A shared syringe – and $80mill bill

With social media and education outreach, major outbreaks of Bloodborne Pathogens (BBP) should be a thing of the past. Not so.

Alarm bells rang when 11 new HIV cases occurred in Nov-Jan in a small Indiana community – double that normally seen in a year .

This “handful of cases” from shared syringes among opioid drug users, had grown to 26 cases when reported in Feb by the Indiana State Department of Health, and by March had grown to 79 cases. By April the number had risen to 135 cases, 84% of whom were coinfected with HCV.

In a US CDC-Medscape Expert Commentary released this week, the number is now at 170 HIV cases, almost all HCV coinfected. The article states, “The lifelong medical care costs alone for treating the persons …will be more than $80 million“.

WHO in 2004 examined the alarming increase in BBP transmission among drug injectors and after a review of over 200 publications concluded that: the evidence for BBP reduction with needle and syringe exchange programs (NSEP) was overwhelming; NSEP need be country-wide; and any contrary legislation needs be repealed.

PS. Proudly, Australia and New Zealand were two of the first countries to use NSEPs nationally – and now via vending machines!

Interestingly, USA banned federal funding of NSEP in 1988, removed the ban in 2009, and reinstated the ban in 2011 (the legislation does not ban NSEPs; just federal funding of them). Opponents of federal support for NSEPs argue that it signals governmental acceptance of, and would facilitate the uptake of, illegal drug use. WHO says not so. Thankfully, in 2011, at least 221 non federal NSEPs operated in the US.

CDC recommends drug injectors be referred to “programs that provide access to sterile injection equipment.” A wise, evidence-based recommendation.

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Travel history is essential – not just for Ebola

There are many lethal, more frequently occurring diseases than Ebola, entering our countries.

Recently, on the chat room of USA Assoc. for Professionals in Infection Control & Epidem (APIC), members have asked how much longer hospitals should ask patients about overseas travel (to alert staff for Ebola).

Malaria is another reason why travel history must CONTINUE to be sought.

Several decades ago as a Malariologist in a developing country, I strove to remind colleagues in developed countries to ALWAYS ask a travel history when any patient presented with fever, chills or headache (FC&H). I have seen a patient walk in unassisted with FC&H at 5pm, and die from P. falciparum cerebral malaria at midnight.

The deaths of two tourists from cerebral malaria in a Springfield Missouri motel last month shows how rapidly and insidiously this disease can kill travelers. And underpins why travel history is essential if patients present with fever to an emergency dept.

In 2011 USA hit an all-time high with nearly 2,000 cases of malaria being diagnosed in travellers.  In 2012 1,687 cases of Malaria were diagnosed in USA, with 1,683 (99.8%) occurring in travelers. Six of the cases died.

Ebola pales into the background in the face of other imported diseases for which a travel history is needed for diagnosis.


Sierra Leone Ebola surge – curfew needed

You probably noted my excitement, after I returned from Sierra Leone, when a week of “zero” days occurred in early May. However recently in Port Loko and Kambia cases have surged and the President has declared a 21 day dusk-to-dawn curfew in these districts.

The graph below (compiled from Ministry Reports) shows why the decree was issued – cases had fluctuated from 0 to 2 per day, but in the last two weeks, 5 cases were reported in one day, then 9 on another, all from the two districts. 15 cases in one week is the highest since March.
Picture of graph
Of the recent cases some have occurred in individuals unlinked to known cases, and others in areas  free of cases for over 40 days – two signs of loosening of behaviours. The good news is that the previous “hotspot”, Freetown Western Urban, had zero cases – the first time in 10 months.

WHO in their latest summary, said the decline had “stalled”. I feel sad for the people of the two curfew districts – and for the contact tracers – and all aid workers and national staff arduously trying to reach zero.

Hopefully in this Ebola warzone, the curfew is the last offence needed to win the battle.


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EXPO-STOP 2012 – US largest blood exposure study published

EXPO-STOP:2012 Survey of US blood exposures is published in JAOHP

Linda Good and I, and the US Association of Occupational Health Professionals in Healthcare (AOHP) are pleased to announce the publication of our 2012 EXPO-STOP Survey in the recent edition of JAOHP.

The survey, the largest in US, examined the 9,494 blood exposures reported from 157 hospitals in 32 states, and calculated annual incidences using 4 denominators.

