Hes fall '17 final

healthcare

Environmental solutionsnews Covering infection prevention, medical waste management & sustainable practices

VOL. NO. 43 VOL. XIII XII NO.

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FALL 2016 2017 WINTER

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‘When’ For Global

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‘If’ But

Flu Pandemic

I

By P.J. Heller

n 1918, an influenza pandemic swept the world, infecting an estimated 500 million people and leaving tens of millions of people dead in what has been described as “the greatest medical holocaust in history.”

Now, nearly a century later — despite advances in medicine and science — concerns are being raised about the possibility of another catastrophic global flu pandemic.

“In the next 20 to 30 years, there will be a pandemic and it will have the potential to bring humanity to its knees,” predicted Dr. Larry Brilliant, chair of the Skoll Global Threats Fund, in an interview earlier this year on CNN. Brilliant, a world-renowned physician and epidemiologist, said a survey he conducted in 2006 of the world’s top epidemiologists found that 90 percent of them thought there would be a pandemic within their children’s or their grandchildren’s lifetime.

“And they thought that if there was a pandemic, a billion people would get sick. As

many as 165 million people would die. There would be a global recession and depression as our just-in-time inventory system and the tight rubber band of globalization broke, and the cost to our economy of one to three-trillion dollars would be far worse for everyone than merely 100 million people dying, because so many more people would lose their job and their healthcare benefits, that the consequences are almost unthinkable. And it’s getting worse, because travel is getting so much better,” he said in a 2006 TED talk.

Experts interviewed for this story agree that it’s not a matter of “if ” but “when” an influenza pandemic will occur.

“The short answer to your question on the possibility of a flu pandemic is yes,” says Dr. Aileen M. Marty, a professor of infectious diseases in the department of medicine at the FIU Herbert Wertheim College of Medicine in Miami. “There is always a risk of a new flu pandemic.”

Continued on page 3

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FALL 2017

Healthcare Environmental Solutions news

Experts say: Not ‘If’ But ‘When’ For Global Flu Pandemic

Continued from page 1

“I definitely think we will see another flu pandemic just because of the nature of the virus . . . ” agrees Dr. Michelle A. Barron, medical director, infection control and prevention, at University of Colorado Hospital.

Adds Dr. Timothy Sly, an epidemiologist and emeritus professor at Ryerson University in Toronto: “We seem to experience influenza pandemics of type A influenza two to four times a century. We could see another anytime. It can occur at any time, and could begin anywhere.”

Influenza A is one of three types of flu viruses, the others being Influenza B and Influenza C. Influenza A viruses infect humans and many different animals, such as avian flu H5N1, H7N9 or H9N2, or swine flu H1N1 or H3N2. Influenza B viruses only circulate among humans and cause seasonal epidemics. Influenza C viruses can infect both humans and pigs, but infections are generally mild and are rarely reported, according to the World Health Organization (WHO).

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Environmental solutionsnews Covering Infection prevention, medical waste management & sustainable practices

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“Most serious influenza outbreaks have resulted from Influenza A viruses, some from Influenza B viruses, and virtually none from Influenza C viruses,” Marty notes.

A m o n g t h e wo r s t cases since 1918 were flu pandemics in 1957 (H2N2), 1969 (H2N3) and 2009 (H1N1).

Pandemic influenza is always caused by an avian influenza A virus, Sly explains, noting that the 2009 swine flu outbreak “was still essentially an avian influenza.”

Bird flu (H5N1) was first reported in humans in 1997 in Hong Kong.

“Since 2003, this avian virus has spread from Asia to Europe and Africa, and has become entrenched in poultry populations in some countries,” WHO reports. “Outbreaks have resulted in millions of poultry infections, several hundred human cases, and many human deaths.”

In its most recent report, WHO said there have been 859 cases of human infection with the bird flu H5N1 virus, including 453 deaths in 16 countries. It also reported 1,557 cases of human infection with the avian influenza H7N9 virus — first reported in China in 2013 — including at least 605 deaths. Human infection in the majority of all those cases was the result of direct or indirect contact with infected live or dead poultry.

Hundreds of millions of birds have been killed worldwide in an attempt to control the spread of avian flu. Avian flu can be transmitted between infected birds or chickens to humans.

Such cases have been reported from about 20 countries worldwide.

However, “a human with avian influenza will not spread it to another bird or chicken or to another human,” Barron notes.

The “nightmare scenario,” Sly says, is if that situation should change and human-to-human transmission becomes possible with people having little to no immunity against the virus.

Such a scenario could occur, he says, if low-pathogenic Influenza A viruses, which are able to circulate easily, interacted with much more deadly avian viruses that have not mutated, allowing the virus to invade the human respiratory tract.

“If genes were re-assorted between these types, for example, then we could emerge with the ‘perfect storm’ — a virus than can spread around the world, and one that is really lethal,” Sly warns. “That is the nightmare scenario.”

FALL 2017

Barron and others agree that the big fear is that a virus might mutate, such as acquiring new genes usually from an animal host and its tendency for the virus to make errors when it copies itself.

“In both instances, the flu virus changes enough so that it looks like a brand new virus to humans, and in the absence of a vaccine, there is a worldwide risk of infection and complications,” she says.

Factors which could exacerbate a global flu pandemic today include the greater worldwide population, people living in closer proximity and having the ability to travel the planet quickly and easily. In 2014, for example, Canada reported the first case of human infection with avian flu (H5N1) virus ever detected in North America.

The case involved a traveler who had recently returned from China.

“With the growth of global trade and travel, a localized epidemic can transform into a pandemic rapidly, with little time to prepare a public health response,” WHO says.

“Because of the ability to travel long distances in very short periods of time, an individual with the new virus just needs a group of susceptible hosts to pass it on,” Barron says. “We saw this with SARS (Severe Acute Respiratory Syndrome). It likely started in Hong Kong, but very rapidly became a global issue with a major outbreak in the city of Toronto.”

