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Dear all,
Please find attached the Australian Influenza Surveillance Report no. 15
2011 for the period of 1 October to 14 October 2011.Of note:
Across all surveillance systems, influenza activity this fortnight has
continued to decrease.
Levels of influenza-like illness (ILI) activity at the community level
during 2011 were consistent with previous seasons, excluding 2009.
During the 2010/11 inter-seasonal period, all jurisdictions reported
higher than usual numbers of notifications, especially in the Northern
Territory and Queensland. The reason for this unusually high activity is
not clear, but do not appear to be due solely to increased testing. Duringthis period, most of the influenza activity was attributed to pandemic
(H1N1) 2009 and A(H3N2) infections.
The main 2011 winter season, commenced and peaked earlier than in previousyears and nationally, the majority of virus detections were pandemic
(H1N1) 2009, with co-circulation of influenza B. The timing of influenza
activity peaks and the distribution of influenza subtypes varied across
states and territories.
At the beginning of the winter season there was a high proportion of
influenza B reported, mostly from South Australia, and very little
A(H3N2). In recent weeks the proportion of A(H3N2) has continued to
increase, with notifications mostly reported from Queensland, Western
Australia and the Northern Territory.
As at 16 October 2011, there have been 25,092 confirmed cases of influenzareported to the National Notifiable Diseases Surveillance System (NNDSS)
in 2011. Nationally, weekly notifications for this season peaked in the
week ending 5 August 2011 with 1,989 influenza notifications.
Whilst the peak in notifications was above the peak frequency experienced
in previous years, except 2009, assessment of this peak in conjunction
with other surveillance systems monitored highlights that this difference
in activity was not significant.
During the season around 84% of influenza related hospitalisations were
associated with pandemic (H1N1) 2009 (42%) or influenza A(untyped) (42%).
Thirteen per cent of persons hospitalised with influenza were admitted to
ICU.
The WHO has reported that influenza activity in the temperate regions of
the northern hemisphere remain low. Influenza activity in the tropical
region is active in a few countries. In New Zealand, rates of national ILIconsultations continue to remain below baseline activity levels.
The Australian Influenza Vaccine Committee (AIVC) has agreed to adopt the
WHO recommendations for the composition of the 2012 southern hemisphere
influenza season vaccine. The recommended viruses are the same as the
current 2011 southern hemisphere and the 2011-2012 northern hemisphere
vaccine compositions.Please note, this will be the final Australian Influenza Surveillance
Report for 2011, unless unusual activity becomes apparent over the summer
months.Thank you very much to all the influenza surveillance systems that
contributed to this report during the season.A summary version of this report will shortly be available on the web at
the following address:
http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-ozflu-flucurr.htmIf you have any questions, comments or feedback please reply to
flu@health.gov.auKind regards,
Influenza Surveillance Team
| Vaccine Preventable Diseases Surveillance | Health Protection &
Surveillance Branch | Office of Health Protection | Department of Health
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Posted on to OZBUG 20 October (was rejected by AICA list initially ). Some ozbug replies below. Full conversation will be on a HICSIG talk page later. Would welcome discussion!
Dear OZBUG and AICA list members,
This is what we’ve come up with in our health service and I would be interested to compare/ get comments from others about their local practices etc. Additionally, we are evolving a set of ‘House rules’ for common clerical areas in wards – also reflected below. I think it is essential that we evolve a standardised, detailed, efficient and safer standard for ward round practice etc.
One suggestion that we have re training – make it required to complete mandatory training (eg. hand hygiene) prior to sign-off of any period of education/study leave. At one of our large hospitals this has been amazingly effective! we are considering general implementation.
best wishes
JohnPRACTICE POINTS FOR MEDICOS
HAND HYGIENE
Please set a good example with this critical patient safety practice. Use the correct method for applying alcohol rub to all parts of the hand – see the last page of the attached HNE report for the action sequence. Dont forget to do your training annually! http://www.hha.org.au/LearningPackage/medicallearningpackage.aspx.
