Flu Fatigue

One of the most subtle, yet most dangerous symptoms of the recent H1N1 flu outbreak is Flu Fatigue. Flu Fatigue is weariness brought on by media hype fed through a 24-hour news cycle that is constantly seeking its next crisis. Flu fatigue results in a built-up immunity to care about future epidemics and a general malaise regarding pandemic preparedness. Assuming that this most recent outbreak is over and should be forgotten is dangerous. History has shown that pandemic diseases are likely to quietly die-down, only to emerge more virulent than ever a few months later. This phenomenon is known as the ‘second wave’.

Second Wave
The three major pandemics over the past 100 years have shared a common epidemiology. The Spanish Flu (1918), Asian Flu (1957) and the Hong Kong Flu (1968) each began as mild illnesses in the springtime. Each of the three pandemics emerged in the autumn as much more virulent killers.1,2 Will the recent H1N1 shift into a more deadly strain this Fall? Pandemic experts such as the World Health Organization’s Director General Margaret Chan are preparing for the worst. “We hope the virus fizzles out, because if it doesn’t we are heading for a big outbreak. I’m not predicting the pandemic will blow up, but if I miss it and we don’t prepare, I fail. I’d rather over-prepare than not prepare.”3

Age of Pandemics
Epidemiologist and Chairman of the National Biosurveillance Advisory Subcommittee Lawrence Brilliant says we’re heading into an ‘Age of Pandemics’. “The 2009 swine flu will not be the last and may not be the worst pandemic that we will face in the coming years. Indeed, we might be entering an Age of Pandemics. In our lifetimes, or our children's lifetimes, we will face a broad array of dangerous emerging 21st-century diseases, man-made or natural, brand-new or old, newly resistant to our current vaccines and antiviral drugs. You can bet on it.”4

Betting on the outcome of a particular epidemic is risky. But amidst the uncertainty, experts agree that humanity will face a deadly pandemic in the future. Hospitals, and especially Emergency Departments, will be inundated by the sick and their families. The time to prepare is now, and several measures must be integrated to provide the maximum protection against transmission of pandemic disease.

Clearing the air
Increasingly, scientists are unraveling the secrets of viral disease transmission. New research has determined that air plays an important role in how we ‘catch’ respiratory diseases.5,6,7 Exhaustive studies following the SARS outbreak in 2003 indicate that this virus was airborne and that it is likely to have spread via a ventilation system within an apartment building.8,9

Recognizing the role air plays in disease transmission, architects, engineers, hospital administrators and building managers are looking to VIGILAIR® technology to reduce airborne pathogens. Installed within a building’s Heating Ventilation and Air Conditioning (HVAC) system, VIGILAIR® technology incorporates Ultraviolet Germicidal Irradiation (UVGI) and filtration to inactivate and remove pathogens within the HVAC air stream. UVGI damages the DNA/RNA of viruses, bacteria and fungi, preventing the microorganisms from reproducing and becoming infectious.

By disinfecting the air as it passes through the HVAC system, VIGILAIR® significantly reduces the amount of infectious microorganisms that are circulated throughout the building. Multiple hospital studies verify VIGILAIR® drastically reduces microbial contamination resulting in reduced infection rates.

VIGILAIR Systems, Inc. is the only UVGI manufacturer that has performed UVGI irradiation tests with live infectious agents including Anthrax, Avian flu (H5N1) and the SARS virus. The VIGILAIR® Biodefense system is the only UVGI technology to earn the Department of Homeland Security’s ‘designation’ as a Qualified Anti-terror Technology.

Fighting Flu Fatigue
Complacency can be costly--the time to make pandemic preparations is now. While no single measure can prevent disease transmission, VIGILAIR® is a technology that is proven to significantly reduce airborne pathogens. VIGILAIR® can play an important role in your comprehensive pandemic preparations. More information on pandemic preparations can be found at www.VIGILAIRsystems.com .