Sly agrees.

“When the 1918 influenza was devastating all the countries, it took about six days to cross the Atlantic by ship, longer than the incubation period for the influenza, so theoretically it was easier to spot and contain before the ship docked. That’s where quarantine took place,” he says. “Now, we do the trip in about five to seven hours, much less than the [one to three day] incubation period of influenza. This means

Continued on page 4

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

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Healthcare Environmental Solutions news

Experts say: Not ‘If’ But ‘When’ For Global Flu Pandemic

Continued from page 3

a person could fly from Hong Kong or Beijing and be in London, New York, Toronto or Madrid for a day or two before anyone knew they were infected. The potential for transmission in crowded areas anywhere on Earth is much more likely now than 100 years ago.

“Also frozen poultry is shipped from Thailand to just about everywhere daily,” he points out. “It could be that the next pandemic virus started out flying at 35,000 feet in a cargo plane.”

Marty notes that while avian flu can be transmitted f ro m a s i c k o r healthy appearing animal via direct or indirect contact, such as at a live animal market, cooked meat is safe and “people cannot get infected by eating properly cooked meat and food.”

Predicting exactly when the next pandemic will occur or its impact — despite various projections that have been made over the years — is impossible, according to the Centers for Disease Control.

“Traditionally, these avian influenzas seem to originate in Southeast Asia, which may reflect the exceptional amount of avian/human interaction in ‘wet’ markets, but this is by no means a requirement,” Sly says.

Barron agrees, saying the “sky is literally the limit” for where an outbreak could occur.

Barron and Sly disagree, however, on whether a flu pandemic would be as devastating as the one that occurred in 1918.

Sly predicts the pandemic would be worse, based on the number of deaths that occurred in the total number of cases. The 1918 pandemic had a case-fatality rate (CFR) of about 2.5 percent globally, he estimates, meaning that for every 100 people infected, an average of 2.5 people died.

The H5N1 virus has a case-fatality rate that has never dropped below 50 percent, he says.

“That’s 20 times more lethal than the 1918 epidemic,” he says. “Clearly, if we were to experience a global pandemic of H5N1 with such a CFR, the results would be catastrophic to an unthinkable degree.

“The H7N9 virus has surpassed the human cases in less than half the time taken by H5N1, and genetically has a greater potential for these last mutations to be made,” he adds. “The human CFR for H7N9 is a bit less, around 33 percent, but even that is still more than 10 times the CFR in 1918. We do need to keep our eye on H7N9.”

Barron, however, says she doesn’t think the number of deaths from a flu pandemic would be as bad as it was in 1918.

“I think we now live in an age where we would be able to quickly identify what the virus was and develop a vaccine while at the same time executing prevention strategies to help contain its spread,” she says. “Also, we are able to give a significant amount of supportive care (fluids, ventilator support, hemodialysis, etc.) that did not exist in 1918.

“I do think we could have more devastation from the perspective of disruption of our daily norms,” she adds. “With the 24-hour news cycle and social media, lots of misinformation is thrown into the mix and can cause unnecessary panic. I think if we look at the recent Ebola 4

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

FALL 2017

outbreak, both scenarios played out. Isolation/containment helped stop the spread of the Ebola virus outside of the initial African countries that were experiencing outbreaks, modern medicine and access to supportive treatment was generally associated with survival, and a vaccine was rapidly developed and appears to be quite effective. In that same notion, there was widespread panic about potential exposure and led to some decisions that in retrospect may have not been appropriate.”

Experts agree that keeping a close watch on flu viruses worldwide is essential.

“To prevent a pandemic, it is important to perform surveillance for these viruses,” Marty says. “Surveillance requires a close collaboration between animal and human sectors and is a combination of event-based sentinel influenza-like illnesses and severe acute respiratory infections surveillance.” “ G l o b a l surveillance is a very important step in preventing any type of pandemic, not just one related to flu,” Barron adds. “It has been the key to our ability to contain SARS, MERS (Middle East Respiratory Syndrome) and Ebola.

I strongly believe that we have the ability to forecast what might come next and what we need to do to be prepared for it. We may not have it exactly right, but most of the things we need to do to prepare for the next pandemic would be the same regardless of what the cause turned out to be.”

The CDC says the U.S. government has ongoing efforts to monitor and assess pandemic threats and prepare for an influenza pandemic.

“Because we cannot predict how bad a future pandemic will be, advance planning is needed at the national, state and local level,” it says.

“Whether the planning is for a government entity, a business, school, community-based organization, or healthcare system, all planning efforts should take into consider multiple scenarios of a pandemic (e.g. moderate, severe, or very severe) so that they can be ready to respond quickly and take the appropriate measures to continue daily operations.”

Whether such a response would include a vaccine remains a question.

Research has been ongoing into a universal flu vaccine that could be applied every 10 to 20 years, eliminating the need for people to have yearly seasonal flu jabs.

“Vaccines have always been the problem,” Sly says. “Influenza viruses mutate while you watch them. To produce a vaccine today on an emerging new virus could be a complete waste because by the time the virus has mutated to start a pandemic, the vaccine would be only partly effective. But once we wait until the virus has started to spread globally, it can take five to six months to develop a vaccine for that virus, and another six to 10 months or more to produce enough vaccine to dose everyone.”

Barron says advances in science, medicine and technology will all help.

“We certainly have much better technology that allows for mass production of vaccines than even 50 years ago,” she says. “Similarly, since most antibiotics were not even in existence 100 years ago, we certainly have significantly more options.”

Even so, Sly warns, “We can never underestimate nature to spring something on us at any time.”

“Global surveillance is a very important step in preventing any type of pandemic, not just one related to flu.”

News Briefs

Utah Approves Stericycle Incinerator Relocation Plan

S

alt Lake City, UT – According to a USNews.com report, Stericycle has agreed to pay the state of Utah a $1.15 million penalty for excessive emissions. The company also will relocate its incineration facility to a less populated area.

