The response to the H1N1 flu virus has been aggressive, with a nationwide vaccination effort, extensive precautions taken to protect health care workers, and even bans on children visiting most local hospitals – though some of those were lifted in late December.
For Dr. Leonard Mermel, medical director of infectious control at Rhode Island Hospital, the last few months have been a challenge, a demonstration of the health care system’s strengths and weaknesses and a chance to learn a great deal.
PBN: What are the biggest risks for health care workers, and are they major transmitters?
MERMEL: Any of us who’ve had kids … know they bring all these viruses to [school] and to the home. … At Hasbro [Children’s Hospital], many of the infections the kids come in with are also viral. But in the hospital as a whole, many of the infections are also bacterial, so there’s greater exposure of health care workers to bacterial infections. … Our main job in infection control is to mitigate the risk of transmission to the health care worker and from the worker to patients.
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PBN: How are most infections spread in health care settings?
MERMEL: There are many ways, either through contact – examining someone, or bathing them, and not washing one’s hands afterward – or through touching the environment in the room, which is often contaminated. Someone might go into a patient’s room, touch the bedrail or the bed stand, and if they don’t have gloves on or don’t clean their hands afterward, they can transmit that to others or to themselves. Transmission can also occur through a respiratory route, such as coughing, and occasionally there are germs that can travel through long distances in the air, like tuberculosis.
PBN: You spoke at the Institute of Medicine a few months ago about precautions against the swine flu in particular. What were your concerns?
PBN: You’ve also noted that there’s no consensus on how to protect health care workers.
MERMEL: There are differences of opinion. I have sort of a loose e-mail group of hospital epidemiologists around the country, and a number of hospitals are doing what we’ve been doing – surgical masks for most interactions, and respirators for high-risk interactions. But I find it amazing that the [World Health Organization] guidelines differ a bit from the CDC’s, which differ a bit from the Canadian CDC guidelines, which differ a bit from professional societies. … When there’s such divergent opinions … I think it reflects a lack of understanding of the biology of influenza transmission.
PBN: In fact, some basic concepts are still being revisited?
MERMEL: We published something earlier this year. One of the basic dogmas in flu is that you can transmit it before you have any symptoms, like small pox, which you can transmit before you have any rash. We looked at all the studies … and we couldn’t find good support for transmission in humans or animals before the symptom onset. What that suggests to me is that we have not really funded basic, simple studies of the epidemiology of influenza in the community setting, or in the hospital setting, where we do things to people that may change the equation. For example, we give people nebulized medications, and we put them on high-flow oxygen masks – things that can create a plume, an aerosol.
PBN: This past year, the flu seemed to hit particularly hard – not just H1N1 – and people’s sense of influenza as a threat really increased. What was your sense?
PBN: What do we do at this point with H1N1?
MERMEL: Thank goodness it looks like we’re on the downward trend in terms of cases. The worst, I’m hoping, is behind us. Moving forward, I would hope that people in state and especially federal government, since they hold the purse strings, think about … the resources that we need to do a better job if a bug like this comes around again that might be more contagious or have a greater risk of harm?
PBN: Did H1N1 turn out to be less of a threat than we expected?
MERMEL: There was a recent article … in a scientific journal … suggesting that maybe this wasn’t as bad as it was trumped up to be. It was an emotionally charged situation when we were at the peak of it. I think we’ve gotten through it, we did a pretty good job, but there are areas of vulnerability – having enough personal protective equipment, having enough vaccines. Some countries, some manufacturers, were running low on alcohol hand gel. Part of this reflects our just-in-time economy, having enough for today and who cares about tomorrow? If you’re going to prepare for a pandemic, that’s not good enough. •
INTERVIEW
Leonard Mermel
POSITION: Medical director, infection control, Rhode Island Hospital; professor of medicine, Brown University
BACKGROUND: Mermel joined Rhode Island Hospital as an attending physician in infectious diseases in 1991. He has co-authored two national guidelines for the prevention and management of intravascular catheter-related infections and has co-authored more than 150 textbook chapters, abstracts and articles in peer-reviewed journals. He is immediate past president of the Society for Healthcare Epidemiology and a technical-expert panel member of the Medicare Patient Safety Task Force for the U.S. Department of Health and Human Services.
EDUCATION: B.A. in biology, 1978, University of Colorado; M.S. in Parasitology & Medical Entomology, 1980, Johns Hopkins University School of Hygiene and Public Health; D.O., 1984, University of Osteopathic Medicine and Health
FIRST JOB: Playing drums in a rock band in Los Angeles
RESIDENCE: Barrington
AGE: 53
