Implementing a Successful Influenza and Updated COVID-19 Vaccination Campaign Among Healthcare Workers in a Delaware Healthcare Facility.

Although influenza (flu) and COVID-19 vaccines are highly recommended for healthcare workers, it is known that vaccination rates are suboptimal in healthcare settings. There is a need to optimize vaccination rates among healthcare workers as there are direct correlations to increased patient safety and protection of staff from healthcare associated infections. Our health care organization employed some novel strategies to increase the uptake of both flu and COVID-19 vaccinations by identifying and addressing common barriers. Barriers were identified through team meetings, review of previous years' vaccination trends, and historical information. Strategies to overcome these barriers included dissemination of information through various team meetings; identifying peer vaccination champions among specific groups that had historically low vaccination rates; creating a sense of urgency with weekly announcements regarding vaccinations; and computer screensavers with graphics promoting vaccinations. We believed education was key to success. Our focus was not only on the vaccination rates, but also on compliance which is defined as either getting the vaccine or submitting a declination after completing an education module. These efforts resulted in the organization achieving more than 95% compliance for both vaccinations. Our vaccination uptake rates for influenza were greater than 85% and updated COVID-19 vaccination rates were around 42%. We believe that the grass-root level work initiated for this year's campaign was one of the drivers for our success and some aspects could be replicated for vaccinating the public as well.

Transmission of Mycobacterium tuberculosis to Healthcare Personnel Resulting From Contaminated Bone Graft Material, United States, June 2021-August 2022.

A nationwide tuberculosis outbreak linked to a viable bone allograft product contaminated with Mycobacterium tuberculosis was identified in June 2021. Our subsequent investigation identified 73 healthcare personnel with new latent tuberculosis infection following exposure to the contaminated product, product recipients, surgical instruments, or medical waste.

Prevention and Control of Nosocomial Varicella During the United States Varicella Vaccination Program Era.

The United States varicella vaccination program has successfully reduced varicella incidence and hospitalizations by ≥90%, consequently reducing the risk of nosocomial exposures. However, patients and healthcare personnel (HCP) continue to introduce varicella zoster virus (VZV) into healthcare settings. Herpes zoster (HZ) is less contagious than varicella, but it can also result in exposures. Unrecognized varicella and HZ may lead to extensive contact investigations, control efforts, and HCP furloughs that result in significant disruption of healthcare activities as well as substantial costs. Robust occupational health and infection prevention programs that ensure healthcare personnel immunity and prompt recognition and isolation of patients with varicella or HZ will lower the risk of VZV transmission and reduce or eliminate the need to furlough exposed HCP and associated costs.

Nationwide tuberculosis outbreak in the USA linked to a bone graft product: an outbreak report.

BACKGROUND: Mycobacterium tuberculosis transmission through solid organ transplantation has been well described, but transmission through transplanted tissues is rare. We investigated a tuberculosis outbreak in the USA linked to a bone graft product containing live cells derived from a single deceased donor. METHODS: In this outbreak report, we describe the management and severity of the outbreak and identify opportunities to improve tissue transplant safety in the USA. During early June, 2021, the US Centers for Disease Control and Prevention (CDC) worked with state and local health departments and health-care facilities to locate and sequester unused units from the recalled lot and notify, evaluate, and treat all identified product recipients. Investigators from CDC and the US Food and Drug Administration (FDA) reviewed donor screening and tissue processing. Unused product units from the recalled and other donor lots were tested for the presence of M tuberculosis using real-time PCR (rt PCR) assays and culture. M tuberculosis isolates from unused product and recipients were compared using phylogenetic analysis. FINDINGS: The tissue donor (a man aged 80 years) had unrecognised risk factors, symptoms, and signs consistent with tuberculosis. Bone was procured from the deceased donor and processed into 154 units of bone allograft product containing live cells, which were distributed to 37 hospitals and ambulatory surgical centres in 20 US states between March 1 and April 2, 2021. From March 3 to June 1, 2021, 136 (88%) units were implanted into 113 recipients aged 24-87 years in 18 states (some individuals received multiple units). The remaining 18 units (12%) were located and sequestered. 87 (77%) of 113 identified product recipients had microbiological or imaging evidence of tuberculosis disease. Eight product recipients died 8-99 days after product implantation (three deaths were attributed to tuberculosis after recognition of the outbreak). All 105 living recipients started treatment for tuberculosis disease at a median of 69 days (IQR 56-81) after product implantation. M tuberculosis was detected in all eight sequestered unused units tested from the recalled donor lot, but not in lots from other donors. M tuberculosis isolates from unused product and recipients were more than 99·99% genetically identical. INTERPRETATION: Donor-derived transmission of M tuberculosis via bone allograft resulted in substantial morbidity and mortality. All prospective tissue and organ donors should be routinely assessed for tuberculosis risk factors and clinical findings. When these are present, laboratory testing for M tuberculosis should be strongly considered. FUNDING: None.

