News & Analysis
The VCU Health System has already i m p l e m e n t e d s o m e o f t h e s e st e p s . Michael Edmond, MD, MPH, MPA, the health system’s epidemiologist, explained that the potential benefits, lack of harm, and limited costs persuaded him to follow the lead of the National Health Service and adopt a bare-below-the-elbows policy. Other physicians at the hospital told Edmond they would like to adopt the policy but said they felt more formal attire was required. “One of the things we needed to do was give them permission,” said Edmond, who was not involved in the creation of the SHEA recommendations. “We recommended no coat, tie, or wrist jewelry.”
The recommendations at VCU are not mandated or enforced, but they are slowly being adopted by staff. The hospital has also added coatracks in clinician workrooms to make it easier for physicians to remove their jackets. Edmond also suggests tucking in ties or rolling up sleeves. “It’s easy to do, but there’s kind of a psychological barrier to it,” said Bearman. He and the other members of VCU’s infectious disease team have adopted an unofficial uniform consisting of a black nylon vest with the health system’s logo. He said the vest is comfortable, has pockets, and is well accepted by staff and patients. Edmond explained that some older professional norms call for more formal
attire, but many younger physicians are comfortable with more casual dress. The SHEA review noted that some studies have found patients prefer that physicians dress formally. However, others found that patients rank physician hygiene above their attire. Edmond pointed out that patient education about potential bacterial colonization of white coats would likely eliminate any preference for formal physician attire. Surveys at his facility found many physicians infrequently wash their white coats, he said, and he suspects that is the same at other facilities. “If patients were aware, they would demand people not be in coats,” he said.
Demonstration Projects in Vietnam and Uganda Show Global Health Security Begins at the Local Level Mike Mitka, MSJ
Justin Williams/Centers for Disease Control and Prevention
I
nfectious disease threats know no borders, especially in a world where a potentiallydeadlyinfectiousdiseaseisonlya24hour plane flight from anywhere in the world. So it’s not surprising that nations are increasinglyrecognizingtheneedforglobalhealthsecurity, for strengthening local capacity to prevent, detect, and respond to public health threats that have global implications. Such a challenge is an ambitious one, especially for developing countries without a strongpublichealthinfrastructure.Tohelpdevelop an approach for achieving this goal, the USCentersforDiseaseControlandPrevention (CDC), partnered with the ministries of health in Vietnam and Uganda, conducted demonstration projects in 2013 in those countries. Findings from these projects, appearing today in the CDC’s Morbidity and Mortality Weekly Report, may help provide templates that other nations can use to both enhance their own health and contribute to global health security.
diseases and other health threats, including chemical, biological, or radiological public healthemergencies.Theregulations,whichare binding on 194 countries (including all WHO member states), are geared toward ensuring rapidgatheringofinformationaboutapossible health threat, fostering an understanding of
what may constitute a public health emergencyofinternationalconcern,andmakinginternational assistance available. The countries that signed on to the International Health Regulations had until June 2012 to meet the core surveillance and response requirements, but more than 80%
Addressing Global Health Threats These efforts could also help nations keep their promises to meet core surveillance and response requirements of the International Health Regulations, which in 2005 were revised by the World Health Organization (WHO) in response to the need to address existing, new, and reemerging infectious
An on-the-ground detection team in a remote village in Kibaale district, Uganda, prepares to assess an individual whose recent death may have been caused by the Ebola virus. Such teams, and efforts to prepare them to address outbreaks, are a key element in global health security.
jama.com
JAMA February 26, 2014 Volume 311, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
787
News & Analysis
788
prevent, detect, and respond to outbreaks of novel influenza viruses, such as H7N9.”
news@JAMA FROM JAMA’S DAILY NEWS SITE
Mock Outbreaks and Preparedness ThedemonstrationprojectinUgandafocused on similar priorities: strengthening the public health laboratory system by increasing the capacityofdiagnosticandspecimenreferralnetworks, enhancing existing communications and information systems for outbreak responses,developinganemergencyoperations center to serve as the focal point for communication, and assessing information emerging from the front lines of response to outbreak threats. To simulate the challenges Ugandan public health workers might encounter in reality, the project created mock outbreaks of multidrug-resistant tuberculosis, cholera, and viral hemorrhagic fever. At the end of the project, 14 of 16 sites demonstrated they had improved in disease recognition, communication, and specimen transport. Laboratories showed an average 14% improvement from the baseline assessment. “The exercise emphasized the importance of preparedness activities in the steps ofpreparedness,response,andrecovery,”said Jeff Borchert, MSEH, from the CDC’s Office of Infectious Disease, who worked in Uganda on theproject,inane-mailexchange.“Nextsteps could include increased focus on preparedness planning in addition to the response aspect so that plans and supplies are in place ahead of any incident that might occur.” In addition to demonstration projects, the CDC is also working in other areas to improve global health security. “CDC has been working with ministries of health around the world in a variety of public health activities, such as training epidemiologists to have core capacities to monitor infectious and noninfectious agents,” said Jordan W. Tappero, MD, MPH, director of CDC’s division of global health protection, Center for Global Health. “We really need to improve our surveillance capacity, the ability to track an event if it happens. Most countries have some way of tracking infectious disease, but those that don’t need to get it.” Such improvements benefit individual countries as well as the global community, Frieden said. “What’s encouraging is when we do this in a country, it doesn’t just make that country safer from a particular threat; it improves the country’s ability to meet any health threat,” he said. “That ability is transferable.”