References

1. Pandemics and Pandemic Threats since 1900. PandemicFlu.gov. Retrieved May 6, 2009 from http://www.pandemicflu.gov/general/historicaloverview.html
2. .Hellerman, C. April 30, 2009. Scientists dig for lessons from past pandemics. CNNHeath.com. Retrieved May 6, 2009 from http://www.cnn.com/2009/HEALTH/04/30/swine.flu.1918.lessons/index.html
3. Jack, A.. May 3, 2009. Chan hits back at WHO critics. Financial Times. Retrieved May 6, 2009 from http://www.ft.com/cms/s/0/e6260d9a-37d4-11de-9211-00144feabdc0,dwp_uuid=819fc44c-33e2-11de-9eea-00144feabdc0.html?nclick_check=1
4. Brilliant, L. May 2, 2009. The Age of Pandemics. The Wall Street Journal. Retrieved May 6, 2009 from http://online.wsj.com/article/SB124121965740478983.html
5. Li Y, et al. Role of ventilation in airborne transmission of infectious agents in the built environment—a multidisciplinary systematic review. Indoor Air 2007; 17: 2-18.
6. Tellier, R. Review of aerosol transmission of influenza A virus. Emerging Infectious Diseases 2006; 12: 1657-1662.
7. Beggs, CB. The airborne transmission of infection in hospital buildings: fact or fiction? Indoor and Built Environment 2003; 12: 9-18.
8. Li, Y, et al. Multi-zone modeling of probable SARS virus transmission by airflow between flats in Block E, Amoy Gardens. Indoor Air 2004; 15: 96-111
9. Yu, I. Evidence of airborne transmission of the severe acute respiratory syndrome virus. New England Journal of Medicine 2004; 350, 1731–1739
Flu Chart- Taubenberger, J, Morens, D. 1918 Influenza: the Mother of All Pandemics. Emerging Infect Dis. Volume 12, Number 1, January 2006. Retrieved from http://www.cdc.gov/ncidod/eid/vol12no01/05-0979-G1.htm

UK Terrorism Experts say Dirty Bomb Threat Increasing

Britain's Home Secretary couldn't be more direct. She said that the threat of of terrorists using a dirty bomb is, "...severe..."

Secretary Jacqui Smith made this assessment as her government launches a new and aggressive effort to combat terrorism that includes a much greater role for citizens. The new effort is described as "extremely broad ranging" and includes training 60,000 citizens in terrorism prevention and response.

Apparently new intelligence has raised concerns over the use of a chemical, biological or nuclear dirty bomb that could contaminate a wide area, endangering thousands, if not millions of people. British Government reports say that the dirty bomb threat is elevated because it has become easier for terrorists to obtain necessary materials from rogue and failed states, as well as from hospitals.

Ms. Smith warns, "Changing technology and the theft and smuggling of chemical, biological, radiological, nuclear and explosive materials make this aspiration more realistic than it may have been in the recent past."

Britain's counter-terrorism forces have grown from 1,700 officers in 2003, to 3,000 in 2009.

UV offers green alternative for cleaning genome lab

Although VIGILAIR is known for disinfecting air circulated through hospitals, our UV technology has several other applications. VIGILAIR Systems has partnered with the Memorial Sloan Kettering Cancer Center to create a UV sterilization system used in a genome lab.
Find the media release here.
Labs that research human DNA require extremely clean environments. Tiny molecular contamination can ruin weeks of hard work by lab techs. Traditionally, workers had to use caustic chemicals and cleaning materials to 'scrub down' the lab. This process has several disadvantages:

• Maintenance staff needed specialized training to complete the task
• Results were mixed
• Chemicals and cleaning materials used in the process are 'hazardous waste' and must be disposed of properly
• Costs associated with manual cleaning are high

After conferring with Sloan Kettering, we went on-site to measure the lab room and to begin our calculations on how to safely and effectively irradiate all the surfaces in the room. We designed an in-room system consisting of UV emitter lamps that were strategically placed in the lab's ceiling. The system produces a predetermined dose of UV capable of inactivating target organisms by a minimum of 99.999%.

The system's controls initiate the lights when the room is unoccupied and shuts-off the lights should anyone enter the room. This prevents any exposure to UV radiation.

We are proud of our partnership with Sloan Kettering, an institution recognized as a world leader in research and patient care.

Is Ebola Airborne?

World Health Organization (WHO) officials are rushing to the Democratic Republic of Congo, desperately trying to contain the spread of the Ebola virus. As of this writing, five people are known to have died from Ebola in the southern province of DR Congo, and the WHO says 166 more deaths since April may be linked to the virus.

Among the problems facing health care workers is the virus’ ability to remain asymptomatic for up to 21 days. Furthermore, researchers do not know why some people recover from Ebola hemorrhagic fever, while most do not. There is no standardize treatment for Ebola and researchers do not yet know the natural reservoir for the virus.

Is Ebola transmitted via the air? In primates the Ebola virus was transmitted through the air in a research facility in Reston, Virginia. Apparently the mutations that allowed the virus to easily transmit via the air also changed its effect on humans. Tests showed that four lab workers tested positive for Ebola Reston virus, but this strain of the virus caused only minor health problems (although all the monkeys in the Reston facility were destroyed to prevent the outbreak from spreading).

