Call to Order and Roll Call
Thesecond meeting of the Subcommittee on Elementary and Secondary Education of the Interim Joint Committee on Education was held on Monday, August 1, 2011, at 10:00 AM, in Room 129 of the Capitol Annex. Senator Vernie McGaha, Chair, called the meeting to order, and the secretary called the roll.
Members:Senator Vernie McGaha, Co-Chair; Senators Walter Blevins Jr., Denise Harper Angel, Jimmy Higdon, and Jack Westwood; Representatives Linda Belcher, Hubert Collins, Ruth Ann Palumbo, Marie Rader, Carl Rollins II, and Ben Waide.
Guests: Wayne Young, Kentucky Association of School Administrators; Dr. Kraig Humbaugh, Director, Division of Epidemiology and Health Planning, Kentucky Department of Health; Dr. Margaret A. Riggs, CDR US Public Health Service, CDC Career Epidemiology Field Officer; Liz Hoo, Kentucky Department of Health; and Alex Freiman, Kentucky Department of Health.
Approval of July 11, 2011, Minutes
Upon motion by Senator Westwood, seconded by Representative Palumbo, the minutes were approved by voice vote.
Prevention and Control of Infectious Diseases
Senator McGaha said that even though illness is the major cause of absenteeism, especially in elementary schools, Kentucky has no requirement for reporting of infectious diseases. He said both he and Senator Harper Angel introduced legislation in prior sessions that would have required reporting and data compilation and education programs regarding infectious diseases.
The first presentation was given by Kevin T. Kavanagh, MD, MS, FACS, Board Chairman, Health Watch USA, who is a strong advocate for requiring health care providers to report infectious disease data to the state. Members were provided a copy of the PowerPoint slides and other materials related to his presentation.
Dr. Kavanagh said non-reporting of infectious diseases has a negative impact on the state Medicaid budget and other health insurance premiums and increases the risk of widespread outbreaks. He provided the following information citing various references which were identified in the handouts. Methicillin-resistant Staphylococcus aureus (MRSA) is a healthcare associated infection but can also be community acquired. Data from the Center for Disease Control (CDC) estimates that approximately 1 in 20 hospitalized patients acquire a healthcare associated infection resulting in 100,000 deaths each year at an annual cost of almost $30 billion. Based on that data, Kentucky rates would equate to 23,000 infections, resulting in almost 1,400 deaths at a cost of $400 million. He said healthcare acquired infections are one of the top ten causes of death in the United States (US) even though many are preventable. Central line infections have been greatly reduced since CDC reporting requirements have been instituted, and checklists have helped to reduce the number of ventilator associated pneumonia and Staph infections during cardiac surgery.
Dr. Kavanagh said the CDC and some major medical organizations produced a 2010 White Paper relating to infection control and epidemiology, in which pillars of control were identified. They included collection of data so effective interventions can be established, such as development of new antibiotics to target specific bacteria; evidence-based prevention practices; research; and changes in community behavior, both in hand washing and increased cleaning of public facilities. Kentucky hospitals are required to report outbreaks, but only four outbreaks were reported in a one year period with no MRSA or Clostridium Difficile (C. Diff) having been reported. Currently, only central line infections in intensive care units are reported to the National Healthcare Safety Network (NHSN), and the reporting of surgical site infections will begin in 2012.
Dr. Kavanagh said the two most common infections are MRSA and C. Diff. MRSA causes skin infections and severe cases may lead to blood and lung infections. C. Diff is a spore forming bacteria which can cause life threatening gastrointestinal infections. He said it is normal for approximately 25-30 percent of the population to be colonized with Staph bacteria and some studies have shown that up to five percent of patients are MRSA carriers. In Kentucky approximately 60 percent of outpatient Staph cultures test positive for MRSA, which is one of the highest rates in the nation. Staph infections result in an annual 18,000 deaths which approximates or exceeds AIDS death rates each year. There was at least one outbreak of MRSA in Kentucky schools last year and most outbreaks involve student athletes. C. Diff is also very common with Kentucky ranked sixth highest in the nation for C. Diff infections.
