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[00:00:06] Tony: Hello, and welcome back to another episode of Microbe Matters, presented by ID Pittstop, where we discuss, dissect, and demystify topics in infectious diseases with our experts here at UPMC and the University of Pittsburgh. I’m your host, Tony Morrison, media specialist here at Pitt ID, and I’m just as curious as you may be about navigating through a world full of microscopic organisms. Please join us as we examine both the dangerous and beneficial microbial microcosms that surround us, promote public health, and showcase research and treatment of modern infectious diseases.

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John and his family were elated to discover that a match had been made for his upcoming kidney transplant surgery. For the last few years, John’s health had been deteriorating as he progressed further into renal failure.

Determined to regain his health, John jumped at the opportunity to receive a solid organ transplant surgery. Without hesitation, Lady Luck had favored John when a donor kidney was secured for his upcoming operation. The surgery was a success, and John eagerly awaited the day he could leave the hospital and his dialysis treatments far behind.

After a few days in the ICU, John suddenly fell very seriously ill.

Nobody was yet sure of the source of his nosocomial infection, but it was spreading through John’s body rapidly. Fortunately for John, he was able to recover, but it did further delay his hopes of going home.

How did this infection jump from one patient to another so quickly?

The hospital they were in was top of its class. Surely it couldn’t have been the hospital’s fault or its staff.

It turns out that his wife, Nancy, had unknowingly become the vehicle for a hospital superbug.

Normally, Nancy is thorough in her hand washing regimen, but this time she had forgotten to after using the vending machine down the hall during visiting hours early in John’s recovery.

If you have ever worked in a hospital, medical office, nursing home, or nursery school, you probably were required to complete some form of infection prevention training.

Infection prevention and control measures are set in place to break the chain of infection, which is made up of six environmental factors or links, that all must be present for pathogens to persist. That’s why it is so important to stay vigilant in settings where people are most susceptible, even if you are just a visitor.

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Last season, we explored the increasing defenses of organisms that resist treatments, many of which are responsible for today’s nosocomial infections or infections acquired in a healthcare setting. Today, we will discuss the key steps that hospitals are taking to reduce the spread of infections, how they are tackling the challenges posed by the pandemic, and the role of vaccines in preventative hospital practices. With me to talk about vaccines from an infection Prevention and control perspective is Dr. Elise Martin. She is the medical director of Infection Prevention and Hospital epidemiology at the Veteran Affairs Pittsburgh Healthcare System, as well as assistant professor of medicine at the University of Pittsburgh. Elise, thank you for taking the time to chat with me on this important topic.

[00:03:37] Elise: Thank you so much for having me. I’m excited to be here.

[00:03:40] Tony: It’s common knowledge that vaccines can be successful at preventing or reducing the severity of an infection. But tell me, how do vaccines work?

[00:03:48] Elise: So when we think about how vaccines work, you really think about what you’re trying to do. What is your ultimate goal with the vaccine? And the idea is you really want your body to be exposed to one of these organisms ahead of time, so you can already make an immune response. And then from that, if you are ever exposed to the future, you’ll ultimately have some level of protection. And we can do this from a variety of means. Most commonly, we all think about getting an injection for our vaccine, but you can also do this if you have one by mouth or if we spray something up your nose. Those can also be reallxy effective strategies. And really, the goal is just to have some pre exposure, have that time to make an immune response, and then you’re protected, ideally, when you ever are exposed to that organism again.

[00:04:29] Tony: Yeah, I feel like most people are afraid of vaccinations for one major reason, and that is to be prodded by the needles. And I don’t think that it’s, like, super well known that there are other means for vaccines, or at least pre exposures.

[00:04:45] Elise: Yeah, and you’ll definitely see it more depending on what types of vaccines you’re getting, especially if you’re getting vaccines for travel, that will have a lot of various options you’d have potentially, to protect you.

[00:04:55] Tony: It sounds to me that the science surrounding vaccine synthesis is foolproof, but exactly how effective are they?

[00:05:01] Elise: So when you think about vaccine efficacy, you really want to think about, what are you calling effective now that might be completely preventing all disease if you’re ever exposed to that organism ever again, but you might also be thinking about preventing its severe disease. And this has come up. When we’ve talked about COVID vaccines, this has been a hot topic around how well does the vaccine work? And really, what do you mean by that? And when I think about vaccine efficacy, it really has a range. So some organisms, the vaccines aren’t as effective, and some are very, very effective. And one example of the one that I think a lot of people say is not that effective is influenza. When you overall look at how well it does preventing all disease, it’s not that great. But there is a lot of data to say that it helps to prevent against severe disease and hospitalization. So it is actually really important to get it, even if it’s not 100% effective. Now, when I compare that to some of the other vaccines, I think the one that we all think about as, like, the best vaccine is really around measles. When you are vaccinated against measles, your level of protection is incredibly high. It’s over 90%. And so it depends sort of somewhere in the middle for all the other vaccines. But it is still important to remember, even if you’re counting just Are you going to have disease? You also really need to factor in, is this impacting other topics like, are you going to have severe disease? And then probably the best example of this working is smallpox. This is one where we had a vaccine, got it out there, and we’ve actually fully eradicated the disease. And so that’s sort of like the absolute best, but everything else is sort of falling somewhere in the middle.

