Bugs that don’t go away: Infectious diseases will strain health system
Patient educators’ role to become vital to prevention
Hospital beds now being emptied by shorter lengths of stay will be refilled in the next decade by patients suffering from infectious diseases some of them illnesses that in the past presented no or only isolated problems in the United States.
The diseases will strain a health care system that is unprepared for them, experts say, demanding that more emphasis be placed on education in the community/public health area to help prevent their spread. In addition to the sheer numbers of patients, the diseases they carry will in many cases be hard to cure and pose dangers to your staff and the public at large. Patient educators will find they are being called upon to perform unusual tasks in addition to prodding patients to get proper vaccinations, you will be teaching people not only how to live with incurable, and possibly fatal, diseases but also how to keep from spreading them.
Many of those who become ill will be afflicted by infections spread by contaminated foods and water supplies infections that are increasingly being pinpointed by the Centers for Disease Control and Prevention (CDC), and that have placed entire communities at risk. In 1993, 600 people got sick from eating hamburgers served at a fast food restaurant chain that were contaminated with Escherichia coli bacteria. As a result, 56 people suffered kidney failure and four children died. In November 1996, 64 cases of E. coli were reported in three states and British Columbia from drinking contaminated apple juice or contact with someone infected by the juice. One child died.
Health experts worry, too, about international infectious disease trends that could easily become major problems in the United States particularly without an intense educational effort to help avert their spread.
Just how devastating these diseases can be and often how preventable with proper education was obvious in 1994, when 47,000 cases of diphtheria were reported in the former Soviet Union. Diphtheria, virtually eradicated 50 years ago by an all-purpose vaccine, killed 1,700 that year, many of them adults who either had never been vaccinated or had let the vaccine’s effectiveness lapse. In fact, cases are still reported each year.
"The adult population in Russia did not keep up their boosters, so they are having an outbreak of diphtheria. It could easily be brought back to the U.S., and we have a large adult population that is not immune," says Sharon Thompson, BSN, nurse epidemiologist at the infectious disease division for the CDC in Atlanta. Half of the reported diphtheria cases in the United States occur among adults, since by the age of 18 the vaccine protection received in infancy has waned. Adults should be vaccinated for diphtheria every 10 years.
With international travel and immigration now the norm, diseases once considered exotic or nonexistent here now have easy access to U.S. communities. Cases of malaria were reported in an affluent area of San Diego County, CA, in 1988 and 1989, and troops returning from the Persian Gulf War brought with them a parasitic blood and bone marrow infection called leishmaniasis.
New infections are emerging
Since the 1970s, the U.S. public health system has had to deal with several infectious diseases that the CDC says appear to be new. These include AIDS, toxic shock syndrome, Legionnaires’ disease, Lyme disease, E. coli infection, hepatitis C, and hantavirus pulmonary.
These complex diseases appear to have materialized out of nowhere, catching physicians off guard and challenging epidemiologists as to their origins. And, just as in the case of AIDS, these new diseases have the ability to cut a wide swath through the community, regardless of economic or social status.
In each case, education has become a crucial part of preventing the spread of the diseases once wide-scale diagnosis is made. For example, teaching proper hand washing, especially after changing children’s diapers in day care centers, can help stop the spread of E. coli.
Experts are equally concerned, however, about the re-emergence of diseases already believed to be under control.
Cases of cholera, malaria, tuberculosis, dengue, and yellow fever are increasing throughout the world. During the mid-1980s, the number of people diagnosed with tuberculosis in the United States began to rise after several decades of decline.
In a curious Catch-22, experts say TB has re-emerged in part because public health departments became less vigilant due to the decrease in cases. But immigration from countries with a high TB rate and the common occurrence of TB as a co-infection in HIV patients are two other reasons Americans are once again at risk, says Zachary Taylor, MD, chief of the infection prevention section of the CDC in Atlanta.
Although the number of TB cases has begun to drop again in the United States, it still poses a problem from immigrant populations. The drop proves the importance of education, experts say, because it is a result of an emphasis on screening and efforts to make sure those infected take proper medication.
But complicating the treatment of diseases like TB and other dangerous microorganisms is the fact that they are becoming antibiotic-resistant.
"One of the first and foremost problem areas of resistance is in treating tuberculosis," says Paul Doering, MS, professor of pharmacy practice at the University of Florida College of Pharmacy in Gainesville. Multidrug-resistant TB organisms have developed, and it is not uncommon for physicians to treat TB cases with three or four drugs, where one or two drugs used to kill the organism, says Doering.
Other more common diseases are also becoming antibiotic-resistant. Streptococcus pneumoniae, a major cause of bacterial pneumonia, is developing resistance to penicillin and other antibiotics.
"In the next 10 to 15 years, hospital beds will be back in use because we have the emergence of so many antibiotic-resistant organisms," warns Ann Kobs, MS, RN, associate director in the department of standards for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
Education will be vital
Kobs urges patient education managers to implement programs that teach people how to prevent the spread of infectious diseases. "If we did nothing else but teach proper hand washing to patients and employees, it would make a huge difference," she says.
She and other health care leaders say they fear that patient educators often work in an information vacuum. According to the Bethesda, MD-based National Foundation for Infectious Diseases, the 10 most frequently reported nationally notifiable infectious diseases for 1995 were, in descending order: chlamydia, gonorrhea, AIDS, salmonellosis, hepatitis A, shigellosis, TB, primary and secondary syphilis, Lyme disease, and hepatitis B. The sexually transmitted diseases (STDs) chlamydia, gonorrhea, AIDS, primary and secondary syphilis, and hepatitis B account for 87% of cases reported for these 10 diseases.
But despite those numbers, educational information on infectious diseases is very limited. "We have education materials on some of the STDs and TB and we use them internally, but we have 300 community outreach classes and I can’t think of one that involves infectious disease," says Sandra Cornett, RN, MS, PhD, patient education coordinator at The Ohio State University Medical Center in Columbus. (See related story on what patient education managers can do to reach the public, this page.)
Even in areas where some efforts are made, such as with STDs, health care officials acknowledge the attempts are minimal.
In a report released in late November, a committee of the Institute of Medicine in Washington, DC, said a bold national initiative is needed to reduce the enormous health burden of STDs. There currently is no effective national system to combat STDs, even though five of the 10 most common diseases reported to the CDC last year were STDs, the report says. The United States, with an infection rate of 12 million cases a year, has the highest STD rate of any developed country.1
STDs cost taxpayers at least $10 billion annually, not including costs associated with sexually transmitted HIV infection. The public sector spends only $1 to prevent and fight STDs for every $43 spent on treatment and other costs.
Reference
1. Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC; Nov. 19, 1996.
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