Chickenpox Vaccine Isn’t the Culprit Shingles cases have been on the rise among older US adults, but the increase apparently isn’t linked with the 1996 introduction of chickenpox vaccination among children. Some had speculated that if fewer children contracted chickenpox, adults who were infected as children wouldn’t get as big of a natural immune system boost. The result could be virus reactivation, causing painful shingles lesions. Health records from nearly 3 million Medicare beneficiaries showed that the rate of herpes zoster increased by 39% over the past 2 decades, but the increase began before the implementation of childhood varicella vaccination. Reasons for the shingles increase remain a mystery. http://jama.md/1cwa5MA When Not to Screen for Oral Cancer Current evidence isn’t sufficient to determine whether primary care clinicians should screen for oral cancer in asymptomatic adults, according to updated recommendations. Experts hope that screening will identify oral cancer before it spreads. But the US Preventive Services Task Force didn’t find that screening by primary care clinicians accurately detects oral cancer or that treating screendetected oral cancer improves outcomes. The task force also found inadequate evidence on the potential harms of screening. The recommendation applies only to primary care clinicians, not dentists or otolaryngologists. http://jama.md/1grLqfz How to Improve End-of-Life Care? Specialized training to help resident physicians and nurse practitioner students improve their skills in discussing end-of-life issues may not enhance patients’ perceptions of the care those trainees provide as death approaches. Researchers randomized more than 400 internal medicine and nurse practitioner trainees between 2007 and 2012 either to attend 8 sessions designed to improve end-of-life communication skills or to receive usual education. Those who underwent the special training fared no better than the control group when patients assessed the quality of communication or the quality of end-of-life care the trainees provided. http://jama.md/1fd7ZQ7
For more on these stories and other medical news, visit http://newsatjama.jama.com.
JAMA February 26, 2014 Volume 311, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
jama.com
RosicaSabotanova/iStock.com
of them failed to meet this deadline and have been given a 2-year extension. CDC Director Thomas R. Frieden, MD, MPH, said he hopes countries can learn from the demonstration projects and implement effective measures to meet the regulations’ requirements. Doing so should help manage disease outbreaks within countries and prevent or minimize their spread to other countries, he said. “We have unprecedented opportunity,” Frieden said, in the form of better technology for rapid detection and response and effective communication tools to report cases, such as social media and texting. “We have a different world now than we had just a few years back.” In Vietnam, the CDC, Vietnam’s ministry of health, and certain international organizationpersonnellaunchedademonstrationproject from March 2013 to September 2013 to improve the country’s capacity to detect and respond to public health emergencies. The project team, which focused on establishing an emergency operations center that would receive, evaluate, and distribute information and coordinate response operations to a disease outbreak, demonstrated that early detection of and response to diseases and outbreaks could be made through this and other enhancements to the country’s health system, such as improving laboratory operations by increasing the capacity of diagnostic and specimen referral networks. MichelleMcConnell,MD,countrydirector, CDCVietnam,saidenhancinginformationsystemsprovedtobethemostdifficultchallenge. “This system, by definition, encompassed many different institutions and levels of the public health system from the national to the provincial and district levels of the public health system,” McConnell said in an e-mail exchange. “Intra- and interdepartmental coordination and communication are critical to global health security, but also one of the greatest challenges.” McConnell added that it is challenging for developing countries to focus on global health security because of economic constraints and other health priorities, but that Vietnam made it a priority. “The Vietnam ministry of health is very aware of the importance and priority of globalhealthsecurityandledwiththehighestlevel of commitment,” McConnell wrote. “Vietnam was one of the first nations in Asia to stop having new cases of SARS during that epidemic and, more recently, has stepped up efforts to
The VCU Health System has already i m p l e m e n t e d s o m e o f t h e s e st e p s . Michael Edmond, MD, MPH, MPA, the health system’s epidemiologist, explained that the potential benefits, lack of harm, and limited costs persuaded him to follow the lead of the National Health Service and adopt a bare-below-the-elbows policy. Other physicians at the hospital told Edmond they would like to adopt the policy but said they felt more formal attire was required. “One of the things we needed to do was give them permission,” said Edmond, who was not involved in the creation of the SHEA recommendations. “We recommended no coat, tie, or wrist jewelry.”