Evaluation of N95 respirator ultraviolet decontamination and clinical reuse with quantitative fit testing.

The supply of N95 respirators has been severely strained by the coronavirus disease 2019 (COVID-19) pandemic. We used quantitative fit-testing to evaluate 16 participants and 45 respirators through up to 4 rounds of ultraviolet decontamination and clinical reuse. The mean fit-test failure rate was 29.7%, and the probability of failure increased through N95 reuse.

Multisociety statement on coronavirus disease 2019 (COVID-19) vaccination as a condition of employment for healthcare personnel.

This consensus statement by the Society for Healthcare Epidemiology of America (SHEA) and the Society for Post-Acute and Long-Term Care Medicine (AMDA), the Association for Professionals in Epidemiology and Infection Control (APIC), the HIV Medicine Association (HIVMA), the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society of Infectious Diseases Pharmacists (SIDP) recommends that coronavirus disease 2019 (COVID-19) vaccination should be a condition of employment for all healthcare personnel in facilities in the United States. Exemptions from this policy apply to those with medical contraindications to all COVID-19 vaccines available in the United States and other exemptions as specified by federal or state law. The consensus statement also supports COVID-19 vaccination of nonemployees functioning at a healthcare facility (eg, students, contract workers, volunteers, etc).

Policy statement from the Society for Healthcare Epidemiology of America (SHEA): Only medical contraindications should be accepted as a reason for not receiving all routine immunizations as recommended by the Centers for Disease Control and Prevention.

SHEA endorses adhering to the recommendations by the CDC and ACIP for immunizations of all children and adults. All persons providing clinical care should be familiar with these recommendations and should routinely assess immunization compliance of their patients and strongly recommend all routine immunizations to patients. All healthcare personnel (HCP) should be immunized against vaccine-preventable diseases as recommended by the CDC/ACIP (unless immunity is demonstrated by another recommended method). SHEA endorses the policy that immunization should be a condition of employment or functioning (students, contract workers, volunteers, etc) at a healthcare facility. Only recognized medical contraindications should be accepted for not receiving recommended immunizations.

Implementing Antibiotic Stewardship in a Network of Urgent Care Centers.

BACKGROUND: Most antibiotics are prescribed in outpatient settings, including urgent care clinics (UCCs); however, few UCCs have described implementing antibiotic stewardship. This study describes interventions to reduce total antibiotic and azithromycin use in a UCC network. METHODS: The researchers conducted a prospective performance improvement project in five UCCs in Delaware, with > 40 providers and > 75,000 visits annually. In April 2017 all providers received in-person education on guideline-recommended management of common infections. The UCC lead physician performed chart audits and provided group and individual feedback. Individual antibiotic utilization rates were provided beginning in February 2018, and chart audits ceased in May 2018. Patient education included posters in waiting and exam rooms, discharge materials, and external website revisions. The researchers used control charts to analyze trends in prescribing over time, and calculated rate ratios (RRs) between pre-/early, mid- and postintervention periods. RESULTS: Compared to the pre-/early intervention study period (54.7 prescriptions per 100 visits), total antibiotic use declined to 40.2 (RR, 0.74; 95% confidence interval [CI] = 0.72-0.75) in the mid-intervention period and to 35.0 (RR, 0.42; 95% CI = 0.40-0.44) in the postintervention period. Azithromycin use declined from 8.5 prescriptions/100 visits to 3.5 (RR 0.64; 95% CI = 0.63-0.65) and 1.9 (RR 0.22; 95% CI = 0.21-0.24), respectively. The control charts indicated decreasing mean antibiotic prescribing rates as well as decreased variability. CONCLUSION: A multifaceted and iterative approach significantly reduced prescribing of all antibiotics, including azithromycin, regardless of diagnosis. Although the approach was initially resource-intensive, sending prescribing data directly to providers automated the process without an observed rebound in prescribing.

