NFL Stars No Match for Bacteria

By Elizabeth Landau
CNN

A 6-foot-4 football player is more than a million times the size of a typical Staphylococcus bacterium. But under the right conditions, that athlete could find himself defenseless against the microscopic bug.

Kellen Winslow recently had a second staph infection and has accused his team of covering it up.

The problem came to the forefront last week with Cleveland Browns player Kellen Winslow, who recently had his second staph infection. He is reportedly the sixth player to acquire staph among the Browns in five years.

Winslow recently said the Browns treated him like a "piece of meat" when he was hospitalized for the condition, and he claimed they covered up the cause of his illness.

After Winslow spoke out, the organization suspended him for one game, then rescinded the suspension after a settlement with Winslow over the weekend. The Browns said in a statement Saturday that the team and Winslow had worked through their differences, and that the team looked forward to his return. Winslow joined the team again Monday.

Peyton Manning of the Indianapolis Colts was revealed to have a staph infection, the Indianapolis Star reported Friday. University of North Carolina-Asheville fans also recently learned that Kenny George, the 7-foot-7 center on the basketball team, had a staph infection complication that led to part of his foot being amputated.

It's unclear how these high-profile athletes acquired their infections, but locker rooms have been found to habor staph bacteria in previous outbreaks. The topic is generating buzz throughout the sports world as more players' staph cases are revealed. Hospitals have long been known to be hot spots for transmitting staph, but recently cases have cropped up in other community settings. Regardless of where these players got their infections, the close quarters of a locker room raise questions about overall risks.

About 30 percent of people carry staph in their noses without exhibiting symptoms, according to the Centers for Disease Control and Prevention.

Experts say Methicillin-resistant Staphylococcus aureus, or MRSA, a form of staph resistant to common antibiotics, has become a more prevalent problem in settings such as contact sports that involve skin-to-skin touching.

Most MRSA infections acquired in community settings present themselves as sores or boils and often appear red, swollen, painful or with drainage such as pus, the CDC says. Infections often occur in cuts and abrasions but also on body parts covered in hair, such as the back of the neck, armpit or groin.

Schools, prisons and other crowded environments are particularly known for transmitting MRSA, said. Elaine Larson, professor of epidemiology at Columbia University's Mailman School of Public Health.

MRSA may spread particularly easily among athletes because they have repeated skin-to-skin contact, share items and surfaces that touch skin and have a hard time staying clean, the CDC says. Athletes often get cuts and abrasions; MRSA can enter uncovered skin breaks and cause infection.

Dr. James Steinberg, medical director at Emory University's Crawford Long Hospital in Atlanta, Georgia, said that environment plays a role in the spread of MRSA but that it's less a factor than coming into contact with a person's skin.

"If you have somebody who has an infection -- he has a draining infection -- and he gets some of his pus on a bench, that staph's going to be there for hours or days before it dries out," he said. "But the higher concentration is going to be on that person's skin."

A second infection in the same person could result from re-exposure or from treatment that didn't get rid of the bacteria colonization, he said.

MRSA has been around in hospital settings since the 1970s, but community-associated MRSA was born in the late 1990s, and is now widespread in the community, said CDC spokesperson Nicole Coffin. A report from the CDC said that the deaths of four children from MRSA in North Dakota and Minnesota during the late 1990s "demonstrate the potential severity of community-acquired MRSA infections."

A study on the St. Louis Rams published in the New England Journal of Medicine in 2003 found that during the 2003 football season, there were eight MRSA infections among five of the 58 Rams players.

To protect against MRSA, the CDC recommends practicing good personal hygiene and taking care of your skin, which includes wearing protective clothing and covering cuts and abrasions with clean, dry bandages. Also, do not share items that come into contact with your skin, such as towels, razors and ointments. Put something between your skin and shared equipment -- for example, sit on a towel on a bench.

Larson said she is not directly familiar with Winslow's situation but understands the dilemma that a team would face if a player contracted a staph infection. There could be economic and psychosocial repercussions -- for example, another team might not want to play against that one, she said.

But in general, other team members should be made aware of the situation so they do not share towels or engage in other behaviors that might transmit the infection.

Still, there is a danger of overreaction, she said. In some instances when a child in a public school has died, the whole school panicked and fumigated the facility, she said.

"It's a good idea to avoid that level of fear, because it's costly and it scares people unnecessarily," she said.

On Thursday, the Brown's General Manager Phil Savage said the team did not alert players to Winslow's staph infection partly because of the health privacy laws and partly because the team was in "game mode" when Winslow had a confirmed diagnosis.

"To come out and talk about that just was going to be another distraction," Savage said on his regular weekly appearance on WTAM radio in Cleveland, Ohio. "That's our job, is to limit distractions as much as we can."

Winslow said in a statement released through his publicist, Denice White of EAG Sports Management, that he had been discouraged from making the issue public.

"This has nothing to do with football, and this has nothing to with my current contract situation," he said. "This is a health concern."

A spokesperson for the Browns did not return a request for comment. An NFL representative said the league has no statement on the issue.

MRSA and Flu Can Overlap into Pandemic Proportions

The importance of MRSA in a flu pandemic by Maryn McKenna
Excerpted from her blog.
http://www.marynmckenna.com/about.html

Constant readers will know that, in another part of my life, I write a great deal about seasonal and pandemic influenza, a subject I've been following since writing the first story in the American media about avian influenza H5N1. And people concerned about MRSA realize that flu and MRSA have an important overlap. For decades, long before the emergence of MRSA, staph was one of the most important contributors to secondary bacterial pneumonia, which occurs after the flu virus has damaged the lung tissue and allows staph and other bacteria to take hold.