The 7,119 sharps injuries (SI) and 2,375 mucocutaneous exposures (MC) resulted in incidence rates of:
• 28.2 SI / 100 occupied beds; 2.2 / 100 staff; 3.3 / 100 nurses; and 0.43 / 100 Adjusted Patient Days.
• 10.1 MC / 100 occupied beds; 0.8 / 100 staff; and 0.15 / 100 Adjusted Patient Days.
• Of Total reported SI, 42% were among nurses and 36% among doctors.
• 44% of reported SI occurred during surgical procedures

The 2012 exposure incidences were significantly higher than those reported in the most recently published surveys by EPINet and Massachusetts Dept Public Health, and, disturbingly, higher than the EPINet incidence published in 2001 following the enactment of the OSHA needlestick Safety and Prevention Act (NSPA).

The study concludes that compliance with the NSPA is, in itself, insufficient to achieve the national reduction in exposures needed

The top 5 lowest-incidence hospitals had incidences 60% lower than their counterpart same-size hospitals. Their successful strategies were reported in the study and included education, repeated competency training, rapid investigation, unflagging diligence, and searching for safer safety devices.

A pre-publication Author Copy of the study is available for personal use and the definitive article is purchasable from AOHP

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Handling New Zealand’s 1st Ebola suspect- excellent test of smooth planning

There is no substitute for repeated, detailed practice.

Ruth Barratt’s Open Access Case Report this week in Healthcare Infection is testimony to thorough planning and training, with the “real run” showing improvements can still be made.
The Report is a clear expose of the importance of Infection Prevention and Control and the availability, use, suitability and shortfalls of Personal Protective Equipment (PPE).
Having returned from Sierra Leone, I can confirm Barratt’s “real-life” is “real-life”. Her emphasis on the necessity of preparedness through practice drills, reflects that required in Ebola Red Zones.
Other mirrorings they found were:
• Staff preferring certain PPE over others (WHO state gown+hood vs coverall is personal choice – there is no evidence one is safer over other, and staff may find gown safer through familiarity, and, in certain cultures, more gender-acceptable);
• Fogging of eye-protection (CDC now recommends face-shields over goggles and many Red Zone staff leave face-shield bottoms outside their hood). Some Ebola Red Zones rub toothpaste on inside of lenses as a defogger (an old SCUBA-diving technique);
• Swapping thick outer gloves for long-cuff surgical outer gloves aids dexterity – others agree;
• Locating in-country sources for preferred PPE;
• Some PPE items being too small for taller/larger staff;
• Gowns not lasting (UNICEF recently published recommended product-specifications for PPE).

The author stressed the importance of having a trained observer in addition to a “buddy”. In Ebola Red Zones such observers are called “hygienists” and their calm, talking-through of each PPE-removal step is considered a God-send by near-exhausted staff.

The patient (who proved Ebola negative) was an Ebola-trained nurse – and assisted the staff with some of her own care and gave feedback on their procedures!

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Two new ways to combat antibiotic resistance

Timely dosing and a body wash may help

Antibiotic resistance is not new – resistance genes have been found in 700 year old faeces!

But WHO state resistance is a major issue in healthcare today. In their Policy Paper, Ontario Medical Association state that antibiotic resistance results in infections being more severe, of longer duration and higher mortality, as well as longer hospital stays and more aggressive treatments with expensive “third-line” antibiotics. This means increased healthcare costs.

Judicious antibiotic use and banning of antibiotics as growth-enhancers in animals are essential. But additional measures are needed.

One new proposal is to change the timing of antibiotic dosing. In a recent paper, Meredith et al used computer modelling to determine that the timing of dose, relative to a bacteria’s recovery, may allow the bacteria to be killed before its production of beta-lactamase can begin.  If successful, it means first-line “old fashioned” antibiotics can still be used.

At last week’s SHEA meeting, a second novel method was proposed. McKinnell et al showed chlorhexidine (CHX) body wash can reduce colonization with MRSA. Compared to MRSA ‘Contact isolation’, they found CHX had fewer MRSA contamination events. Also, the authors argued that CHX use may result in a higher quality of care compared to isolation.

In another life (almost 40 years ago!), I researched the effect of whole-body CHX bathing on the normal flora of patients pre-operatively and concluded in a book chapter, “The course that is apparent is a return to the early concept of ‘total body’ reduction of Staphylococcus aureus carriage..” Goes to show – if you live long enough…:)

Sierra Leone – helping rebuild the local school

Walking by the local village, angelic children’s voices singing “ABCDEFG” enticed me to a dilapidated hut.