The recommendations at VCU are not mandated or enforced, but they are slowly being adopted by staff. The hospital has also added coatracks in clinician workrooms to make it easier for physicians to remove their jackets. Edmond also suggests tucking in ties or rolling up sleeves. “It’s easy to do, but there’s kind of a psychological barrier to it,” said Bearman. He and the other members of VCU’s infectious disease team have adopted an unofficial uniform consisting of a black nylon vest with the health system’s logo. He said the vest is comfortable, has pockets, and is well accepted by staff and patients. Edmond explained that some older professional norms call for more formal
attire, but many younger physicians are comfortable with more casual dress. The SHEA review noted that some studies have found patients prefer that physicians dress formally. However, others found that patients rank physician hygiene above their attire. Edmond pointed out that patient education about potential bacterial colonization of white coats would likely eliminate any preference for formal physician attire. Surveys at his facility found many physicians infrequently wash their white coats, he said, and he suspects that is the same at other facilities. “If patients were aware, they would demand people not be in coats,” he said.
Demonstration Projects in Vietnam and Uganda Show Global Health Security Begins at the Local Level Mike Mitka, MSJ
Justin Williams/Centers for Disease Control and Prevention
I
nfectious disease threats know no borders, especially in a world where a potentiallydeadlyinfectiousdiseaseisonlya24hour plane flight from anywhere in the world. So it’s not surprising that nations are increasinglyrecognizingtheneedforglobalhealthsecurity, for strengthening local capacity to prevent, detect, and respond to public health threats that have global implications. Such a challenge is an ambitious one, especially for developing countries without a strongpublichealthinfrastructure.Tohelpdevelop an approach for achieving this goal, the USCentersforDiseaseControlandPrevention (CDC), partnered with the ministries of health in Vietnam and Uganda, conducted demonstration projects in 2013 in those countries. Findings from these projects, appearing today in the CDC’s Morbidity and Mortality Weekly Report, may help provide templates that other nations can use to both enhance their own health and contribute to global health security.
diseases and other health threats, including chemical, biological, or radiological public healthemergencies.Theregulations,whichare binding on 194 countries (including all WHO member states), are geared toward ensuring rapidgatheringofinformationaboutapossible health threat, fostering an understanding of
what may constitute a public health emergencyofinternationalconcern,andmakinginternational assistance available. The countries that signed on to the International Health Regulations had until June 2012 to meet the core surveillance and response requirements, but more than 80%
Addressing Global Health Threats These efforts could also help nations keep their promises to meet core surveillance and response requirements of the International Health Regulations, which in 2005 were revised by the World Health Organization (WHO) in response to the need to address existing, new, and reemerging infectious
An on-the-ground detection team in a remote village in Kibaale district, Uganda, prepares to assess an individual whose recent death may have been caused by the Ebola virus. Such teams, and efforts to prepare them to address outbreaks, are a key element in global health security.
jama.com
JAMA February 26, 2014 Volume 311, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
787
News & Analysis
788
prevent, detect, and respond to outbreaks of novel influenza viruses, such as H7N9.”
news@JAMA FROM JAMA’S DAILY NEWS SITE
Mock Outbreaks and Preparedness ThedemonstrationprojectinUgandafocused on similar priorities: strengthening the public health laboratory system by increasing the capacityofdiagnosticandspecimenreferralnetworks, enhancing existing communications and information systems for outbreak responses,developinganemergencyoperations center to serve as the focal point for communication, and assessing information emerging from the front lines of response to outbreak threats. To simulate the challenges Ugandan public health workers might encounter in reality, the project created mock outbreaks of multidrug-resistant tuberculosis, cholera, and viral hemorrhagic fever. At the end of the project, 14 of 16 sites demonstrated they had improved in disease recognition, communication, and specimen transport. Laboratories showed an average 14% improvement from the baseline assessment. “The exercise emphasized the importance of preparedness activities in the steps ofpreparedness,response,andrecovery,”said Jeff Borchert, MSEH, from the CDC’s Office of Infectious Disease, who worked in Uganda on theproject,inane-mailexchange.“Nextsteps could include increased focus on preparedness planning in addition to the response aspect so that plans and supplies are in place ahead of any incident that might occur.” In addition to demonstration projects, the CDC is also working in other areas to improve global health security. “CDC has been working with ministries of health around the world in a variety of public health activities, such as training epidemiologists to have core capacities to monitor infectious and noninfectious agents,” said Jordan W. Tappero, MD, MPH, director of CDC’s division of global health protection, Center for Global Health. “We really need to improve our surveillance capacity, the ability to track an event if it happens. Most countries have some way of tracking infectious disease, but those that don’t need to get it.” Such improvements benefit individual countries as well as the global community, Frieden said. “What’s encouraging is when we do this in a country, it doesn’t just make that country safer from a particular threat; it improves the country’s ability to meet any health threat,” he said. “That ability is transferable.”