During clinical work, do NOT to wear anything on your hands
Wrist watches and bangles are discouraged – they must be removed prior to any procedure
Hand disinfection is still required both prior to putting gloves on & after taking them off for a procedure or body fluid exposure risk situation (eg. taking a wound dressing down)
Hand hygiene prior to patient contact should be done AFTER closing the patients curtain (or get someone else to close it- assume that it is highly contaminated)CLOTHING STANDARDS
Bare-below-the-elbows is the safest standard to follow as it facilitates good hand hygiene practice – sleeves, scarves or coats all act as fomites and become heavily contaminated quickly during average day of clinical contact. The old idea that a suit, coat and/or neck tie engenders respect is outmoded from the microbial and patient safety points of view
Wear a clean shirt/blouse every day
Launder or dry clean woollen jumpers/jacket coats at least weekly; it is best NOT to wear these during clinical care unless you can roll up the sleeves
Lanyards, neck ties, and unsecured long hair should be avoided entirely – all have a potential to act as fomites
Scarves, hijabs and other headress should be cleaned daily and their ends secured.EQUIPMENT, FOMITES, WARD ROUND PRACTICE
Use large alcohol wipes to clean and disinfect all examination equipment PRIOR to use on patients- this includes stethoscopes, tendon hammers etc.
Mobile telephones, pens, identity cards are usually heavily contaminated with hospital pathogens. Refrain from touching them during a clinical interaction and clean them frequently for your own & your patients protection
Ensure that your stethoscope is not cracked or damaged and has no cloth or plastic labels on it
Refrain from touching your hair, clothing, the curtains or the patient environment prior to contacting the patient during a clinical interaction
Avoid sitting on patient bedsideand Control Unitsms.ative bacteria and infection due to resistant pathogens such as MRSA, Clos. Avoid placing medical charts on the beds. For rounds involving a few patients, take a trolley for the clinical records. Ask one of the team to be the scribe. This person should then avoid contact with the patients environment or bedside chart.
Bedside charts are part of the contaminated patient environment and should remain at the bedside. It works best for the person who examines the patient to also look at the bedside chart.SUGGESTED HOUSE RULES FOR SHARED CLERICAL WARD AREAS
(these get discussed amongst each ward team (including JMOs/Registrars) and responsibilitities are agreed/assigned by the Nurse Manager)
These areas are highly contaminated with hospital pathogens eg. Norovirus, MRSA, VRE, multi-resistant Gram negatives and the like. For your own protection, never consume food in these areas!
1. A home for all forms and sheets: each type should have their own labelled (predictable) place- this should be standardised in every ward if possible. If the shelf labels are peeling off or absent, get the labeller and fix it! Remember this will save you time!
1. Daily clear away: loose papers, request forms, faxes, coffee cups, roles of tape, clips, used pens etc- all should go into the bin. Restore order! Remove mouse pads – little need for these. Remove old notices and any adhesive tape from the benches.
1. Daily cleaning and disinfection: once the clutter is cleared, use large alcohol wipes to clean:
* Bench tops
* Phones buttons, handset and its saddle
* Computers- keyboards, mouse, tops of screens, computer boxes and leads.kept under desk .1. Bedside charts: these are heavily contaminated with patient pathogens. They should remain at the bedside and not be jumbled with patient notes or taken to shared clerical areas.
1. Patient notes: if these are taken on a ward round, then they should be kept separate from the patient environment. Take a trolley that can act as a support for writing the notes. The note writer should not contact the patient environment.
While I am at it, Craig Boutlis and I put together a list of 10 commandments for physicians which may be of interest: http://www.asid.net.au/hicsigwiki/index.php?title10_infection_prevention_commandments_for_medicos
Clearly a long way to go.
Dr John Ferguson
Director, Infection Prevention & Control, Hunter New England Health
Infectious Diseases Physician, Division of Medicine, John Hunter Hospital
Clinical Microbiologist, Hunter Area Pathology, Pathology North
Conjoint Associate Professor, University of Newcastle, University of New England
Locked Bag 1, Newcastle Mail Centre, NSW 2310
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 | john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.org26th October:
This posting above led to quite some debate about evidence levels etc and whether I was proposing to audit clothing standards etc.
I’d previously suggested that a plain wedding band was ok- have deleted this from above and have stopped wearing one!Additional reply from JF 20 October to OZBYG reply postings:
I think that there are persuasive reasons why a precautionary principle is indicated and I think that the medical profession (esp ID people) should get much more strongly behind processes to improve both hand hygiene compliance and other hygienic measures. The hand hygiene compliance, behaviours and clothing standards of many doctors in our health service really do let the team down; this is becoming even more evident to patients and others as the nurses improve. If doctors are to improve then I think we (ID folk) need to adopt high, consistent standards that provide that example. Without understanding that HH is one component standard precautions and a whole medical asepsis equation, practice can degenerate in to just a glib splashing of rub. It is possible to adopt a system of care that protects patients more effectively without taking any greater amt of time.