Community prevention practices should include thorough cleansing of high contact surfaces, covering sores and wounds, proper hand washing, and not sharing personal items such as towels, razors, soap, and clothing. MRSA bacteria can be killed by alcohol, ammonia, and hand sanitizers, but C. Difficile can only be eliminated by using Clorox bleach. The Illinois Department of Public Health has a publication with protocols for effective cleaning of school systems. Incident reporting would encourage more thorough cleaning with appropriate agents in schools and other community facilities.
Dr. Kavanagh said that communities and health departments need to become more involved. The percentage of Staph infections in many European counties is only between 5-10 percent. Health care agencies in those countries stress hand hygiene, the use of fewer antibiotics, and heightened surveillance through public reporting. US federal agencies, including the CDC and the US Department of Health and Human Services, stress the importance of accurate and transparent reporting to prevent the spread of infectious diseases. Dr. Kavanagh said it is his opinion that the health care industry has been less than stellar in addressing the epidemic and many institutions have not implemented checklists and protocols to prevent outbreaks. The Comprehensive Unit-based Safety Program (CUSP) is a federal effort to reduce central line-associated bloodstream infections and catheter-associated urinary tract infections. The Kentucky Hospital Association administers CUSP in the state and reported in August 2010 that 39 Kentucky hospitals were participating although that number had dropped to 33 in April 2011. The University of Kentucky hospital had the highest rate of central line infections in the state, based on Medicare billing data, but they do not participate in CUSP. Kentucky was awarded a CDC grant for reporting of outbreaks. Outbreaks are defined as cases which exceed a health care facility’s normal baseline, although lack of reporting makes it difficult to compare data. Dr. Kavanagh said that even though the health care system is a profitable industry, many hospitals complain that in-depth reporting is financially burdensome. He said Norton Healthcare has been very transparent in reporting while remaining very profitable. Information on hospital finances are made available by the American Hospital Directory, which is a Louisville corporation, and information can be accessed through their Website, www.ahd.com.
Dr. Kavanagh said reporting through the NHSN is standardized and not duplicative. NHSN provides information to state health departments and the CDC and the data is also used to generate aggregate data and state comparisons. Standardized reporting would also help in the development of treatment techniques and more accurate billing procedures. He said Medicare has not paid for care related to healthcare-acquired infections for several years although billing procedures makes it difficult to recover payments.
Dr. Kavanagh said, in a February 2010 poll, 90 percent of Senator Harper Angel’s constituents wanted healthcare-acquired infections reported to the health departments.
In response to questions from Representative Collins, Dr. Kavanagh explained that ventilator-associated pneumonia is a lung infection that may occur when a breathing tube is inserted in a sterile environment such as the windpipe, although studies have shown that most infections related to this procedure would be eliminated if proper protocols are used. He said a leading cause of fatalities during the H1N1 outbreak were concomitant Staph infection in the lungs. Even though the use of alcohol wipes and rubs in hospitals may have decreased the number of healthcare-associated Staph infections, the occurrences of C. Diff and community Staph infections appear to be increasing, although lack of data makes it difficult to ascertain the actual number of cases. He said he does not believe that the CDC has established good prioritizations of standards of care to prevent and treat infectious diseases and that the healthcare industry lobbies against reporting because it would necessitate an increase in staff, reprioritization of monetary resources to control infections, and negative publicity if many incidents were reported. He reiterated that the spread of infection can be controlled by hand hygiene, decreased utilization of antibiotics, surveillance and identification, decolonization or isolation of patients, and public reporting. Dr. Kavanagh said very little has been done to change intervention since Senator McGaha first introduced legislation to report infectious diseases.
In response to a question from Senator Westwood, Dr. Kavanagh said that standardization of definitions of infections is one point used to lobby against public reporting. He said there are standardized definitions of when a patient needs to be treated for infection.
