Healthcare-associated infections are a critical public health challenge in Arizona and in the US. Healthcare associated infections (HAIs) are acquired during healthcare treatment and can be devastating and even deadly- and they’re largely preventable. You may have seen the article in last week’s Republic about dirty needles and their link to transmission of viruses and drug-resistant superbugs. The article mentions a recent Arizona incident in which unsafe injection practices at a pain management clinic- which had been investigated by our disease detectives in AZ’s public health system and summarized in an MMWR article last Summer.
Arizona’s public health system takes a layered approach to preventing HAI’s in our state. It starts with our Licensing team- who regulates the healthcare institutions where care is given. Our regulations set the standards that prevent infections and our teams of surveyors do routine checks and complaint investigations to make sure facilities are in compliance with our standards. We already have solid infection control regulations for hospitals and nursing homes… but our current Rulemaking for healthcare institutions will be establishing new infection control standards across the board that’ll be applied consistently across all health care institutions in the second half of 2013.
At another level, our Medical Facilities Licensing team and our HAI Program collaborate to ensure the safety of patients in Arizona by jointly providing technical assistance and guidance to licensed healthcare facilities in response to identified infection control breaches. Through our HAI Program and our HAI Advisory Committee– we generate guidance documents for all healthcare facilities and promote best practices for infection control and injection safety like materials produced through the CDC’s One and Only Campaign and our No Place Like Home initiative which is Arizona’s approach to the national Partnership for Patients: Better Care, Lower Costs project.
The next layer is our network of public health disease detectives. Our Healthcare-Associated Infections Program and the counties conduct epidemiologic investigations when we get reports of unsafe injection practices affecting multiple patients. For example… last year we investigated 3 separate instances of unsafe injection practices- exposing 327 people to disease and resulting in 3 infections. Each of the investigations identified unsafe injection practices like: 1) Re-inserting a used syringe into a medication vial; 2) Using a single-dose vial for more than one patient; 3) Diluting medicine beyond the manufacturer’s recommendations; 4) Improper use of personal protective equipment prior to spinal/lumbar injections; and 5) Illegal contamination of needles/syringes and injectable reagents.
Many of the gaps in infection control have roots at the national level. A national drug shortage on many reagents and medications (including appropriate concentrations and single-use vial sizes) has compelled some healthcare practitioners to search for alternate solutions to ensure availability and to use medications as economically as possible. Some practices, like using single-dose vials for multiple patients, may be considered an industry standard in some fields and may still be taught and practiced, despite CDC injection safety guidelines inclusion in Standard Precautions since 2007. Many of these challenges can be safely addressed through medication repackaging into single-dose vials by a licensed compounding pharmacy appropriately applying the U.S. Pharmacopeia standards.
In short- healthcare associated infections remain a public health problem nationally and in Arizona- but by continuing to effectively use our licensing survey teams, effectively using the network of disease detectives we have in our county and state public health system, and by leveraging the work of our HAI Advisory Committee, the One and Only Campaign, and Arizona’s No Place Like Home Initiative- preventing healthcare associated infections remains a Winnable Battle.
Examine the attached research data recently released (see email below) from ADHS and you will see that marijuana usage among teens is falling in Arizona. Anyone can spin a political agenda with one singular and specific study finding, but the headline does not match the study findings. I encourage you all to read the data to see the factual story that unfolds in this very relevant and timely research regarding our youth (Grades 9-12). The study findings clearly suggest that since the Arizona Medical Marijuana Act has come into existence we have witnessed a reduction in youth cannabis consumption.
The Dispensary model has been on hold since the inception of the ADHS Medical Marijuana Program, so ADHS allowed MMJ Patients and Caregivers to grow their own medicine. This patient/caregiver model has now cut into the black market and positively impacted teen marijuana use. This is the backdrop of this newly released study on student marijuana use. The study clearly illustrates how percentage rates among All Students grades 9-12 have clearly fallen. The Percentage of Students Who Used Marijuana During Their Lifetime (All Students) scores fell (-7.5%) seven and one half percent from the previous score of 31% as reported in a study from 2011 Monitoring the Future, to 28.7% in the new study 2012 Arizona Youth Survey.
If we look at the same survey question of Marijuana Use in the Past 30 Days we’ll see the same pattern of marijuana use reduction. The Percentage of Students Who Used Marijuana During Their Lifetime (All Students) scores fell (-6%) six percent from a previous score of 15.2% in the 2011 Monitoring the Future study to just 14.3% in the new 2012 Arizona Youth Survey.
Did we see scores fall among other more prevalent student health risks? No! Look to the benchmarks of Alcohol, Tobacco, and Other Drugs (ATODs) scores and you will note that Alcohol, Cigarettes, Hallucinogens, Cocaine, and inhalant scores increased among All 9-12 Students with regard to Usage in the Past 30 Days. Unfortunately, we as a community, are NOT doing a better job parenting our youth. That should be the headline for Mr. Humbles Blog. Proposition 203 and the ADHS MMJ Program has actually helped reduced teen marijuana usage.
