Archive for the ‘Infection control’ Category

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As with Ebola Outbreak, Social Determinants of Health Crucial in Recent Rural U.S. HIV Outbreak

August 25, 2015

Rachel Parrill, PhD, RN, APHN-BC, is an associate professor of nursing at Cedarville University in Ohio

by banditob/flickr creative commons

by banditob/flickr creative commons

This past fall, with the world watching, a crisis unfolded in West Africa that challenged our understanding of sociocultural environments, epidemiology, and health. The spread of Ebola and the intercontinental transmission of the disease exposed weaknesses in our epidemiological defense system. It also drew attention to the powerful role that cultural beliefs and practices can have on disease transmission during outbreaks.

In that same time frame, and with similar cultural etiologies, another infectious crisis played out much closer to home. The setting: the rural Midwest, in and around the small town of Austin, Indiana. The disease: HIV. The crisis: an unprecedented outbreak—one with incidence rates (up to 22 new cases a day at the height of the outbreak) estimated to be higher than those in many sub-Saharan African nations and transmission rates through injection drug use higher than in New York City. Contributing to this “perfect storm” were socioeconomic factors characteristic of many rural settings, including poverty, low education levels, limited access to health care, and few recreational or employment opportunities.

In my work as a faculty member in a rural Midwest setting, I introduce undergraduate and graduate nursing students to concepts of public health nursing and try to provide opportunities for them to engage in local health initiatives. However, I often encounter an unconcerned or unengaged attitude towards the health risks associated with rural life—both on the part of my students and the community members that we serve.

Our local rural community seems mostly untouched by notable urban problems such as injection drug use, prostitution, sexually transmitted infections, and rampant violence, and issues seen in surrounding larger metropolitan communities like homelessness and human trafficking typically capture the interest of my nursing students far more than the run-of-the-mill comorbidities they often see in rural community members, such as heart disease, diabetes, cancer, and unintentional injury.

So I was captivated by the story that unfolded this past year in nearby Austin, Indiana, just a three-hour drive from our university. The devastation experienced by this community so similar to the one I call home provided a poignant learning opportunity for my nursing students, and for the broader nursing community.

In my role as a faculty member, I challenge nursing students to consider a broad range of social determinants of health when examining the health of a community. For example, I invite students to examine the income and educational levels of a community in light of important health indicators. We discuss the fact that health is too often connected with wealth, educational opportunities, neighborhood characteristics, race and gender inequalities, and social policy.

Similar to the West African Ebola outbreak, the HIV outbreak in Austin reveals the effects of sociocultural environments on health. The outbreak occurred among a network of injection drug users, mostly within multiple generations of a small group of families. In terms of context, Austin suffered from not only a high rate of prescription drug use, but also a lack of medical and drug rehabilitation services, inadequate public health infrastructure, a knowledge deficit regarding HIV risk, and a strong community-fed stigma surrounding HIV infection very similar to the one that played a role during efforts to combat the Ebola crisis. Read the rest of this entry ?

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Legionnaires’ Outbreak in New York City: Some Basics for Nurses

August 12, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

11148_loresIn the largest U.S. outbreak of Legionella infection since 1976, when there were 221 cases and 34 related deaths in an outbreak at a Philadelphia American Legion convention, more than 113 cases of the disease have been diagnosed in New York City since mid-July. Twelve people have died.

Legionnaires’ disease is neither rare nor exotic; it is a type of community-acquired pneumonia (it can also be hospital acquired). Symptoms include fever, cough, and progressive respiratory distress. Legionella can also cause a milder, flulike illness known as Pontiac fever that generally resolves without treatment. Because many cases of Legionnaires’ disease are never actually diagnosed, mortality rates are difficult to determine, but the rate currently is estimated at 5% to 30%.

The CDC estimates that 8,000 to 18,000 people are hospitalized with Legionnaires’ disease each year in the U.S., yet only about 3,000 cases are diagnosed and reported. Most cases of Legionnaires’ disease are sporadic, unlinked to any outbreak. The infections often are not recognized as Legionnaires’ disease, for several reasons.

