Tagged CDC

How to Fight ‘Scary’ Superbugs? Cooperation — And A Special Soap

Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts — funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC.

People in hospitals are vulnerable to these bugs, and people in nursing homes are particularly vulnerable. Up to 15% of hospital patients and 65% of nursing home residents harbor drug-resistant organisms, though not all of them will develop an infection, said Dr. Susan Huang, who specializes in infectious diseases at the University of California-Irvine.

“Superbugs are scary and they are unabated,” Huang said. “They don’t go away.”

Some of the most common bacteria in health care facilities are methicillin-resistant Staphylococcus aureus, or MRSA, and carbapenem-resistant Enterobacteriaceae, or CRE, often called “nightmare bacteria.” E. coli and Klebsiella pneumoniae are two common germs that can fall into this category when they become resistant to last-resort antibiotics known as carbapenems. CRE bacteria cause an estimated 600 deaths each year, according to the CDC.

CREs have “basically spread widely” among health care facilities in the Chicago region, said Dr. Michael Lin, an infectious-diseases specialist at Rush University Medical Center, who is heading the CDC-funded effort there. “If MRSA is a superbug, this is the extreme — the super superbug.”

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes.

In Chicago, researchers are working with 14 nursing homes and long-term acute care hospitals, where staff are screening people for the CRE bacteria at admission and bathing them daily with chlorhexidine.

The Chicago project, which started in 2017 and ends in September, includes a campaign to promote handwashing and increased communication among hospitals about which patients carry the drug-resistant organisms.

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical director of epidemiology at the Orange County Health Care Agency. “We don’t have an infinite amount of time,” he said. “Taking a chance to try to make a difference in CRE’s trajectory now is really important.”

The CDC-funded project in California is based in Orange County, where 36 hospitals and nursing homes are using the antiseptic wash along with an iodine-based nose swab. The goal is to prevent new people from getting drug-resistant bacteria and keep the ones who already have the bacteria on their skin or elsewhere from developing infections, said Huang, who is leading the project.

Huang kicked off the project by studying how patients move among different hospitals and nursing homes in Orange County, and discovered they do so far more than imagined. That prompted a key question: “What can we do to not just protect our patients but to protect them when they start to move all over the place?” she recalled.

Her previous research showed that patients with the MRSA bacteria who used chlorhexidine for bathing and as a mouthwash, and swabbed their noses with a nasal antibiotic, could reduce their risk of developing a MRSA infection by 30%. But all the patients in that study, published in February in the New England Journal of Medicine, already had been discharged from hospitals.

Now the goal is to target patients still in hospitals or nursing homes and extend the work to CRE. The traditional hospitals participating in the new project are focusing on patients in intensive care units and those who already carried drug-resistant bacteria, while the nursing homes and the long-term acute care hospitals perform the cleaning — also called “decolonizing” — on every resident.

One recent morning at Coventry Court Health Center, a nursing home in Anaheim, Calif., 94-year-old Neva Shinkle sat patiently in her wheelchair. Licensed vocational nurse Joana Bartolome swabbed her nose and asked if she remembered what it did.

“It kills germs,” Shinkle responded.

“That’s right — it protects you from infection.”

In a nearby room, senior project coordinator Raveena Singh from UC-Irvine talked with Caridad Coca, 71, who had recently arrived at the facility. She explained that Coca would bathe with the chlorhexidine rather than regular soap. “If you have some kind of open wound or cut, it helps protect you from getting an infection,” Singh said. “And we are not just protecting you, one person. We protect everybody in the nursing home.”

Coca said she had a cousin who had spent months in the hospital after getting MRSA. “Luckily, I’ve never had it,” she said.

Coventry Court administrator Shaun Dahl said he was eager to participate because people were arriving at the nursing home carrying MRSA or other bugs. “They were sick there and they are sick here,” Dahl said.

Results from the Chicago project are pending. Preliminary results of the Orange County project, which ends in May, show that it seems to be working, Huang said. After 18 months, researchers saw a 25% decline in drug-resistant organisms in nursing home residents, 34% in patients of long-term acute care hospitals and 9% in traditional hospital patients. The most dramatic drops were in CRE, though the number of patients with that type of bacteria was smaller.

The preliminary data also shows a promising ripple effect in facilities that aren’t part of the effort, a sign that the project may be starting to make a difference in the county, said Zahn of the Orange County Health Care Agency.

“In our community, we have seen an increase in antimicrobial-resistant infections,” he said. “This offers an opportunity to intervene and bend the curve in the right direction.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

How Easy Are Vaccine Exemptions? Take A Look At The Oregon Model

As measles outbreaks continue in the Northwest and across the nation, newly revealed health records from Oregon suggest it’s surprisingly easy to opt out of required vaccinations in that state — as in several others.