In September of 2014, the Division of Waste Management and Radiation Control (DWMRC) learned of allegations that Stericycle was processing medical waste in a manner that violated its permit. The state immediately launched an investigation into the company’s North Salt Lake City operations. Further investigations followed, amid vocal opposition against the Illinois-based company voiced by residents and environmental groups.

Stericycle’s relocation search led to Tooele County. The company submitted plans for the new facility to the Utah DEQ while the violations and penalties were being sorted out. DWMRC approved the air-quality and solid-waste permits, respectively, for the Tooele County Facility on September 1, 2017. The proposed facility will be located on a 40-acre parcel in a manufacturing zone that includes Wasatch Regional Landfill, U.S. Magnesium, and ATI metals.

According to a DEQ news release, the Tooele County plant will have two incineration units equipped with an automated, continuous waste feed system capable of operating 24 hours a day. Each incinerator will be designed and sized to process 2,050 pounds of hospital, medical, and infectious (HMI) waste per hour, for a total hourly processing volume of 4,100 pounds per hour. The maximum permitted capacity at the new facility will be 18,000 tons of HMI waste per year, or an average of 49.3 tons per day – two and half times more medical waste each year than the facility in North Salt Lake City. The permit allows human tissue and fluid, surgical tools, needles, vaccines and pharmaceuticals to be processed.

Each incinerator will have a two-stage combustion system to ensure complete destruction of waste, and each unit will be equipped with its own air pollution control (APC) system. The APC system will include a selective non-catalytic reduction system (SNCR), waste heat boiler, evaporative cooler, baghouse, carbon-injection system, dry sorbent injection, wet gas absorber, and carbon bed, according to the DEQ statement.

The facility will generate bottom ash and fly ash, which Stericycle will analyze for hazardous compounds, then transport and dispose in a permitted landfill.

Skyline Medical Signs Binding Letter of Intent for Merger Transaction with CytoBioscience

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inneapolis, MN (GLOBE NEWSWIRE) – Skyline Medical Inc. (NASDAQ:SKLN) (“Skyline” or “the Company”), producer of the FDA-approved STREAMWAY® System for automated, direct-to-drain medical fluid disposal, announces the signing of a binding letter of intent for a merger transaction with CytoBioscience, a privately held biomedical company. The letter of intent is subject to entering into a definitive merger agreement.

CytoBioscience creates and manufactures devices used in human cell research focused on new therapeutic drug development and has a well-known scientific and technical staff, collaborative partnerships with leading pharmaceutical companies and strategic alliances with key groups and academic institutions. CytoBioscience has reported a current backlog of $6 million in orders and anticipated contract research work. Its ion channel instrument was selected by the FDA for its own cardiac safety testing on preclinical new drug compounds. Cytobioscience’s board and management has extensive relationships with hospitals and government entities that it intends to leverage to open new markets for the Skyline STREAMWAY® System operating room safety products.

The plan calls for an initial planning session between the leaders of the two groups, to lay out a combined operating and business strategy and forge a step by step plan of action for the next six months, with the work being repeated again six months later.

The merger is expected to close by September 30, 2017.

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FALL 2017

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

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Untreated Medical Waste Dumping in Scenic Utah

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t. George, UT – Local government officials are looking for alternatives to dumping untreated medical waste at the Washington County Landfill in southwestern Utah, StGeorgeUtah.com reports.

Until the issue came up at a meeting in July, some members of the county’s solid waste board were unaware that the medical waste was being taken to the county landfill. County and city officials immediately began sorting out the best way to allay public fears, while remaining business friendly.

The owner of a local waste treatment and disposal company has voiced his concerns about earthquake activity causing fissures in the dam that holds the landfill. In this area of Utah, which borders Nevada and Arizona, earthquakes, such as a 3.4 magnitude shaker that occurred in July, are not uncommon.

According to Utah State law, up to 200 pounds of untreated medical waste may be dumped into landfills and buried. The weight limit applies to each single dumping.

Solutions offered at the meeting included sending the waste outside the county or state and purchasing sterilization or incineration equipment.

A representative from Republic Waste volunteered to research alternatives and present findings at the next solid waste board meeting in November.

Secretary Price Appoints Brenda Fitzgerald, M.D., as CDC Director and ATSDR Administrator

H

ealth and Human Services Secretary Tom Price, M.D., recently named Brenda Fitzgerald, M.D., as the 17th Director of the Centers for Disease Control and Prevention (CDC) and Administrator of the Agency for Toxic Substances and Disease Registry (ATSDR).

“I am extremely proud and excited to announce Dr. Brenda Fitzgerald as the new Director of the CDC,” said Secretary Price.

“Having known Dr. Fitzgerald for many years, I know that she has a deep appreciation and understanding of medicine, public health, policy and leadership—all qualities that will prove vital as she leads the CDC in its work to protect America’s health 24/7. We look forward to working with Dr. Fitzgerald to achieve President Trump’s goal of strengthening public health surveillance and ensuring global health security at home and abroad. Congratulations to Dr. Fitzgerald and her family.”

Dr. Fitzgerald has been the commissioner of the Georgia Department of Public Health (DPH) and state health officer for the past six years. She replaces Dr. Anne Schuchat, who has been the acting CDC director and acting ATSDR administrator since January 20. Dr. Schuchat is returning to her role as CDC’s principal deputy director.

Dr. Fitzgerald, a board-certified obstetrician-gynecologist, has practiced medicine for three decades. As Georgia DPH Commissioner, Dr. Fitzgerald oversaw various state public health programs and directed the state’s 18 public health districts and 159 county health departments. Prior to that, Dr. Fitzgerald held numerous leadership positions. She served on the board and as president of the Georgia OB-GYN Society and she worked as a health care policy advisor with House Speaker Newt Gingrich and Senator Paul Coverdell. She has served as a Senior Fellow and Chairman of the Board for the Georgia Public Policy Foundation.