Automated outbreak detection of hospital-associated pathogens: Value to infection prevention programs.

OBJECTIVE: To assess the utility of an automated, statistically-based outbreak detection system to identify clusters of hospital-acquired microorganisms. DESIGN: Multicenter retrospective cohort study. SETTING: The study included 43 hospitals using a common infection prevention surveillance system. METHODS: A space-time permutation scan statistic was applied to hospital microbiology, admission, discharge, and transfer data to identify clustering of microorganisms within hospital locations and services. Infection preventionists were asked to rate the importance of each cluster. A convenience sample of 10 hospitals also provided information about clusters previously identified through their usual surveillance methods. RESULTS: We identified 230 clusters in 43 hospitals involving Gram-positive and -negative bacteria and fungi. Half of the clusters progressed after initial detection, suggesting that early detection could trigger interventions to curtail further spread. Infection preventionists reported that they would have wanted to be alerted about 81% of these clusters. Factors associated with clusters judged to be moderately or highly concerning included high statistical significance, large size, and clusters involving Clostridioides difficile or multidrug-resistant organisms. Based on comparison data provided by the convenience sample of hospitals, only 9 (18%) of 51 clusters detected by usual surveillance met statistical significance, and of the 70 clusters not previously detected, 58 (83%) involved organisms not routinely targeted by the hospitals' surveillance programs. All infection prevention programs felt that an automated outbreak detection tool would improve their ability to detect outbreaks and streamline their work. CONCLUSIONS: Automated, statistically-based outbreak detection can increase the consistency, scope, and comprehensiveness of detecting hospital-associated transmission.

Statewide Antibiotic Stewardship: : An eBrightHealth Choosing Wisely Initiative.

OBJECTIVE: To implement a collaborative statewide antibiotic stewardship initiative in both the ambulatory and inpatient settings. METHODS: Five participating Delaware health systems each convened internal team(s) to translate the vision set forth by the eBrightHealth LLC Choosing Wisely Work Group into clinical action through process improvement efforts at their institutions. The teams focused on implementing antibiotic time-outs, and on improving antibiotic prescribing for upper respiratory infections in ambulatory settings. The learning network utilized an "all teach, all learn" methodology via monthly conference calls and quarterly face-to-face meetings. RESULTS: All inpatient teams implemented antibiotic time-outs for at least 1 unit. Other interventions included commitment posters; submitting antibiotic utilization data nationally; provider/patient surveys; local stewardship champions; and provider prescribing data feedback. Barriers to implementation included competing priorities, lack of reliable utilization data, and suboptimal provider engagement. Overall antibiotic utilization decreased by 9%, compared to the pre-intervention period. CONCLUSIONS: This initiative has demonstrated the value of multidisciplinary teams, from varying healthcare systems, coming together to work on a single project. While each team's interventions and specific goals differed slightly, all teams implemented new initiatives to promote appropriate use of antibiotics. POLICY IMPLICATIONS: Antibiotic stewardship is a national priority. Acute care hospitals are required to have antibiotic stewardship programs; similar programs are proposed for ambulatory settings.

Is There a Correlation Between Infection Control Performance and Other Hospital Quality Measures?

Quality measures are increasingly reported by hospitals to the Centers for Medicare and Medicaid Services (CMS), yet there may be tradeoffs in performance between infection control (IC) and other quality measures. Hospitals that performed best on IC measures did not perform well on most CMS non-IC quality measures. Infect Control Hosp Epidemiol 2017;38:736-739.

Status of the Prevention of Multidrug-Resistant Organisms in International Settings: A Survey of the Society for Healthcare Epidemiology of America Research Network.