The indirect evidence equation, explained in greater detail in a recent review (In ICHE )is:
1. There is mounting evidence that even minor env contamination per se is sufficient to place patients at risk from colonisation and subsequent infection (VRE, MRSA, C diff, MRGN)
2. Contamination of clothing and fomites with similar hospital pathogens is well demonstrated, occurs quickly and is highly prevalent
3. Fomites (including clothing) are no different to a contaminated environment in terms of the potential for causing patient contamination. Actually they may have a greater potential than other room / env contamination in that they come in to close contact with patient skin etc.. Long sleeved shirts and trousers definitely come in to frequent contact with the patient and their env if care is not taken. Pinned ties still pick up hospital flora and cross contaminate the ubiquitous stethoscope around the neck, which usually dangles at crotch level.
In essence, there is really no difference between patient contact by a fomite or a transiently contaminated hand.Moreover , most patients do not wish to be contaminated with hospital pathogens- they expect hygienic care and are truly frightened by the unhygienic habits of most doctors (and others).
From another point of view, the adoption of a different dress standard, especially say for an ICU or Theatre, can make people step more easily in to a different behavioural norm. In northern Europe , many hospitals now require healthcare staff to change in to short sleeved scrubs upon arrival, wherever they work. The hospital wards do not have the feel of a usual outside environment and staff are more likely to adopt a range of other recommended behaviours. We’ve done this in our neonatal and adult ICUs and it seems to make a difference. Visiting staff have to leave their coats and paraphenalia etc at the door.
With plain wedding band , compared with a studded ring, one can still effectively spread alcohol rub over all hand and ring surfaces which is impossible otherwise. No rings definitely for procedures and a better standard is no rings at all but then again is it impt enough in comparison with other larger issues?
Trousers- daily laundering makes sense, however with care (nb stethoscopes) one can avoid contacting trousers with patients or their env (hence the need not to sit on beds etc). The only way to make it happen is to use laundered scrubs. Phones, pens etc are a potential problem if they get used by the bedside.
THe underlying politics about the house rules are that most nurses are tired of tidying up after the doctors etc and no-one wants to take responsibility for these common areas which frequently contact patient care equipment, hands, stethoscopes etc. Of course there will never be good evidence to assoc contamination of these areas with patient cross transmission. However for personal safety, work efficiency and professional reasons it makes sense for hygienic order to prevail. Mouse pads- no need for these with optical mice- the language was ambiguous!
John
I think John’s point is not to debate journal artciles and evidence and jewellery design, but that it is important to set clear expectations and standards for professional including hygiene for everyone caring for patients.
We all know that multi-pronged approaches are what is required to facilitate complex behaviour change in humans – whether that behaviour is bringing green bags to the shops, recycling or hand hygiene. This must include having good positive role models supporting clear cultural expectations (as John’s suggestion), removing barriers (like available hand rub as mentioned below), rewards for compliance and disincentives for deviation etc etc etc.
Also pretty clear that by itself, education based purely on evidence is unlikely to be very effective in supporting change for most people, and even more so when the evidence base is incomplete.
So – I’m a bit over debating evidence of sleeves, rings etc and think we should have moved on.
I think John’s examples are great ideas, love the 10 commandments, and will be trying something similar in the patch I have some influence over.
Would be great to see if anyone else has some innovative ideas for improving doctor hand hygiene – preferably that they’ve tried and evaluated – to share.
Kind regards
Helen
Helen Van Gessel
ID physician, acting regional medical director WA Country Health Service, Great Southern
On 20/10/2011, at 7:28 PM, “Trent Yarwood” <trentyarwood@gmail.com> wrote:
> An article looking at short-sleeves was presented at our journal club
> earlier this year:
>
> Burden et al, J Hosp Med 2011; 6(4),177-182 DOI: 10.1002/jhm.864
>
> They concluded that surgical scrubs (and by extension, freshly
> laundered civvies) become rapidly colonised, to the point that
> bacterial counts are not different to infrequently laundered white
> coats. Interestingly, they also measured bacterial counts on the
> inner wrists of the wearers and also found no difference; ergo it is
> washing your hands (and wrists) and not what you wear above them that
> is important.
