Yu-hui Ferng

Impact of Non-Pharmaceutical Interventions on URIs and Influenza in Crowded, Urban Households:

Objectives. We compared the impact of three household interventions—education, education with alcohol-based hand sanitizer, and education with hand sanitizer and face masks—on incidence and secondary transmission of upper respiratory infections (URIs) and influenza, knowledge of transmission of URIs, and vaccination rates. Methods. A total of 509 primarily Hispanic households participated. Participants reported symptoms twice weekly, and nasal swabs were collected from those with an influenza-like illness (ILI). Households were followed for up to 19 months and home visits were made at least every two months. Results. We recorded 5,034 URIs, of which 669 cases reported ILIs and 78 were laboratory-confirmed cases of influenza. Demographic factors significantly associated with infection rates included age, gender, birth location, education, and employment. The Hand Sanitizer group was significantly more likely to report that no household member had symptoms (p<0.01), but there were no significant differences in rates of infection by intervention group in multivariate analyses. Knowledge improved significantly more in the Hand Sanitizer group (p<0.0001). The proportion of households that reported ≥50% of members receiving influenza vaccine increased during the study (p<0.001). Despite the fact that compliance with mask wearing was poor, mask wearing as well as increased crowding, lower education levels of caretakers, and index cases 0–5 years of age (compared with adults) were associated with significantly lower secondary transmission rates (all p<0.02). Conclusions. In this population, there was no detectable additional benefit of hand sanitizer or face masks over targeted education on overall rates of URIs, but mask wearing was associated with reduced secondary transmission and should be encouraged during outbreak situations. During the study period, community concern about methicillin-resistant Staphylococcus aureus was occurring, perhaps contributing to the use of hand sanitizer in the Education control group, and diluting the interventions measurable impact.

Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research.

In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)-strategies other than vaccines and antiviral medications-to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the acceptability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research.

Predictors of flu vaccination among urban Hispanic children and adults

Background Flu vaccination is effective for preventing infection, but coverage levels in the USA remain low—especially among racial/ethnic minorities. This study examines factors associated with flu vaccination in a predominantly Hispanic community in Manhattan, New York. Methods Households were recruited during the 2006–2007 and 2007–2008 flu seasons. Primary household respondents were interviewed to determine knowledge of flu transmission/treatment and vaccination status and demographic information for all household members. Results Vaccination coverage was 47.3% among children <5, 39.3% among 5–17-year-olds, 15.3% among 18–49-year-olds, 31.0% among 50–64-year-olds and 37.1% among adults ≥65 in year 1; and 53.1% among children <5, 43.6% among 5–17-year-olds, 19.5% among 18–49-year-olds, 34.1% among 50–64-year-olds and 34.3% among adults ≥65 in year 2. For children, younger age, having a chronic respiratory condition (eg, asthma), and greater primary respondent knowledge of flu were positively associated with vaccination. Among adults, female gender, older age, higher education, greater primary respondent knowledge of flu, having been born in the USA and having a chronic respiratory condition were positively associated with vaccination. The most common reasons cited for not being vaccinated were the beliefs that flu vaccination was unnecessary or ineffective. Conclusions Possible methods for increasing vaccination levels in urban Hispanic communities include improving health literacy, making low-cost vaccination available and encouraging providers to use other office visits as opportunities to mention vaccination to patients. Registration number This study is registered at http://ClinicalTrials.gov (NCT00448981).

Barriers to Mask Wearing for Influenza‐like Illnesses Among Urban Hispanic Households

OBJECTIVES To identify barriers to mask wearing and to examine the factors associated with the willingness to wear masks among households. DESIGN AND SAMPLE We used data sources from a study assessing the impact of 3 nonpharmaceutical interventions on the rates of influenza: exit interviews; home visits with a subset of the mask group; and a focus group. MEASURES Risk perception score, univariate analysis, and logistic regression were conducted to identify the characteristics and predictors of mask use. Thematic barriers to mask wearing were identified from qualitative data obtained at home visits and focus group. RESULTS Respondents from the mask group, when compared with the nonmask group, demonstrated higher risk perception scores concerning influenza (maximum score: 60, means: 37.6 and 30.2, p<.001) and increased perception of effectiveness of mask wearing (maximum score: 10, means: 7.8 and 7.3, p=.043). There was no significant association between demographic, attitudinal, or knowledge variables and adherence to wearing masks. Thematic barriers were identified such as social acceptability of mask use, comfort and fit, and perception of the risk/need for masks. CONCLUSIONS Face masks may not be an effective intervention for seasonal or pandemic influenza unless the risk perception of influenza is high. Dissemination of culturally appropriate mask use information by health authorities and providers must be emphasized when educating the public.

Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

OBJECTIVE To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool. METHODS Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool. RESULTS The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%). DISCUSSION During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved. CONCLUSION To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges.

Antibiotic identification, use, and self-medication for respiratory illnesses among urban Latinos.