Chickenpox Vaccine Isn’t the Culprit Shingles cases have been on the rise among older US adults, but the increase apparently isn’t linked with the 1996 introduction of chickenpox vaccination among children. Some had speculated that if fewer children contracted chickenpox, adults who were infected as children wouldn’t get as big of a natural immune system boost. The result could be virus reactivation, causing painful shingles lesions. Health records from nearly 3 million Medicare beneficiaries showed that the rate of herpes zoster increased by 39% over the past 2 decades, but the increase began before the implementation of childhood varicella vaccination. Reasons for the shingles increase remain a mystery. http://jama.md/1cwa5MA When Not to Screen for Oral Cancer Current evidence isn’t sufficient to determine whether primary care clinicians should screen for oral cancer in asymptomatic adults, according to updated recommendations. Experts hope that screening will identify oral cancer before it spreads. But the US Preventive Services Task Force didn’t find that screening by primary care clinicians accurately detects oral cancer or that treating screendetected oral cancer improves outcomes. The task force also found inadequate evidence on the potential harms of screening. The recommendation applies only to primary care clinicians, not dentists or otolaryngologists. http://jama.md/1grLqfz How to Improve End-of-Life Care? Specialized training to help resident physicians and nurse practitioner students improve their skills in discussing end-of-life issues may not enhance patients’ perceptions of the care those trainees provide as death approaches. Researchers randomized more than 400 internal medicine and nurse practitioner trainees between 2007 and 2012 either to attend 8 sessions designed to improve end-of-life communication skills or to receive usual education. Those who underwent the special training fared no better than the control group when patients assessed the quality of communication or the quality of end-of-life care the trainees provided. http://jama.md/1fd7ZQ7
For more on these stories and other medical news, visit http://newsatjama.jama.com.
JAMA February 26, 2014 Volume 311, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/17/2015
jama.com
RosicaSabotanova/iStock.com
of them failed to meet this deadline and have been given a 2-year extension. CDC Director Thomas R. Frieden, MD, MPH, said he hopes countries can learn from the demonstration projects and implement effective measures to meet the regulations’ requirements. Doing so should help manage disease outbreaks within countries and prevent or minimize their spread to other countries, he said. “We have unprecedented opportunity,” Frieden said, in the form of better technology for rapid detection and response and effective communication tools to report cases, such as social media and texting. “We have a different world now than we had just a few years back.” In Vietnam, the CDC, Vietnam’s ministry of health, and certain international organizationpersonnellaunchedademonstrationproject from March 2013 to September 2013 to improve the country’s capacity to detect and respond to public health emergencies. The project team, which focused on establishing an emergency operations center that would receive, evaluate, and distribute information and coordinate response operations to a disease outbreak, demonstrated that early detection of and response to diseases and outbreaks could be made through this and other enhancements to the country’s health system, such as improving laboratory operations by increasing the capacity of diagnostic and specimen referral networks. MichelleMcConnell,MD,countrydirector, CDCVietnam,saidenhancinginformationsystemsprovedtobethemostdifficultchallenge. “This system, by definition, encompassed many different institutions and levels of the public health system from the national to the provincial and district levels of the public health system,” McConnell said in an e-mail exchange. “Intra- and interdepartmental coordination and communication are critical to global health security, but also one of the greatest challenges.” McConnell added that it is challenging for developing countries to focus on global health security because of economic constraints and other health priorities, but that Vietnam made it a priority. “The Vietnam ministry of health is very aware of the importance and priority of globalhealthsecurityandledwiththehighestlevel of commitment,” McConnell wrote. “Vietnam was one of the first nations in Asia to stop having new cases of SARS during that epidemic and, more recently, has stepped up efforts to