  • Legionella infection is easily treated empirically (that is, without confirmatory lab testing) with common antibiotics, with the patient usually recovering. This is a practical and cost-effective approach to community-acquired pneumonia, but many cases of Legionnaires’ disease are never diagnosed as anything more specific than “pneumonia.”
  • When Legionnaires’ disease is suspected, the most common test ordered—Legionella urinary antigen—tests for only one of more than 46 Legionella species: pneumophila serotype 1. While a significant percentage of cases may be attributable to pneumophila serotype 1, a negative Legionella urinary antigen test does not rule out Legionnaires’ disease.
  • Only a Legionella culture has the potential to identify any Legionella strain, and special culture media is needed. In most labs, a respiratory specimen sent for culture is not routinely tested for Legionella.

Legionella does not spread from person to person. It is transmitted by aerosolized water from sources such as whirlpools, hot tubs, hydrotherapy tubs, showers, indoor waterfalls or decorative fountains, grocery produce misters, or cooling towers on large buildings. Legionella prefers large, complex plumbing systems over natural bodies of water, because plumbing systems provide the temperature range, commensal organisms, and stasis that best support Legionella growth.

Who’s at risk. As with community-acquired pneumonia caused by other organisms, the people most likely to become infected are those with preexisting health problems such as COPD, diabetes, or immunosuppression; smokers; and people over 50. Children are usually not infected with Legionella unless they are immunosuppressed. Read the rest of this entry ?

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AJN in August: Oral Histories of African Nurses, Opioid Abuse, Misplaced Enteral Tubes, More

August 3, 2015

AJN0815.Cover.OnlineOn this month’s cover, a community nurse practices health education with residents of a small fishing village in rural Uganda. Former AJN clinical managing editor Karen Roush took the photo in a small community center made of dried mud bricks, wood, and straw.

According to Roush, nurses wrote the lessons out on poster-sized sheets of white paper and tacked them to the mud wall as they addressed topics like personal hygiene, sanitation, food safety, communication, and prevention of infectious diseases. The reality of nursing in Africa is explored this month in “‘I Am a Nurse’: Oral Histories of African Nurses,” original research that shares African nurse leaders’ stories so we may better understand nursing from their perspective.

Some other articles of note in the August issue:

CE feature: A major source of diverted opioid prescription medications is from friends and family members with legitimate prescriptions.  “Nurses’ Role in Preventing Prescription Opioid Diversion” describes three potential interventions in which nurses play a critical role to help prevent opioid diversion.

From our Safety Monitor column: More than 1.2 million enteral feeding tubes are placed annually in the United States. While the practice is usually safe, serious complications can occur. “Misplacements of Enteral Feeding Tubes Increase After Hospitals Switch Brands,” a report from the Pennsylvania Patient Safety Authority, reviews cases of misplaced tubes and offers guidance for how nurses can prevent such errors in their own practice.

Clinical feature: It is no surprise that physical activity comes with numerous physical and mental benefits, nor that a majority of Americans do not get enough exercise. “The Evolution of Physical Activity Promotion” updates nurses on physical activity guidelines and provides tips for encouraging patients to improve their physical activity. This feature also highlights the importance of decreasing one’s amount of sedentary and sitting time, even in physically active people. Read the rest of this entry ?

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Hepatitis A, B, and C: The Latest on Screening, Epidemiology, Prevention, Treatments

July 16, 2015
One of several posters created by the Centers for Disease Control and Prevention to raise awareness that millions of Americans of all ages, races, and ethnicities have hepatitis C—and many don’t know it. Posters are available to order or download for printing at www.cdc.gov/knowmorehepatitis/media/posters.htm. Poster © Centers for Disease Control and Prevention.