Purpose: The purpose of this study was to describe the extent to which antibiotic and nonantibiotic medications commonly used for upper respiratory infections (URIs) were correctly identified by a sample of urban dwelling Latinas and the association of medication identification with antibiotic use and self‐medication. Data sources: One hundred women completed an interview and were asked to identify whether a list of 39 medications (17 antibiotics, 22 nonantibiotics) were antibiotics or not, whether anyone in the household had used the medication, their ages, and the source of the medication. Results: Overall, participants correctly identified 62% of nonantibiotics and 34% of antibiotics. Seventy three (73%) women in the study reported antibiotic use by at least one member of the household in the past year. Among users, self‐medication was reported in 67.2% of antibiotics for adults, but in only 2.4% of children. There was no difference in antibiotic recognition between those who self‐medicated and those who did not, but antibiotic self‐medication was associated with a significantly lower recognition of nonantibiotics (p = .01). Implications for practice: Measures to improve antibiotic utilization should address self‐medication and consider the cultural and social context in which antibiotic use occurs.

Effect of Intensive Education on Knowledge, Attitudes, and Practices Regarding Upper Respiratory Infections Among Urban Latinos

Background:Although upper respiratory infections (URIs) take a major social and economic toll, little research has been conducted to assess the impact of educational interventions on knowledge, attitudes, and practices of community members regarding prevention and treatment of URIs, particularly among recently immigrated urban Latinos who may not be reached by the mainstream healthcare system. Objectives:The objective of this study was to assess the impact of a culturally appropriate, home-based educational intervention on the knowledge, attitudes, and practices regarding prevention and treatment of URIs among urban Latinos. Methods:Using a pretest-posttest design, Spanish-language educational materials available from sources such as the Centers for Disease Control and Prevention were adapted based on feedback from community focus groups and provided to households during an in-person home visit every 2 months (generally three to four visits). Outcome data regarding knowledge, attitudes, and practices were collected in home-based interviews using an 85-item instrument adapted and pilot tested from three other validated instruments. Nonparametric and multiple linear regression analyses were used to summarize data and identify predictors of knowledge scores. Results:Four hundred twenty-two households had complete data at baseline and 6 months. Knowledge and attitude scores were improved significantly, and use of alcohol hand sanitizer and rates of influenza vaccine were increased significantly (all p <.01). Discussion:Although this home-based educational intervention was successful in improving knowledge, attitudes, and self-reported practices among urban Latinos regarding prevention and treatment of URIs, further research is needed to determine the cost-effectiveness of such a person-intensive intervention, the long-term outcomes, and whether less intensive interventions might be equally effective.

Preferences Among Immigrant Hispanic Women for Written Educational Materials Regarding Upper Respiratory Infections

The need for culturally appropriate health education materials for Hispanic populations has been widely recognized, and Spanish-language materials are available through a number of private and governmental organizations. We convened two focus groups to elucidate preferences regarding how health-related messages are obtained and to identify which educational materials available in Spanish were preferred by 26 recently immigrated Hispanic homemakers who had received 15 different bimonthly written documents as part of a community-based clinical trial to prevent household transmission of colds and influenza. Participants gave three primary reasons for volunteering to participate in the study: to provide better care for their children (96.2%, 25/26), to get information (96.2%, 25/26), and to get free products (47.1%, 8/17). Their primary sources of health-related information were relatives and friends (42.9%, 6/14), clinicians (35.7%, 5/14), mass media (14.3%, 2/14) or the emergency room (7.1%, 1/14); none mentioned the internet. Materials using either a question and answer or true/false format were clearly preferred, even when other options were more colorful or had lower reading levels. Printed educational materials may be ineffective unless they include a more systematic assessment of the user’s perceived needs for the information as well as consideration of format. In this population, a question and answer or true/false format and materials that could be shared with their children were greatly preferred.

Surgical site infections in a longitudinal cohort of neonatal intensive care unit patients.

Objective:To estimate the incidence and identify risk factors for surgical site infections (SSIs) among infants in the neonatal intensive care unit (NICU).Study Design:A prospective cohort study of infants undergoing surgical procedures from May 2009 to April 2012 in three NICUs was performed. SSI was identified if documented by an attending neonatologist and treated with intravenous antibiotics. Independent risk factors were identified using logistic regression, adjusting for NICU.Result:A total of 902 infants underwent 1346 procedures and experienced 60 SSIs (incidence: 4.46/100 surgeries). Risk factors for SSIs included younger chronological age (odds ratio (OR) 1.03 per day decrease, 95% confidence interval (CI) 1.01, 1.04), lower gestational age (OR 1.09 per week decrease, CI 1.02, 1.18), male sex (OR 1.17, CI 1.04, 1.34) and use of central venous catheter (OR 4.40, CI 1.19, 9.62). Only 43% had surgical site cultures obtained and Staphylococcus aureus was most commonly isolated.Conclusion:SSIs complicated 4.46% of procedures performed in the NICU. Although few modifiable risk factors for SSIs were identified, future efforts should focus on evaluating the impact of current prevention strategies on the incidence of neonatal SSI.

Multicenter Study of Hand Carriage of Potential Pathogens by Neonatal ICU Healthcare Personnel.

A multicenter surveillance study was performed to determine the rates of hand carriage of potential pathogens among healthcare personnel in four neonatal intensive care units. Staphylococcus aureus, enterococci, and gram-negative bacilli were recovered from 8%, 3%, and 2% of 1000 hand culture samples, respectively.