Dr. Fitzgerald holds a Bachelor of Science degree in Microbiology from Georgia State University and a Doctor of Medicine degree from Emory University School of Medicine. She completed post-graduate training at the Emory-Grady Hospitals in Atlanta and held an assistant clinical professorship at Emory Medical Center. As a Major in the U.S. Air Force, Dr. Fitzgerald served at the Wurtsmith Air Force Strategic Air Command (SAC) Base in Michigan and at the Andrews Air Force Base in Washington, D.C.

News Briefs

Scientists Discover Calcium’s Role in C. diff Disease

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nn Arbor, MI – Researchers from University of Michigan Medical School and the U.S. Food and Drug Administration have established a link between calcium and growth of Clostridium difficile (C. diff), according to findings of a new study published in the online journal PLoS Pathogens.

Clostridium difficile kills about 30,000 Americans a year and sickens half a million others. The U-M laboratory study shows that the bacterium spores, which lie dormant in the gastrointestinal system, activate when conditions are right. That is, when a combination of excess calcium and a bile salt produced by the liver, taurochlorate, triggers an enzyme that breaks the hard shell and lets the spores multiply.

Certain patients stricken with C. diff show low levels of Vitamin D in their blood due to disease or prescriptive medications. Without adequate Vitamin D, calcium doesn’t get absorbed and the excess stays in the gut. In the laboratory study, the scientists noted a 90 percent lower rate of C. diff spore germination in mouse guts when calcium levels were low.

Further study conducted by the FDA Center for Biologics Evaluation and Research with C. diff spores confirmed the calcium-C. Diff connection. The connection between bile salt and C. diff spore germination was first discovered at U-M in 1982.

According to professor of microbiology and immunology at U-M, Philip Hanna, Ph.D., and his graduate student, Travis Kochan, the discovery could lead to more effective prevention and treatment of C. diff. Giving patients calcium supplements to awaken all the dormant C. diff spores in a patient’s gut at once, then administering a targeted drug that will kill them in the germinated form, is a possible approach. This strategy could be used to prevent the bouts of nosocomial diarrhea, which releases spores that spread the disease.

www.gient.net

South Carolina Fines Hospital $28,000 for Mishandling Hazardous Materials

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olumbia, SC – State Department of Health and Environmental Control (DHEC) found a number of hazardous waste violations at two Columbia hospital facilities after a complaint was filed in September of 2016, reports TheState.com.

According to an official DHEC document, investigators found that Palmetto Health Baptist and Palmetto Health Richland failed to properly label hazardous waste or labeling was missing or incorrect. Some containers holding hazardous waste were found uncovered and storage areas were not easily accessible. In addition, documentation and shipping papers were found to be incomplete, not up to date or lacking certification.

The DHEC has directed the hospital to conduct a personnel training program in accordance with the regulations; submit an updated DHEC Form 1965 to include the pharmaceutical P-listed, acute hazardous waste streams, the U-listed waste streams; submit an updated DHEC Form 2701 to include all the listed hazardous wastes; submit a written procedure/ protocol for managing pharmaceutical P-listed and acute hazardous wastes at the facility; and pay a civil penalty in the amount of $28,000.00.

A spokeswoman for Palmetto Health Baptist and Palmetto Health Richland said that the violations arose when the waste disposal company that handled the medical waste for the two facilities went out of business and was purchased by a competitor. The new company mislabeled and handled nonhazardous medical waste as though it were hazardous, the hospital’s spokeswoman said. The increase bumped the hospitals into a higher classification. The two hospitals have long been classified as low producers of hazardous medical waste and the increase subjected them to a change in requirements. Calling the mix-up a processing error, the spokesperson added that no hazardous medical waste was placed in the environment.

Palmetto Health has since hired a new company to handle waste.

info@gient.cn FALL 2017

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

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News Briefs

Fermented Foods: An Inexpensive Way to Prevent Sepsis

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ew Delhi, India – Administering fermented foods to patients stricken with sepsis could save millions of lives, according to an article published in the August issue of the journal, Nature.

Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. Blood flow becomes impaired, depriving major organs of nutrients and oxygen, causing them to weaken. In severe cases, organ damage occurs. In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs—lungs, kidneys, liver— may quickly fail and the patient can die.

According to the National Institutes of Health severe sepsis strikes more than a million Americans annually. An estimated 28 and 50 percent of these people die—far more than the number of U.S. deaths from prostate cancer, breast cancer and AIDS combined. Sepsis contributes to significant newborn mortality rates worldwide, too.

But now a team of American and Indian researchers led by University of Nebraska Medical Center pediatrician, Dr. Pinaki Panigrahi, may have found a way to prevent sepsis. In his earlier research, Panigrahi had noticed that a strain of bacteria, Lactobacillus plantarum, which exists in kimchi, pickles and other fermented vegetables, could ward off infections, particularly those that begin in the lungs of babies. hospitals treat sepsis with antibiotics and intravenous fluids.

2017Typically, hEs News Although antibiotics can resolve the illness within days or weeks, concerns about overuse of antibiotics have motivated scientists to look for alternatives. A 60-day probiotic study was conducted with 4,556 newborns at least 8 months old and weighing more than 4.5 lbs. The study demonstrated that babies who ate the microbes for a week, along with some sugars to feed the microbes, had a dramatic reduction in risk of death and sepsis. Mortality dropped by 40 percent, from 9 percent to 5.4 percent.

San Diego Declares Hepatitis A Outbreak a Public Health Emergency

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an Diego, CA – A hepatitis A virus (HAV) outbreak in San Diego that began about a year ago now has claimed the lives of 15 and hospitalized more than 260, according to CountyNewsCenter.com.

