Preventing respiratory infections and antibiotic resistance. According to the CDC, acute respiratory infections such as pneumonia and influenza are still the primary cause of infection-related deaths and the eighth leading cause of death in the U.S.3 The CDC supports yearly influenza vaccination for prevention for everyone 6 months of age and older,4 as well as good respiratory and hand hygiene and avoiding sick contacts.5 Healthy People 2020 set a target goal for influenza vaccination for children and adults at 70% (the baseline was less than 50%) but has set a higher goal of 90% for health care workers.6 Other suggested vaccines to decrease the morbidity and mortality associated with respiratory infections for infants, children, and adults include Haemophilus influenzae type B (HIB), pertussis, and pneumococcal. The CDC maps active surveillance of seasonal outbreaks of influenza by reports from physicians, laboratories, and hospitals to help with infection control (cdc.gov/flu/weekly/fluactivitysurv.htm). In January 2015, the CDC reported an epidemic in the US for the 2014-15 flu season because protection by vaccination was lower due to the new variants of influenza A H3N2 viruses.
The CDC also likens hand washing to a “do-it-yourself” vaccine for preventing many infectious diseases, especially upper respiratory infections and diarrheal pathogens. The CDC recommends using soap and running water, scrubbing for 20 seconds and thoroughly drying your hands, especially after blowing your nose, using the toilet, and before preparing food and eating.7 For health care workers in the U.S., the Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient care in health care settings that may involve exposure to blood and other body fluids. It does not allow health care workers to wear artificial nails and mandates that a provider’s hands must be decontaminated before direct contact with patients, following the recommendations from the CDC’s Guidelines for Hand Hygiene in Healthcare Settings8 or the World Health Organization’s WHO Guidelines on Hand Hygiene in Health Care (cdc.gov/handhygiene/Guidelines.html).9 Universal precautions for all health care workers include hand washing before and after every patient contact and the use of personal protective equipment (gloves, gowns, and eye protection) as indicated before exposure to body fluids, along with appropriate patient isolation to prevent and contain infectious diseases. For highly infectious diseases such as Ebola, special training is required in the use of personal protective equipment (PPE) with guidelines and a video (cdc.gov/vhf/ebola/hcp/ppe-training/index.html).10
Since the 1980s there has been an emergence of multidrug resistance in infectious diseases such as Staphylococcus aureus and Clostridium difficile. This has often been attributed to the overuse or misuse of antibiotics.11,12 Clostridium difficile is a health care-associated infection causing diarrhea and has been linked to 14,000 U.S. deaths each year, with that primary diagnosis in health care settings more than tripling from 2000 to 2009.13 Clostridium difficile is transmitted via a fecal-oral route and is a toxin-producing, Gram-positive anaerobic bacillus that forms spores resistant to many commonly used cleaning agents or germicides. The spores can remain on hands or environmental surfaces for months. Due to the increasing incidence of C-difficile infection, a recent meta-analysis of antibiotics showing the risk of community-associated C-difficile infection found that it could be reduced by lowering exposure to high-risk antibiotics and by proper infection control measures applied to nursing homes, ambulatory care settings, and hospitals.14
Acute respiratory infection, a common diagnosis in primary care, is cited as the most common reason for inappropriate use of antibiotics. The CDC reported that 58% of the antibiotics prescribed to children younger than 14 years old in the outpatient office setting were for diagnostic codes of acute respiratory infections, such as the common cold and other respiratory viral illnesses that most often do not require antibiotics.15 One of the core measures that the CDC has advocated for preventing drug-resistant infections and decreasing the use or need for antibiotics is to promote immunization, infection control in health care settings, and general hand washing. Patient and public education on when antibiotics are and are not indicated for common respiratory viral illnesses, as well as the dangers of taking an unnecessary antibiotic or failing to take the antibiotic as prescribed, may help reduce inappropriate prescribing. Providers can also use rapid flu tests to help with the diagnosis, prescribe appropriate antiviral medication if needed, and reassure the patient if results are negative. The CDC offers free patient informational brochures for patients and the providers such as Cold or Flu. Antibiotics Don’t Work For You.16 Also, in the health care setting, practices should display reminders of the importance of respiratory and hand hygiene for patients and health care workers, offer face masks, tissues, and safe disposal areas, and triage sick patients isolated in the waiting areas to decrease the spread of disease to others.
