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21. Infectious Disease Under the rubric of infectious disease, witnesses gave testimony on several different conditions, each with its own strategy for prevention. Forty-four witnesses addressed infectious disease as a primary or secondary area of concentration in their testimony. Several others, particularly health department representatives, identified needs or objectives in infectious disease as part of more extensive statements. Infectious diseases result in approximately 2 million years of life lost before age 65; 52 million hospital days; and nearly 2 billion days lost from work, school, and other major activities each year. The estimated direct cost is more than $17 billion annually, in addition to lost workdays and other indirect costs.t Testimony made clear that although much of the nation's public health focus is on prevention of chro- n~c disease, there are important targets to meet in reducing the incidence of infectious disease. Some conditions that received more attention in the past because of epidemic rates or outbreaks, such as tuber- culosis and legionnaires' disease, require sustained or renewed attention. One important issue that emerged, for example, is the recent increase in tuberculosis after a long period of decline. It is especially impor- tant to address this because of the widespread view among the public and some health professionals that it is a disease of the past. Several witnesses attribute at least a part of the increased rate of tuberculosis to the spread of AIDS and human immunodefic~ency vi- rus (HIV) infection, which depress the immune sys- tem. (#034; #177; #201; #580J Although campaigns to immunize all school chil- dren have done a considerable amount to reduce childhood communicable diseases-and continuation and expansion of these campaigns are viewed as vital to future success-efforts to immunize very young children, some targeted groups of adults, and the elderly have been much less effective. The influenza vaccine costs only $2.50 per dose and is "very cost effective," yet rates are far below the 1990 objective of vaccinating 60 percent of older adults annually. (#247) To reach the target audience, Outreach programs will be required," says William Carter of the Seattle Veterans Administration Medical Center, and "these programs will have to address the motivational issues underlying people's reluctance to obtain flu vaccine." (#247) The hepatitis B vaccine, too, is 164 Healthy People 2000: Citizens Chart the Course widely available, yet many in high-risk groups do not avail themselves of the opportunities for immuniza- tion. Testimony also made clear that continued, sustained efforts are needed to combat infectious diseases posing persistent public health problems. For example, the country has yet to achieve the reduction in hospital-acquired (nosocomial) infections that officials say is possible through preventive stra- tegies. According to Michael Jarrett, Commissioner of the South Carolina Department of Health and En- vironmental Control: Due to change in reimbursement and in practice patterns, only the sickest of patients are now in the hospitals. There are fewer patients in the hospital but their severity of illness has increased. These patients are individually more vulnerable to infection than the typical patient of 5-10 years ago. However, this is due as much to reimbursement changes as it is due to the increased sophistication of medical technol- ogy. (#108) Another recurrent theme in the testimony worth emphasizing is the need to improve reporting and data collection. Suggestions in this area were diverse, but all pointed to the important role of surveillance and dissemination of data in preventing infectious disease. IMMUNIZABLE DISEASES Several witnesses addressed goals related to increased immunizations. For both older adults and very young children, immunization rates generally fall below desired levels. Immunization rates for adults also are low, generally less than 5 percent for targeted groups for hepatitis B and influenza.2 (#298) Educational campaigns, improved strategies to encourage indivi- duals to choose to be vaccinated, research on vaccines with fewer side effects, free or subsidized immuniza- tions, and mass immunization programs are among the strategies recommended to increase the immuniza- tion rates. Linda Randolph of the New York State Depart- ment of Health identifies several immunization goals

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for adults: ensuring that all women of childbearing age are immunized against rubella; ensuring that all high-risk groups are informed of the importance of vaccination against hepatitis; and ensuring that all those at special risk of contracting pneumococcal pneumonia, and most of those at risk of becoming severely ill from influenza (i.e., the elderly, the disabled, and the chronically ill), will be fully immunized. Randolph also wants all pregnant women to be screened for current hepatitis B infection so that if they test positive, their newborn infants can be immunized to prevent acquisition of the disease. f#l77) Much of the testimony reinforced the need to reach these goals. Several witnesses expressed concern about the low influenza immunization rates among the elderly. Carter notes that only about 20 percent of persons aged 65 and older receive the influenza vaccine in any given year.3 He reports that a pilot program at several Veterans Administration hospitals and health maintenance organizations succeeded in increasing the immunization rate to more than 50 percent during the first year. Such an intervention could be initiated at most, if not all, medical centers. (#247) Influenza vaccines are very cost-effective, witnesses emphasized. Steven Mostow of the