[00:06:32] Tony: There seems to be a lot of varying opinions about vaccines these days, but in your opinion, who should be vaccinated and why?

[00:06:41] Elise: So I think that’s, again, where I come back to sort of what the CDC compiles and this group, the Advisory Committee on Immunization Practices. It’s a group of experts that really sit down and go through each one of the vaccines. What is the benefit of that vaccine? What are some of the potential drawbacks? Who’s going to receive the benefit of that vaccine? And they make those recommendations, and I honestly think that those are really good recommendations. So regardless of which vaccine it is, I do follow those pretty closely for myself for what I recommend for my patients, and then also what I recommend for my own family, who, as an ID physician, I do get a lot of calls and questions, and certainly did during COVID about should I or shouldn’t I with these vaccines. And for the most part, I thought for most of these, it is very, very beneficial to get it.

[00:07:28] Tony: Elise, are there any reasons for someone to not get vaccinated? What are some negative effects to consider when getting a vaccine?

[00:07:37] Elise: So there are some potential concerns. When I think about negative issues, I think the biggest one we think about are side effects. So every vaccine can have side effects, and some of those are expected. So around COVID, many of us got our COVID vaccines, and maybe we had arm pain, swelling or redness at the site muscle aches, body aches, to even having potentially more severe reactions. And for some of these side effects, they’re pretty common and very mild, and then some are very, very rare, but could be more significant when they occur. And for each vaccine, the way I look at it and the way I counsel patients is to say, well, what is the side effect and what is the risk of that particular side effect? And then what is the risk of actually getting the disease? And if the risk of getting the disease is infinitely more catastrophic, then really balancing that and saying, well, it’s probably going to be really beneficial to get the vaccine and be protected. And then the other question along this, you think, is your risks and benefits maybe not just the benefit to yourself, but to the benefit of the people around you. So maybe my personal risk of getting one of these illnesses and having a poor outcome is pretty low. But what’s the risk to my spouse? What’s the risk to my elderly family member that I’m around a lot, or someone I have in my family that maybe has a transplant or cancer or an immunocompromised person? So my being protected can actually help them. So I really try to balance all of those pieces in the conversation.

Additionally, there is another group where they can have negative implications and usually where we counsel not to get vaccines, and these are immunocompromised patients. Now, most of the vaccines, highly beneficial, really important, but there are other vaccines, particularly live vaccines, where the way the vaccine works is you actually give a live, attenuated or sort of less aggressive version of the organism for your body to then fight off and built immunity that would not be appropriate for a lot of immunocompromised folks. And so that’s where it’s especially important for everyone around them to be safe and healthy, to keep them protected from one of those illnesses.

[00:09:37] Tony: So now that we know everything that we need to make an informed decision on getting vaccinated, what’s next? How do you counsel patients about staying healthy following a vaccine?

[00:09:49] Elise: So I do this in two ways. So for patients, specifically, someone that I’m going to see in the hospital or someone that maybe I saw in the clinic, and they’re going to ask me about what to do next, it’s going to depend on what we vaccinated you for. So if it’s something where we have extremely high vaccine efficacy and the risk of being exposed to that is pretty low, there may not be much I’m going to have as an additional recommendation. But for some things, especially when COVID cases were really high. And we know vaccines aren’t perfect, especially for my immunocompromised patients. I did counsel them to be thoughtful about where they were going and if they were going to be around others that may have the virus, or maybe even scenarios where I would recommend masking and then a different aspect of my particular job. So I work in infection prevention within a hospital. I also have to counsel my healthcare providers. So they may need to get a vaccine for COVID, maybe they’re going to get a vaccine for hepatitis B or something else within the hospital. I really try to remind people that the vaccines are really important, but you also have to do other preventative measures in the hospital specifically to help reduce risk. And one example would be something called standard precautions. It’s what we do for all patients to washing your hands, avoiding bloodborne pathogen exposures, avoiding needle sticks. And when you think about something like hepatitis B, although you may be protected, I still don’t want you to get a needle stick. So we still have to do various things to stay healthy in addition to the vaccines.

[00:11:15] Tony: So are there any diseases that are particularly important to consider being vaccinated for?