OBJECTIVE To examine self-reported practices and policies to reduce infection and transmission of multidrug-resistant organisms (MDRO) in healthcare settings outside the United States. DESIGN Cross-sectional survey. PARTICIPANTS International members of the Society for Healthcare Epidemiology of America (SHEA) Research Network. METHODS Electronic survey of infection control and prevention practices, capabilities, and barriers outside the United States and Canada. Participants were stratified according to their country's economic development status as defined by the World Bank as low-income, lower-middle-income, upper-middle-income, and high-income. RESULTS A total of 76 respondents (33%) of 229 SHEA members outside the United States and Canada completed the survey questionnaire, representing 30 countries. Forty (53%) were high-, 33 (43%) were middle-, and 1 (1%) was a low-income country. Country data were missing for 2 respondents (3%). Of the 76 respondents, 64 (84%) reported having a formal or informal antibiotic stewardship program at their institution. High-income countries were more likely than middle-income countries to have existing MDRO policies (39/64 [61%] vs 25/64 [39%], P=.003) and to place patients with MDRO in contact precautions (40/72 [56%] vs 31/72 [44%], P=.05). Major barriers to preventing MDRO transmission included constrained resources (infrastructure, supplies, and trained staff) and challenges in changing provider behavior. CONCLUSIONS In this survey, a substantial proportion of institutions reported encountering barriers to implementing key MDRO prevention strategies. Interventions to address capacity building internationally are urgently needed. Data on the infection prevention practices of low income countries are needed. Infect Control Hosp Epidemiol. 2016:1-8.

Assessing Occupancy and Its Relation to Healthcare-Associated Infections.

Occupancy has been associated with risk for healthcare-associated infections, yet its definition varies widely. Occupancy can be modeled as a function of census, acuity of the patient care unit, staffing ratio, or some combination. This article discusses the appropriate parameterization of these measures and how to interpret their impact. Infect Control Hosp Epidemiol 2016:1-3.

Research Methods in Healthcare Epidemiology and Antimicrobial Stewardship: Use of Administrative and Surveillance Databases.

Administrative and surveillance data are used frequently in healthcare epidemiology and antimicrobial stewardship (HE&AS) research because of their wide availability and efficiency. However, data quality issues exist, requiring careful consideration and potential validation of data. This methods paper presents key considerations for using administrative and surveillance data in HE&AS, including types of data available and potential use, data limitations, and the importance of validation. After discussing these issues, we review examples of HE&AS research using administrative data with a focus on scenarios when their use may be advantageous. A checklist is provided to help aid study development in HE&AS using administrative data. Infect Control Hosp Epidemiol 2016;1-10.

Using the Comprehensive Unit-based Safety Program model for sustained reduction in hospital infections.

BACKGROUND: Prompted by the high number of central line-associated bloodstream infections (CLABSIs), our institution joined the national On the CUSP: Stop BSI initiative. We not only report the significant impact that the Comprehensive Unit-based Safety Program (CUSP) had in reducing CLABSI, but also report catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP) in 2 intensive care units (ICUs). METHODS: At our community-based academic health care system, 2 ICUs implemented CUSP tools and developed local interventions to reduce CLABSI and other safety problems. We measured CLABSI, CAUTI, and VAP during baseline, the CUSP period, and a post-CUSP period. RESULTS: CLABSIs decreased from 3.9 per 1,000 catheter days at baseline to 1.2 during the CUSP period to 0.6 during the post-CUSP period (rate ratio, 0.16; 95% confidence interval [CI], 0.07-0.35). CAUTIs decreased from 2.4 per 1,000 patient days to 1.2 during the post-CUSP period (rate ratio, 0.4; 95% CI, 0.24-0.65). VAP rate decreased from 2.7 per 1,000 ventilator days to 1.6 during the CUSP and post-CUSP periods (rate ratio, 0.58; 95% CI, 0.30-1.10). Device utilization decreased significantly in both ICUs. CONCLUSIONS: Implementation of CUSP was associated with significant decreases in CLABSI, CAUTI, and VAP. The CUSP model, allowing for implementation of evidence-based practices and engagement of frontline staff, creates sustainable improvements that reach far beyond the initial targeted problem.

Lack of Comprehensive Outbreak Detection in Hospitals.

Timely identification of outbreaks of hospital-associated infections is needed to implement control measures and minimize impact. Survey results from 33 hospitals indicated that most hospitals lacked a formal cluster definition and all targeted a very limited group of prespecified pathogens. Standardized, statistically based outbreak detection could greatly improve current practice.