While our ADHS Director chose to highlight that 16.4% of 12th Graders who smoked marijuana reported getting marijuana from a card holder, he did not report that this percentage was far less (11.6%) among All Student Surveyed. Nor did our ADHS Director point out that a far higher percentage (14.8%) of this marijuana was reportedly transferred from “Family/Relatives”! In fact, if we look at this same survey data with regard to where Teens got their Alcohol, 16.6% reported that their “Parent or Guardian” gave it to them. There is no accounting for parental responsibility, nor will our State ask for more parental responsibility within the home environment.
To directly address Will Humbles concern, this newly published data should be viewed as a clear link to the facts, and the facts suggest that although 80% of the 30,000+ ADHS Cardholders have been allowed to grow their own, teen use in Arizona has fallen, while it has grown in State without MMJ laws. No doubt Teen Use will continue to fall when the majority of the 99 Statewide licensed Arizona Department of Health Services Medical Marijuana Dispensaries finally open. When more dispensaries open for business this winter and spring, the patient/caregiver grower model will start to be greatly reduced. MMJ patients and their caregiver growers who live within 25 miles from a State Licensed MMJ Dispensary will no longer be allowed to renew their patients cultivation rights to legally grow their own medicine, thus MMJ distribution control will only become stronger. It may take a good year to wash out the medical marijuana growing rights granted by the state as a stop-gap measure while the Arizona Department of Health Services Medical Marijuana Dispensary program was being scrutinized and challenged. Rest assured the control and distribution issue will only strengthen with time.
ADHS Licensed Dispensaries will grow better medicine, tested for quality and purity, and at less cost to patients than “black market street marijuana.” Dispensaries will continue to hurt the black marketers who exacerbate youth drug problems by selling a variety of illegal and harmful drugs to our children. Licensed Dispensaries will follow the laws or suffer the consequence of losing their license. They will create jobs and pay taxes while serving patient card holders, many of whom do in fact find medical value from this natural herb. State Licensed Dispensaries will only sell to Qualified ADHS Card Holder Patients 21 years of Age or Older, and it is a fact that most card holders are over 30, NOT under 30.
ADHS Director, Will Humble, should take pride in his MMJ program, not run for political cover. The Patient Card program has helped our youth avoid marijuana, and no doubt the State Regulated Dispensaries will further reduce youth drug abuse, as it has in all other States with Regulated Dispensary programs.
Will Humble’s blog hits the mark regarding the “bottom line” on injection safety: transmission of bloodborne pathogens like hepatitis B virus, hepatitis C virus, and HIV through unsafe injections in healthcare is entirely preventable. That is, if healthcare providers follow the simple rules outlined by the One & Only Campaign. Those are: “One Needle, One Syringe, Only One Time.”
Like Arizona, New York State is no stranger to investigations stemming from unsafe injection events. In fact, the New York State Department of Health (DOH) has undertaken 11 such investigations over the past decade. In the wake of those investigations, New York has made changes to its Public Health Law, strengthening professional medical conduct rules and enhancing mandatory infection control with a new emphasis on injection safety. It has increased its regulation of ambulatory surgery facilities and set up the internal NYSDOH multi-disciplinary Healthcare Disease Transmission (HDT) workgroup, which oversees unsafe injection investigations and ensures a consistent and timely response by the department.
Still, a key component in the battle against unsafe injections is furthering education about proper practices, for both healthcare providers and patients. That is why the DOH joined the One & Only Campaign as a charter partner state three years ago. New York has reached thousands of providers through trainings, presentations and Grand Rounds.
Our work over the past three years indicates that while most providers are following correct procedures, there is still a worrisome pocket of practitioners who are not following correct procedure as outlined in the Centers for Disease Control and Prevention’s (CDC) Standard Precautions of 2007. We have also encountered some provider “denial” that unsafe injections are a real problem in the U.S. (Incredulous providers have asked us point blank: “What idiot would reuse a syringe?”). Certainly, the USA Today article cited by Humble and headlines about outbreaks across the country prove this conviction that poor practices “just can’t be happening”, is a dangerous misperception. The Safe Injection Practices Coalition reports over 150,000 U.S. patients have been told they might have been exposed to bloodborne pathogens via unsafe injection practices over the past decade. We believe this number might just be the “tip of the iceberg,” of persons who may have been exposed, as many episodes of exposure risk are not identified due to the difficult nature of these investigations in healthcare settings.
At a time when we take preventive measures in so many aspects of healthcare, from yearly physicals to colonoscopy screening, we encourage more state health departments to take the proactive step of joining the One & Only Campaign. The Campaign offers a state/local health department toolkit, which outlines easy ways busy health departments can sign on to the Campaign and start spreading the word about injection safety. Isn’t an “ounce of prevention worth a pound of cure?” Please follow this link for more information:
Guthrie Birkhead, MD, MPH
Deputy Commissioner, Office of Public Health
New York State Department of Health