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OCR for page 164
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
Representative terms from entire chapter:
infectious diseases