With 378 HAV cases reported as of August 29, 2017, San Diego officials declared a public health emergency, which allows the county to request state funding to help stop the spread of this dangerous liver disease.

The area’s homeless population has been hit the hardest since the outbreak began in November 2016.

This summer, the health department installed 40 portable hand-washing stations has been performing additional sanitation measures, such as cleaning surfaces with bleach-spiked water in places with concentrations of homeless people. Teams of public health nurses fanned out to conduct vaccination and education campaigns at homeless services providers, community health clinics, faith-based community organizations, substance abuse treatment providers, hospital emergency departments, jails, and probation facilities.

Hepatitis A infections are common among the homeless population due to the lack of access to sanitary facilities. The disease is usually transmitted by touching objects or eating food that someone with HAV infection handled and/or having sex with an HAV-infected partner.

Symptoms include fever, fatigue, nausea, loss of appetite, yellowing of the eyes (jaundice), stomach pain, vomiting, dark urine, pale stools, and diarrhea. Not everyone who tests positive for the disease has experienced symptoms, however.

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News Briefs

Scrap Metal Recycling Challenge Raises Money for New Ventilators in BC

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ampbell River, British Columbia – Campbell River Hospital Foundation’s annual Scrap Metal Challenge raised $16,795 this year toward purchasing two $54,000 ventilators for the hospital’s Emergency Department, reports CampbellRiverMirror.com.

A representative from ABC Recycling, the company that provides the collection bins and does the actual recycling, said that the fundraiser was especially impressive given that the scrap values have gone down about half what they were several years ago ($150 to $250 per ton to around $85).

The Foundation recognized Marine Harvest, which collected $5,000 worth of scrap from agricultural facilities. The fundraiser’s organizers said the 2017 challenge was the most successful since they started holding the event six years ago.

Hawaii Hospital Fights Sepsis with Rapid Response

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ilo, HI – More Hawaiians are dying from sepsis than mainlanders in California’s largest city, Los Angeles, concludes a new study published by the Public Library of Science (PLOS).

The sepsis mortality rates were five times higher in Hawaii residents — 14.4 per 100,000 people — than in Los Angeles, 2.7 per 100,000. Native Hawaiians have the highest rate of sepsis death in Hawaii: 29 per 100,000 people. The researchers chose the two locations for the study because of their diverse populations and access to case records for immunocompromised patients and certain ethnic minorities.

A team of researchers from the University of Hawaii Cancer Center and University of Southern California’s Department of Preventive Medicine and Norris Comprehensive Cancer Center conducted the study.

The involved more than 190,000 Japanese-American, Native Hawaiian, Latino, black and white U.S. residents age 45-94 over 17 years. Of the 49,000 participants who died from a range of causes, 345 died of sepsis.

“A higher incidence [of sepsis] has been reported for older people, in persons with a compromised immune system including cancer patients, and in ethnic minorities. Potential reasons for death-rate differences, according to the study, include cancer, obesity, gender, ethnicity and access to health care,” the researchers wrote.

At Hawaii’s Hilo Medical Center, an average of 63 sepsis patients were treated per month so far this year. The high survival rate – 93.6 percent – is attributable to vigilance and intervention, the paper emphasizes. Since the organization implemented a “sepsis alert” program, patients with suspected sepsis receive immediate attention and a coordinated response by ICU and ER staff, respiratory therapists, lab technicians and X-ray technicians.

Despite such effective attention and treatment, patients with weak immune systems, such as elderly and very young, are particularly susceptible to repeat sepsis infections after leaving the hospital. A delay in seeking care can increase the risk of serious illness and even death. Awareness of sepsis symptoms by the patient and their family members can spell the difference between effective treatment and complications. Warning signs include fever, low blood pressure, sleepiness, high heart rate, shivering, confusion, low oxygen levels, rapid breathing, lethargy and pale appearance.

A higher infection rate in non-whites and a higher likelihood to develop organ dysfunction has been documented in previous studies. The researchers think that high mortality rates could be attributed to regional differences in health care access and death coding as well as differences in clinical care as shown for African Americans. Identifying ethnicity-related genetic factors related to the incidence and prognosis of sepsis may lead to developing more complete sepsis prevention, rapid early detection, and effective treatment approaches, the researchers concluded.

Sepsis is a contributing factor in six percent of all U.S. deaths. In 2015, Centers for Medicare and Medicaid Services began enforcing national standards for treating sepsis to reduce death rates.

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Parasite that Causes Meningitis Found in Five Florida Counties www.royal-basket.com

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HEALTHCARE ENVIRONMENTAL SOLUTIONS news

FALL 2017

A

parasitic nematode that can cause meningitis in humans and animals has been found in rats and snails across five Florida counties, according to a study in published PLoS ONE. A research team from University of Florida College of Veterinary Medicine and the Florida Museum of Natural History collected baittrapped deceased rats from multiple sites in Alachua, Leon, St. Johns, Orange and Hillsborough counties. Additionally, the team collected 37 rat fecal samples from 24 different sites across the four counties. They identified A. cantonensis, commonly called lungworm, in about a quarter of the rats they tested.

The nematode is prevalent in Southeast Asia, tropical Pacific islands (including Hawaii), but has not been considered a health threat in continental United States. Another study conducted in Jamaica immediately following an outbreak of angiostrongyliasis in humans found 32 percent of all rats sampled infected with lungworm. Previous studies in Florida found environmental rat fecal samples positive for the parasite in south Florida, specifically Miami (Miami-Dade County).

Lungworm, which relies on rat and snail hosts to complete its lifecycle, can pose a health risk to humans and animals that ingest infected snails, infected frogs and crustaceans or unwashed produce contaminated by snails or rat feces. While the fatality rate of infection in humans is low, the parasite can cause eosinophilic meningitis if it becomes trapped and dies in the brain. Clinical signs of infection in adults include headache, stiff neck, fever, vomiting, nausea and paralysis of the face and limbs. The most common symptoms of infection in children are nausea, vomiting and fever.