Prevention by vaccination. Vaccines confer active immunity by exposing the host to an antigen that stimulates the production of antibodies, with the immunity lasting for years up to a lifetime. Prior to vaccines, many infants and children died from childhood diseases such as whooping cough, polio, measles, Haemophilus influenzae, and rubella. Consequences of inadequate and delayed vaccinations for children include the spread and recurrence of previously eradicated diseases, loss of herd immunity, and increased health care costs.17
Measles is a highly contagious, but vaccine-preventable, viral disease that was declared eliminated in the U.S. in 2000.18 However, with increased parental opposition to immunizations for children, and with the advent of increased international travel, outbreaks have occurred. Given that the measles vaccine is highly effective (94% for one single dose and greater lifetime immunity for the complete series), measles outbreaks in the U.S. are often cited as indications of a weakness in our immunization program.18 A person infected with measles is capable of infecting 12 to 18 other people if the contacts are susceptible. The fatality rate associated with the disease from the complications has been estimated at a low of .2% in the U.S. and as high as 15% in undeveloped countries.18 In the U.S., from January 1 to August 24, 2013, there were 159 cases of measles. Of those, 92% were unvaccinated or had unknown vaccination status, and 26% of the cases were imported. Two-thirds of the cases were in communities “with pockets of philosophical or religious exemptions.”19 In North Carolina, an outbreak of 23 cases occurred “mainly among persons not vaccinated because of personal belief exemptions.”19
When children who are eligible to be immunized do not receive the vaccination, the public and individuals who are immune-compromised are at risk because of the loss of the “herd” effect. The cost burden to contain an outbreak is also very high to taxpayers supporting their health department’s communicable disease investigations. A 2004 outbreak in Iowa of three confirmed cases that identified 1,000 contacts was estimated at $140,000; another outbreak of three confirmed cases in two Arizona hospitals was estimated at $800,000.18 Most recently, a measles outbreak investigation has been linked to an amusement park in California with 178 reported cases from 17 states and the District of Columbia from January 1 to March 27, 2015.20
Our nation’s Healthy People 2020 program has set a target vaccination rate for children at 95% for MMR, poliovirus vaccine, hepatitis B, and varicella vaccine. All states have laws regarding required immunizations to attend public schools to protect the public, with the allowance of exemptions. Schools report this information, and health departments and primary care providers can follow up in communities with high rates of unvaccinated, at-risk populations to educate parents on the protection that vaccinations provide.
Vaccination rates for children in kindergarten in the U.S. for the school year 2013-14 were reported as follows:
In 49 states and the District of Columbia (DC), median vaccination coverage for three vaccines was 94.7% for the MMR vaccine, 95.0% for varying local requirements for the diphtheria, tetanus toxoid, and acellular pertussis vaccine, and 93.3% for varicella vaccine among states with a two-dose requirement. Of the 49 states and DC reporting vaccination coverage estimates, 27 did not report meeting the Healthy People 2020 target of 95% coverage for two doses of MMR vaccine. Median exemption levels continue to be low overall (1.8%).21
There are many safety myths regarding vaccinations, especially a false association between MMR and autism that requires public education and debunking. Effective management strategies for improving vaccination rates in the U.S. population include a personalized and consistent patient education message by a trusted provider about the seriousness of these diseases and the safety of the vaccines. Other strategies include the use of electronic medical records (EMR), patient and provider reminder systems, social marketing, and educational outreaches, especially about the safety myths and the elimination of the personal belief exemption from all states.22,23,24 The CDC and the Institute of Medicine (IOM) have information on vaccination schedules and safety available on the CDC website.25
Recommended adult vaccines that may be indicated based on age and/or medical indications include influenza, tetanus, diphtheria, pertussis (Tdap), varicella, human papillomavirus (HPV), zoster, MMR, pneumococcal, meningococcal, and hepatitis A and B. Recommendations and the suggested schedule can be found on the CDC website.26