To first do no harm takes awareness, detailed diligence to practice routinely

threeTo first do no harm is a fundamental principle followed by physicians and advanced practice clinicians (APCs). And few would argue that a decided majority believe they adhere to that precept most of the time. But it isn’t always the case when health-care folks are faced with the conundrum of sitting out or going to work while showing symptoms of infection, potentially spreading illness to patients and colleagues.

Reasons Why Physicians and Advanced Practice Clinicians Work While Sick tries to identify a comprehensive understanding of the reasons attending physicians and APCs work while sick. Of the medical professionals surveyed, 95 percent believe working while sick puts patients at risk. But of this same group, 83 percent reported working while sick at least once in the previous year. Nine percent said they worked while sick at least five times the previous year! Among the reasons cited for this disconnect: difficulty in finding someone to cover, a strong cultural norm to come to work unless remarkably ill and ambiguity about what constitutes “too sick to work.”

Effective hand hygiene is another way to help ensure no harm is done, yet hand hygiene remains low in most hospitals. Hand hygiene among physicians: performance, beliefs, and perceptions shows that at a large university hospital adherence averaged 57% and varied markedly across medical specialties. In multivariate analysis, adherence was associated with the awareness of being observed, the belief of being a role model for other colleagues, a positive attitude toward hand hygiene after patient contact, and easy access to hand-rub solution. Conversely, high workload, activities associated with a high risk for cross-transmission, and certain technical medical specialties (surgery, anesthesiology, emergency medicine, and intensive care medicine) were risk factors for non-adherence. Another related piece: Physician ‘defiance’ towards hand hygiene compliance: Is there a theory–practice–ethics gap?

Even when hand hygiene is practiced, potential problems arise. Contamination of Medical Charts: An Important Source of Potential Infection in Hospitals notes that medical charts should be considered a source of infection. The authors say “our study confirms that a hospital chart is not only a medical record but also an important source of potential infection. The plastic cover of the medical chart can harbor potential pathogens, thus acting as a vector of bacteria. Additionally, chart contamination is more common in ICUs. These findings highlight the importance of effective hand-washing before and after handling medical charts. However, managers and clinical staff should pay more attention to the issue and may consider some interventions.” In short, hand hygiene that is practiced at the door upon entry is largely negated when a non-gloved hand then pulls back a contaminated curtain or handles a bacteria-laden medical chart. We must stay ever aware of infection vectors all along the chain of infection.

Coronaviruses continue to be emerging health threat worldwide

twoCoronaviruses are common throughout the world, particularly emerging as a significant threat to health and the economy during the past 10 years. They can infect people and animals. Several different coronaviruses can infect people and make them sick. They usually cause mild to moderate upper-respiratory illness. But some coronaviruses, like the one that caused Severe Acute Respiratory Syndrome (SARS) in 2003, can cause severe illness.

SARS: lessons from a new disease discusses the far-reaching impact of the coronavirus SARS, which rocked the world economy when borders were closed, causing social disruption and negatively affecting business and trade. The piece is a chapter in the World Health Organization’s world health report, 2013. The report says international travel to affected areas fell sharply by 50 to 70 percent. Hotel occupancy dropped by more than 60 percent. Businesses, particularly in tourism-related areas, failed, while some large production facilities were forced to suspend operations when cases appeared among workers.

A more positive impact came when the outbreak created a level of media attention that raised awareness and political commitment, helping to contain the disease. It demonstrated that nations can put aside politics to achieve positive public health results.

A second coronavirus that impacted the economy is Porcine Epidemic Diarrhea Virus (PEDV). PEDV spread rapidly after first being found in the U.S. in April, 2013. The virus ravaged the pork industry and cost billions, spurring significant study into the disease and its causes. Evidence of infectivity of airborne porcine epidemic diarrhea virus and detection of airborne viral RNA at long distances from infected herds is a study whose results indicate PEDV traveled 10 miles downwind from naturally infected farms. It suggests that airborne transmission should be considered a potential route for PEDV dissemination.

A third coronavirus to strike is Middle East Respiratory Syndrome (MERS), which has hit hard in Saudi Arabia and spilled across its borders. The most significant to date was the outbreak in South Korea last year.