Rose Medical Center in Denver, comments that although Medicare policies have been liberalized somewhat to cover vaccinations, insufficient funds are available to provide vaccinations for all those at risk. (#380) Others noted the rise in hepatitis B from approximately 45 cases per 100,000 population in 1978 to approximately 69 per 100,000 in 1985,4 and the consequent importance of immunizing those at risk for the disease. Hepatitis can be transmitted through contact with infected blood or through sexual contact. High-risk groups include health professionals, intravenous drug users, mentally ill or retarded patients in institutions, and recipients of blood transfusions. (#414J The American Association of Occupational Health Nurses says that "hepatitis B is the major infectious occupational health hazard in the health care industry." (#558) Several witnesses proposed subsidizing hepatitis B vaccine so that it could be available at low cost or without charge. (#084; #414; #558) One study was mentioned, however, which found that many health professionals failed to be immunized even when it was readily available at no cost. (#558; #576; #580) The American Medical Association says that 90 percent of both those at intermediate risk (e.g., prisoners, staff at institutions for the mentally retarded, and health care workers) and those at high risk (e.g., drug users, hemodialysis patients, immigrants or refugees from countries where hepatitis B is endemic, and household contacts with hepatitis B carriers) should be immunized by the year 2000. The institutionalized mentally retarded, who also are at high risk, should be immunized routinely according to the American Medical Association (AMA). (~095) Robert Bernstein, Commissioner of the Texas Depart- ment of Health, proposes as an objective that hepatitis B cases be reduced about half to fewer than 12,000 per year by the year 2000. (~020) Targets also were proposed for childhood immunizations. The American Academy of Pediatrics (AAP) says that 95 percent of children should be fully immunized by the age of two for measles, rubella, mumps, polio, and diphtheria. This would amount to a 14-24 percent increase over 1985 immunization rates. The AAP feels that achievement of this goal will depend on public awareness of the need for full immunization, vaccine cost, the development of new vaccines, and federal and state support for a vaccine program. (#115) Witnesses stressed the importance of providing information and referrals about immunizations to all mothers of newborns. (~020) The AAP also proposes as an objective for the year 2000, the eradication of measles throughout the world. According to its testimony, there were 2,700 cases in 1985 in the United States.6 The cooperation of all countries is required to meet this goal. (#115) A proposed target for older children is that at least 97 percent of all children attending child-care facilities and schools (kindergarten through twelfth grade) should be fully immunized and should be in compli- ance with state laws or regulations. (~020) Through a rigorous program of immunization record checks and parental notification of noncompliance, Detroit schools increased the number of entering students who were completely immunized from 70-72 percent in the fall to 90-91 percent at the end of the year, with 96-97 percent immunized against measles, mumps, and rubella. A representative of the Detroit Department of Health says, "Strict enforcement of school immunization requirements is the only oppor- tunity to change immunization from parental option to legal mandate. It is the single greatest force in raising the immunization levels of the community to the extent necessary to control and prevent vaccine preventable disease." (~393) The AMA recommends that routine pediatric vaccines be given to adults to raise their level of immunity by at least a factor of three. (#095) Infectious Disease 16S

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Witnesses also called for more attention to immunizations against diphtheria, tetanus, and polio- myelitis. (#298, #791) NOSOCOMIAL INFECTIONS Another area of infectious disease control that received considerable attention is nosocomial (hospital-acquired) infections. Several witnesses cited data from the Centers for Disease Control (CDC) on the scope of the problem. Those figures show that 5 percent of hospital patients acquire a nosocomial infection, resulting directly or indirectly in 80,000 to 100,000 deaths a year. According to the CDC figures cited, about 32 percent of these infections are preventable.7 ('t575; #619) Lorraine Harkavy, a former president of the Association for Practitioners In Infection Control, tells of the needless suffering and high cost of nosocomial disease. She says that more than $2.8 billion is spent each year to treat it.8 Like several other witnesses, she recognizes that Infection is often a consequence of a highly technological medical equation" whereby "important and life saving invasive procedures such as surgery, catheters, immunosuppressive drugs, and sophisticated antibiotics Expose the patient to the risk of acquiring a nosocomial infection." Yet simple procedures-such as care providers' washing their hands-could help reduce the rate of infection. Nevertheless, "we are far from our goal of minimizing and preventing what has become a major public health problem and one of the leading causes of death," and, she says research into nosocomial infec- tions should be given a top priority for government funding by the year 2000. (~084J The American Hospital Association (AMA) says that infection control is a high priority for hospitals. The AHA says that the Greatest challenge" to institu- tions seeking to reduce the incidence of infections is ensuring that health care providers comply