The tie that binds: ICPs a vital link in a small world’ of emerging infections

"Every person is a new door, opening up into other worlds."
John Guare’s play, Six Degrees of Separation

In an increasingly small infectious-disease world characterized by speed, connectivity, and globalization, infection control professionals are emerging as the critical link between clinical care and public health, said Julie Gerberding, MD, director of the Centers for Disease Control and Prevention (CDC).

"Infection control professionals are the strong link in the communities between health agencies, health care organizations, clinicians, and laboratorians," she said recently in Phoenix, at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

"In fact, in many communities, you are the only link; so [you] are an important component of our overall approach. The small world network model — the concept of connectivity, globalization, and speed — creates very important challenges for us as leaders of public health, APIC, and the infection control world," Gerberding explained.

Delivering the keynote address before some 3,500 ICPs, she acknowledged her deep roots in infection control by saying at the onset, "It’s great to be home." Gerberding directed the old CDC hospital infections program before being fast tracked to the top of the agency, in part, because she was a calming voice of reason during the 2001 anthrax attacks. Now, in response to terrorism, medical epidemiology and criminal investigations are so overlapped that there actually are peer-reviewed papers co-authored by the CDC and the FBI, she noted.

"FBI agents and field investigators and public health epidemiologists are going to training exercises to really learn how to work together effectively and accelerate the information in advance of an attack but also during an attack," she said.

Under Gerberding’s leadership, the CDC is in the process of reinventing itself with its Futures Initiative, and ICPs will play a key role in the changing public health network. For example, when severe acute respiratory syndrome (SARS) turned into a global outbreak in 2003, infection control professionals in the United States were instrumental in guiding their local community response.

"Clearly, knowledge management is what you do in the health care setting," she said. "You are technical experts. You have unique skills, capabilities, and knowledge that you have to disseminate to the practitioners, clinicians, and administrators in your domain. With SARS — and I am using SARS as an example, but you could take any health threat — lots of information emerged immediately on-line in various formats in the middle of the crisis. Very often the infectious disease physician, the hospital epidemiologist, and the infection control nurse took this information as it was boiling off the computer and translated it into specific plans and action steps that could be utilized at the front lines."

That particular form of knowledge management — taking real-time information and quickly turning it around to local action — is becoming an increasingly important role for ICPs, she said.

"At the front line, you are very often the only person who has the capability of translating that information into effective action," Gerberding said. The CDC is trying to assist ICPs in this regard by providing more quick-time interim infection control and disease guidance.

"We don’t have to go through a complex clearance process, which takes weeks. We can turn information around within hours if we need to," she said.

"This is one way that CDC is learning to be faster and try to put decision-support tools in your hands as quickly as possible. I don’t know if you have any idea how hard it is for a government agency to be fast, but I must say CDC has really evolved in this direction. We can do many things fast, [but] we don’t want to sacrifice scientific creditability for the sake of speed, so that is always the balancing point," Gerberding noted.

The ICP as the alert clinician 

While ICPs must rapidly accumulate and dispense information, they also are critical in detecting a new threat at the onset, she added. "We [talk] a lot about the alert clinician as the early warning system for events like SARS or terrorism," Gerberding said. For example, an Italian physician alerted the CDC very early in the SARS outbreak that there was a staggering 56% attack rate among hospital workers in Hanoi.

"[That] caused us at CDC to set up our emergency operations center because, as you know, there is no disease that has an attack rate like that in the health care setting," she pointed out. "So something had to be new, and that really caused us to move into full action. [Similarly], the alert infection control professional is critical to this enterprise."

Gerberding said she was struck by the infectious disease toll on the Third World as she begins to travel widely as the CDC director.

"We are at the dawn of the era where infection control really is a global enterprise," she noted. "I have seen something in every single country I have visited that has told me how important health care epidemiology and infection control is in the developing world."

Beyond the humanitarian concerns, there is the real-world knowledge that infectious diseases anywhere can spread to anywhere else. But Gerberding clearly thinks U.S. medicine has lost some of its beside manner, noting that a recent article found that the average physician listens to patients only about 18 seconds before interrupting and presumably cutting the interaction short.

Within their own health care settings, she urged ICPs to be caring patient advocates who actually interact, listen, and — presumably with hands washed — touch patients.

"When is the last time you actually touched a patient?" she asked APIC attendees. "Not saw a patient, passed by a patient, looked at the patient’s room or their infection control environment. But actually laid a hand on a patient, to touch them, to serve as that strong tie of humanitarianism and true caring in the health care setting. That is usually missing in health care, because nobody has time to do it, least of all busy ICPs. But it is the most important tie so if you can it only once a year, it is still a strong tie to the whole small world of the health care environment to that one patient and that patient’s family. I am on wards at San Francisco General right now because, in part, I feel I am losing that caring perspective and have to go back and recover it. We can all to more to be the tie that binds the system."

Six degrees of separation

As a unifying concept throughout her talk, Gerberding returned again and again to the classic sociology theory of "six degrees of separation."

"The theory is — and has been tried in sociological experiments — that if you know one person and you ask that person who they know and who those people know, there is usually only six degrees of separation between the person you first talked to and the ultimate target, whether it’s Elvis Presley or George Bush," she said.

While the general theory is well-known because of John Guare’s play and a subsequent film, there is actually a scientific basis for the phenomenon through a concept called weak ties.

"Weak ties in the [terms] of sociology are people who may spend most of their time in their community but occasionally they jump over to some other community," Gerberding explained. "They are a weak tie that links the highly clustered part of the small world with another highly clustered part. So they serve as a shortcut. They transmit information or familiarity, or in the case of diseases, they move the disease from one sub-population to another."

Weak ties and the SARS outbreak

For example, the weak tie in the global SARS outbreak was the physician who traveled to a Hong Kong hotel and infected other weak ties who took the disease back to their communities.

"We can even hypothesize that there is some animal, perhaps the civet cat, that served as the weak tie to move the corona virus from the transmission pattern in the animal kingdom to the transmission pattern in the human population," she said.

"This is very interesting to think about because it tells you some prospective things that need to be done. Whenever there is a new problem, we need to be thinking about the weak ties because that is our best chance for intervention," added Gerberding.

Both health care workers and patients functioned as weak ties during the SARS outbreak, enabling the virus to move to other settings. "Sometimes, we saw patterns where this was a health care worker who worked in more than one facility; sometimes, it was a patient who was moved from one facility to another. But clearly, these were weak ties that set off additional cascades of transmission."

In terms of zoonotic infections, monkey pox found a weak tie last year in asymptomatically infected Gambian rats, which infected prairie dogs that then transmitted it to humans. An unintended consequence of the CDC’s rapid response to that outbreak is a growing population of wallabies on the "farm," a CDC animal holding area outside of Atlanta.

As a way to quickly stop spread of the outbreak, the CDC purchased exposed animals — including wallabies — from a store in the Midwest called Pete’s Pocket Pets, Gerberding explained.

"Unfortunately, we don’t know much about wallaby contraception, so we have an [expanding] colony of wallabies," she said. "Weak ties, small world."