The study sheds new light on the extent of the parasite’s geographic range in Florida, according to Heather Stockdale Walden, an assistant professor in the UF department of infectious diseases and pathology and the study’s lead author. Stockdale Walden says that A. cantonensis is likely to be more prevalent in the southeastern U.S. than previously thought. Researchers have surveyed 18 counties and found that nearly 23 percent of rats, about 16 percent of rat fecal samples and nearly 2 percent of land snails tested positive for the nematode.

Study co-author John Slapcinsky, collections manager of invertebrate zoology at the Florida Museum, warns that A. cantonensis may have arrived in Florida by way of snails that inhabited cargo containers or potted plants. If the parasite infects more animals, health risk to humans could increase.

Stockdale Walden said more than 2,800 cases of human-rat lungworm infection have been documented worldwide since the parasite was described, but the actual number of cases is likely greater as the disease can go undetected or be misdiagnosed.

While no human cases of infection with rat lungworm, or Angiostrongyliasis, have been reported in Florida, eating lungworminfected snails killed a white-handed gibbon at Zoo Miami in 2003 and a privately owned orangutan in Miami in 2012.

Stockdale Walden advises people to thoroughly wash produce, avoid raw or undercooked frogs and crustaceans and to teach children not to eat or handle snails.

Infection with rat lungworm can also cause meningitis in animals, as well as limb weakness or paralysis, neck pain and central nervous system problems. To protect pets and livestock, be mindful of snails in animals’ living space, Stockdale Walden said. Check watering troughs for snails that might have fallen in and monitor animals for snail-eating habits.

Managing rat populations could help curtail the parasite in facilities that house animals, such as zoos and conservation centers, she said.

Many physicians and veterinarians are not aware of this parasite or its presence in the United States, and many infections may be misdiagnosed. Human and veterinary medicine would benefit from better, more reliable diagnostics tests, especially in areas with a high prevalence of A. cantonensis, the study authors concluded.

News Briefs

Antimicrobial Resistance: Better Control Needed in Small Hospitals

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esearchers from The Center for Disease Dynamics, Economics and Policy (CDDEP) who compared rates of antimicrobial resistance (AMR) at large tertiary care hospitals and small community hospitals found little difference between the two, according to a study published in the journal, Clinical Infectious Diseases.

The conclusion is important because AMR susceptibility at tertiary care hospitals (TCHs) was thought to be greater than at small community hospitals (SCHs), where patients are admitted with less severe and complex illnesses that carry less risk of resistant infection.

Led by Dr. Ramanan Laxminarayan, Director of The Center for Disease Dynamics, Economics and Policy in Washington, D.C., researchers used statistics from a national antimicrobial susceptibility database to compare annual and aggregated rates of AMR in community and tertiary care hospitals.

The team focused on the incidence of multidrug-resistant Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa occurring between 1999 to 2012.

“While in inpatient settings, S. aureus, K. pneumoniae, A. baumannii were higher in SCHs, and S. aureus and P. aeruginosa were higher in TCH outpatient settings, after accounting for time trends and hospital-level variability, no significant variation had occurred,” they wrote.

Increasing rates of those pathogens, especially E. coli, point to a growing national problem and need for improved control measures in the smaller hospitals, the team concluded.

The Yucky Truth about Stethoscopes

A

team of researchers from Yale University School of Medicine and the department of medicine at Veterans Affairs Connecticut Healthcare System in West Haven, Connecticut were aware of low stethoscope cleaning rates, but thought they could improve matters with a pilot hygiene program.

Their study findings, published in the July issue of the American Journal of Infection Control, showed a slight change – between 58 percent and 63 percent improvement – for hand hygiene, but stethoscope cleaning remained the same as at the start of the program: zero.

Microbiology data has shown that stethoscope contamination after a single exam is comparable to that of the physician’s dominant hand, the researchers wrote. Potential pathogens cultured from stethoscopes included Staphylococcus aureus, Pseudomonas aeruginosa, Clostridium difficile, and vancomycinresistant enterococci.

The team timed their program to coincide with the start of clinical rotations.

They developed a training session featuring a PowerPoint presentation about stethoscope contaminants and hygiene. The presentation was well-received by house staff, interns and attending physicians, as were the reminder flyers the team posted. Hand hygiene, as observed by study team members, improved. But the hand sanitizer they provided was not used on the stethoscopes. The team found that less than five percent of the trainees, including the residents, followed through. The Centers for Disease Control has guidelines for disinfecting noncritical medical equipment (including stethoscopes) between patients and such procedures evaluated for all second-year residents.

“Standard education may not be the answer. We believe that stethoscope hygiene should be included in all hospital hand hygiene initiatives. Perhaps accountability can be increased by designating a team member, such as a senior resident physician, to be the team leader and champion to remind and ensure that stethoscope and hand hygiene are performed. It would be interesting to see if adding stethoscope and hand hygiene to the end-of-rotation provider evaluations makes a difference,” the study authors said.

www.a-solutionsinc.com FALL 2017

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News Briefs

New Jersey Hospital System Diverts Nearly 27 Tons of Medical Waste from Landfill

W

est Orange, NJ – RWJ Barnabas Health has received a Gold Healthy Hospital Award for diverting 53,588 pounds of medical waste from landfills and reducing its supply costs by more than $2 million.

The prestigious designation comes from Stryker’s Sustainability Solutions (SSS), a leading reprocessor of medical devices. The company recognizes hospitals that “demonstrate outstanding leadership in health care sustainability and overall hospital quality through single-use device (SUD) reprocessing.” SUD devices include pulse oximetry, tourniquet cuffs, blood pressure cuffs and compression hoses.

In 2016, RWJBarnabas’ reprocessing program increased its waste disposal savings by more than 28 percent over 2015. In the first six months of 2017, the numbers have nearly doubled, RWJ Barnabas said in a news release.