with standards of care that reduce the risk of nosocomial infection. (~576) An approach favored by the Health Insurance Association of America is setting specific targets for reducing the rates of nosocomial infection associated with the urinary tract, surgical wounds, the respiratory tract, and intravenous-related bacteremia. Most hos- pitals track these rates, and CDC statistics provide baseline figures. Each institution should meet goals reflecting reductions in the percent of patients who acquire nosocomial infections, according to the 166 Healthy People 2000: Citizens Chart the Course association. (#619) The AHA points out, however, that it is often difficult for hospitals to measure accurately the progress toward infection control goals. The number of infections at the average hospital may be too small to see a statistically significant change in rates after implementation of a control program. The reliability of infection rates may also have to be evaluated because of weaknesses in even sophisticated surveil- lance systems. Jarrett suggests that requiring public disclosure of rates at individual hospitals might lead to swifter reductions in infection rates. (#108J Nursing homes, too, must improve their infection control procedures, witnesses say. Katherine Hunter, a clinical microbiologist in Birmingham, Alabama, suggests that a 1990 objective stating that all nursing homes should have a results-oriented infection control committee analogous to those in hospitals must be continued for the year 2000. She identified three strategies to reduce nursing home inactions: upgrade inspection criteria by agencies to be more clinically relevant; increase the training level of nursing home employees to at least 85 percent skilled level; and initiate one-on-one working relationships between nursing home and infection control personnel or organizations, such as the Association for Prac- titioners in Infection Control. (#259) Recognizing the complex nature of nosocomial infections, along with the universally felt need to do more to combat them, HenIy Isenberg of the Long Island Jewish Medical Center says that "perhaps by the year 2000 some real understanding of this very costly problem may be gained." (#438) TUBERCULOSIS Me rise in incidence of tuberculosis, following its steady decline, was an area of concern for several witnesses. Poverty, overcrowded urban areas, home- lessness, and the AIDS epidemic may all be contr~but- ing to the sudden upsurge in cases, they say. Tuber- culosis has become a nosocomial infection of nursing homes and homeless shelters, according to testimony. (~259) Kathy Harris of the Detroit Department of Health described the tuberculosis epidemic in her city, adding that the number of cases will increase "until the public is made aware of the transmission of tuber- culosis and available treatment." She believes that an all-out effort to educate the public and professionals about the disease is needed.

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The majority of people in Detroit believe tuberculosis no longer exists, that it was ~cured" years ago. Those who are aware of tuberculosis do not believe the documented statistics regard- ing the rise of the disease or that tuberculosis can kill. Tuberculosis is still considered a "poor man's disease," and tints stigma prevents some individuals from even seeking testing, along with the misconception that "you must be locked ups to be treated. (~4173 Harris is especially concerned about counteracting the disease among the hidde~the homeless, drug users, and others who are at high risk but who do not understand the importance of preventive health measures or who refuse to be tested. She also includes families that do not receive regular medical care in this group. (#417) Dieter Groschel of the American Society for Microbiology sees two other populations that require special attention in the fight against tuberculosis: "Aside from the immunosup- pressed person, tuberculosis is still mainly borne by minorities (62 percent in 1982) and foreign-born poor (26 percent)." (#580) Responding to similar con- cerns, Bernstein proposes that by 2000, the incidence of tuberculosis in the United States be reduced to 6 cases per 100,000 population, but that in counties bordering Mexico the goal should be 12 cases per 100,0()0. (#0203 OTHER INFECTIOUS DISEASES Although immunizations, nosocomial infections, and tuberculosis received the most attention from wit- nesses, other topics were also mentioned. Some not- ed that food-borne disease is an important, often overlooked problem. (#259; #348) Hunter empha- sizes the importance of reducing the incidence of food-borne disease: "Even though enteric infections may not present the morbidity and mortality of other infections, there can be considerable costs, ranging from the costs of medication to the man-hours lost.n (#259) Charles Treser, representing the Washington State Public Health Association, is also concerned about food-borne disease and infectious diseases with an environmental component, such as water-borne (legionnaires' disease) and vector-borne (diarrhea) diseases. He says that "as we address new and emerg- ~ng problems like toxic substances and hazardous waste, we [must] not lose sight of the problems of infectious diseases that are still there and require some kind of a maintenance efforts" (~348) Isenberg recommends that attention be given to the increase in acute rheumatic fever in a number of states and a possible increase in hospital- or com- munity-acquired p neu mococca1 d is ease. (# 438J Thomas Grayston of the University of Washington echoes Isenberg's concern, especially as it applies to pneumonia, which ranks as the sixth leading cause of death in the United States.9 It is especially devastat- ing to older persons