In the past few years, we've been reminded of this interaction because of the shocking rise in cases of necrotizing pneumonia caused by MRSA. Twice in the past two years, the CDC has asked state health departments to report any cases of flu/MRSA co-infection; in the 2006-07 flu season, 22 children died from MRSA necrotizing pneumonia secondary to flu.

Comes now one of the giants of staph research to warn of an unconsidered danger of MRSA: as a contributor to deaths in a flu pandemic. Dr. Theodore Eickhoff, who wrote some of the earliest papers on hospital-acquired staph infections, has written an assessment in Infectious Disease News of two new pieces of research into deaths during the 1918 flu pandemic. Both papers contend that it was bacterial pneumonia that was the major killer in that global storm of death, and not the novel flu virus itself.

Eickhoff looks forward from those findings to consider what havoc a new pandemic could wreak in this era of massive MRSA transmission. He contends that national planning for pandemics — a huge effort and expense for the US and other governments over the past few years — has paid insufficient attention to the possibility that bacterial infection will be as significant a danger as whatever new flu has emerged:

Authors of both of these reports point out that their findings have important implications for pandemic preparedness today. U.S. preparedness policy, and indeed that of almost all other countries, has been focused on preventing or modifying influenza virus infection itself. Thus, vaccine development and anti-viral drugs (eg, neuraminidase inhibitors) have been the major efforts, and a great deal of stockpiling has already taken place.

Clearly it is equally necessary to stockpile antibiotics effective against primarily community-acquired organisms causing post-influenza pneumonia today, including both MSSA and MRSA. Much more consideration needs to be given to the possible role of pneumococcal and possibly other bacterial vaccines as part of pandemic preparedness.

Flu Shot Might Have Prevented MRSA Pneumonia

College student dies of rare ailment; MRSA pneumonia case brings warning
By CHERIE BLACK

A college student in Whatcom County died from a rare case of MRSA pneumonia -- prompting health officials to urge state residents to be vigilant about their health and to get a flu shot if they haven't.

Chris Feden, 20, a student at Western Washington University, died from what county health officials said was MRSA pneumonia, a rare staph infection that he may have contracted after getting the flu.

Separately, an 18-year old Pacific County resident died from respiratory failure, which wasn't caused by MRSA pneumonia, although it was believed to have been flu-related.

Respiratory illnesses, including the flu, typically peak in Washington in February and March and can be serious and even fatal. Cases of MRSA -- methicillin-resistant staph aureus -- are increasing in number nationwide, including in Washington, and can complicate influenza and other respiratory illnesses.

MRSA pneumonia, a relatively new infection that wasn't on national health officials' radar until about five years ago, is rare, but it may also be on the increase, health officials say.

MRSA infections have been common in health care settings for decades, and in recent years have spread into the community at large, particularly in relatively crowded facilities.

Although MRSA can be deadly, the infection itself is relatively common, and most people show no symptoms. The bacteria can be living in the nose and not cause problems.

But if an infected person catches the flu or other severe respiratory illness that becomes pneumonia, the lungs are weakened and people can infect themselves by inhaling the MRSA they already carry.

MRSA pneumonia first gained attention during the 2003-04 influenza season, when 15 cases linked to the flu were diagnosed across the country, according to the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report from April 2007. No formal surveillance was conducted, and few additional cases of MRSA pneumonia were reported to the CDC between the 2004 and 2006 flu seasons.

Between December 2006 and January 2007, there were 10 reported cases of severe MRSA pneumonia, including six deaths, in previously healthy children and adults in Louisiana and Georgia.

No statistics are kept for MRSA pneumonia in Washington, the state Health Department said.

"It's a combination of a community-acquired infection and flu season," said the state's health officer, Dr. Maxine Hayes. "It can cause catastrophic events, which is what happened to this young man," she said, referring to Feden. "Influenza is serious, and sometimes people think it's just a bad cold, but here we have a staph infection superimposed to that."

"Now we have MRSA and now we have more complications, and it's a killer."

Hospitals can test for MRSA through a nasal swab culture or a culture from a wound, which yields results in an hour or a few days, depending on which test is used.

Though MRSA is contagious through human contact, local public health authorities said the risk of MRSA infection to members of the Western Washington campus is very low.

"While this is a tragic loss of a young life, and our thoughts are with the family and friends of this young man, there is no evidence of an outbreak of severe MRSA in our community. This appears to be an unusual and random event," said Dr. Greg Stern, the health officer for Whatcom County.

The state Health Department is providing support to health officials in Whatcom and Pacific counties while they investigate the deaths. Health Secretary Mary Selecky said people should be aware that are in the middle of flu season, and while it has been an average one in Washington so far, getting a flu shot is still recommended, and it's not too late.

As for MRSA, simple steps such as covering coughs, washing hands and alerting a physician if there is a history of MRSA infections help reduce infection, she said.

"MRSA pneumonia is uncommon in this country, but we're still in flu season, and it can lead to pneumonia."

Feden's death, she said, "is an unfortunate reminder of the seriousness of the disease."

WHAT IS MRSA PNEUMONIA?

Methicillin-resistant staph aureus pneumonia is a relatively new and rare infection described as pneumonia with complications of MRSA, which is a common bacterium resistant to antibiotics.

ABOUT MRSA PNEUMONIA

How do you get it? A victim already has a MRSA infection, which may or may not make him sick. The victim then gets influenza or another severe respiratory illness that turns into pneumonia. The MRSA infection spreads to the weakened lungs, resulting in MRSA pneumonia.