According to existing literature, Ebola does not spread through the air in natural settings, although it can be spread via aerosols in lab experiments. How the virus knows when it is in a lab, I’m not certain. Viruses rely on sugars and proteins that allow them to bind to cells they’d like to infect. Small changes, such as the mutation that permitted airborne transmission, probably changed the lethality for humans infected by Ebola Reston, even though it retained its virulence in monkeys.

There are claims, however, that airborne human to human transmission of Ebola occurred in 1976. Reports say that Mayinga N'Seka (seen as the patient in the image to the right), a nurse in Zaire may have contracted the virus via the air. Evidence is thin, and even if it was true, Nurse Mayinga did not infect any other humans before she died.

Ebola is a mysterious and deadly microorganism. We’ve come far in understanding this killer, but as with so many viruses, we are just one shift, drift or mutation away from a potential pandemic.

(This 1976 photograph shows two nurses standing in front of Kinshasa case #3 (Nurse Mayinga) who was treated and later died in Ngaliema Hospital, in Kinshasa, Zaïre - CDC/Dr. Lyle Conrad)

Best of the web

Keeping track on how states are dealing with legislation on Hospital Acquired Infection reporting? Then check out this blog:

About Health Transparency

You can easily see the status of legislation that mandates the reporting of quality measures. While you're there, you may find the 'Cost Measures' link interesting. You can see the disparity in costs/payments for various procedures in several communities. As far as I can tell, the site is a public/private partnership that is legit, not a shell shill for an industry group.

Doctors as terrorists: A potential bio-threat?

All eight people arrested in connection with the recent terror attacks in London and Glasgow are medical professionals employed by the UK’s National Health Service (NHS). Seven of the eight are medical doctors or medical students and the final suspect is a lab technician. This sad chapter casts a cloud over Muslim MDs who are speaking out against the recent violence.

But the attacks also illuminate the concern over the use of biological weapons by extremists. Physicians and those training to become physicians have access research facilities in hospitals and universities. While exotic pathogens such as anthrax and smallpox are difficult to obtain, healthcare professionals may have access to other 2^nd tier agents that can be used as, or refined into, a bio-weapon. The CDC enumerated some of these ‘B & C’ level threats:

Category B

Second highest priority agents include those that

• are moderately easy to disseminate;
• cause moderate morbidity and low mortality; and
• require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance.

Category B agents include

• Coxiella burnetti (Q fever);
• Brucella species (brucellosis);
• Burkholderia mallei (glanders);
• alphaviruses,
• Venezuelan encephalomyelitis,
• eastern and western equine encephalomyelitis;
• ricin toxin from Ricinus communis (castor beans);
• epsilon toxin of Clostridium perfringens; and
• Staphylococcus enterotoxin B.

A subset of List B agents includes pathogens that are food- or waterborne.
These pathogens include but are not limited to

• Salmonella species,
• Shigella dysenteriae,
• Escherichia coli O157:H7,
• Vibrio cholerae, and
• Cryptosporidium parvum.

Category C

Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of

• availability;
• ease of production and dissemination; and
• potential for high morbidity and mortality and major health impact.

Category C agents include

• Nipah virus,
• hantaviruses,
• tickborne hemorrhagic fever viruses,
• tickborne encephalitis viruses,
• yellow fever, and
• multidrug-resistant tuberculosis.

Could doctors bent on jihad create and release a biological agent? While there are many technical hurdles inhibiting such attacks, physicians are among the few who can overcome these obstacles. The recent attacks in the UK indicate that terrorists have not surmounted the technical barriers to obtain, process and disseminate a biological agent. If they had such a weapon, they probably would’ve used it. The fact remains, however, that terrorist groups can recruit people who are highly educated and highly motivated to use whatever means available to kill Westerners.

Terror organizations have relied on scientists in the past. A Pakistani scientist with an advanced degree in microbiology is reported to have obtained anthrax spores under the guise of legitimate research. Papers uncovered by coalition forces in Afghanistan in December 2001 showed that the scientist corresponded directly to al-Qaeda's No. 2 commander, Ayman al-Zawahiri. Al-Zawahiri is a doctor by training, having worked as a surgeon.

More recent developments are also cause for concern as this NPR story notes:

“But a worrying, almost prophetic, story emerged Wednesday from Baghdad: a Church of England clergyman, Andrew White, who is president for the Foundation of Reconciliation in the Middle East, based in Iraq, said he was at a conference in Amman, Jordan in April when he was taken aside by a Sunni religious leader.