Environmental Contamination and Viral Shedding in MERS Patients during MERS-CoV Outbreak in South Korea investigates the environmental contamination from four patients in MERS-CoV units of two hospitals. It finds that “most of touchable surfaces in MERS units were contaminated by patients and health care workers and the viable virus could shed through respiratory secretion from clinically fully recovered patients. These results emphasize the need for strict environmental surface hygiene practices, and sufficient isolation period based on laboratory results rather than solely on clinical symptoms.”

Antibiotic overuse in animal feed operations damaging to human health

threeThe misuse and overuse of antibiotics for production purposes at Concentrated Animal Feeding Operations (CAFOs) is a direct assault on their therapeutic value for humans.

Factory farms, antibiotics and superbugs: Lance Price at TEDxManhattan is a splendid YouTube piece that discusses the misguided use of antibiotics in CAFOs. The speaker is Lance Price, Director of the Antibiotic Resistance Action Center at the Milken Institute School of Public Health. He so aptly points out that “if you’ve designed a system that requires a constant input of antibiotics just to keep animals from being sick, then that system’s broken.” Antibiotics are not and should not be used as production tools.

CAFOs are heavily dependent on antibiotics. They allow animals to grow faster and larger because they need not expend energy fighting off illness. The World Health Organization has recommended that the non-therapeutic use of antibiotics in these operations be re-evaluated because resistant strains of human pathogens have been identified, creating a public health risk. Simply put, antibiotic overuse causes antibiotic effectiveness in humans to wane dangerously.

It’s worth taking a few minutes to watch this eye-opening presentation. Price does a marvelous job of boiling it down to the essentials.

Air pollution from CAFOs can negatively impact public health. Asthma, headaches, respiratory problems, eye irritation, nausea, weakness, and chest tightness are a just a few issues that can result. Antibiotics, Bacteria, and Antibiotic Resistance Genes: Aerial Transport from Cattle Feed Yards via Particulate Matter is a piece that accurately begins with the premise that modern industrial-scale animal feeding operations relies extensively on veterinary pharmaceuticals, including antibiotics, to augment animal growth. Following excretion, antibiotics are transported through the environment via runoff, leaching, and land application of manure; however, airborne transport from feed yards has not been characterized.” It goes on to conclude that wind-dispersed particulate matter from feed yards harbors antibiotics, bacteria, and antibiotic-resistant genes.

Some of all this has begun to register with some major suppliers, who are looking more closely at misuse of antibiotics in their supply chains. It’s a start. Consumer awareness remains a huge hurdle.

C. diff moves easily throughout hospitals; cost in lives, money soars

twoClostridium difficile (C-diff) remains a major problem in our hospitals. This costly bug is aerosolized in toilets and easily moves throughout hospitals on shoes, clothing, air and hands. More than 200,000 cases are reported in the United States each year. The costs in lives and dollars are staggering.

C-diff is a bacterium that causes diarrhea and more serious intestinal conditions such as colitis. It is a tough and opportunistic bacteria that can invade the intestines of people whose gut bacteria have been wiped out by heavy doses of antibiotics, according to the U.S. National Institutes of Health (NIH).

C. diff Infection Increases Hospital Costs by 40% notes that C. diff is one of the most common healthcare-associated infections. It maintains that C. diff increases hospital stays by 55 percent, increases by 77 percent the chances a patient is readmitted and, most importantly, finds that C. diff increases hospital costs by 40 percent. Clearly, efforts to reduce and prevent infection save money.

Airborne Spread of Clostridium difficile points out that transmission of C. diff is difficult to interrupt, particularly given that studies show the spores can be spread through the air. Read more at the link.

Antibiotic Resistant threats in the United States, 2013 addresses C. diff as an “urgent threat.”

Global fight to wipe out TB progresses, continues on multiple fronts

Tuberculosis under a microscope

While progress in the fight against Tuberculosis (TB) has been made in recent years, the battle must continue because there’s plenty of work that remains to be done.

The National Action Plan for Combating Multidrug-Resistant Tuberculosis was developed by The White House and has a stated vision of: “The United States will work domestically and internationally to contribute to the prevention, detection, and control of multidrug-resistant tuberculosis in an effort to avert tuberculosis-associated morbidity and mortality and support a shared global vision of a world free of tuberculosis.”