>
> The exclusion of wedding rings from the bare-below-the-elbow policy
> has always seemed silly to me. There is no magic antibacterial
> quality of a wedding band that makes it less likely to trap bacteria
> than any other piece of jewellery and this has been confirmed in some
> trials (doi:10.1016/j.ijnurstu.2008.02.010) and refuted in others
> (doi:10.1308/003588408X242051). My wedding ring is mixed white and
> yellow gold and there is a small ridge around the join, so the
> argument that they are flat and therefore don’t trap crud is not
> always valid. It is for social reasons that wedding bands are
> excluded from these sort of policies and I think we have to
> acknowledge that.
>
> While I agree with most of Prof Ferguson’s points in the OP, I think
> that our interns are already burdened with hundreds of things that
> someone from every department thinks is “the most important thing you
> need to know” and a list this long will be lost in the noise (the
> internet slang for this is tl;dr : “too long; didn’t read”).
>
> I think emphasising hand hygiene using the five moments and making
> hand-rub universally available is pragmatically going to achieve more
> than adding to the huge number of things the interns have to remember.
>
> Trent Yarwood
> ID Registrar
> Cairns
>
> Conflicts: Long-sleeves, rolled below the elbow. Clean shirt every
> day but not always new trousers. No tie (even pre-Cairns), Tie-clip on
> my lanyard. Wears wedding ring and watch. Only pinches wrapped
> chocolates from the nurses stations. Last cleaned my stethoscope this
> morning.
>
> —
> Trent Yarwood
On Thu, Oct 20, 2011 at 4:07 PM, Mary-Louise McLaws <m.mclaws@unsw.edu.au> wrote:
Dear Allen
Annette Pantle (when she was with the Clinical Excellence Commission) and I examined the evidence and politics for bare-to-the-elbow and we concluded in 2009:
Guidelines for uniforms/work clothes which was released by UK DH in Dec 2007 was based at that time on only 2 unpublished literature reviews plus expert input from HCWs and trade unions (this could be called eminence-based rather than evidence-based).
This literature was concluded that wearing short sleeves was based on cuffs become heavily contaminated and are more likely to come into contact with patients. Evidence for no ties listed as common sense that it is poor practice to. Because ties are rarely laundered but worn daily. They perform no beneficial function in patient care and have been shown to be colonised by pathogens1. Guidelines on laundering garments worn during patient care – advised that laundering should be with warm water wash with detergent will remove pathogens including MRSA. Allen, if this is good enough for shirts then I guess pants should be included!
2. Opposition to the UK policy came from 2 sources:i. Concern that public prefers to see their HCW dressed professionally (surgeons)
* Observant Muslim HCW believed that it is immodest to bare forearms in public. Female Muslim radiographer in UK resigned over requirement to comply with policy however policy supported by local Iman and trust chaplain (ref http://news.bbc.co.uk/2/hi/uk_news/england/berkshire/7593827.stm), although I believe Muslim scholars have considered this and have no objections to rolling up sleeves.
1. CDC guidelines released in 2002 recommended keeping natural fingernails trimmed and no artificial fingernails or extenders. No recommendations were made about wearing rings in healthcare settings – I believe this was due to social reasons and remained unresolved when we were looking at the evidence (back in 2009) although at the time there was evidence of bacterial colonising skin under rings which may not be removed with usual hand hygiene practices.1. We suggested that our standard should at least consider all staff to be bare below the elbows whilst undertaking hand hygiene different nuance to remaining bare below the elbows.
M-L
Professor M-L McLaws, Professor of Epidemiology in Healthcare Infection and Infectious Diseases Control
School of Public Health & Community Medicine| Samuels Building| The University of New South Wales|SYDNEY NSW 2052 AUSTRALIAI’d imagine that the reaction that our staff would have would be to ask “what is the evidence supporting these recommendations?”
For example, why would a ring on the 4th finger of the left hand be any less likely to become contaminated than a plain ring on any other finger? How often do you need to change mouse pads?! Does it really matter whether you have a new shirt each day if you don’t wear a new pair of pants each day?
(I wear a wedding ring and change my shirt each day)
Allen
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