Senator Harper Angel said the hospital lobby insists that reporting is already required and additional efforts would be duplicative and the General Assembly does not support duplicative requirements. She asked Dr. Kavanagh to be very specific about the difference between duplication and standardization. Dr. Kavanagh said one incident report per patient would be submitted to the NHSN, although the aggregate data would be disseminated to multiple sources. He said only health care institutions with high incidents of infections would be negatively impacted and additional personnel and man-hours may be required to meet reporting requirements. Currently only central line infections that occur in ICU settings are required to be reported to the NHSN, even though a majority of central lines are installed in other hospital areas where there is less sterility which increases the risk of infection. Surgical site infections will soon be required to be reported to the NHSN. Dr. Kavanagh said schools could report outbreaks through local health departments although reports would be generated by health care facilities where students are treated. He said infectious disease is a community problem with many outbreaks occurring in nursing homes, dialysis centers, outpatient surgery centers, and other health care facilities; and that a definition for what constitutes an outbreak is needed, such as a specific number of cases over a specified time period.
Representative Waide expressed concern about protection of patient personal data, duplicative reporting, and increased costs associated with additional tests that may be required to identify various strains of bacteria and infection. Dr. Kavanagh said the previously proposed legislation did not require surveillance cultures, although such cultures should be done in specific settings, especially in preoperative patients. The proposed legislation would have required surveillance culture data when done be reported to the state to develop aggregate data. He said reports would be submitted to NHSN which uses federal patient law safeguards. There were no requirements in the legislation for schools to do reporting since students are not treated for infections at schools. Dr. Kavanagh said he would obtain more information on procedures that NHSN uses to ensure protection of patient data and report back to the committee.
Senator Higdon related that he was recently at one of the schools in his district at which only one sink in three worked in the boys’ restroom. He recommended that all schools, even those categorized to be replaced, be held to high standards in cleanliness to prevent infectious diseases.
Senator Blevins said that since data from the American Hospital Directory shows hospital gross receipts have been reported in the $2 trillion range and prevention could save many additional health care dollars and alleviate the toll on people’s lives, there is no reason why health care industries should resist reporting the occurrences of infectious diseases.
In response to a question from Representative Palumbo, Dr. Kavanagh said the only statistics available for Kentucky are two research studies. One was a 2009 study using 2008 data published in the Journal of American Medical Association about C. Diff incidents and the other was published by the Center for Disease Dynamics, Economics, and Policy based on data from outpatient laboratories regarding the percentage of Staph outpatient cultures which also contained MRSA.
Representative Rader asked if Kentucky urgent care centers and physician offices are doing enough by state regulation to ensure those facilities are the safest for Kentucky’s children. Dr. Kavanagh said that many of those facilities are now associated with various hospital systems and it is important to ensure that safe practice protocols and checklists are used and data reported. He said that as integration progresses and systems become larger, the medical community will become even larger and speak with a single voice.
In response to a question from Representative Belcher about who is responsible for paying for treatment of infections that could have been contracted in a medical setting, Dr. Kavanagh said Medicare and Medicaid billing data is very complicated, but ultimately the costs are paid for by society through federal health programs and higher insurance rates. He explained that Medicaid uses a diagnostic-related code system resulting in a flat payment for major diagnoses and that a new billing system is being implemented, which will generate data but at a much later date. Reporting infectious diseases to the state would be much simpler than the complex federal system and many grants are available to assist hospitals in meeting reporting requirements. Legislation to require reporting is not designed to be punitive to the healthcare industry but used only as a mechanism to identify and prevent the spread of infectious diseases.
Senator Harper Angel related that Medicaid in Kentucky will no longer pay for hospital-acquired infections, which will help balance the Medicaid budget. She said the infections are referred to as never occurrences meaning they should never have happened.
In response to a question from Senator McGaha, Dr. Kavanagh said it is difficult to define baseline because reporting is not required. The CDC does not have a good definition for baseline because it is left to each institution to establish its own baseline. Senator McGaha said Norton Healthcare needs to be commended on their groundbreaking move to publicly report data. He thanked Dr. Kavanagh for his informative presentation.
