HPV Vaccine Coverage- Disparities Abound

Today I am giving the VCU Infectious Diseases Fellowship lecture of herpes viruses and human papilloma virus (HPV) infections.

I stumbled across this recent article in Clinical Infectious Diseases on low uptake of the HPV vaccine. In this report, minority and below poverty adolescents consistently had higher series initiaion than white and above poverty adolescents.

HPV infects all and vaccination is highly effective. Socio-cultural barriers, prejudice against vaccination and misinformation on vaccine safety must all be addressed.

Influenza Vaccine and Cardiovascular Risk

Here is twist on the potential benefits of influenza vaccination. As summarized in this article published in JAMA, influenza vaccination may impact cardiovascular  risk.

The authors performed a meta-analysis with 5 published and 1 unpublished randomized clinical trials of 6735 patients (mean age, 67 years; 51.3% women; 36.2% with a cardiac history; mean follow-up time, 7.9 months).

Receipt of influenza vaccine was associated with a lower risk of composite cardiovascular events (2.9% vs 4.7%; RR, 0.64 [95% CI, 0.48-0.86], P = .003) in published trials. The greatest effect was seen  in patients with more active coronary disease.

Association does not mean causality and these results must be replicated with adequately powered, prospective, multi-center trials of influenza vaccination with specific cardiac endpoints.

Decreased cardiac risk of death may be a persuasive argument for those clinic patients insistent on avoiding influenza vaccination.

I am back on the ID Consult service this week and back to a proper daily grind.

Mandatory Public Reporting of Central Line Associated Bloodstream Infections- Validation is Essential

Mandatory public reporting of central line bloodstream infection (CLABSI) reporting is the norm across much of the country. Are the reportss accurate?

Here is a manuscript on validation of CLABSI reporting published in the American Journal of Infection Control. Trained Colorado Department of Public Health and Environment staff members performed onsite validation visits that included interviews with infection preventionists to assess surveillance practices and retrospective chart reviews of patients with positive blood cultures in specific intensive care units (adult and neonatal) and long-term acute care hospitals during the first quarter of 2010.

Fifty-five CLABSIs from the original sample were identified; 33 (60%) in the adult intensive care unit, 7 (12.7%) in the neonatal intensive care unit, and 15 (27.3%) in the long-term acute care hospital. Of the 55 CLABSIs identified by reviewers, 18 (32.7%) were not reported by the hospitals, 37 CLABSIs (67.3%) were reported correctly into the National Healthcare Safety Network, and 1 CLABSI was over-reported. 

Surveillance was loose with 33% of CLABSIs being under-reported.

This is concerning. Validation is essential to promote accuracy in reporting.

Medical School Curriculum on Social Justice as a Determinant of Health- The Next Generation

I believe that healthcare is a universal human right.

It is well known that social determinants

cause and impact many diseases either in resource rich or poor countries. We largely learn about disease from a biomedical perspective and generally give short shrift to social determinants of health.

Here is a an interesting article that reports a social justice curriculum at the Geisel School of Medicine at Dartmouth.The curriculum stresses physicians' obligation to participate in social justicework as an educational tool. It also emphasizes the importance of a mandatory, longitudinal, immersive, mentored community outreach practicum.

Although we advocate a biopsychosocial model of medical care, the curriculum is generally light on the ''social'' .

My hope is that this and similar social justice curricula will improve recognition and action on social determinants of disease, including access to healthcare, by the next generation of physicians.

Structured Exercise as Preventive Medicine

How well does exercise compare to prescription medications on decreasing mortality? 

Here is a study comparing prescription medications versus structured exercise.  The authors included 16 (four exercise and 12 drug) meta-analyses in the comparison. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. 

Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). 

Of note, none of the studies reported harm from exercise.

The clinical significance? Exercise should be considered as an alternative or adjunct to prescription medications to reduce morbidity and mortality.

Take your 'exercise pill.'

Bundles for Hand Hygiene: An optimal Approach?

Bundles for infection prevention are now standard fare and include interventions to improve hand hygiene compliance. 

Here is a systematic review published in Clinical Infectious Diseases of studies to improve hand hygiene compliance. Of the 8,148 studies evaluated, six randomized controlled trials and 39 quasi-experimental studies were analyzed. 

Three studies evaluated the interventions education, reminders, feedback, administrative support, and access to alcohol-based hand rub [ABHR] as a bundle, which was associated with improved hand hygiene compliance (pooled odds ratio [OR]=1.82; 95% confidence interval [CI]=1.69, 1.97). Another bundle of education, reminders, and feedback evaluated in three studies was associated with improved compliance (pooled OR: 1.47; 95% CI: 1.12, 1.94).

So the optimal hand hygiene approach includes:

• Hand hygiene education
• Reminders and prompts
• Hand hygiene compliance monitoring with feedback
• Support (financial and administrative) to achieve and sustain the above 

And, once you put your foot on the hand hygiene compliance accelerator, coming off the gas will eventually bring the program's success to a halt. These are not one time interventions.

Sustainability is the key.

Perhaps MRSA is Hiding in the Gym

Here is a recent news article on MRSA affecting NFL players on the Tampa Bay Buccaneers.

Although we were unable to detect MRSA in the VCU gym in this study head authored by Dr. Dan Markley, the same may not be so for an NFL franchise.

MRSA, that pesky pathogen.

Wash your hands after gym workouts!