[00:11:23] Elise: Lots. I think kind of sort of everything on that list. I really do think it’s important.

All the childhood vaccines, I think are really important for kids as we hit those various levels to avoid getting sick, having severe disease or complications in the hospital, we think a lot about COVID influenza.

Getting your hepatitis vaccinations, your TDAT vaccine is also really important. And then something I really counsel a lot of people because I have even family members that are asking, do I still need these vaccines? Are these diseases things that we don’t really see anymore? Interestingly, for a lot of things, we’re actually seeing resurgence of, especially the childhood diseases, measles, pertussis. And so I think it is really important to be vaccinated for those, to keep yourself safe, helps to avoid illness and protect everyone around you. And I do think it’s really important to help society sort of achieve this level of herd immunity. If we all do our part and all keep ourselves healthy, we can also help keep our community healthy.

[00:12:23] Tony: How often do you see breakthrough infections in the hospital or healthcare setting?

[00:12:29] Elise: So this is a really good question, and I will say it was a very, very hot topic in the world of COVID because everybody got the vaccine in that first six months that it got rolled out. We all felt wonderful, like, we’ve got this, it’s going to be behind us. But we do see breakthrough vaccines for every one of the things we have available. It is possible if you are exposed to still breakthrough and less likely for certain things. But I think the most important thing when you think about breakthrough infections in general is what does that breakthrough infection look like? Is it an infinitely better outcome than it would be if you were not vaccinated? And specifically for COVID-19 we had an overwhelming amount of data to say if you were vaccinated, especially these additional boosters that folks got, they had better outcomes. And I think a lot about the data we have on people sort of older age, where they had really good outcomes and helped to reduce mortality. And although we obviously don’t want to keep getting vaccines forever, it does actually seem to have a really important benefit. Now, interestingly, from a healthcare perspective, this actually comes up a lot as a topic, breakthrough infections, and a lot of what we do in hospitals around outbreak exposures, we have to decide, well, what is the risk of someone having a breakthrough? They were vaccinated, is it safe for them to work? And in some cases, one example that actually I’ve seen not too long ago was actually an exposure to pertussis or whooping cough. This one, unfortunately, when we do see breakthrough infections, although the vaccine itself is good, and in some cases, we actually give out antibiotic prophylaxis to folks even who are vaccinated, because we don’t want them to get sick. Because it can be so awful when you have whooping cough.

[00:14:04] Tony: Yeah, thankfully, I’ve never experienced it before.

[00:14:08] Elise: Me either.

[Both Giggle]

[00:14:10] Tony: Okay, Elise, now that we’ve gone over the basics of vaccines, why don’t we jump right into the topic of infection control?

It’s no secret that hospital outbreaks occur around the globe, and vaccine mandates in healthcare facilities have become widespread. From an infection prevention perspective, why is it so important for healthcare personnel to be up to date on their vaccinations?

[00:14:33] Elise: So this is definitely my job, so I’ll put my biases out there. I think it’s incredibly, incredibly important to do this, and for a couple of reasons. I mean, first, and I think probably the most obvious, we don’t want to spread infections in the hospital. We don’t want anybody to come in and be receiving care for whatever the reason is and come out with some new infection and come out sicker than they did when they walked in. So I think that’s incredibly important and probably the biggest why that we think about on a daily basis. But there’s also actually a bunch of other reasons, and one area that I advocate this a lot is around not wanting to get sick. You yourself need to be healthy to take care of your patients in the hospital. If we have too many people that are sick, it’s really hard to do that. And we actually saw this, and I know a number of hospitals across the US had this during the COVID pandemic, where we just had a lot of nurses who were out. And it was really, really difficult to provide appropriate medical care when you have that many people now, even not just thinking on sort of a global hospital level, but this is definitely a major problem in hospitals where maybe one person came in with the infection and they infected their own team, and having one person who works in transplant or cardiothoracic surgery or something where there aren’t that many people to do that job, if they get sick, it’s hard. If they get their whole team sick, it’s impossible. There’s no way to provide that care. And then patients need to be shifted and sent elsewhere where they can receive appropriate care. So really important from maintaining a workforce perspective as well. And then one area that I think people don’t always think about, but definitely comes up in my line of work, is the concept of furlough. So if you get exposed to certain illnesses, you may not be eligible to work because it’s so high risk that you will have an infection, and we won’t know you have an infection until after you’re already infectious. And this came up during COVID So I think people thought about it a lot then. But we also have this with other pathogens. One example we see a lot in the hospital is varicella, or the virus that causes chickenpox and shingles. When we have an exposure in the hospital and someone is not vaccinated, not previously infected, we don’t find out early enough for them to get post exposure prophylaxis or vaccination, they actually need to leave the hospital for days, eight through day 21 after that exposure. And that’s huge. That’s a really long time to have people out. And so from an overall healthcare perspective, it’s really important for us to stay healthy, avoid spread, and then just maintain that ability to provide really high quality care.

