Testimony by Jane Siegel, MD
Joint Legislative Committee on Aging
Oct. 13, 2016
Charge # 1 Examine strategies for preventing and controlling outbreaks of Influenza and bacterial Pneumonia disease in Texas’ Long Term Care Facilities. Evaluate whether existing public health and prevention policies, reporting requirements meet or exceed quality standards, as well as identify any tools and actions the state can foster in antimicrobial stewardship.
Thank you for the opportunity to comment on the issues related to infectious diseases and long-term care (LTC) facilities. My name is Dr. Jane Siegel, and I am a pediatric infectious disease physician, specializing in pediatric health care epidemiology and infections in immunocompromised individuals. Since 2008, I have served as chair of the Texas Advisory Panel for Prevention of Healthcare Associated Infections and Preventable Adverse Events. I also was a member of the Centers for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee for eight years, from 1996 to 2004. I have had experience with long-term-care-type facilities as medical director of the Corpus Christi State Supported Living Center for Adults With Intellectual and Developmental Disabilities. I’m here on behalf of the Texas Medical Association, which represents more than 49,000 physicians and medical students.
We appreciate your interest in long-term care facilities. Residents of LTC facilities are at high risk for certain infectious diseases, in part because of their existing medical conditions, including advancing age, and in part because a residential facility is a setting in which infections are more likely to be transmitted. We know that there are effective measures can be put in place to reduce the burden of certain infectious diseases in these facilities due to increased contact among residents.
As we enter influenza season, it is timely to discuss opportunities to strengthen our response to outbreaks in LTC facilities. Influenza is a disease that disproportionately impacts the health of older residents of long-term care facilities — often requiring hospitalization and sometimes leading to death. According to CDC, the risk for complications and hospitalizations from influenza are higher among persons 65 years of age and older, young children, and persons of any age with certain underlying medical conditions. An average of more than 200,000 hospitalizations per year are related to influenza, with more than 60 percent occurring in persons older than 65 years. A greater number of hospitalizations occur during years when certain strains of influenza are predominant. In nursing homes, attack rates may be as high as 60 percent, with fatality rates as high as 30 percent.
While we can remain diligent in our efforts to prevent influenza by good hand hygiene like washing with soap and water, using alcohol-based antiseptic hand gels and the like, a new resident, health care personnel, or a visitor can easily introduce influenza into a facility. And it only takes two or more ill residents to indicate a potential outbreak. While outbreaks are required to be reported to public health authorities, it is critical for facilities to have a relationship and plan with local or state public health agencies before any outbreak. Resources for surveillance, testing, and chemoprophylaxis medications for patients and healthcare staff should all be prioritized. LTC facilities should be recommended to develop plans to have either on-site capability for rapid influenza testing or access to 24-hour, off-site turnaround with a contracted lab. When plans are already established, responses to outbreaks can be quicker and more effective.
Understanding who may be at highest risk during a potential influenza outbreak is critical in an effective response. In part, we could better understand this if we can measure vaccine coverage at each facility. Currently Texas long-term care facilities are only required to offer influenza vaccine each year to residents and staff and the two recommended pneumococcal vaccines to all residents and staff members who are 65 years of age or older or, if younger than 65 years, have other conditions for which these vaccines are recommended. Each health care facility in Texas is also only required to create and implement an employee vaccination policy. There are no required specifications as to the content of a facility’s vaccine policy. Facilities are already required to keep a record of receipt of or exemption from vaccination for employees and residents. However, state-level collation of this coverage information and making aggregate data available could help public health awareness of how well facilities are in terms of promoting and implementing vaccination and monitoring vaccine coverage. Patients and families will be better informed on facilities’ success in achieving best public health practices.
Other infectious agents that may be transmitted in LTC facilities are managed more effectively when the presence of certain agents is known. This is especially true with serious infections such as those caused by multidrug resistant organisms (MDROs). The Texas Department of State Health Services (DSHS) has been analyzing and helping manage MDRO outbreaks in long-term care facilities in Texas. Currently, however, residents may be transferred to and from acute-care facilities without any communication to the receiving facility about the MDRO colonization or infection status of the patient. Requiring transfer forms to include a patient’s known MDRO history is essential to communications to an accepting facility, whether it is another LTC or an acute-care facility. This can help identify opportunities to prevent the spread of an infection through a community and protect others from acquiring these difficult-to-treat infections. As antibiotics are among the most frequently prescribed medications in nursing homes, these settings can play a key role in state and national efforts to reduce the threat of antibiotic resistance. This issue seriously impacts all citizens, regardless of their connection to long-term care facilities.
In my experience, it is often difficult for people to understand the threat posed by multidrug resistant organisms. The following factors summarize the impact of uncontrolled MDROs:
- If MDROs become prevalent, we could face the situation where we have NO effective antibiotic to treat serious infections in patients and therefore experience excessive death rates.
- MDROs travel with patients as they move into the many different facilities in the community where health care is provided (e.g., acute-care hospitals, LTC facilities, ambulatory clinics, dialysis units); therefore, control plans must be community-wide.
- There are two strategies, which together, prevent the increase of MDROs:
a. Infection control: Prevent transmission among patients. This requires knowing when someone who is known to have an MDRO is present in a facility.
b. Antimicrobial stewardship: Use appropriate antibiotics only to treat bacterial infections according to established guidelines for best drug, best duration.
At the national level, the president established a commission to develop a work plan for controlling antimicrobial resistance that encompasses LTC facilities. The CDC has provided a toolkit for controlling antimicrobial resistance in LTC facilities. In addition, the Centers for Medicare & Medicaid Services recently issued a final rule making major improvements in the care and safety of the nearly 1.5 million residents in the more than 15,000 LTC facilities that participate in the Medicare and Medicaid programs (announcement attached). These changes represent the first comprehensive update since 1991 and represent a response to the increased complexity of the LTC facility population and in the knowledge that has accumulated in the fields of resident care and quality assessment practices. This rule addresses “updating the long-term care facility’s infection prevention and control program, including requiring an infection prevention and control officer and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.”
At the state level, several states have enacted legislation that requires improved communication to receiving facilities concerning MDRO status. Texas can help by ensuring facilities’ infection control programs have the resources to appropriately use antimicrobials to treat infections while at the same time reducing microbial resistance. Requiring the addition of known MDRO information to the currently existing transfer form would be one important step to contribute to prevention of MDRO infections.
In addition to resources, facilities also must have the tools and education on how to apply antimicrobial stewardship activities in Texas facilities. DSHS and the Texas Health and Human Services Commission should be required to develop a statewide plan for better stewardship of antimicrobials. This should focus on fostering communication among public and private health care settings. DSHS should conduct physician, provider, and facility education campaigns.
TMA stands ready to work with this committee and members of the LTC community to implement steps that could have tremendous positive impact on the aged all across Texas. I am happy to answer questions at this time.