How is it spread? MRSA is commonly spread by direct human contact. Although flu can spread from a sufferer, MRSA pneumonia is not an airborne disease and is not contagious.

How common is it? MRSA pneumonia is relatively new, and there are no statistics in Washington and no formal U.S. surveillance. Nationwide, there were 15 cases during the 2003-2004 flu season and 10 cases, including six deaths, between December 2006 and January 2007 in Louisiana and Georgia, according to the Centers for Disease Control and Prevention.

How deadly is it? MRSA pneumonia often affects young, otherwise healthy people and can be fatal. The patients who died did so within three to five days of the onset of respiratory symptoms. MRSA should be suspected in people with severe pneumonia, especially during the influenza season, and in those with a history of MRSA infection, according to the CDC.

MORE ONLINE

For more information about MRSA, visit the state Health Department's Web site at goto.seattlepi.com/r1087 or the Western Washington University MRSA information page at www.wwu.edu/mrsa.

P-I reporter Cherie Black can be reached at 206-448-8180 or cherieblack@seattlepi.com.
Read her To Your Health blog at blog.seattlepi.com/toyourhealth.

Jump Seen in Staph-Linked Flu Deaths in Kids

By LINDSEY TANNER , AP Medical Writer, Medicine & Health / Health

(AP) -- More children have died from flu because they also had staph infections, according to a new government report that urges parents to have their kids get the flu shot. The number of deaths wasn't high - 73 during the 2006-07 flu season - but there was more than a fivefold increase in hard-to-treat complications. And preliminary figures indicate deaths rose again during this past winter's flu season.

Public health officials say the numbers underscore the importance of a brand new recommendation that all children, from 6 months through 18 years, get routine flu shots. Before this year, shots were recommended for kids under 5 years.

More than half the children who died were between ages 5 and 17 and had been healthy until they got the flu.

Parents shouldn't panic, "but it's an important message to say even healthy children develop complications and die almost before anything much can be done for them," said Dr. Gregory Poland, a Mayo Clinic infectious disease specialist. He was not involved in the federal study, but has worked with a federal vaccine advisory committee and has consulted for vaccine makers.

Flu season is just beginning, and this year's vaccine should be widely available this month.

While few children die from the flu virus, it puts about 20,000 U.S. kids in the hospital each year.

Only 6 percent of the children studied who died had been fully vaccinated against the flu. Two doses are recommended each flu season for children ages 6 months to 8 years who have not been vaccinated previously; for older kids, just one dose a year is needed.

The study, appearing in the October edition of Pediatrics for release Monday, is based on an analysis of reported flu deaths from the 2004-05 through 2006-07 seasons. Flu deaths in children during those seasons totaled 47, 46 and 73, respectively.

The percentage of those who also had bacterial infections jumped from 6 percent to almost 36 percent. Most had staph infections, and 60 percent of those involved the dangerous MRSA bug, which is resistant to antibiotics.

More recent data suggest flu deaths among children have continued to rise, with 86 tallied for the 2007-08 season in a preliminary report last month, said Lyn Finelli, the study's lead author, who is a researcher for the Centers for Disease Control and Prevention.

Preliminary information also suggests there has been no drop in fatal flu-staph cases in children, and those could still be on the rise too, she said.

Staph germs commonly live in the nose or skin without causing illness; more than one-fourth of U.S. children and adults carry them.

These bugs can become deadly when they get into the bloodstream, sometimes through wounds. The flu is thought to make people more susceptible to bacterial infections like staph, Finelli said.

Details on how children in the study died were not available, but some developed bacterial pneumonia, seizures and shock.

Finelli said parents should take children to the doctor when they have flu symptoms and signs of other complications. These could include extreme fatigue, no thirst, or in older children complaints about feeling very ill.

Hand Washing: Time Well Spent

Reston Hospital Center has boosted its hand-hygiene compliance, which has led to a drop in the infection rate.

By Manoj Jain
Special to The Washington Post
Tuesday, August 5, 2008

One morning on hospital rounds, I saw a physician colleague enter the intensive care unit where a patient lay intubated and sedated. With his hands unwashed and ungloved, the physician palpated the patient's abdomen, scratched his own head and then placed his stethoscope on the patient's chest to listen to his heart. Then he walked to the nurses station, rubbed his nose and entered a note in the patient's chart.

There was nothing unusual about this. Not washing hands scrupulously remains common practice for professionals at most hospitals, even though abundant research shows that it controls outbreaks of infectious disease, reduces transmission of resistant organisms and cuts infection rates among hospitalized patients.

That same day in a public restroom, I noticed a man go straight from the urinal to the door, bypassing the sinks. Unfortunately, that's a common occurrence, too.

Despite recommendations, nearly 60 percent of health-care workers do not wash hands while on duty. Among the general public, according to a Harris Interactive survey conducted last year, 12 percent of women and 34 percent of men do not wash their hands after using a public restroom. Why?

For one thing, rigorous hand washing is time-consuming. Guidelines advise that we first rinse, then soap for 20 seconds, then rinse again for 30 seconds; after this, we paper-dry our hands and turn the faucet off using the paper towel. For health-care workers, the procedure is supposed to be followed before and after every patient encounter. That means two minutes per patient visit, which adds up to an hour for a doctor who sees an average 30 patients a day, and 2 1/2 hours per shift for an ICU nurse. I have yet to find a doctor or a nurse who is so diligent.