That the effort is far from complete becomes clear when some facts about TB are noted. Among them:

  • TB is a top infectious disease killer worldwide.
  • In 2014, 9.6 million fell ill with TB and 1.5 million died from the disease.
  • Over 95% of TB deaths occur in low- and middle-income countries, and it is among the top five causes of death for women aged 15 to 44.
  • In 2014, an estimated 1 million children became ill with TB and 140,000 children died of TB.
  • TB is a leading killer of HIV-positive people: in 2015; one in three HIV deaths was due to TB.
  • Globally in 2014, an estimated 480,000 people developed multidrug-resistant TB (MDR-TB).
  • The Millennium Development Goal target of halting and reversing the TB epidemic by 2015 has been met globally. TB incidence has fallen by an average of 1.5% per year since 2000 and is now 18% lower than the level of 2000.
  • The TB death rate dropped 47% between 1990 and 2015.
  • An estimated 43 million lives were saved through TB diagnosis and treatment between 2000 and 2014.
  • Ending the TB epidemic by 2030 is among the health targets of the newly adopted Sustainable Development Goals.

The 20th edition of The World Health Organization’s Global Tuberculosis Report (2015) was recently published. It uses data from 205 countries and territories, which account for more than 99% of the world’s population. The global TB report documents advances in prevention, diagnosis and treatment of the disease. It also identifies areas where efforts can be strengthened.

Also of note from the report: From 2016, the goal is to end the global TB epidemic by implementing the End TB Strategy. Adopted by the World Health Assembly in May 2014 and with targets linked to the newly adopted Sustainable Development Goals (SDGs), the strategy serves as a blueprint for countries to reduce the number of TB deaths by 90% by 2030 (compared with 2015 levels), cut new cases by 80% and ensure that no family is burdened with catastrophic costs due to TB.

Bacterial and viral shedding can contaminate surfaces for months


Bacterial and viral shedding occurs constantly. Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination is a study that outlines how surfaces can be contaminated. The study notes that severe acute respiratory syndrome (SARS-CoV), Middle East respiratory syndrome (MERS-CoV) and influenza virus can survive on surfaces for extended periods, sometimes up to months. Factors influencing the survival of these viruses on surfaces include: strain variation, titre, surface type, suspending medium, mode of deposition, temperature and relative humidity, and the method used to determine the viability of the virus. . . . Infection prevention and control implications include the need for hand hygiene and personal protective equipment to minimize self-contamination and to protect against inoculation of mucosal surfaces and the respiratory tract, and enhanced surface cleaning and disinfection in healthcare settings.

Infection control specialist Jon Otter expands on the topic at his blog: Surface contamination and respiratory viruses with pandemic potential (SARS, MERS and influenza): an underestimated reservoir? Otter points out that “laboratory studies show that SARS-CoV, MERS-CoV and influenza virus can survive on surfaces for extended periods, sometimes up to months. Environmental sampling in field settings has identified contamination with SARS-CoV and influenza virus (no studies yet for MERS-CoV), but important to note that many of these studies used PCR to detect the virus, so there is often no way to tell whether the virus is alive or not. At the very least, detection of nucleic acid is a marker of shedding.” He goes on to say “surface contamination is an important potential reservoir for transmission of these respiratory viruses, so should not be underestimated from an infection prevention and control viewpoint.”

With you in the room, bacteria counts spike is a piece at YaleNews that says “human occupancy was associated with substantially increased airborne concentrations” of bacteria and fungi of various sizes. Occupancy resulted in especially large spikes for larger-sized fungal particles and medium-sized bacterial particles. The size of bacteria- and fungi-bearing particles is important, because size affects the degree to which they are likely to be filtered from the air or linger and re-circulate, researchers in the study cited note.

Respiratory Virus Shedding in a Cohort of On-Duty Healthcare Workers Undergoing Prospective Surveillance begins with the premise that healthcare-associated transmission of respiratory viruses is a concerning patient safety issue. The study follows and tests healthcare workers (HCWs) for influenza virus. It found that HCWs working while ill was common, as was viral shedding among those with symptoms. Asymptomatic viral shedding was infrequent, but did occur. HCWs should refrain from patient care duties while ill, and staffing contingencies should accommodate them.