In Oregon — which has the highest kindergarten vaccine exemption rate in the U.S. — about 95% of parents whose kids skip one or more vaccines use a print-your-own certificate to do so.

That’s according to data from the Oregon Health Authority, which shows that of more than 31,500 non-medical vaccine exemptions submitted last year, nearly 30,000 were documented by parents who watched an online education video and then printed out a do-it-yourself form.

Fewer than 2,000 chose the second option: to talk to a health care provider and obtain a signature.

The state, where 7.6% of kindergartners were exempt from one or more vaccines in the 2017-18 school year, has had an education requirement for non-medical exemptions in place since 2013.

But Oregon state Rep. Mitch Greenlick, a Democrat who has proposed a bill to eliminate non-medical vaccine exemptions, criticized the online educational module.

“It’s obviously letting too many people off the hook,” he said.

It’s clear why parents are overwhelmingly choosing the online option, said Dr. Saad Omer, a vaccine and infectious-disease expert at Emory University in Atlanta: convenience.

Omer and other public health officials find this trend worrisome, because kids who remain unvaccinated can catch — and spread — dangerous diseases such as measles, posing a risk to themselves and the wider community.

In the U.S. this year, at least 387 cases of measles have been detected in 15 states, according to the Centers for Disease Control and Prevention. Most of the cases are clustered in six outbreaks, including an outbreak centered in Clark County, Wash. The county is part of the Portland, Ore., metro area, a well-known hot spot for vaccine hesitancy. At least 78 cases of measles have been linked to that outbreak, with four of those confirmed in Oregon. The state has reported six additional measles cases not linked to that outbreak.

Across the U.S., nearly all cases of the highly contagious disease have occurred in unvaccinated children, officials said.

Evidence shows, however, that making it more difficult to obtain vaccine exemptions can reduce the rates of those who opt out.

“The ease of exemption is a big predictor,” said Omer, who has been named the inaugural director of the Yale Institute for Global Health, starting in July.

He favors counseling by a health care provider as one good way to strengthen requirements. That not only makes it harder to get exemptions, but also puts parents in touch with “the most trusted source” of information, Omer said.

In Washington state, overall vaccine exemption rates fell by about 40% after passage of a 2011 law that required a health care provider’s signature on exemption forms, according to a 2018 study by Omer.

Oregon is one of 17 states that allow exemptions based on philosophical opposition to vaccination, as well as religious or medical reasons. Only three states — California, Mississippi and West Virginia — ban all non-medical exemptions.

In 10 of the states that allow personal or philosophical exemptions, a parent’s signature on a statement or a form is all that’s required to opt out. In three states, the paperwork has to be notarized. Only two states — Washington and Michigan — require consultation with a health care provider.

Since 2015, when Michigan began requiring parents to participate in an education session at their local health department, vaccine waiver rates fell from 4.8% in 2014 to 3.6% in 2017, said Lynn Sutfin, a spokeswoman for the Michigan Department of Health and Human Services.

Three states — Arkansas, Oregon and Utah — offer an online education option, which includes scientifically based information compiled by state health officials.

Utah, with a 5.2% kindergarten exemption rate, began allowing use of the 20-minute online education module last summer. Since then, more than 8,700 certificates have been printed, said Rich Lakin, immunization program manager for the Utah Department of Health.

But the new option is rife with problems, said Lakin. People have submitted fictitious names such as “Mickey Mouse” into the system, he said. Others have used the web-based portal to criticize health officials for requiring documentation for exemptions.

In Oregon, Greenlick’s proposed bill to ban non-medical vaccine exemptions sparked a firestorm of opposition, with hundreds of parents showing up at recent public hearings to protest. Action is pending.

Jennifer Margulis, 49, of Ashland, Ore., said she has used the state’s online education module to exempt all four of her children from some vaccine requirements. She said the video, which takes about 40 minutes, requires active participation — clicking through a series of screens.

“You really have to pay attention. It’s a lot of information,” she said. “I did not find it convenient. I found it interesting and time-consuming.”

She said the online option is a good alternative for parents who want to make their own choices about vaccination, despite scientific evidence and advice from public health officials.

One Oregon lawmaker, Sen. Jeff Golden, a Democrat from Margulis’ district, has opposed the bill banning non-medical vaccine exemptions, calling for “less sweeping and authoritarian options.”

But a legislative aide, Adam Lohman, said Golden wasn’t aware so many Oregonians were opting out of vaccinations using the online module. “He would be interested in an option that preserves parent choice and makes it more stringent,” Lohman said.