In the past few years, the hand-washing exercise has gotten simpler, with the increased acceptance of alcohol-based gels. I enter a patient's room, squirt gel onto my palms from the wall dispenser, then rub the back of my hands, my fingertips and my thumbs as I introduce myself and ask the patient why he or she is there. Then as I exit, I gel my hands again as I ask, "Do you have any questions?"

Despite the ease of using alcohol gel, studies show that nearly a quarter of health-care workers do not regularly disinfect their hands. Few realize that our bodies are like petri dishes teeming with 300 trillion organisms and that our hands are like swabs for the transmission of antibiotic-resistant bacteria such as MRSA, pseudomonas and C. difficile.

What can we do to improve hand-washing rates?

First, we must admit that the "Just do it!" approach of the past 150 years has failed. Behavioral theory tells us that changing behavior in a change-resistant culture cannot be accomplished with a single intervention.

We need a carrot-and-stick approach. Let the carrot be a campaign of incentives and awards for hand washers, similar to the eat-more-vegetables campaigns that many parents conduct with their children.

Then we need the stick. Health facilities need to monitor the hand-washing rate for each unit and provide feedback and improvement strategies to health workers at the bedside. Observers need to be stationed in ICUs and hospital wards, much like traffic cops at the bottom of a hill. Repeated failures to comply, as in the case of my physician colleague, would result in a letter to the offender and a note in his credentialing file or employment record.

Hospital administrators, not just their staffs, also need a stick over their heads. Starting in October, hospitals will be penalized for the consequences of unwashed hands: Medicare will no longer pay for complications arising from certain hospital-acquired infections, which in many cases result from poor hand hygiene. This will be a powerful incentive for health executives to improve hand-washing compliance.

An aggressive approach to hand washing has worked. At the University of Geneva, a hospital-wide program promoting hand hygiene helped lower the hospital-acquired infection rate from 17 percent to 10 percent between 1994 and 1998.

At Novant Health hospitals in Charlotte and Winston-Salem, N.C., a 2005 hand-washing campaign -- complete with billboards and computer screen savers -- brought about a sustained drop in MRSA and hospital-acquired infections. At Reston Hospital Center, an awareness campaign introduced in 2006 has boosted hand-hygiene compliance to more than 90 percent; it also led to a drop in the hospital's infection rate.

A 2007 study from John Hopkins showed that using simple checklists as reminders about basic hygiene such as hand washing and about proper draping, gloving and masking reduced the central intravenous line infection rate by 66 percent in ICUs.

About my physician colleague: I approached him and gently reminded him. "The patient likely has resistant bacteria -- it is really important that we wash our hands after every encounter." Suddenly self-conscious, he groped for the alcohol gel dispenser just a few feet away.

As for the man in the public restroom: I'm sure that I got his germs on my hands from the door handle.

Manoj Jain is an infectious disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:health@washpost.com.

10 Germy Surfaces You Touch Every Day

Experts Tell Where Cold and Flu Viruses and Other Germs Lurk
By JOSEPH BROWNSTEIN and RADHA CHITALE
ABC News Medical Unit
Sept. 5, 2008

Many surfaces and objects you come in contact with every day are covered in germs -- but then again, so are you. Many of the surfaces that we come into contact with on a daily basis are a breeding ground for dangerous germs -- including the viruses that can lead to cold and flu.

"Ninety percent of you is composed of germ cells," said Philip Tierno, director of clinical microbiology and immunology at NYU and author of "The Secret Life of Germs." He explained that while we are constantly in contact with germs, only a small minority will cause any harm. "Of the 60,000 types of germs that people come in contact with on a daily basis ... only about 1 [percent] to 2 percent are potentially dangerous to normal people with normal immunity," he said.

That works out well for us, because pretty much any surface contains some of these microscopic organisms. "There's very few surfaces that are truly clean," said Dr. Aaron Glatt, president and CEO of New Island Hospital in Bethpage, N.Y., and a spokesman for the Infectious Disease Society of America. "You're almost never going to culture something and not find some germs on it."

With that in mind, there is a simple activity that anyone can engage in to stay as safe as possible from surface germs.

"People should know that washing their hands is the single most important mechanism we have to prevent infection," said Glatt. While he stressed that "the optimal goal is to practice good personal hygiene, good household hygiene and good food hygiene," Tierno also noted the importance of clean hands. "You don't need to live in a bubble ... but you do need to be aware," he said. "You can touch surfaces, but just clean up before you eat or drink or before you touch your face." "If you wash your hands prior to touching your face or prior to eating or drinking, which should be the norm, you cut your risk to virtually nil."

Purses and Wallets:
Although they serve similar functions for women and men, purses and wallets are germy for entirely different reasons.
"It behooves you not to put your purse on the floor or outside ground if you can help it," said Tierno. But many women don't follow that bit of advice, so their purses pick up the bacteria from wherever they're placed -- from the soiled ground to the bathroom floor.

While some might be willing to put it there because they think the floors are cleaned regularly and thoroughly, that isn't always the case. "The way these places are cleaned is not ideal all the time," said Tierno. Instead, he recommends putting your purse on a bench or a seat.

Wallets, meanwhile, pick up a lot of bacteria from what goes into them."Men's wallets were pretty bad on the inside," said Charles Gerba, a professor of microbiology at the University of Arizona whose work has earned him the nickname "Dr. Germ."

Paper currency has a way of getting around, from germ-filled hand to germ-filled hand. It picks up germs, viruses and often trace amounts of illegal drugs -- that's not just an urban legend; several studies have confirmed that a majority of U.S. currency contains trace amounts of cocaine. And of course, all of that ends up in your wallet.