The achievement is noteworthy because not all SUD reprocessing programs are as successful.

According to an EPLab Digest article published in 2015, a number of factors need to be in play.

The paper’s authors, Helen Brann, CMRP, Materials Manager, Duke University Heart Center, and Angela Capone, RN, BSN, Cardiovascular Specialist, WakeMed, emphasized C-level buy-in and staff education and engagement. A reprocessed device utilization and collection plan and a strong vendor partnership that ensures efficiency and dependability are both highly important.

WakeMed in Raleigh, North Carolina, saw its SUD reprocessing savings in the EP lab grow 326 percent between 2011 and 2014 to $750,000. Duke University Heart Center in Durham, North Carolina, saw its savings drop 43 percent — by over $355,000 — from 2013 to 2014, however.

“Duke learned first-hand that discounted purchase prices and combined contracts don’t always equate to greater savings. Reprocessing savings are a combination of purchase price and volume of units purchased from a vendor committed to maximizing the value of the program, “ the authors wrote.

RWJBarnabas Health is the most comprehensive health care delivery system in New Jersey, treating over 3 million patients a year. The system includes eleven acute care hospitals and is New Jersey’s second largest private employer – with more than 32,000 employees, 9,000 physicians and 1,000 residents and interns.

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Bio-Haz Solutions Announces New Partnership with CSR Professional Services, Inc.

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esquehoning, PA – Bio-Haz Solutions, a Pennsylvanian-based provider of regulated medical waste services and compliance programs, recently announced their new partnership with CSR Professional Services, Inc. Bio-Haz Solutions has partnered with CSR to provide a full suite of data protection services for their clients.

David Henritzy Bio-Haz Solutions President, stated, “Most business owners think it is better to not report a breach, and that could not be further from the truth. It is not only important to report a breach because it is the law, it is important to report it in the most expedient manner possible and to report it correctly to the proper regulatory authorities. Determining if there was a reportable breach, deciding who needs to be notified, and what that notification needs to be are just a couple of things that CSR can assist with. From the selfassessment questionnaire to breach reporting, our partnership with CSR means that we will be there to help our clients every step of the way as they improve their data security.”

News Briefs

Leapfrog Group Report on Wyoming Hospital Safety

A

survey by healthcare safety consultant, the Leapfrog Group, confirms Wyoming Hospitals are on par with the national average for patient readmissions, reports WyomingPublicMedia.org. Across the U.S., patients return to hospitals for treatment at a rate of 15 percent. The reasons are many, but the readmissions contribute to higher healthcare costs.

Leapfrog partnered with the Wyoming Business Coalition on Health to evaluate twelve providers in the state to assess infection and injury rates, medication safety, and the quality of inpatient and maternity care. Although hospitals must report on these areas to meet federal regulations for Medicare and Medicaid reimbursements, the Leapfrog survey collects data in more categories. Because of the in-depth nature, not all facilities have the resources to spend the 80-120 hours it takes to complete the survey. Yet for patients in a state where patients may have access to only one hospital, Leapfrog’s detailed report can provide valuable information to healthcare consumers, a group spokesperson said.

Hand Hygiene Reminders Meet with Mixed Reviews

A

ccording to study findings published in the August issue of the American Journal of Infection Control, adult patients and parents of young patients who were empowered to remind healthcare providers to perform hand hygiene helped increase compliance. However, not everybody liked the approach.

Use of patient empowerment tools (PET) is recognized as an effective way to encourage caregiver behaviors such as hand hygiene adherence.

Findings of a 2012 study that was conducted at the University of Wisconsin showed that PET strategies held promise for boosting compliance rates.

While nearly all the patients who were surveyed understood the importance of hand hygiene, only about half felt comfortable speaking up – particularly to physicians.

In the new West Virginia University study, researchers from the Schools of Public Health, Psychology, and Medicine gave patients tongue depressors that had laminated pictures and messages (e.g, “Did you wash your hands?”; “Please wash your hands. Thank you!”). The patients were instructed to hold up the tongue depressors as reminders to staff and physicians.

The study was conducted at West Virginia Medicine J.W. Ruby Memorial Hospital, a 645-bed tertiary care teaching hospital in Morgantown. In addition to the tongue depressor signs, adult patients, and parents of pediatric patients were asked to complete a survey. Researchers emailed a separate survey to resident and attending physicians from the departments of internal medicine, pediatrics, and family medicine.

The follow-up survey revealed that, while most parents and adult patients agreed with the PET strategy, just over half of the physicians felt that patients should not be reminding providers. Overall, physicians indicated that they would prefer a patient to speak up rather than use a PET to remind them to perform hand hygiene. The researchers had hypothesized the opposite, that physicians would prefer patients use a PET over verbal communication. “Healthcare workers have expressed concern that patient empowerment will have a negative impact on the patient-physician relationship,” the researchers wrote.

Major organizations, such as the Centers for Disease Control and Prevention, the World Health Organization, and the Joint Commission, recommend using patient participation as part of the plan to improve health care worker hand hygiene. The World Health Organization’s SAVE LIVES: Clean Your Hands campaign identifies patient involvement as a crucial component when implementing a hand hygiene improvement strategy.

In March 2002, the Joint Commission’s Speak Up campaign was established. The initiative focuses on methods to improve patient education and involvement, which in turn helps prevent medical errors.

“If patient involvement is to be successful, health care workers must accept it as helpful and not as a threat. As the patient empowerment movement grows, we should work to improve physician acceptance of patient involvement, if it is to be successful,” the researchers concluded.

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News Briefs

Antibiotic Use Spikes in India

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ew Delhi, India – India is has become the world’s largest antibiotics consumer, followed by China, Brazil, Russia, and South Africa, according to findings by Center for Disease Dynamics, Economics and Policy researchers. The study, “Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data,” was published in the July issue of Lancet.