 First visit Through the broken doors I saw a room with about  30 children – who immediately stood and chanted in perfect unison, “Good afternoon sir“. I don’t know who had the biggest grin, the children or me!
Pre - rebuild I’d passed the small hut many times and never knew it was a school. It is voluntary, and Bailor and assistant-teacher Mustapha, unpaid. Classes are conducted six days a week from 3-6pm and on Saturdays they ask a 1,000 Leones (20 cents) “fee” from those who can afford it. few attend on Saturday.

In an impromptu geography quiz (“Where do you think I come from”), I noticed they had no map so my wife Jenny and I bought books, pencils etc and a large wall atlas – the children recognized Africa, and pointed to Sierra Leone – but couldn’t quite fathom New Zealand’s distance. And couldn’t believe NZ had fewer people than their country.

The school, originally built by a UN peacekeeping contingent from Mongolia in 2008, was in a poor state and on one of my visits Bailor gently asked could we help fund the repair of the leaking school. I suggested he obtain a quote and Momoh Sesay the village Chairperson, upon hearing this, took the lead. Momoh is an engineer, (unemployed since Ebola – as were most in the village) and next day he had a detailed written quote for me – $900! Low, because he would use the unemployed builders, painter and artist in the village.

I mentioned the project to WHO colleagues and without exception, all donated and raised the $900. After giving Momoh Sesay and the teachers the go-ahead, the village was soon abuzz. Leaving the following Wednesday, I was sad not to be able see the project finished . No problem they said “We’ll start tomorrow and finish it before you go“.

All hands on deck  Children painted

They started that Friday 8am and worked 5 days straight including Sunday, (“God will forgive us for not attending church”). At one stage I counted 15 men, women and paint-covered children lending a hand – the village was proudly rebuilding their own school.

Saving the animals    New animals

I suggested we preserve the Mongolian’s original painted animals (a panda, two lions and Pooh Bear) so I borrowed a hacksaw blade from my hotel and showed some helpers how to cut out the animals from the original plywood walls – by day’s end they had all four neatly cut out and edges sanded. The village artist bought paints and restored each animal to its former glory and attached them to the new walls – big smiles abounded! And he skillfully painted a sign acknowledging the WHO Ebola response team’s donation.

School completed

The finished school was fitted with mosquito netting all round and we had a grand opening Tuesday evening!

Momoh Sesay’s wife, Aisha, cooked all day and WHO staff and villagers reveled in the grand opening party. Aisha is Head of the nearby Dance Academy (they’ve performed nationally and internationally but had only had 2 engagements since Ebola) and she brought her dancers and drummers and “Rubberman”, the troupe’s contortionist – and the dusty street was transformed into a festive stage.

Rubberman on stool

Village gathered   Children performing v2

Hinta 1 - group at opening

What a profound, humbling, once-in-a-lifetime experience.

Rare Bubonic Plague outbreak from pet dog – and possible human transmission

Two exceptions to the rule – bubonic plague not from rat fleas, but from a pet dog; and possible human to human transmission – the first in USA in 90 years.

As a former laboratory manager I was mindful of the “rare ones” i.e. identifying diseases that are exotic or rarely seen – or more importantly, missing the diagnosis. More so if the disease is communicable.

In a recent CDC MMWR, Runfola, House, Miller, et al. published such an event occurring in Colorado.

The index patient was admitted to hospital ill with fever and cough, worsening to pneumonia. A lab culture automatedly misidentified the pathogen as Pseudomonas luteola but as the patient’s condition worsened, the culture was sent to the state lab and correctly identified as Yersinia pestis, the cause of bubonic plague.

Investigation revealed the dog had recently died, and three persons who had contact with the dog were found to be ill, two with pneumonia. One of the three had contact with the index patient and human to human transmission could not be ruled out. Two of the cases were veterinary employees who euthanized the ill dog.

In total, 114 people were investigated as they had contact with the dog or the index patient. No other cases were detected and the four patients recovered with appropriate therapy.

Untreated Bubonic plague (the “Black Death”) can be fatal in 93% of cases and although the initial laboratory misidentification resulted in occult exposure to numerous healthcare workers, an astute physician and rapid investigation resulted in zero fatalities in this outbreak.