"I listened to him for 40 minutes, and he went on about how they were going to destroy Britons and Americans and how they were going to be doing more in the U.K. and U.S., and he finished by saying 'those who cure you will kill you,'" White said. “

Now is not the time for fear mongering. But we should be aware that terrorists are able to attract and radicalize even the most educated in the community. It’s a reminder that we must remain vigilant on many fronts in order to protect ourselves from threats of terrorists.

APIC’s MRSA Study: a good start

The Association for Professionals in Infections Control (APIC), has just released a comprehensive study that found MRSA rates may be much higher than earlier thought. Results showed that MRSA infection and/or colonization rates are at least 8 times greater than the results of previous studies. You can find the study on APIC’s web site here.

The study is significant because it surveyed a broader spectrum of hospitals and patients than any earlier study. So now that you know the prevalence of MRSA, what to do about it? APIC has some direction there as well. Health care workers can download the Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings. This resource is another good start, although it only devotes 2 pages to environmental transmission of MRSA. A quick check of the text finds 62 mentions of the word ‘contact’, as in ‘contact transmission’. There are zero mentions of the term ‘airborne’, as in ‘airborne transmission’.

Why the omission? Could it be that there is no science to back-up the assertion that MRSA is spread via the air? Perhaps these studies were overlooked:

Significance of Airborne Transmission of Methicillin-Resistant Staphylococcus aureus in an Otolaryngology–Head and Neck Surgery Unit¹
In this 2001 study, Japanese doctors attempted to measure if MRSA could be found in the air of a surgical hospital ward. The rooms of three patients who acquired MRSA after surgery were monitored with air samplers and surface swabbing.
Results:
MRSA was detected in all three rooms in the air and on surfaces. 20% of the MRSA particles were within the respirable range, of less than 4 µm.
From the study:

“Methicillin-resistant S aureus was recirculated among the patients, the air, and the inamimate environments, especially when there was movement in the rooms. Airborne MRSA may play a role in MRSA colonization in the nasal cavity or in respiratory tract MRSA infections. Measures should be taken to prevent the spread of airborne MRSA to control nosocomial MRSA infection in hospitals.”

Reduction in MRSA environmental contamination with a portable HEPA-filtration unit.²

In 2006 microbiology researchers in the UK wanted to know if filtering the air in a hospital would lead to a decrease in MRSA found on horizontal surfaces. Ward rooms housing “…heavy MRSA dispensers…” were supplied with portable HEPA filtration units.
Results:
95% of settle plates placed in the wards showed MRSA contamination. Plates were placed in a variety of locations, mostly along the perimeter of the room. When HEPA filtration was introduced, measurable MRSA decreased between 73%-95%. This study makes a direct link between air and the dispersion of viable MRSA.

From the study:

“Although this cannot replace standard infection control measures (e.g. isolation, hand hygiene, protective clothing and cleaning), it is likely to reduce cross-infection risks significantly and could provide a relatively cost effective method for enhancing MRSA control.”

The relationship between airborne colonization and nosocomial infections in the intensive care unit.³
In 2005 Turkish researchers used more than 900 data points to measure airborne pathogens and the colonization of those pathogens in hospital patients. The study tracked 179 patients and found that MRSA is definitely airborne.
Results:
Researchers proved that MRSA was airborne through the use of air samplers. The two most common airborne pathogens were MRSA and Acinetobacter baumannii. Furthermore, the study says there is a link between the concentration of these airborne pathogens and colonization in patients.
From the study:

“It can be concluded that, total number of airborne viable particles in the critical areas such as operating theatres and intensive care units, seems to be a significant risk factor for the development of nosocomial infections in immuno-compromised patients.”

An outbreak of Serratia marcescens infection in a special-care baby unit of a community hospital in United Arab Emirates: the importance of the air conditioner duct as a nosocomial reservoir.⁴

A deadly outbreak of S. marcescens vexed the staff members of a NICU located in the United Arab Emirates (UAE). In total 36 infants were infected, leading to the death of five babies. Concerned healthcare workers desperately worked to find the source of the outbreak.

Results:

Researchers determined that the reservoir of the deadly pathogen was the air conditioning system that fed the NICU. Despite many typical infection control interventions such as staff education, environmental cultures, isolation of colonized patients, compliance with aggressive infection control measures and recognition of the role of cross contamination the colonization of infants grew. When environmental sampling suggested that contamination was emanating from the air conditioning system, the hospital thoroughly sanitized the system. After this measure the 20 week outbreak ended.

From the study:

“…the growth of serratia from airflow samples suggested that the primary source of
this outbreak was the AC duct.”
“In conclusion, we have documented in this report the results of extensive surveillance and the importance of the AC duct site as a reservoir of nosocomial pathogens in the SCBU of a community hospital. The possibility of airborne transmission in nosocomial spread should not be underestimated.”

