CDC unveils updated plan for emerging infections

ICPs can play key role in surveillance, prevention

The Centers for Disease Control and Prevention has issued an ambitious new plan to combat emerging infectious diseases, calling for wide-ranging clinical and public health partnerships to meet threats ranging from antibiotic resistance to bioterrorism.

"CDC can’t implement this plan alone," says Susan Binder, MD, one of the primary authors of the document and associate director for medical science in the CDC division of parasitic diseases. "It is going to require the combined efforts of many different disciplines and organizations. Certainly, the infection control practitioners, the managed care organizations — everybody who delivers health care — we see as part of implementing this plan."

Indeed, ICPs can make important contributions to the success of the plan due to their critical position within an expanding health care continuum, emphasizes Patti Grant, RN, BSN, MS, CIC, infection control professional at RHD Memorial Medical Center and Trinity Medical Center, both in Dallas.

"We see so many people, not only in acute care but also in extended ambulatory care and the clinic systems so many of us are having to incorporate into our practice," she says. "As frontline practitioners, we can have a large impact on the success of this program, at least in the United States."

Updating the CDC’s 1994 emerging infections plan, the new document has been published in a condensed overview format. An unabridged version is available by mail or via CDC Web sites on the Internet.^1-3 (See editor’s note on p. 167 for information on how to obtain these documents.) The updated plan outlines specific objectives and goals to upgrade infection surveillance, expand research, and bolster prevention and control efforts. The plan focuses on nine target areas for action, including antibiotic resistance and diseases that cross international boundaries through travel and immigration. (See goals and targets, p. 168.)

"The aim of this plan is to build a stronger, more flexible U.S. public health system that is well-prepared to respond to known disease problems, as well as to address the unexpected, whether it be an influenza pandemic, a disease caused by an unknown organism, or a bioterrorist attack," the CDC states in the plan. ". . . Because no one knows what new diseases will emerge, the public health system must be prepared for the unexpected."

Avian flu looms large

In addition to the host of emerging and re-emerging infections cited in its 1994 plan, the new document cites several recent infectious disease threats among the events that prompted the CDC to issue the updated version. Those include the emergence of the first human infections with the H5N1 avian influenza A strain in Hong Kong last year, an event that raised the specter of a global flu pandemic similar to the one that killed 20 million people in 1918. (See Hospital Infection Control, March 1998, pp. 33-39.) Likewise, in 1996 and 1997 respectively, the first documented infections with Staphylococcus aureus with intermediate resistance to vancomycin were reported in Japan and the United States. (See HIC, October 1997, pp. 145-152.)

"If drugs like vancomycin cannot be replaced as they lose their effectiveness — or if the emergence and spread of drug resistance cannot be limited — some diseases might become untreatable, as they were in the pre-antibiotic era," the CDC report states. "In addition, the recent discovery that a strain of the virus that causes HIV/ AIDS has been infecting humans at least since 1959 illustrates how infectious agents can remain undetected for years before emerging as public health problems. Each of these incidents underscores the need for a public health infrastructure that is ready to address whatever disease problems that might arise."

In addition, the CDC plan emphasizes the importance of emerging infections that cross international boundaries via travelers, immigrants, and refugees. International air travel has increased substantially in recent years, and more travelers are visiting remote locations where they can be exposed to infectious agents that are uncommon in their native countries, the CDC reminds. In that regard, it has become increasingly important to assess a patient’s travel history to detect the geographic movement of infectious diseases, says Arnold Monto, MD, a consultant on the CDC plan and professor of epidemiology at the University of Michigan in Ann Arbor. For example, Monto cites a case where a patient — who had been camping recently in the southwestern United States — initially confounded clinicians at a Boston hospital when he was admitted with swelling lymph nodes and other symptoms of an ancient disease of the "re-emerging" variety.

"They didn’t realize he had plague," Monto says. "So taking a good history in terms of travel is very important."

Along those same lines, an act of bioterrorism may be first detected by clinicians at various hospitals who piece together common factors in a series of incoming infected cases.

"Basically, it’s going to be up to infection control people who see unusual illnesses to keep a high index of suspicion for infections which they might not ordinarily associate with their geographic area," Monto says. "When something turns up, they very definitely need to report it."

Funding remains an issue

Given the formidable challenges outlined and the far-reaching goals and objectives required to meet them, funding for the plan may be as critical a factor as any infectious agent. "This is not funded per se," Binder says. "This is not a plan to spend money we have. This is an identification of activities that need to occur. That is going to depend on funding to a large extent. [But] everything in there, we think, should be carried out."

By the same token, the CDC plan underscores the annual costs of infectious diseases, including an estimated $4.5 billion in hospital charges due in nosocomial infections (1992 dollars). "I think that identifying some of these issues as high priorities is really critical," Binder says. "Antimicrobial resistance is a great example of one that has to be tackled. It cannot be tackled as a series of infection control programs in individual hospitals, given the movement of patients between hospitals, long-term-care facilities, communities, and home health care."

Indeed, heightened communication and other improvements in infection surveillance and prevention become more important as the line between clinical care and public health continues to blur.

"We used to be able to more easily segment hospitals vs. communities," Binder says. "As that boundary between the two begins to disappear, we need to think about infection control in different ways and control of resistant organisms in different ways. That is part of what the plan is acknowledging."

In that regard, more interaction and communication between clinical settings and public health departments is occurring in Texas, where state health officials have added significant emerging pathogens such as vancomycin intermediate-resistant S. aureus to the list of reportable conditions, Grant says. By the same token, public health officials are communicating more directly with health care professionals working in clinical settings, she adds.

"Just last week I got a fax from Austin related to an eastern equine encephalitis case which occurred in a nearby county," Grant notes. "That was not occurring two years ago. Our health department here is making an effort to contact ICPs as soon as possible. We know who each other are. I have the phone numbers to Dallas County [health department] memorized."

(Editor’s note: Copies of the plan are available from the Office of Health Communications, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Mail Stop C-14, 1600 Clifton Road, Atlanta, GA 30333. The plan can also be accessed from the NCID home page on the Internet at http://www.cdc.gov/ncidod/publicat.htm.)

References

1. Centers for Disease Control and Prevention. Addressing emerging infectious disease threats: A prevention strategy for the United States. Atlanta: U.S. Department of Health and Human Services, Public Health Service; 1994.

2. Centers for Disease Control and Prevention. Preventing emerging infectious diseases: A strategy for the 21st century. Overview of the updated CDC plan. MMWR 1998; 47(No. RR-15):1-14.

3. Centers for Disease Control and Prevention. Preventing Emerging infectious Diseases: A Strategy for the 21st Century. Atlanta: CDC, in press.