Since 2013, Indian Council of Medical Resistance’s (ICMR) Antimicrobial Resistance (AMR) surveillance network has been gathering data from tertiary care public and private hospitals on drug resistance. The statistics have helped the organization to monitor resistance patterns across the country and the results have many healthcare leaders concerned.

Findings of a Princeton University study published in Lancet Infectious Diseases three years ago showed that global antibiotic use rose 36 percent in the decade ending 2010. Among the 16 groups of antibiotics studied, cephalosporins, broad-spectrum penicillins and fluoroquinolones accounted for more than half of that increase, with consumption rising 55 percent from 2000 to 2010.

While antibiotic demand has been increasing along with the rising threat from superbugs, such as carbapenem resistant Enterobacteriaceae (CRE), higher incomes in certain countries, such as China are giving more people in these regions access to medical care, which is increasing prescriptions. In addition, some of the nations with the highest antibiotic use have been slow to implement regulations to curb antimicrobials – for both humans and farm animals.

Historically, a majority of feed-grade antibiotics have been available to livestock producers over-the-counter, without approval from a veterinarian. In the U.S., the Food and Drug Administration moved all human medically important feed-grade antibiotics into the Veterinary Feed Directive (VFD) drug development and approval category at the beginning of this year.

The policy change effectively banned the use of feed grade antibiotics farmers used to help boost livestock weight. The agency has also restricted meat producers’ access to the drugs, requiring them to obtain prescriptions from licensed veterinarians and only for the purpose of treating sick animals.

India’s Public Health Authorities released their National Action Plan on Antimicrobial Resistance. The Plan identifies six strategic priorities including: • • • • • •

improved awareness of antimicrobial resistance through effective communication strengthening knowledge and evidence through surveillance reducing the incidence of infection through effective infection prevention and control optimizing the use of antimicrobial agents in health, animals and food promoting investments for antimicrobial resistance activities, research and innovations and strengthening India’s commitment and collaborations on antimicrobial resistance at international, national and sub-national levels.

The directive comes at a crucial moment. According to a study published in Environment Health Perspectives, chickens raised at 18 farms in six districts in Punjab were found to be resistant to a range of antibiotics. Antibiotic resistance was twice as high in meat-producing commercial farms compared to egg-producing farms, with multidrug-resistant E. coli found in 94 percent of broiler chickens and 60 percent of egg layers. Of these, 87 percent of the broilers and 42 percent of the layers were found to have ESBL (extended spectrum B-lactamase) positive bacteria.

The push for more control and has been supported by India’s Ministry of Health and Family Welfare, Ministry of Food Processing Industries, Ministry of Environment, Forest and Climate Change, Ministry of Chemicals and Fertilizers, as well as Indian Council of Medical Research, Indian Council of Agricultural Research, the Public Health Foundation of India and Center for Science and Environment.

Paramount Citizens Oppose Medical Waste Facility

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aramount, CA – Citizens attending a South Coast Air Quality Management District (AQMD) meeting here in July expressed concerns about emissions coming from a Paramount medical waste treatment facility, reports SCPR.org.

Medical Waste Services, which has been operating on a temporary research permit for the past two years, wants to triple the amount of waste it now treats. The plant is located about 700 feet from a home and about 1,000 feet from an elementary school. Residents have expressed concerns about the location, as well as the cumulative effect of emissions from the waste treatment facility and those from metals processing plants in the Paramount-Long Beach area.

Medical Waste Services has applied for a permit to extend its operations from three days to seven days a week and to operate permanently in Paramount. AQMD records indicate that the facility has treated up to 9,000 pounds of medical waste a day three days a week during the trial period. The company initially sought approval to treat 10,000 pounds a day seven days a week, but in a cautionary move, the air board issued the temporary permit and stipulated a 3,000 daily limit. The plant has been operating in complete compliance with the air quality standards.

According to the AQMD, Medical Waste Services uses a pyrolysis chamber to break down the waste. The Paramount plant is one of just two facilities in California that utilize a pyrolysis unit to process medical waste. The other facility, Aemerge RedPak Services, is located in the Mojave Desert city of Hesperia. The state has no commercial medical waste incinerators.

The California Department of Public Health (CDH) has publicized the need for more medical waste treatment capacity in the state, stating, “the current pyrolysis units in California do not have adequate capacity to treat all of this kind of waste generated in the state.”

At the same time AQMD is considering Medical Waste Services’ permit application, the agency also is monitoring hexavalent chromium “hot spots” caused by emissions from a number of metal processing facilities in the Southland. L.A. County’s public health department has directed four metal plants to curtail emissions. The companies have challenged the investigators’ findings.

According to CDH figures for last year, California generated approximately 125 million pounds of medical waste, of which bout 13 million pounds were sent out of state for treatment.

The agency’s Medical Waste Management Program (MWMP) regulates the generation, handling, storage, treatment, and disposal of medical waste under the state’s Medical Waste Management Act. The MWMP permits and inspects all medical waste offsite treatment facilities and medical waste transfer stations.

MWMP acts as the local enforcement agency in a number of local jurisdictions that elected to have the State implement the large quantity generator inspection program for medical waste management. In addition, a new law signed by Gov. Jerry Brown this year allows local air quality boards to temporarily shut down polluters. That law goes into effect January 1, 2018.

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Covering Infection prevention, medical waste management & sustainable practices

VOL. XIII NO. 3

FALL 2017

TOP STORIES Experts say: Not ‘If’ But ‘When’ For Global Flu Pandemic

PAGE 1

Scientists Discover Calcium’s Role in C. diff Disease

PAGE 7

Fermented Foods: An Inexpensive Way to Prevent Sepsis

PAGE 8

Parasite that Causes Meningitis Found in Five Florida Counties

PAGE 10

Hand Hygiene Reminders Meet with Mixed Reviews

PAGE 13

Antibiotic Use Spikes in India

PAGE 14

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