[00:17:10] Tony: Yeah, I can see it being really difficult. If a subspecialties team is completely out, you have to cargo ship all of the patients to new facilities where they’re exposing themselves to a different kind of infection that they could get there that maybe wasn’t present in the one they.

[00:17:27] Elise: Just came from, or the alternative is then they sit there and wait. So if you need some surgery where we only have one person in this region of Pennsylvania that can actually do that, and that person and or their critical team of people that they work with are all out.

Maybe we can’t even transfer you. Maybe you just have to sit here for an extra week or two, and that’s not really great patient care either. And so all those components really need to be factored in when people are deciding yes or no on specific vaccines and things we can do to prevent infection.

[00:17:56] Tony: Yeah, and some of those surgeries and treatments are time sensitive as well. So it really is a matter of life and death.

[00:18:02] Elise: Oh, absolutely.

[00:18:04] Tony: What are some ways in which nosocomial infections can spread? How quickly does it occur, and at what point does it become an outbreak?

[00:18:11] Elise: So it depends on the pathogens. So we do see this in the hospital, and this is actually the bulk of what I do for my job is really avoiding spread. And then if we think there is spread, identifying that quickly to prevent it within our hospital. So maybe with a case of COVID maybe we have one or two, and then really delving into that, putting things into place to avoid additional spread. And that’s where vaccines can be really helpful to avoid that and maintain a workforce. But we’ll see this with other organisms. We’ll look at everything in the hospital for various potential nosocomial spread of pathogens and really be tracking that in real time. And sometimes it’s something that really should never happen in the hospital. And so even a single case may be something that gets us really motivated to look into it. And some things are a little bit more common. And maybe you wouldn’t consider it to be an outbreak until you have multiple.

[00:19:00] Tony: Yeah, I think when people think nosocomial infections, they think ICU units and intensive care, but there are many other ways in which these pathogens can enter and through the hospital, and it can be through, really, anybody going in and out of the hospital.

[00:19:17] Elise: Yeah, I mean, I had a colleague that had an outbreak of, like, a gastrointestinal infection that popped up from a behavioral health setting where they were actually, like, preparing food and doing activities with the individuals who were there.

So, I mean, you can really have a lot of potential ways to spread infections, and it is really important for everybody to be thoughtful.

[00:19:37] Tony: Yeah. And from the epidemiologist perspective, that’s where the shoe leather approach comes in. Is that what you call it?

[00:19:45] Elise: We do, and I am incredibly grateful to have amazing infection Preventionists that really help me really dig into a lot of this, gather the data, and be sure we really have the right thing identified so we can put it in all the things we need to into place to prevent spread.

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[00:19:59] Tony: Paging Dr. Sherlock.

[Elise Giggles]

Clearly, healthcare facilities are quite complex settings and therefore require infection prevention measures in place.

But tell me, can you use vaccines to control outbreaks in hospitals?

[00:20:17] Elise: You can, and there are a number of pathogens where it may be spreading within the hospital. And one of the things we’ll do to keep healthcare workers safe is actually give them vaccines early in that exposure window, and that’ll help decrease the potential spread within those individuals. So we could vaccinate our healthcare workers, we could even vaccinate some of the patients. And doing that early, if we can identify things early, can actually decrease spread and keep everyone healthy.

[00:20:41] Tony: Vaccines appear to be an effective tool in the infection control toolkit, but apart from public health, how do vaccines affect the globe?

[00:20:50] Elise: So they are incredibly important from a global perspective. And it’s everything from keeping individuals healthy to maintaining a workforce. Just think about how everything shut down during COVID and supply chains were an issue, food was an issue.

Just all the things that we would take for granted on a daily basis within our lives can be negatively impacted if we have very significant spread of infections. And I think having vaccines in our toolkit and a lot more healthy people allows us to maintain all of that wonderful stuff within our society.

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[00:21:24] Tony: Well, thank you again, Elise, for discussing this universally relevant topic with me today. It was great to have you on the show.

[00:21:31] Elise: It was my pleasure. Thank you so much for having me.

[00:21:34] Tony: And that’s all the time we have for today. Please join us next time as we take a trip south of the border with Dr. Carolyn Fernandez and discuss how to stay healthy while traveling. Until next time, I’m Toni Morrison, and this is microbe Matters.

Thanks for listening. If you enjoyed today’s topic, please rate, write a review and be sure to subscribe to the show wherever you listen to podcasts, so you never miss an episode.

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