Because men keep wallets in their pockets, the wallet is close to body temperature -- an ideal temperature for bacteria to breed. "When handling the contents of your wallet, after it, wash your hands," said Tierno.

The problem isn't as bad with coins, largely because the metals -- particularly nickel -- often kill many of the bacteria.

Remote Control:
The next time you sit down for a late-night movie at home, you may want to keep your hand out of the popcorn bowl if you've been handling the remote. People are constantly handling their remote controls -- and, as Gerba points out, nobody ever disinfects them.

No wonder, then, that it is often the dirtiest object in a hotel room. Tierno recommends wiping it down at least once a week, and more often if someone who is sick handles it. Gerba points out that sickness will make the remote even worse, because people who have a cold or the flu tend to "jump in bed with the remote control and contaminate it."

The laundromat is hardly a bower of cleanliness, but even laundry done at home is rife with germs. There is about 0.1 gram of fecal material in a piece of underwear, Gerba said. That amounts to approximately 100 million E. coli bacteria in an average undergarment load.

Unfortunately, only 5 percent of people use very hot water to wash their clothes and then dry them for a full 45 minutes, a process Gerba said would kill more bacteria. Skipping these steps means that transferring wet clothing into a dryer leaves a film of germs all over your hands.

To minimize exposure to harmful bacteria, Gerba recommends doing laundry that requires bleach as a first load to disinfect the machines and saving undergarments for a final load. He also cautions against using the same sorting tables for clean and dirty laundry since the E. coli from the dirty clothes will transfer to the table and then back onto your freshly laundered clothes.

"Your clothes are a lot germier than they were 50 years ago," Gerba said. "Never kiss anyone who has just done laundry for you."

Foodwise - You may be better off preparing your food on another surface than a cutting board.

According to Gerba, there are 200 times more fecal bacteria on a cutting board than a toilet seat. The reason, he explained, is that many people rinse off their cutting board rather than thoroughly washing it. "You have potential pathogens when you're dealing with food," said Tierno. He recommended preparing a solution of a quart of water and "a jigger of bleach" and then wiping down food preparation surfaces before making anything on those areas of the kitchen.

Your Phone:
The telephone provides a convenient meeting place for two different sources of germs -- your hands and your mouth. After all, as Tierno, pointed out, "People are the source of most of the germs."These germs are not just from your hands, but sources like your saliva as well -- which is why the mouthpiece is often even dirtier than the handle.

And again, it's not a device people clean too often, which is why both land lines and mobile phones present a problem. A study done in Israel last year showed that 20 percent of hospital workers' cell phones had some form of harmful bacteria on them.

Buttons:
These innocuous-looking offenders are difficult to avoid, which is part of the reason why push buttons can be crawling with germs. Further, ubiquitous buttons, found on ATMs, elevators, telephones and drink machines, among other things, are located in areas that are not often cleaned and disinfected to kill bacteria and viruses.

Gerba noted that the first-floor buttons in elevators were the dirtiest."Everyone needs to go to the first floor," he said. Worse, these germs get transferred to the body part that comes in contact with faces the most -- fingers and hands. While avoiding these types of buttons can be almost impossible, Gerba does have a few recommendations. "Knuckle it or wait for someone else to push it for you."

Airplane Bathrooms:
"These are probably the worst," Gerba said. "They are the germiest restrooms you'll run across." But bathrooms in general are not as germ-ridden as other areas -- a kitchen sink or laundry machine, for example. Compared to several items on this list, toilets are a beacon of cleanliness because they are cleaned and disinfected on a regular basis, even public toilets.

Airplane bathrooms get cleaned, but the high volume of people they must cater to in a short amount of time leaves them very dirty very quickly.Gerba said a normal aircraft has one bathroom per 50 people. Discount airlines have one bathroom per 75 people.

"There is a thin layer of E. coli over the sink," and other surfaces, Gerba said, adding that many people, especially men, will not wash their hands effectively because the sink is small, and dirty hands transfer germs to the face easily. Interestingly, the cleanest toilets are probably those in public areas of a hospital, Gerba said.

Shopping Carts:
An individual probably has a fairly short interaction with the shopping cart at the local grocery store. Unfortunately, that interaction covers all the danger zones for contamination: hands, faces and food. In one study done by his group, Gerba said he found E. coli on almost half the shopping carts the group tested. These are the microbes and pathogens that are transferred from the cart to your hands, to the food you select and then to the face if the hands touch it.

In addition, children often sit in the seat provided in larger shopping carts, adding to the germ load on the cart. "That's putting a kid's butt where you put your broccoli," Gerba said. A shopping cart is a good example of an item where a quick wipe down with a disinfecting wipe and some alcoholic hand sanitizing gel recommended by the Centers for Disease Control and Prevention can prevent a lot of cross-contamination.

Prevention in a Pump

Sanitizers Give the Upper Hand Against Colds - by Dr. Clifford Bassett

From kindergarten through middle and high school, many schools and classrooms now have an abundant supply of donated liquid hand sanitizers.

These antiseptic gels are quickly becoming an additional level of protection between students and ubiquitous viruses, which, especially during the wintertime cold and flu season, are present on a variety of common surfaces.

Even the kids seem to notice a difference.

"Since we starting using liquid hand sanitizer in our school, my classmates seem to be healthier, with fewer kids getting colds," said Dylan, a seventh grader at East Side Middle School in New York City.

And in many ways, these sanitizers offer a low-cost, low-tech solution to a common, potentially costly seasonal problem.