Kraig E. Humbaugh, M.D., M.P.H., Director, Division of Epidemiology and Health Planning, Kentucky Department for Public Health; and Margaret A. Riggs, PhD, MPH, MS, CDR US Public Health Service, CDC Career Epidemiology Field Officer, Kentucky Department for Public Health, provided information on the prevention and control of MRSA in school settings. Members were provided copies of the PowerPoint slides and various handouts related to the presentation.
Dr. Humbaugh said that MRSA is a Staph bacterium that is resistant to traditionally used antibiotics to treat Staph infections. The CDC estimates about two percent of the population is colonized with MRSA which means that the bacteria is living on their skin. The bacteria may be present under the armpits and in the groin or nose areas and may be a part of certain individuals’ flora, although some of those individuals may not be infected. MRSA is treatable with the use of newly produced antibiotics and treatment protocols. The most common infection caused by MRSA is skin or soft tissue infections and early treatment is necessary to avoid serious complications. The most common way for transmission of MRSA is for a person who is colonized or infected to touch someone who is susceptible and who may have microabrasions or breaks in the skin which allows the bacteria to enter the body and cause infection. Another less common way for MRSA transmission is for a colonized or infected person to leave germs on inanimate objects, although transmission without contact is much less likely because MRSA bacterium is susceptible to drying out and to light. Certain conditions will enable the bacteria to live longer, such as dark, moist environments.
Dr. Humbaugh said CDC has identified certain factors which increase the risk of widespread infection. The risk factors were crowding in institutional settings, including schools; frequent contact among individuals, such as athletic or sports teams; persons with compromised skin, especially in settings where skin to skin contact would occur, such as sporting competitions; coming in contact with contaminated surfaces; using shared items, such as towels, razors, and jerseys in sports or school settings; and the lack of cleanliness and personal hygiene which makes one more susceptible or increases the likelihood of MRSA. Higher risk populations include sports participants, inmates in correctional facilities, military recruits, day care attendees, tattoo recipients, and methamphetamine users. The best preventive practice is to avoid spread through skin to skin contact and one of the best preventive protocols in school settings is frequent thorough hand washing by washing 20 seconds with soap and water and drying with clean paper or cloth towels. Students should keep cuts and scrapes clean and covered; wash hands thoroughly and frequently; avoid contact with persons having infected skin; and should not share personal items, such as razors, bars of soap, deodorant, and sports equipment and jerseys. Dr. Humbaugh said that antimicrobial products, such as soaps, have not been found to be more effective than regular soap and water because it is the action of rubbing or friction that cleanses the hands and removes bacteria. Studies have shown that antibacterial soaps may actually promote bacterial resistance and it is not recommended that schools buy the more expensive antibacterial soap for their students. Alcohol-based hand sanitizers are good for school settings when soap and water is not available, such as on athletic fields, but does not replace the most effective means of soap and water hand washing to prevent the spread of diseases.
Dr. Riggs said the most important prevention method is to wash germs away, which lessens the need for harsh chemicals to kill them; and cleaning and disinfecting surfaces in a school setting is the main objective. Cleaning should be concentrated in areas that are commonly touched by many students, such as doorknobs, light switches, table tops, restrooms, floors, lockers, and athletic equipment, to control infectious diseases and influenza. It is recommended that an EPA registered disinfectant be used to remove germs from the school environment if the initial cleaning phase did not eliminate the germs and that the disinfectant be allowed to air dry to destroy the germs. Green cleaning agents are recommended since many children are allergic to various ingredients in disinfectants or have health conditions, such as asthma, that may cause adverse reactions. A handout related to green cleaning was provided to the members. Dr. Riggs said proper cleaning protocols should be used and green cleaning is recommended to protect students, custodial staff, and the environment. The green cleaning handout related to hospital settings but would also be applicable in school settings.