Although there is ample evidence that MRSA and other pathogens are transmitted via the air, most infection control measures focus on contact precautions. Data indicate that contact transmission predominates, so the emphasis on contact precautions is warranted.

It is reasonable, however, to also address other environmental contributors to infection. As we’ve learned recently in reducing VAP, a bundling approach yielded impressive infection rate reductions. Bundling recognizes that infection control is multifaceted and requires new thinking and new strategies. Bundling’s success proves that infection control is achieved through a system of evidence based measures.

Instead of thinking about infection control as breaking a single link in the ‘chain of transmission’, consider infection as a web with many avenues of opportunity. One of those avenues, the airborne route, deserves greater attention.

References

1. Significance of Airborne Transmission of Methicillin-Resistant Staphylococcus aureus in an Otolaryngology–Head and Neck Surgery Unit
Teruo Shiomori, MD, PhD; Hiroshi Miyamoto, MD, PhD; Kazumi Makishima, MD, PhD
Arch Otolaryngol Head Neck Surg. 2001;127:644-648.

2. Reduction in MRSA environmental contamination with a portable HEPA-filtration unit
TC Boswell; PC Fox
Journal of Hospital Infection 2006 May;63(1):47-54

3. The relationship between airborne colonization and nosocomial infections in the intensive care unit
G Dürmaz, et al
Mikrobiyol Bul. October 2005 (article in Turkish)

4. An outbreak of Serratia marcescens infection in a special-care baby unit of a community hospital in United Arab Emirates: the importance of the air conditioner duct as a nosocomial reservoir
S. A. Uduman, et al
Journal of Hospital Infection (2002) 52: 175±180

A meeting of creative minds

I was privileged last week to attend the evidence based design and a passion for improving the environment of care in health facilities world wide. The Center is known for matching new design technology with progressive hospital administrators who are looking for innovative ways to improve patient care.
Environment Standards Committee (ESC) members volunteer their time to bring evidence based ‘best practices’ to such organizations such as the American Institute of Architects (AIA).
ESC members tend to be recognized leaders in architecture and design who are simultaneously extremely creative and pragmatic. They marry their expertise with a hunger for innovation to produce solutions that are aesthetically, environmentally and economically beneficial.
Following the meeting, we were given a tour of the building. Richard Smith was kind enough to show us the newly designed structure of 1305 York Avenue, a part of the Weill Cornell Medical College. Mr. Smith demonstrated how attention to design details have yielded a significantly better care experience for patients who receive ambulatory outpatient services here.
Many of the innovations stemmed from a patient survey that highlighted patient perceptions about care. Changes in design to floor plans and internal procedures have produced a streamlined admissions process that reduces waiting time, assures HIPPA privacy and eliminates paper records. It would be difficult to review all the innovations of this building, so I will share some images of the tour.

Center For Health Design

Healthcare takes a new look at airborne pathogens

The concept of airborne disease transmission was well accepted in the early to mid 1900's. It was frequent that you would see UV lights in hospital wards for upper air disinfection. UV lights were a standard form of infection control in TB wards.
But then times changed. Aggressive measures helped to eradicate TB from our country. Drugs such as vaccines proved effective and immediate. Hospitals, like all buildings, began to have ventilation to exhaust contaminated air while bringing in fresh air. Scientists and researchers turned away from studying airborne transmission and moved on to newer issues.
Since the advent of SARS, pandemic influenza and a resurgence in TB, scientists are once again turning their attention to airborne transmission. We've prepared a new white paper that examines some of the findings of these new studies. Like all good research it answers some questions and raises some more! Hopefully this spark new interest in studying airborne transmission.

UV 911

From the Journal of Emergency Medical Services, word of an excellent application of UV—disinfection of ambulance interiors.

UV’s germicidal action makes it a perfect tool to sanitize the surfaces in an ambulance. After all, ambulance crews are our first responders and are likely to transport ill people in the case of an epidemic or pandemic. The article notes that UV-C is more effective on deactivating viruses than chlorine.

The article points out many of UV's benefits:

“UV-C lights have many advantages. They're environmentally friendly with no dangerous materials to handle or store, so employees won't need to handle any toxic chemicals. The lights are also immediately effective, economical and operator friendly. (Just flip a switch.) Maintenance is easy—periodic cleaning and annual lamp replacement should do it. Installation involves only simple wiring, timer switches and a power connection.”

Check out the complete article by clicking here. Although we do not design such application, the principle is the same for VIGILAIR HVAC protection systems.