Hand sanitizers are gaining popularity, as they are portable, easy to use and perfect for places where there is no faucet and sink available for hand washing, such as in the subway or on a train.

Thus far, several studies over the past few years have suggested that hand sanitizers do limit the spread of germs. In a September 2005 study in the journal Pediatrics, researchers showed that families who used alcohol-based gels had a 59 percent lower rate of gastrointestinal illnesses -- which cause diarrhea and vomiting -- caused by germs spread from one family member to another.

Other research has focused more on the germs that cause common colds and the flu, tracking rates of school absenteeism among kids whose families use the products.

As for my New York City based allergy practice, I have personally observed that among my employees and co-workers who aggressively use gel-based alcohol sanitizers, there has been a change in successfully avoiding the vicious cycle of recurrent cold-like infections. The goal is to reduce transmission of a variety of viruses, including the common cold as well as gastrointestinal infections.

The Centers for Disease Control and Prevention have recommended alcohol-based liquid gels over using soap and water, as long as your hands are not very soiled.

Not All Hand Sanitizers Created Equal -
One caveat: It is important to check the bottle for the level of alcohol in a sanitizer.

It is generally thought that it should contain at least 60 percent alcohol -- even better if the concentration is greater than 90 percent. Apparently, less potent solutions are not very helpful in killing the viruses that cause many household infections.

Of course, plain old soap and water is just fine if it's available. But this is not always the case when it comes to our busy lives -- especially bearing in mind that we will be taking on those pesky germs at home, school and work.

Nowadays, many different approaches are used in the fight against germs. We have "foam based" disinfectants, antibacterial soaps, cleaning wipes and aerosolized disinfectants. In a more vigorous environment, especially in health care or medical settings, iodine-based and other chemical disinfectants are frequently utilized for more robust infection-busting capability.

So now for the final question: Can hand sanitizers save you completely from cold and flu? The answer, most likely, is no. But just like conscientious hand washing, avoiding sick co-workers and maintaining a healthy diet may certainly help keep you well this holiday season.

Dr. Clifford Bassett is vice chair of the Public Education Committee for the American Academy of Allergy, Asthma and Immunology. He is also an assistant clinical professor of medicine and otolaryngology at the Long Island College Hospital in Brooklyn, N.Y.

Cheap Black Market Antibiotics- Bad Choice for Uninsured

No Prescription for Antibiotics? No Problem
By HOWARD MARKEL - Contributor to The New York Times

Jose Martinez, a 29-year-old Dominican immigrant who runs a bodega on the Upper West Side of Manhattan, almost always manages to find whatever his customers need on his store's bulging shelves.

When asked for medicine for an infection, Mr. Martinez often reaches for a box of pills called Ampitrex, a brand name for the antibiotic ampicillin.

The pills sell for 50 cents each and are easily bought at bodegas on the Upper West Side and in Washington Heights, East Harlem, Brooklyn, Queens and the Bronx.

Under federal law, ampicillin, like all antibiotics, requires a doctor's prescription. But Ampitrex is made in the Dominican Republic, where it is readily available and smuggled in small quantities into the United States. It is then sold in small markets much like over-the-counter pain relievers.

''In my country you can go into any store and get antibiotics like this one,'' Mr. Martinez said. ''This Ampitrex, it's 500 milligrams and absolutely pure. For throat pain, infections, it works by the next day. One to two days tops. Once you feel better, that's it. You're done taking the pills.''

Carlota Hurtado, 69, of Washington Heights said that getting antibiotics without seeing a physician, or even a pharmacist, was easy. ''Once in a while, when I have been sick with a cold or a sore throat, I have gone into a bodega to buy antibiotics,'' she said. ''I know a lot of people who when they are sick do the same thing. I take them until I feel better. When the cold goes away, I throw the pills away.''

Easy access to antibiotics is now common in certain areas around the nation, especially in border states. Dr. Richard Besser, director of the Campaign for Appropriate Antibiotic Use for the Centers for Disease Control and Prevention, said the sales at bodegas were only part of a much broader problem involving antibiotic overuse in America.

Many health officials are increasingly concerned. Antibiotics are prescribed only for bacterial infections. They are ineffective against viruses. Different antibiotics are used for different types of bacteria, so merely taking one does not mean it will cure an ailment. Taking the wrong antibiotic may cause worsened infections or allergic reactions.

Most antibiotics need to be taken for 7 to 14 days. When taken for only a few days, the likelihood of a mutation in a bacterium's genetic structure is increased. These changes can make the germs resistant to the antibiotics meant to kill them.

Unlike folk remedies, some of which may be toxic but pose a risk only to the person taking them, antibiotic misuse has far wider ramifications. For example, until recently, ampicillin was the drug of choice for infections of bacteria called streptococcus pneumoniae, a common causes of pneumonia and ear infections. But according to the C.D.C. about 35 percent of the strains of this germ across the nation are now resistant to ampicillin.

Dr. Stuart Levy, a microbiologist and the author of ''The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers,'' published this year, described antibiotics as societal drugs. ''Their use by an individual impacts others in the society because of the drug's ability to affect the bacteria in that community and to propagate resistant germs,'' he said.

''Over-the-counter antibiotics are more likely to be misused,'' he added, increasing the likelihood of resistance and the spread of resistant bacteria to others.

This problem often begins as a local phenomenon, he said, but the resistant germs spread as people move from place to place.

Dr. Jaime Lopez-Santini, a physician at Settlement Health, a nonprofit clinic in East Harlem, says his patients tell him they can get any antibiotic they want. ''By the time they come to see me with a sore throat,'' he said, ''they have already treated themselves with antibiotics they purchased at bodegas.''