Dr. Riggs said guidelines were developed in 2007 for Kentucky schools, with specific detailed guidance for athletic departments. This information was provided in a handout to the committee. The guidelines were disseminated with assistance from the Kentucky Department of Education and are currently available on KDE’s Website. She said it is the recommendation of CDC and the Kentucky Department of Health that exclusion of students from school or sports activities should only be reserved for those who are unable to keep infected skin covered with a clean dry bandage and maintain good personal hygiene. The only exception would be student athletes who participate in a sport with regular skin to skin contact where the bandages are difficult to keep in place, such as wrestling. School staff and students should be educated about how to prevent and treat infection and how to recognize signs and symptoms of potential MRSA infection.
In response to a question from Senator Higdon, Dr. Humbaugh said local health departments are encouraged to have their environmentalist check restroom facilities at schools before the school year begins and that additional inspections should be conducted when outbreaks of shigella, salmonella, or other diseases occur. He said inspections could be mandated through regulation.
Senator McGaha asked Roger Wagner, Superintendent, Pike County Schools, to inform the committee about a MRSA epidemic in the school system. Representative Collins said that Pike County is the largest county in area in the state and currently has five high schools. He said that two of the district’s schools were classified as Category 5 and that the Pike County Board of Education elected to use the non-recallable nickel to generate funding to build new schools. Mr. Wagner said two new schools will open this year and two more new schools will open next year. Representative Collins said new facilities will be an important factor in changing the health environment for students in Pike County.
Mr. Wagner described the 2007 outbreak in the school system, which was brought to his attention by a parent of a student athlete who tested positive for MRSA. At the time, he was not aware of other incidents occurring throughout the state and the outbreak became a public relations nightmare for the school system. School administrators and nurses, local health department employees, board members, the media, and various other agencies and citizens all worked together to alleviate the problem. Schools were closed and all of the buildings, furnishings, buses, athletic facilities, and common areas were thoroughly cleaned and sanitized. Education programs were provided on the identification, prevention, and treatment of MRSA, with special emphasis on ensuring that students were not stigmatized if they had contracted the infection. Mr. Wagner said that the local health department played a vital role in the epidemic and continues to provide needed inspections and education programs for the school system. Schools are required to provide hand wash in all classrooms and additional custodial staff has been employed to ensure cleanliness. Posters have been placed throughout the school showing proper hand washing techniques and the family resource center director and practical living classes provide instruction regarding infectious diseases. Mr. Wagner said reporting would help schools prevent and mitigate widespread outbreaks.
In response to a question from Senator Higdon about public reaction to the use of the non-recallable nickel, Mr. Wagner said the situation in Pike County was unique in that revenue from natural gas taxes was split in half from $1 billion to $500 million, which drastically impacted school funding. To offset the loss of revenue, the board had requested and the taxpayers approved a property tax increase that included the non-recallable nickel.
Senator Higdon said he agrees that local health departments provide a valuable service and that the new food service regulations recently implemented have made Kentucky a safer place to buy food.
In response to questions from Representative Rollins, Mr. Wagner said that custodial staff is trained annually and an increased emphasis has been placed on cleaning of frequently used surfaces and items, such as headphones and keyboards. Also additional custodians were hired to provide a cleaner environment. He was not aware of guidance relating to cleaning that has been issued by the Kentucky Department of Education but utilizes local health department personnel to provide staff training and educational resources.
Senator McGaha commended Superintendent Wagner on the steps the district has taken to prevent the spread of infectious diseases. He said he will continue to pursue public reporting and will work with Senator Harper Angel on the legislation. He said it is also important to provide readily available resources for educators, parents, and the public on how to identify, prevent, and treat infectious diseases.
Next Meeting and Adjournment
Senator McGaha announced that the Interim Joint Committee on Education will hold its next meeting at the Elkhorn Crossing School in Scott County on Monday, September 12, and the subcommittees will not meet. There being no further business to discuss, the meeting adjourned at Noon.