Infectious Disease Alert Updates
By Carol A. Kemper, MD, FACP
Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center
Candida auris Outbreak in Southern California
SOURCE: Karmarkar EN, O’Donnell K, Prestel C, et al. Rapid assessment and containment of Candida auris transmission in postacute care settings — Orange County, California, 2019. Ann Intern Med 2021;174:1554-1562.
Quietly, in 2018-2019, Candida auris was introduced and quickly spread among southern California long-term acute care facilities (LTAC) and ventilatory-capable skilled nursing facilities (vSNF). Before long, an outbreak was in full swing, involving 182 cases at nine different facilities.
Previous to this, only two cases of C. auris, both urinary isolates, had been detected in California. But beginning in October 2018, laboratory surveillance began to detect C. auris in random urine specimens in southern California. By February 2019, C. auris was detected in a patient in a vSNF in Orange County.
Within a month, point prevalence surveillance was begun in 17 facilities in the area, initially identifying 44 additional patients in three LTAC and six vSNF. Surveillance was expanded, patients were tested at discharge from a facility, and clinical specimens were examined for suspicious yeast. Point prevalence surveillance continued every two weeks at any facility with an identified case, and then monthly for those with negative surveillance for two consecutive testings two weeks apart.
By October 2019, 182 cases of C. auris had been identified, confirming ongoing transmission within and between facilities. The median age was 72 years (range, 29 to 93 years). A majority of the patients were non-ambulatory (73%), and many were dependent on tracheostomies and gastrostomy tubes. Fourteen (8%) patients developed clinical infection, including infections of the blood stream (43%), urine (21%), and wounds, abdominal abscesses, drains, and respiratory specimens (14% each). By January 2020, 22 of 182 patients (12%) died within 30 days of identification of C. auris, and 47 (26%) died within 90 days, although only one of these deaths was directly attributed to C. auris.
At the same time, investigation revealed critical gaps in infection prevention, environmental cleaning and disinfection, respiratory therapy practices, and hand hygiene, which were rectified. Follow-up assessments demonstrated improvement in cleaning practices, better signage, chart labeling, and improved hand hygiene rates. Improved infection prevention practices and ongoing surveillance were able to limit the outbreak to just two facilities.
Whole genomic sequencing of 81 available isolations revealed they were all highly related within clade III, indicating the outbreak likely began with a single unrecognized case, with fairly recent transmission between the nine facilities. Susceptibility studies of 137 isolates showed them all to be azole resistant (fluconazole minimum inhibitory concentration (MIC) ≥ 32 mcg/mL) and echinocandin susceptible. Ten (7%) were amphotericin resistant (MIC ≥ 2 mcg/mL, confirmed by Etest), confirming multidrug resistance.
There is an urgent need for enhanced surveillance for C. auris in acute care and long-term care facilities throughout the United States. State and local governments should work to improve infection control and environmental cleaning in LTACs (and provide sufficient educational resources, guidance, and funding). Further, there is a need for proactive national interfacility communication and notification for patients colonized and infected with multidrug-resistant/extremely drug-resistant organisms.
Healthcare Worker Vaccine Mandates
SOURCE: Emanuel EJ, Skorton DJ. Mandating COVID-19 vaccination for health care workers. Ann Intern Med 2021;174:1308-1310.
“The mutual dependence and reciprocal interest which man has upon man, and all the parts of civilised community upon each other, create that great chain of connection which holds it together.”
— Thomas Paine, Rights of Man, 1791.
Twenty months into the COVID-19 pandemic, and the United States is still wallowing in arguments about vaccine mandates, including those specifically directed at healthcare workers (HCWs). As of October 2021, only 21 of 50 states (42%) require either vaccination or routine testing of HCWs. Only six states mandate “vaccination or termination” for HCWs, barring an acceptable medical or religious exclusion. Nine states have laws actively banning employers from mandating vaccination.
It was not until August 2021 that the federal Department of Health and Human Services (HHS) mandated vaccination for 25,000 members of its own workforce, and as of Nov. 3, 2021, the White House announced that the Centers for Medicare and Medicaid Services (CMS) would require HCWs working in any facility providing care to such patients to be fully vaccinated — covering 17 million workers and 76,000 acute care facilities. Within a week, 10 states filed a lawsuit in the U.S. District Court for the Eastern District of Missouri, alleging that CMS does not have the authority to regulate vaccination, and the court granted a preliminary injunction Nov. 29, 2021.
