapy animals as a vector: In a letter to the Journal of Hospital Infection, Drs. J. Scott Weese and Sandra L. Lefebvre of the Ontario Veterinary College at the University of Guelph report on two therapy dogs that became transiently colonizedwith C. difficile (on its paw pads) and MRSA (on its coat; found on the hands of its handler) after visiting health care facilities, demonstrating how easily bacteria can move in and out of hospitals. Constant readers will recognize Weese’s name: He is one of the most important investigators of MRSA in food animals and pets, and among other things has written infection-control guidelines for therapy animals.
  • In the Canadan Medical Association Journal, Drs. Anne G. Matlow and Shaun K. Morris of the University of Toronto and the Hospital for Sick Children caution that while hospitals may be getting better at infection control, there is not yet as much attention to it as there should be in ambulatory-care settings: urgent care centers, surgery centers and doctors’ offices. They offer a checklist of the minimal things that a physician practice should do.
  • And in the UK, Baroness Masham of Ilton, a member of the House of Lords, offers her online notes on serious infections with community MRSA, which the Brits are calling PVL-MRSA in recognition of the toxin that the strain produces. The notes are in advance of a series of questions that she intends to pose to government ministers during a Question Time on Wednesday.

More soon.

MRSA in a hospital nursery

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Via the Boston Globe and the blog of the hospital’s CEO comes work of an ongoing outbreak of community-associated MRSA in the newborn nursery at Beth Israel Deaconess Medical Center in Boston:

…between last November and March, BIDMC experienced several occurrences or “clusters” of methicillin-resistant Staphylococcus aureus, or MRSA, infections that have affected some of our patients (19 newborns and 18 mothers) days to weeks after discharge from our obstetrics and newborn services. These infections have been, for the most part, superficial skin infections and breast infections. It is important to note that no babies in our Neonatal Intensive Care Unit have been affected. (Paul Levy, president and CEO, BIDMC)

The paper and the blog post report that the Massachusetts Department of Public Health (DPH), the Boston Public Health Commission (BPHC), and the federal Centers for Medicare and Medicaid Services (CMS) are all investigating, and the Centers for Disease Control and Prevention (CDC) has sent epidemiologists to sort out transmission. Levy, the CEO, admits on his blog that in sorting out this outbreak, the hospital has found its staff’s infection-control procedures to be not-adequate.

By sheer chance, this occurs as I am writing a chapter on just this phenomenon of the blurring of the MRSA epidemics of hospital-acquired and community-associated staph. As constant readers know, the original MRSA strains arose in hospitals in the 1960s (1961 in the UK, 1968 in the US), and the separate community strain was first noticed in the 1990s. (Though there are intriguing hints about earlier cases that a few smart physicians noticed and no one else took seriously.)

But for about 5 years now, the community strain has been moving into hospitals and causing outbreaks there, particularly in mothers and newborns: first in New York City, and then in Houston, and now quite widely. The Globe article references some others.

Why this is important: Because CA-MRSA and HA-MRSA are different, and not just because they originally occurred in different settings or had different resistance profiles. CA-MRSA (which is a term that is obviously becoming much less useful than it once was) also appears, in newer research, to colonize the body in different ways — not just the nostrils, but also the armpit, groin, and genitals, possibly including vaginal colonization. So there may be an additional risk of transmission from mother to child during birth that has not been anticipated — or from mother to child to health care worker to another child to that child’s mother.

Now, mind you: Good infection control ought to anticipate all those posibilities, because good infection control does the right thing every time. But as we’re finding out, very few institutions manage to train their staff in such a way that they do the right thing every time or close to it (Novant Health Care, creators of the Soapacabana video, seem to have managed it, and won a major award for it). Most health care workers, even very well-intentioned ones, find themselves in time crunches or responding to unexpected emergencies, and make risk-based judgments about what they must do, and what they can afford to let slide.

If CA-MRSA is becoming a hospital organism, and its unique risks of colonization are not recognized by the hospital staff, then their judgments of relative risk will be off — and what would have been a relatively safe risk to take in one instance becomes a significantly unsafe risk in another.

That’s all speculation, of course: I’m not reporting on Beth Israel and have no inside knowledge of their outbreak. But it does describe a phenomenon that has been occurring in other medical centers, and it underlines one of the risks attendant on these epidemics blurring. When CA-MRSA moves into a hospital, the MRSA ecology changes, and the risks of transmission change. It is essential that staff training keep up with that, or additional mistakes will be made.