and those with chronic illnesses. (#693J Grayston also calls for a major research effort to help prevent the common cold. The tremendous amount of research into the cause and cure of AIDS has resulted in "much more sophisticated ways to produce vaccines," he says, although he believes that the ultimate answer "probably is going to have to be prevention." (#693) Other nonimmunizable diseases, including chicken pox, typhus, giardiasis, bacterial meningitis, legionellosis, and Lyme disease also were addressed. (~312) Various reviewers brought up several "sources" of infectious diseases that command attention in any attempt to control their spread. For example, child care centers serve as transmission conduits for chil- dren's diseases including giardiasis, c~yptosporidiasis, and cytomegalovirus. (#790) The problems associ- ated with control of diseases imported by both immigrants and travelers must be addressed if infec- tious diseases such as measles and poliomyelitis are ever to be eradicated. (#789; #791) IMPLEMENTATION Despite the diversity of testimony on infectious diseases, some issues were raised that relate to preventive strategies for several different conditions. One such overarching issue is the need for better surveillance, reporting, and data collection. A number of needs were identified Examples include broaden- ing participation in the CDC's National Nosocomial Infection Survey (#4384; increasing uniformity in the definition and calculation of nosocomial infection rates (#619~; monitoring illnesses brought in by immigrants or foreign travelers (~177; #2014; improv- ing data collection on conditions associated with environmental factors and disseminating data to health officials in a useful form (~348~; and establish- ing a standardized reporting system for infectious diseases throughout the United States that is com- patible with the health objectives. (~259) Witnesses emphasized that obtaining and disseminating data are Infectious Disease 167

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essential in the fight against infectious disease. Improving laboratory capability is another overarch- ing issue. The objectives proposed in this area relate, for example, to reducing the time from receipt of a sample in the laboratory to communicating useful information to the physician. Some of the suggestions for improved laboratory performance also relate to expanded surveillance and reporting. (~438J Many of the goals identified in this category are extensions of goals established for 1990. Witnesses REFERENCES noted that achieving them is equally or more urgent now. Harkavy, observing how many 1990 goals re- main relevant for the year 2000, offered the follow- ing perspective on the effort to make gains in infec- tious disease control: Perhaps it is not so much ~ need for new objectives, but rather a recognition that reaching these goals requires vigilance, manpower, resources, and money, much of which is not being directed to the achievement of these current needs, let alone future ones." f#O84) 1. Amler RW, Dull HB (Eds.~: Closing the Gap: The Burden of Unnecessary Illness. New York: Oxford University Press, 1987 2. William WW, Hickson MA, Kane MA, et al.: Immunization policies and vaccine coverage among adults: The risk for missed opportunities. Ann Intern Med 108:616-625, 1988 3. Fedson DS: Influenza and pneumococcal immunization strategies for physicians. Chest 91(3):436-443, 1987 4. Centers for Disease Control: Hepatitis Surveillance Report No. 50. Atlanta: 1986 5. National Center for Health Statistics: Health United States, 1986 (DHHS Publication No. [PHS] 88-1232), 1987 6. Centers for Disease Control: Summaly of notifiable diseases in the United States, 1985. Morbid Mortal Wkly Rep 34(54):1-21, 1987 7. Centers for Disease Control: National Nosocomial Infections Study. Atlanta: 1984 8. Dixon RE: Cost of nosocomial infection and benefits of infection control programs. Prevention and Control of Nosocomial Infections. Edited by RP Wenzel. Baltimore: Williams and Wilkins, 1987 9. National Center for Health Statistics: Health United States, 1989. (DHHS Publication No. [PHS] 90-1232), 1990 TESTIFIERS CITED IN CHAPTER 21 020 Bernstein, Robert; Texas Department of Health 034 Buttery, C. M. G.; Virginia Department of Health 084 Harkavy, Lorraine; LMH Health Associates (Potomac, Maryland) 095 Hendee, William; American Medical Association 108 Jarrett, Michael; South Carolina Department of Health and Environmental Control 115 King, Caroler American Academy of Pediatrics 177 Randolph, Linda; New York State Department of Health 201 Smith, George; Tennessee Department of Health and Environment 247 Carter, William; Seattle Veterans Administration Medical Center 259 Hunter, Katherine; Baptist Medical Centers, Montclair (Alabama) 298 Williams, Robert; Baylor College of Medicine 312 Dickson, Bob; Texas Commission on Alcohol and Drug Abuse 168 Healthy People 2000: Citizens Chart the Course

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348 Treser, Charles; University of Washington 380 Mostow, Steven; Rose Medical Center (Denver) 393 Gaines, George; Detroit Department of Health 414 Love, Melinda; Detroit Department of Health 417 Harris, Kathy; Detroit Department of Health 438 Isenberg, Henry; Long Island Jewish Medical Center 558 Babbitz, Matilda; American Association of Occupational Health Nurses 575 Reveal, Marge; Anterican Dental Hygienists' Association 576 Owen, Jack; American Hospital Association 580 Groschel, Dieter; American Society for Microbiology 619 Schramm, Carl; Health Insurance Association of America 693 Grayston, J. Thomas; University of Washington 789 Carpenter, Charles C. J.; Brown University 790 Weller, Thomas; Harvard University 791 Lucas, Adetokunbo; Carnegie Corporation of New York Infectious Disease 169