Addressing contamination on shoes, floors is necessary infection control step

oneThe largest surface inside a hospital with the potential for bio-aerosol is the floor, a massive touch point for every step taken inside hospitals. A Penn State University experiment, Resuspension of allergen-containing particles under mechanical and aerodymnamic forces from human walking – Introduction to an experimental controlled methodology, shows how floors can impact infection control.

Allergens originating from mites, insects, animal dander and fungal spores are found in building surface reservoirs such as floors, upholstery and beds. Epidemiological evidence indicates that these allergens are strongly associated with the development of bronchial hyper-reactivity (BHR), or asthma. Although life threatening in rare occasions, asthma affects nearly 50 percent of the population in developed societies, resulting in much distress and lost time from school and work.

Among the chief observations from the experiment: “The main observations derived from the experiments performed were: (1) for a continuous disturbance, re-suspension was only observed during the first two minutes with an initial burst of particle re-entrainment followed by an exponential decrease to undetectable value; (2) air-puff disturbances had a much higher impact on dust re-suspension than the vibration disturbances; (3) particles were more easily re-suspended from linoleum flooring than from carpet flooring; (4) German roach dust was more easily re-suspended by air streams than quartz dust; (5) Re-suspension Factor (RF) and Relative Risk (RR) values derived from the present experiments show consistency with previous research values.”

Microbial Populations in a Hospital Under Construction is a study that is tracking bacteria on shoes throughout a hospital, beginning with the building of the hospital.

From the study: “Comparing the before- and after- tour bacterial communities from our shoes to the communities found on the floors, we can say with confidence (P = 0.002) that our shoes went home with some hospital bacteria. Perhaps equally interesting is that the grouping of shoes A+C and B+D remained the same both before and after the tour. This implies that even when the communities on one’s shoes are affected by where you are walking, you can still find the underlying signal that can identify whose shoes they were from one hour to the next. . . . With this much information gleaned from 32 samples, we are now more than ever looking forward to beginning our 12,392 sampling project of this hospital in full operation.”

Hospitals miss opportunity to help put a lid on spread of HAI

twoThe reasons hospitals traditionally have offered for not having toilet seats fall short when you check out some of the links we’ve provided below. At best, flushing lidless toilets simply isn’t good hygiene. At worst, the practice is a vehicle for the spread of disease. We believe that hospitals not only should have lids on their toilets but also encourage their use, particularly when flushed. If it means updating fixtures, so be it. The cost of this simple, preventative measure when weighed against the enormous costs of hospital acquired infection is well worth it. Prevention as always is critical, and every little bit counts.

Potential for aerosolization of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination risk concludes that lidless conventional toilets increase the risk of Clostridium difficile (C. difficile) environmental contamination, and the authors suggest that their use is discouraged.

Survival of Salmonella in bathrooms and toilets in domestic homes following salmonellosis reports on testing for Salmonella bacteria on domestic toilets where a family member recently suffered an attack of salmonellosis. It shows that the survival and environmental spread of Salmonella bacteria persisted in four out of six households tested, specifically in the biofilms material found under the recess of the toilet bowl rim which was difficult to remove with household toilet cleaners. The results suggest that during diarrhoeal illness, there is considerable risk of spread of Salmonella infection to other family members via the environment, including contaminated hands and surfaces in the toilet area.

The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet is a study intended to determine the level of aerosol formation and fallout within a toilet cubicle after flushing a toilet contaminated with indicator organisms at levels required to mimic pathogen shedding during infectious diarrhea. It determines that “Although a single flush reduced the level of micro-organisms in the toilet bowl water when contaminated at concentrations reflecting pathogen shedding, large numbers of micro-organisms persisted on the toilet bowl surface and in the bowl water which were disseminated into the air by further flushes.”

Microbiological Hazards of Household Toilets: Droplet Production and the Fate of Residual Organisms finds that large numbers of bacteria and viruses when seeded into household toilets were shown to remain in the bowl after flushing, and even continual flushing could not remove a persistent fraction. The detection of bacteria and viruses falling out onto surfaces in bathrooms after flushing indicated that they remain airborne long enough to settle on surface throughout the bathroom. Thus, there is a possibility that a person may acquire an infection from an aerosol produced by a toilet.