The lesson: double-check organism identification if patient has plague-like symptoms (this is third time Y. pestis has been mistaken for P. luteola).


PS. I returned home this week from Sierra Leone and will write an “update” post asap.


Day 45: A single-digit week and schools opening!

Single digit. Last week was first with single digits – 9 cases – helped by 3 zero days. Now striving for first zero week. I’d love to see it before I leave – SL’s have had hell for 12 months – over 12,000 cases, nearly 4,000 deaths, many children. 221 healthcare workers died.  Picture1
EHU in school - CopyTents galore with primary school in background Schools in! After a year of closure, excitement is palpable – schools open Tues! There’s been intense decommissioning of temporary (now surplus) Ebola centres – many erected on school grounds. Teams in protective gear sweated to ensure schoolyards were handed back safe and clean – many with a new coat of paint. Many workers can sustain 45mins in the suits outdoors – I lasted 25mins indoors. Some schools had many tents erected, cement paths laid, latrines dug, etc., and at handback don’t want any evidence whatsoever – major logistics!Our task is to ensure the 2000 odd HCW (all trained well in “Ebola”) are upskilled in basic “Infection Prevention & Control” before resuming their former hospital roles.        NB. IPC did not exist in SL before Ebola
Burying stigma.Try as we may, it is hard to neutralize the “Ebola” stigma attached to materials reclaimed from previous Ebola centres (some in unused boxes in store). As a greenie it is hard and staff aggressively cull materials so that receivers are absolutely assured of safety, The rest is burnt or buried.

These beds didn’t pass cull.


IMG_0041What a treat to train this group of Port Loko drivers, sprayers & car washers from PLAN.

Friday is “Mufti” – you wear “Afrikana” – they said I blended in well but for the hair!

The brave haircut. Talking of hair – some aid workers go without a haircut for their deployment – after all, scissors are a “sharp”. But I am now freshly shorn as I found a barber who changed his gloves between clients and disinfected all his clippers and scissors with alcohol-spray between uses – the cut was $8 –  I gave him extra $2 for getting A+ in hygiene – and asked him did he want a job in Infection Prevention!
IHP Camp Port Loko-Aerial photo            Stayed in Port Loko IHP-DEMA Tent City again – their drone takes excellent aerials!
Evidence-based decisions at the edge.  In Infection Prevention and Control, we strive to ensure all our recommendations to colleagues and clients are evidence-based and guidance from CDC, WHO and our Professional Associations enables us to pretty well achieve this. This Ebola epidemic, in a poverty-stricken country, has raised questions that push us hard. I can’t thank enough our international IPC consultants here in WHO and CDC, whose combined knowledge is enabling us to make practical and safe decisions at the edge of evidence.
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Best regards, Terry.

PS. Strange feeling – I have just 3 weeks before my deployment ends.


Sierra Leone Day 36: ZERO again! Lockdown, Tragic tryst & Hospital fear

Yesterday was 2nd ZERO day in 2 weeks!

Last weekend was 3-day Lockdown

– everyone indoors save for aid staff and 7000 gov workers delivering soap, brochures, advice & support
 What was daily a bustling road and marketplace that you weaved your vehicle through  – was eerily empty! Not a soul – an Apocalypse. This is Lockdown  IMG_2908
 IMG_2925 IMG_2916IMG_2924  IMG_2922 Lockdown means travel to distant districts to assist local staff. Mine were Tonkolili, Port Loko and Kambia. IHP camp at Port Loko is “tent city” all for aid workers –I was the “1,000th guest” (no prize tho) and 88 staying the night. The Danish disaster-response group DEMA were hosts –respond within 24hrs of a disaster; have tents up in a week; underground piping 2 weeks later. 8 to a tent, all with own “room”, 24/7 light, power, internet, reception and cafeteria. No one snored but the stretchers creaked with resolving minds.
 Tragic tryst. The woman who contracted Ebola and broke the 3-week Zero in Liberia, may have contracted it via unprotected sex with her Survivor partner – prompting the Liberian Gov to extend the “protected sex period” from 90 days (semen safe time) – to “Indefinite pending further research”.
  Hospital fear. This Health Unit wall chart reveals a troublesome issue – all patient visits and drug treatments suddenly stopped in Oct – when word spread that you, “contracted Ebola by going to hospital

PHU wall chart - pts stopped coming v2

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Regards, Terry