Although all acute care health facilities, rehabilitation centers, and long-term acute care facilities are required to report HCW influenza vaccination rates to the National Health and Safety Network (NHSN), no specific requirement for influenza vaccination, or for any other vaccine (e.g., hepatitis B virus), for HCWs exists. So why mandate this vaccine and not others, such as influenza? For years, the healthcare community has tacitly recognized a low level risk of nosocomial transmission of influenza and other respiratory viruses from HCWs to patients. However, the frequency of nosocomial exposure was low, the risk of mortality from influenza is low (~0.02% to 0.03% for H1N1 influenza in 2009), and antiviral treatments are available. In contrast, COVID-19 appears to be more transmissible than influenza, nosocomial exposures are frequent, the mortality rate is higher (~1% to 1.4% in the United States), and effective treatments are lacking.
What are the arguments in favor of mandatory COVID-19 vaccination for HCWs?
1. These authors argue that first and foremost, HCWs have an ethical obligation to “do no harm” and to protect their patients and their patients’ families. This includes everyone working in a healthcare capacity, from the administrators to the janitors. Masking HCWs is helpful at reducing risk, but masks are designed to protect the wearer — and provide lesser protection when exhaling/talking near another person. So, while personal protective equipment (PPE) is helpful for protecting the HCW, it does not adequately prevent transmission to patients (who are unmasked).
2. Secondly, HCWs have an obligation to set an example and promote healthy behaviors. Much has been made about the real and imagined risks of the various COVID-19 vaccines. But if 17 million HCWs stand together in their willingness and acceptance of the real but tiny risk of COVID-19 vaccination, it can only serve to make others in the community more accepting. HCWs understand and can interpret the data about vaccine efficacy and risk far better than anyone else in the workforce and can serve as examples to their families and communities.
3. Mandates increase vaccine rates.
I would like to add the following to these arguments:
- We, as a society, and HCWs in particular, have an obligation to protect those who cannot protect themselves, including the developmentally disabled, the elderly, and the infirm. The very patients at greatest risk from COVID-19 infection are the least likely to have an adequate immune system response to vaccination. We place elderly patients in nursing homes, ostensibly for their safety. And yet, The New York Times reported on Oct. 21, 2021, a 69% vaccination rate among nursing home workers, and a rate of less than 60% in 10 states. In our county, mortality from COVID-19 infection for people 70-79 years of age is 21.8%, and for the very elderly (85 years and older) it is 35.2%. Although many individual nursing homes have mandated vaccination for their staff, some are waiting for a federal mandate.
- Available therapies for COVID-19 are often ineffective. When nosocomial exposure occurs, even the best supportive care may not be sufficient to guarantee survival. After 20 months of COVID-19, we know that nosocomial outbreaks often are not started by infected patients, but by employees with community-acquired infection. This risk can be decreased with HCW vaccination.
- HCWs don’t just have an obligation to protect our patients, but to protect each other.
- HCWs have an obligation to be first in line for vaccination — and to be willing to possibly accept more risk — not only because we are at greater risk for exposure, but because we should be the first on that field. That is our job. There is a shared and proud history of HCWs being the first in line.
- Mandates and deadlines can help HCWs who procrastinate, dawdle, or who are sitting on the fence. I heard one HCW say, “I was glad someone made the decision for me.” For those who may see grief at home for the decision, it takes the decision out of their hands.
- Vaccination preserves the workforce. With our first COVID-19 patient, 82 HCWs were exposed, and 70 were furloughed for 14 days. Within a day — and a single unrecognized patient — half of our intensive care unit nurses, three critical care physicians, and half of our respiratory therapists were sent home. It quickly became apparent to everyone that hospitals were going to run out of staff. Vaccination not only reduces the risk of acquired HCW infection, but vaccinated employees exposed to COVID-19 are followed and offered testing — and they can continue to work. Unvaccinated employees with exposure still are furloughed. Facilities cannot function if essential staff are unable to work.
- Vaccination reduces the workload on Employee Health and Infection Prevention. In our facility, both departments have spent hundreds of man hours following up on patient and HCW exposures — requiring individual assessment of risk, exposure, PPE, vaccination, and counseling. Despite SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) screening before all procedures and for all admissions, exposures continue to occur. It is a huge amount of work. But much of that work is reduced if the workforce is vaccinated.
- Vaccination promotes camaraderie and well-being among the staff. If you know a colleague has chosen not to be vaccinated, how does that make you feel? In a very real way, their choice affects others working on the unit.
Candida auris Outbreak in Southern California; Healthcare Worker Vaccine Mandates
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