CDC director: Toll of HAIs unacceptable

Some 3,000 attendees gather for decennial conference

The staggering burden of health care associated infections (HAIs) in lives and dollars is "unacceptable," but changing the status quo is difficult because the health care system is woefully skewed toward treatment rather than prevention, Thomas Frieden, MD, MPH, director of the Centers for Disease Control and Prevention, said recently in Atlanta at the opening of the Fifth Decennial International Conference on HAIs.

"The toll of HAIs is unacceptable," he said. "One in 20 patients in U.S. hospitals each year becomes infected. There are an estimated 100,000 deaths annually, $33 billion dollars in medical costs, longer hospitalizations and we don't [even] know what the burden is outside of hospitals."

Addressing some 3,000 attendees from 74 nations, Frieden said sharply reducing HAIs could be a critical benefit of health care reform efforts in the United States.

"We know that reducing health care infections is going to require political will and sufficient funding," he said. "Prevention is a 'best buy' in the health sector. HAI prevention is particularly a best buy because the cheapest ICU admission is the ICU admission that didn't happen. As health reform moves forward, one of the important early wins will be a substantial reduction in HAIs."

Noting that many HAIs were simply viewed as inevitable when he was in medical training, Frieden acknowledged some of the growing number of success stories of infection preventionists driving rates toward zero. However, he contrasted those gains with the bleak statistics on infection prevention measures already known to be effective.

"Only about a third of hospitals are in compliance with key guidelines," he said. "Hand hygiene is the exception rather than the norm, [and] surgical antimicrobial prophylaxis remains at much lower levels than we would like. And to make it all worse, the at-risk population is growing as our population ages. As obesity increases it increases the risk of things like surgical site infections."

Massive federal initiatives to reduce HAIs in recent years — including slashed reimbursements for preventable infections — are making slow but promising progress, he said. The undermining bottom line is that the health care system still doesn't have enough built-in incentives to prevent infections. A striking example came in questions and comments from the audience about program cuts and a general de-emphasis of infection prevention efforts in some hospitals. This at a time when HAIs are about as bright on the national radar as they've ever been.

"In our health system as it is structured currently, the incentives are very problematic," Frieden said. "We pay more for more care, but we don't pay more for more prevention. This is what our reimbursement system has done to the health care system."

IPs should make every effort to show where their programs have decreased infection rates and reduced costs while improving patient outcomes, he advised. "The problem is really with our broader health care system — we don't measure prevention effectively and we don't incentivize it," he said. "I'm optimistic that with the impending changes in the health care system that can change."

Defends respirator decision

While conceding that some aspects of the H1N1 pandemic influenza A response "could have been better," Frieden defended the widely criticized decision to recommend N95 respirators to protect health care workers.

"We followed a process that was open and transparent," Frieden said. "There had been a recent Institute of Medicine review that we looked at carefully. We are now looking at the issue again, and we will be back in the next few months with a position on that. We can go back and look at different aspects of the response – it certainly could have been better and we need to do that — but I think the big picture is that the public health system at the local, state and federal level responded rapidly and effectively to minimize disease, disruption and death from H1N1."

In response to a question about the issue by Hospital Infection Control & Prevention, Frieden primarily emphasized the positive aspects of the pandemic response. After diagnosis of the first U.S. case on April 15, 2009, the CDC rapidly distributed flu tests, provided treatment guidelines and emphasized infection control measures, he stressed. "We provided community guidance that actually changed behavior on how people washed their hands, covered their coughs and whether they went to work when they were sick," Frieden said.

Nevertheless, many pandemic response planners and infection preventionists view the respirator decision as a serious mistake, arguing that there were inadequate supplies of the N95s and health care workers were much more likely to be compliant with surgical masks. On the other hand, the CDC was under considerable pressure from health care unions and worker safety advocates to hold to the more stringent measures.

"There are some that might say it was a false alarm or it wasn't that bad — and certainly it could have been a lot worse if the case fatality rate of H1N1 had been much higher," he said. "It was not a mild pandemic at all. It caused about 250,000 hospitalizations in this country, killed 12,000 people — five times as many children and young adults as a normal flu season would. It caused enormous destruction and dislocation and public health responded very effectively. Everyone who worked on that — tens of thousands of people throughout the country — deserve the credit for the effective response."