Tuesday Jan 20, 2015
Need for Infection Control Not Going Away Anytime Soon
The holidays may be past, but 'tis still the season … for rampant viral upper respiratory infection, that is. Let's take a look at some numbers:
- According to CDC estimates, influenza-related illness kills more than 50,000 Americans(www.cdc.gov) every year. This flu season promises to be especially virulent; as of Dec. 30, it had already been classified as an epidemic(www.cdc.gov).
- Last year, California had its worst outbreak of pertussis in 70 years with more than 9,000 reported cases. In 2012, the CDC received reports of 48,277 cases of pertussis nationwide(www.cdc.gov), including 20 pertussis-related deaths, the most since 1955.
- The common cold leads to 110 million physician visits annually at a conservative cost estimate of $7.7 billion per year(archinte.jamanetwork.com). Overall, Americans spend $2.9 billion on OTC drugs and another $400 million on prescription medicines to relieve symptoms of simple upper respiratory infections.
It's clear from these statistics that infectious disease is everywhere. From the air we breathe, to the food we eat, to the surface of our skin and mucous membranes, microorganisms outnumber us by multiple powers of 10. And although only a fraction of those organisms are infectious, infection is still a leading cause of morbidity and mortality.
Employers who require workers to obtain doctor's notes for sick days are using a tactic that runs contrary to the idea that isolation is critical to infection control. Such policies leave employees with the choice of going to work when ill or going to a doctor's office for a condition -- such as a common cold -- that may not require treatment.
Thanks to scientists such as Koch and Semmelweis, we've known for many years that the microorganisms that cause these diseases propagate in numerous ways, but they can be stopped, or at least contained, by good infection control measures. Isolation. Sterilization. Simply keeping away from other individuals when we are ill is often enough to prevent a potential epidemic.
As primary care physicians, we live on the front lines of the infection control war. From encouraging patients to cover their coughs to disinfecting our offices and washing our hands, family doctors set the example for preventing transmission of bacteria and viruses. Encouraging appropriate and timely vaccination ensures that the most susceptible among us (the very young and the very old) will be protected should an outbreak occur. Our offices need to accommodate the separation of sick and well patients, preventing the spread of airborne pathogens to otherwise healthy patients. Some offices even have isolated negative-pressure areas for those with upper respiratory infection, although a quick literature search yielded no data on efficacy.
With limited time and resources to spend with each patient, it's imperative to make the education component of our visits count. In my practice, I use a practiced, five-minute dialogue during which I review the anatomy and physiology involved in most head colds (from nose to pharynx to larynx to trachea) and discuss why symptoms occur. I also draw stick drawings of the anatomy for patients as I go and allow time for questions. I occasionally use Google image searches to pull up more artistic or even real anatomical images. However, you accomplish it, the key is giving the patient information that makes sense and gives insight to the disease process. Even from patients who are just there for a "sick note," I can't count the number of times I've heard something like, "I learned more in that 15 minutes than I ever have during a sick visit."
And speaking of sick notes, this is one of the most common requests in my office -- and, I'd wager, in many of yours -- because many employers require proof of a doctor visit to account for any missed work days due to illness. Aside from the fact that this practice begs a study to look at how many unnecessary appointments it generates each year, this requirement runs counter to the ideas above -- that relative isolation is a key to infection control. Patients go to work sick, thus endangering their co-workers, for fear of being punished for missing work.
There may be no easy answer, and without data, we'll never begin to change policy. However, one Canadian practice has implemented a novel protocol that may curb the demand for sick notes in its community: charging employers a per-note fee(www.cbc.ca).
One final note: I'd honestly like to meet the person who came up with the idea that early intervention would prevent a head cold and discuss the ramifications of this falsehood. What I've found is that providing patients with tips for managing the initial symptoms of most infections helps prevent the mad dash to the office on day two of what appears to be a viral upper respiratory infection. I created a handout with a few OTC medications like ibuprofen, benzocaine lozenges and nasal saline, as well as some simple tips to control symptoms. I encourage patients to hang it in their medicine cabinet or bathroom at home and use those interventions for the first three to four days, with the caveat that they can always come see me anytime they feel the need.
Empowering autonomy with a safety net of care seems to pervade the literature on patient-physician relationships, and this approach offers patients some degree of control over an otherwise uncontrollable situation. At the same time, it decreases the number of sick patients -- typically at the height of transmissibility -- sitting in the waiting room alongside young children and elderly patients.
Lets' face it: Until we find a cure for the common cold -- which is neither common nor a single entity, so good luck -- infection control will remain a big part of our job all year round. As new physicians, we need to overcome the mistakes of the past, educate our patients on the evidence, and seek to study and learn as much as we can about adequate infection control and treatment.
Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.
Posted at 11:10PM Jan 20, 2015 by Gerry Tolbert, M.D.