Experts look at the culture of care
Lucy Tompkins (left) and Sasha Madison (right)
The more than 800 physicians who have received influenza vaccines from SHC this year may not need a reminder that flu season has or is about to arrive. But to provide some context for physicians and flu, we talked in mid-November with Lucy Tompkins, M.D./ Ph.D., the Lucy Becker Professor in Medicine and of Microbiology and Immunology and hospital epidemiologist; and Sasha Madison, M.P.H., C.I.C., SHC’s manager of infection prevention.
The basic take home message is, not surprisingly, “get a flu shot,” and then practice hand and respiratory hygiene. Then keep up-to-date with web based information on this year’s flu season on the SHC Intranet (the “Pandemic Planning” link from quick links on the SHC intranet home page), or at a public SUMC site:
Physicians may call SHC’s Occupational Health and Safety Department at (650) 724-0667 to obtain information on how to obtain an influenza immunization.
Then, if you want to find out why and what’s new in the field of SHC-specific influenza epidemic and pandemic preparations, read on:
Q: Influenza has always affected humans so what’s different about this flu season?
TOMPKINS: There is some interesting epidemiological research on the horizon that can improve the way we deal with epidemics and potential pandemics, but this year we are seeing some thematic changes in the way we are looking and dealing with flu beyond the science. Specifically, there are some shifts in public policy and physician culture.
Q: Aren’t physicians tired of hearing words like “culture” when it purports to describe what they do at work?
TOMPKINS: Maybe, but we really are dealing with issues that I as a physician would consider a shift in the culture of practice. TB testing is now part of the credentialing process, and influenza immunization will be required on an opt-in, opt-out sign off system in California effective in July 2007 (Senate Bill 739). More generally, the biggest shift over at least the past few years is the leadership role physicians are expected to play in areas such as immunizations. This is evidenced in other areas of practice, such as the emphasis JCAHO puts on physician involvement in hospital safety and improvement programs, and the rise in National Patient Safety Goals as an integral part of practice and hospital operations. There are many administrative issues involved with influenza protection, and the hospital has a great team to prepare for that. Candidly, we need physician expertise and leadership not only to set an example but to assure credentialing agencies that our medical staff is not simply a passive “customer” of hospital administration’s efforts.
MADISON: We are looking beyond this flu season to something more serious. A hospital pandemic team, headed by Emergency Services faculty member Eric A. Weiss, is working with us and many groups to provide the structure the hospital and the community need to get through an influenza epidemic. If we can learn and implement the appropriate safety, hygiene, triaging and related steps needed for an ordinary flu season, we will be creating a template and be that much farther ahead to take things to the next step when the expected pandemic strikes.
Q: So far, what have you done to protect health care workers, patients and the public for this season?
MADISON: Most of our efforts have focused on education, immunization and the use of protective equipment, such as N95 respirators. Proper use is crucial. During the Toronto SARS epidemic a few years ago, there was the possibility that some health care workers infected themselves by removing protective devices inappropriately. We’ve produced posters and other written materials, but we’re expecting that the hospital intranet and Stanford University websites will be the central clearing house for physician information.
TOMPKINS: The more physicians learn now, the easier time we’ll all have learning the specifics we’ll have to add to that knowledge at the time of “the big one.” Put simply, it’s easier to learn five things rather than 30 things, particularly when you are stretched thin caring for patients, families, coworkers and yourself during a crisis.
Q: Speaking of a pandemic, with incubation of six to eight months for manufacturers to produce a vaccine, is there any hope for an effective vaccine?
TOMPKINS: A pandemic by definition occurs when a new strain, for which no one has natural or acquired immunity, erupts, so it will be necessary to react quickly if we are to be effective in maximizing protection. We’re encouraged by research under way now that may bring us close to growing a viral-specific vaccine in animal cells so we won’t be dependent on the slow - and unprofitable, by the way - production of chicken egg-grown vaccine. Cell growth will significantly speed up production, and several companies are at work on this.
Q: Some 841 physicians received influenza vaccines this year from SHC’s Occupational Health. How does this stack up with the past?
TOMPKINS: Far fewer people received vaccines than should have.
MADISON: This is a national problem - people doing crucial jobs in high risk situations aren’t getting immunized. Locally, this is the first year that we specifically tracked physician use of our free vaccines at both Occupational Health and at flu clinics held hospitalwide, so it’s difficult to compare with previous years. Of course some physicians received immunization elsewhere, and we haven’t tracked that. But suffice it to say, that we have physicians in our community who haven’t been vaccinated.
Q: Why do you think the response rate is lower this year?
TOMPKINS: Anecdotal evidence suggests that since H5N1, the Asian bird flu, wasn’t in the news and on people’s minds, the public, including healthcare workers, didn’t make getting a vaccination a priority. Flu disappeared from the public’s radar screen. This is really unfortunate, especially since unlike 2005, we have ample supplies here to vaccinate anyone who requests it. Getting the word out is always a challenge. By the way, the practicing physician community has done quite a bit to get the word out, although specialty groups are uneven in promulgating information nationally. Pediatricians and family practice associations, which deal with immunizations as a core part of their practices, have consistently done a great job in this regard. Groups are starting to provide more information, especially now that this can be done flexibly using web resources.
Q: But there were shortages. Palo Alto Medical Foundation, for example, cancelled patient immunization sessions after they ran out.
MADISON: We bought both Chiron and Sanofi-Pasteur vaccine and our supplies arrived early. However Sanofi-Pasteur experienced delays in delivering some of its vaccine supplies. But by the time physicians read this, PAMF and other locations should have received supplies and resumed immunization clinics.
Q: What about nasal vaccine, or prophylaxis, such as Tamiflu (oseltamivir)?
TOMPKINS: The nasal inhaler is a live virus and carries minimal risk but is a practical, although expensive, alternative for healthy persons under age 50. Tamiflu does reduce symptoms but it’s impractical to take throughout the season. It’s expensive, it’s not as efficient at suppressing transmission as vaccine, and recent evidence from Japan indicates it might have neurological side effects. It’s also not readily available right now, although we hope it might be a useful tool if there is a pandemic to provide some measure of protection for health care workers in the absence of an effective vaccine.
Q: So it’s too late to be immunized?
TOMPKINS: No, it is not too late: it’s better late than never. We expect Occupational Health to have supplies available throughout the season, and we recommend that anyone who hasn’t been vaccinated should receive a flu shot as long as they are not symptomatic. By the way, immunization can be received in conjunction with mandatory TB screening required for credentialing.
Q: How long does the flu virus incubate before becoming symptomatic?
MADISON: About 24 hours. This is important, because people who are infected can transmit virus before even knowing they’re sick. Even if you’ve committed to staying home at the first signs of flu (achiness, fever), you’re already 24 hours too late.
Q: Any final thoughts?
TOMPKINS: Stay healthy and keep taking care of patients. There are only a limited number of ways to make that possible. One step is to employ hygiene measures, such as hand washing protocols and masks. The hospital has a key role to play by ensuring that influenza-infected patients are isolated, for example, and that hygiene awareness and tools - such as hand hygiene gels, masks and awareness materials are available. But the most basic way to prevent the spread is to personally avoid the flu, and I can think of only two ways to do that - quarantine yourself, which is rarely practical, or get a flu shot.