Pharmacists like Orlando Cueva of Morningside Heights try to warn customers of the dangers of self-prescribed antibiotics, but often with poor results. ''Many people come in and ask for antibiotics, and I tell them that it requires a prescription from a doctor,'' he said. ''But they say: 'No, it doesn't. I can buy them at any bodega.' ''

An East Harlem pharmacist, Godette Wallace, said, ''You have to understand, these are very poor people, and they don't have the money to see a doctor.'' As a result, he added, they have to find other ways to get medicine.

Elissa Maas, vice president of community health for the California Medical Association Foundation, which researches health care for the state, said her agency had seen ''an antibiotic underground,'' extending from the Mexican border to northern California.

''In our focus groups, Chinese and Russian immigrants, as well as Latinos, spoke about the relative ease with which they can obtain antibiotics at small markets, even swap meets,'' Ms. Maas said.

In El Paso, Salvador Balcorta, who directs the Faith Family Health Center, a community health and human services organization, says that many people in the United States are just beginning to experience a phenomenon that is part of daily life on the border. ''When you couple the problems of poor access to health care and poverty with the ease of self-medication, you have a much bigger problem,'' Mr. Balcorta said.

Dr. Jeffrey Brosco, a pediatrician who sees many Cuban and Nicaraguan patients in Miami, said it was not enough to ask what medicines a child was taking or if he was taking home remedies.

''We also ask if the child is already taking antibiotics and, specifically, which antibiotic, and how frequently they are taken,'' Dr. Brosco said. ''Amoxicillin is the most common, but I have seen many others. All are self-prescribed and easily purchased.''

While the practice is illegal, it is extremely difficult to control. Dr. David A. Kessler, the former Food and Drug Administration commissioner, who is now dean of Yale Medical School, said: ''F.D.A. 101 tells us that this is illegal. No question. It is being sold illegally and shipped into this country in ways that don't comply with our laws.''

But practically, he added, the agency cannot go to every bodega, although it can go after the company that makes these antibiotics if they are involved in their distribution.

In New York, the sale of Ampitrex and other antibiotics without prescription goes largely unchecked. Spokesmen for the State Health Department, the New York City Health Department, the Drug Enforcement Administration, the State Board of Pharmacy and the State Education Department's Office of Professional Discipline all said that while they occasionally reported complaints to the state attorney general's office, they neither seized the antibiotics nor apprehended those selling them.

The New York City Police Department said it rarely, if ever, arrested people for the sale of antibiotics.

Dennis Murphy, a spokesman for the Customs Service, said seizing antibiotics at the borders was not a high priority.

Dennis Baker of the office for regulatory affairs of the F.D.A. said:

''Even when a local or state regulatory authority moves in to close down these operations, they tend to move to another location. It's very difficult to get our hands around this.''

Infection Risk Linked to Premature Delivery

Each year in the United States, more than half a million babies are born prematurely, before 37 completed weeks of pregnancy. Many pre-term births are induced labor or cesarean delivery due to pregnancy complications or health problems in the mother or fetus, the premature rupture of membranes (PROM), or infections such as vaginal or urinary tract. But the trigger of almost half of all preterm births remains unknown. However, researchers suspect that an undiagnosed infection may be the trigger in a significant number of these cases.

To better understand the role infection plays in preterm birth, researchers at Stanford University in California studied samples of amniotic fluid saved from 166 women who went into premature labor at the Hutzel Women's Hospital in Detroit from 1998 to 2002. At the time, doctors used standard tests to check for signs of infection, but doctors David Relman and Dan DiGiulio used more sophisticated molecular testing known as polymerase chain reaction (PCR). They discovered that of the 113 women who delivered prematurely, 25 showed infection-those with the heaviest infection delivering the earliest. "We were surprised with the amount of unexpected bacteria we found in the fluid and the fact we encountered new species of bacteria," said Dr. DiGiulio.

Dr. Robert Goldenberg of the Drexel University College of Medicine in Philadelphia was not surprised by the results and suspects that as scientists continue to study amniotic fluid with improved techniques many more pathogens will be identified, according to ScienceNews. "We only know the names of relatively a few of all the bacteria that exist, and a lot of them are difficult to culture or can't be cultured with our current technology."

The researchers say this is likely their findings are an understatement, considering that the samples were so old the DNA in them had begun degrading. Currently, Dr. Relman and his team are studying fresh, rather than stored, amniotic fluid from 2,000 women who get routine amniocentesis in their second trimester. They hope that by identifying the infections before they induce preterm labor or birth, they "could potentially create a treatment for these infections and prevent a lot or possibly all of premature births."

Premature birth is a serious health problem. Premature babies are at increased risk of developing a wide range of health problems, as well as lasting disabilities, which include cerebral palsy, mental retardation, neurological, lung and gastrointestinal problems, vision and hearing loss, and learning disabilities. Premature babies often require care in a neonatal intensive care unit (NICU), whose specialized staff and equipment can deal with the multiple problems these ‘preemies' face.

The Stanford study was reported in PLoS One, the online journal of the Public Library of Science.

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Increased Scrutiny Has Hospitals Focusing More on Safety

By Keith Darcé
UNION-TRIBUNE STAFF WRITER
August 9, 2008

Sharp HealthCare executives have spent the past two weeks trying to reassure the public that their hospitals are safe amid news that recent lapses in management and medical care at Sharp Grossmont caused the deaths of at least three patients.