One of several CDC posters intended to raise awareness that millions of Americans of all ages, races, and ethnicities have hepatitis C—and many don’t know it. Posters are available to order or download for printing at http://www.cdc.gov/knowmorehepatitis/media/posters.htm. Poster © Centers for Disease Control and Prevention.

It’s crucial that nurses in all health care settings stay informed about the changing landscape of viral hepatitis in the United States. Hepatitis affects the lives of millions, too many of whom are unaware that they have been infected.

Right now, there’s good news and bad news about hepatitis in the U.S. While the incidences of hepatitis A and B in the United States have declined significantly in the past 15 years, the incidence of hepatitis C virus infection, formerly stable or in decline, has increased by 75% since 2010. Suboptimal past therapies, insufficient provider awareness, and low screening rates have hindered efforts to improve diagnosis, management, and treatment of viral hepatitis.

The authors of a CE feature in the July issue of AJN, Viral Hepatitis: New U.S. Screening Recommendations, Assessment Tools, and Treatments,” are thoroughly versed in the subject. Corinna Dan is viral hepatitis policy advisor, Michelle Moses-Eisenstein is a public health analyst, and Ronald O. Valdiserri is director, all in the Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services (HHS).

Their article succinctly and clearly covers

  • the epidemiology, natural history, and diagnosis of viral hepatitis.
  • new screening recommendations, assessment tools, and treatments.
  • the HHS action plan, focusing on the role of nurses in prevention and treatment.

Read the rest of this entry ?

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An Unending Series of Challenges: APIC Highlights the ‘New Normal’ in Infection Control

July 6, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

Panelists to the Opening Plenary, Mary Lou Manning, Michael Bell, CDC, Russell Olmsted, Trinity Health, Phillip W. Smith, Nebraska Biocontainment Unit discuss various topics pertaining to infection control.

APIC panelists (APIC president Mary Lou Manning; Michael Bell, CDC; Russell Olmsted, Trinity Health; Phillip W. Smith, Nebraska Biocontainment Unit) discuss various topics pertaining to infection control.

At the 42nd annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC), held in late June in Nashville, experts from around the world shared information and insights aimed at infection preventionists but of interest to nurses in many practice settings.

APIC president Mary Lou Manning, PhD, CRNP, CIC, FAAN, opened the first plenary with the observation that to be presented with an unending series of challenges is the “new normal” in infection control and prevention. Collaboration is more important than ever in health care, she said, and “there is strength in our combined efforts.”

Cathryn Murphy, PhD, RN, CIC, in accepting APIC’s highest infection prevention award, added that trust, friendship, and passion are essential if these efforts are to succeed.

‘I’m not at Ground Zero. I’m in Dallas.’ The highlight of the opening session was a fascinating conversation with key U.S. players in the Ebola crisis. Seema Yasmin, MD, a former CDC Epidemic Intelligence Service officer and now a staff writer at the Dallas Morning News, described how hard it had been to convey accurate information in the midst of rising public hysteria in the U.S.

As an epidemiologist, Yasmin became an interview subject as well as reporter. She recalled that, after months of worrying about colleagues at risk in West Africa, a reporter asked her, “How does it feel to be at Ebola Ground Zero?” Her reply: “I’m not at Ground Zero. I’m in Dallas.”

Later in the conference, Dr. Yasmin reminded the audience that every disaster drill should include a “public information” component and warned that “misinformation spreads much quicker than a virus” in today’s media environment, adding that we “can’t repeat the same [accurate, informative] message often enough.”

Practice drills vs. the real thing. Philip W. Smith, MD, medical director of the Biocontainment Unit at the University of Nebraska Medical Center, described the unit staff’s experiences in treating Ebola. UNMC’s special unit was built more than 10 years ago after the devastating SARS outbreak in Canada that left 33 dead, including several health care workers. Until Ebola cases arrived in the U.S., the unit had been used for training and occasional patient overflow. Dr. Smith emphasized that, even while the unit was not being used, their mantra was “drill, drill, drill” to ensure that staff would function expertly when this specialty care was needed.