They're not alone in that challenge. Hospitals everywhere are vulnerable to human error, and they've all had to deal with patient-care crises.

In the past 16 months, state and federal regulators have named at least five hospitals in San Diego County with serious problems that contributed to the deaths of five patients, including those at Sharp Grossmont, and put hundreds of others in harm's way.

Since the California Department of Public Health began issuing fines in January 2007 for “immediate jeopardy” mistakes – those causing death or grave injury – it has penalized 39 hospitals statewide.

Local hospital administrators have strived to reduce errors by boosting training for their staffs, hiring more workers who focus on regulatory compliance and borrowing ideas from the airline industry, where workers contend with pressures and risks similar to those in an operating room or emergency department.

GROWING SCRUTINY
Health regulators and the public are paying more attention to the quality of patient care at hospitals:

California regulators are imposing fines as high as $25,000 on hospitals for each “immediate jeopardy” mistake that endangers patients. They're also publicizing the penalties.

In October, Medicare will stop paying for the cost of treating many infections and injuries caused by hospital errors.

Consumers, emboldened by the power of the Internet, are increasingly choosing hospitals based on quality rankings and reports.

The administrators said significant mistakes at their facilities generally have not increased over the years, but that scrutiny and prevention efforts have.

“I don't think there is any question that hospitals are more focused on quality and safety than ever before,” said Chris Van Gorder, president and CEO of Scripps Health, which operates four hospitals in the county.

Two of the network's hospitals – Scripps Memorial and Scripps Green, both in La Jolla – have suffered “immediate jeopardy” cases since last year.

The other facilities with such incidents include Sharp Grossmont, UCSD Medical Center in Hillcrest and UCSD's Thornton Hospital in La Jolla.

Besides handing out penalties, California health regulators are drawing the public's attention to big hospital mistakes by issuing news releases.

Starting in October, Medicare will stop paying hospitals for the cost of treating many of the mistakes their doctors and nurses cause.

And consumers concerned about the quality of their medical care can tap dozens of Web sites to compare hospitals.

Other policies are helping to create an overall carrot-and-stick approach to making hospitals safer. For example, Medicare and a growing number of private insurers base some of their payments on hospitals' ability to meet or exceed quality standards for patient care.

The elevated scrutiny is transforming the way many hospitals operate.

Teamwork has become the mantra among doctors and nurses, who traditionally have been divided by strict codes of hierarchy. Also, some hospitals have asked patients to join their systems of checks and balances.

At Thornton Hospital and the UCSD Medical Center in Hillcrest, surgery patients go through a checklist with their doctors and nurses before receiving anesthesia. Among other things, the list is designed to ensure that the right person has the right operation.

It was modeled after safety checklists that pilots use before flying.

“The culture of silence and the culture of secrecy that used to exist in hospitals is being stripped away,” said Memphis-based hospital consultant Stephen Harden, a commercial airline pilot and former Navy Top Gun instructor.

He helps hospitals, including those in the University of California system, and physicians apply safety practices from the aviation world to their health care settings.

The higher level of monitoring will push even the best medical centers to do a better job of preventing errors, said regulators and some hospital operators. But they also wonder whether heightened attention to each “immediate jeopardy” case will help patients make better decisions when choosing a hospital.

“It's difficult for consumers to judge whether a particular problem is isolated or whether it's part of a series of events,” said Ken August, spokesman for the state Department of Public Health. “Trying to decide the quality of care of a facility strictly from news stories is difficult at best.”

Sharp HealthCare's four hospitals have always done as much as possible to keep patients safe, said Nancy Pratt, the network's senior vice president of clinical effectiveness.

“Every health care organization wants to fix these things. It's not a lack of interest or effort,” she said.

But for decades, hospitals largely didn't face outside pressure to improve patient care.


In California, the shift kicked into high gear in January 2007, when state regulators began issuing fines as high as $25,000 for each serious safety breach. Regulators are developing rules to double that limit, and there is a bill in the Legislature to raise the maximum penalty even higher.

Nationwide, the current drive to minimize hospital mistakes dates back to 1999, when the Institute of Medicine issued its landmark report “To Err is Human.” The study estimated that 98,000 Americans die each year because of hospital and physician errors.

The recent increase in federal and state requirements for hospital patient care suggests that regulators aren't satisfied with the pace and breadth of change, said Roy Snell, CEO of the Health Care Compliance Association, which represents 7,000 professionals who manage regulatory compliance for hospitals and physician groups.

Most health care organizations are proficient at identifying lapses, Snell said, but they often fall short when correcting a weakness that requires changing well-established routines or punishing specific staff members.

Part of the problem is that the people charged with enforcement and disciplinary actions frequently come from the same ranks of doctors and nurses who make the mistakes, he said.

One solution is to transfer those duties to regulatory compliance specialists.

In a recent survey, about 52 percent of the compliance association's members said their responsibilities include helping ensure the quality of patient care, Snell said. That represents a major shift since the association was created 12 years ago, when almost none of the group's members dealt with quality assurance.

But some health care providers worry about giving oversight of medical care to people lacking clinical backgrounds. They said those individuals might not fully understand the complex and technical nature of hospital medicine.

“The idea is to improve patient care, not to punish doctors,” said Dr. Gary Vilke, who heads UCSD Medical Center's peer review committee.

An increasingly punitive regulatory system runs the risk of discouraging hospitals from disclosing mistakes, said Debby Rogers, vice president of quality and emergency services for the California Hospital Association.

“There's a balance of creating an environment where reporting (errors) is rewarded,” she said. “The last thing we want is for people not to report.”