Then, in August of 2014, “Suddenly, nine years of drills had to be translated into reality, and there was not much room for error.” He spoke of how inserting a central line while wearing three pairs of gloves, a face shield, and maximal personal protective equipment (PPE) topped by a sterile gown was a very different challenge from repeated practice runs of the same procedure.

Dr. Smith also noted that the transport of patients with Ebola—airlifting from West Africa, ambulance transport, and movement through the hospital to the unit—was “enormously complex and time-consuming.” A special incident command structure was set up just for transport, in addition to the main hospital incident command center.

A horizontal culture was also vital to their work. “There was no hierarchy,” he said. Cultivating a “classless society,” staff developed a strong sense of team under stressful conditions where they were responsible for each other’s safety.

Nonhierarchical work habits stayed with staff after the unit was closed and they returned to their regular assignments. However, when they continued to make “best practice” suggestions to coworkers, they were met with anger and pushback instead of the thanks and cooperation that had been the norm in the Biocontainment Unit. Read the rest of this entry ?

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AJN July Issue: Hepatitis Update, Ehlers-Danlos Syndrome, Nursing’s Blind Spots, More

July 1, 2015

World_Hepatitis_Day_AJN_July_CoverOn the cover of AJN‘s July issue is the 2015 logo for World Hepatitis Day, which takes place on July 28. About 400 million people around the globe live with viral hepatitis, a disease that kills 1.4 million people every year—approximately 4,000 a day. While incidences of hepatitis A and B have declined in the United States in recent years, hepatitis C infection, formerly stable or in decline, has risen at an alarming rate. To learn more about hepatitis in the U.S.—and the role nurses can play in prevention and treatment—read our July CE, “Viral Hepatitis: New U.S. Screening Recommendations, Assessment Tools, and Treatments.”

The article reviews the epidemiology and diagnosis of viral hepatitis, new screening recommendations and innovations in assessment and treatment, and an updated action plan from the Department of Health and Human Services, in which nurses can play an important role in the coordination of care.

Some other articles of note in the June issue:

• CE feature: “Nursing Management of Patients with Ehlers–Danlos Syndrome.” An often debilitating condition, Ehlers–Danlos Syndrome (EDS) refers to a group of hereditary connective tissue disorders that has historically been misunderstood and underdiagnosed due to a lack of familiarity with its signs and symptoms. As awareness and recognition of the syndrome improve, nurses are increasingly likely to care for patients with EDS. This article gives an overview of the syndrome and provides guidance on ways to manage symptoms, recognize and prevent serious complications, and improve patients’ quality of life. Read the rest of this entry ?

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Breastfeeding’s Benefits vs. Fear of Infection Risks from a Mother’s New Tattoo

June 24, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

scalesPeople, it seems, still have strong feelings about tattoos—and about breastfeeding, too. This month, a judge in Sydney, Australia, ordered the newly tattooed mother of an 11-month-old baby to stop breastfeeding. The judge maintained that the mother’s tattooing the previous month presented “an unacceptable risk of harm” to the baby because the mother could have contracted HIV or hepatitis B (HBV) during the procedure.

The woman had tested negative for both HIV and hepatitis B since she received the tattoos. But poor aseptic technique during tattooing can result in the transmission of bloodborne infections, and people infected with HIV or HBV may not immediately test positive for either virus.

However, while HIV can be transmitted in breast milk, studies indicate that breastfeeding by hepatitis B surface antigen-positive women does not pose a significant risk of infection to their infants.

The theoretical risks put forth by the judge in this case were no match for the well-documented benefits of breastfeeding, and the injunction has already been overturned on appeal.

Still, the case raises interesting questions about how risks to a breastfeeding baby are determined. What if the father had been the person with new tattoos, and he still had a sexual relationship with the baby’s mother? It’s unscientific (and discriminatory) to focus on the breastfeeding mom as the sole potential source of bloodborne pathogen risk. Read the rest of this entry ?

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