Cocooning and Epidemics

Pertussis bacteria (Bordetella pertussis)
Pertussis bacteria (Bordetella pertussis) (Photo credit: Sanofi Pasteur)

On the red eye this week from Seattle to NYC I was reminded of Washington State’s Whooping Cough (pertussis) epidemic. It was a full flight and at least ten people seated near me had deep hacking coughs the entire flight. It’s likely that at least a few of them had untreated pertussis and have now spread it to susceptible people. There were a few small infants on the flight and they are the most vulnerable to getting severe pertussis and dying of it. Adults with pertussis can have a cough that is so forceful it can cause them to vomit. A milder form of the cough can last for months. And pertussis is highly preventable with appropriate vaccination.

In Washington State we are in the midst of a pertussis epidemic. Mary Selecky, the Secretary of Health at the Washington State Department of Health, officially declared an epidemic on April 3, 2012, even though epidemiologic data indicate that pertussis cases exceeded the epidemic or outbreak threshold in late December, 2011. Declaring an epidemic allowed Governor Christine Gregoire to mobilize state emergency funds to provide more pertussis vaccinations to uninsured people in Washington State. It also allowed her to call on assistance from the federal government in the form of CDC investigators to monitor and advise intervention strategies.

According to the Washington State Department of Health website,  through the week of May 19th, a total of 1,738 cases of pertussis have been reported in Washington State for 2012, compared to 146 cases for the same time period in 2011. Since January 114 infants less than 12 months have been hospitalized with pertussis; 23 of those were under three months of age and presumably were the sickest and probably required the longest hospitalizations. No deaths have been reported from this year’s pertussis epidemic in the state.

Current US recommendations for vaccination against pertussis include the usual combination childhood vaccination series starting at two months of age, then a booster shot for adolescents ages 11-12 years. A more recent recommendation is for an additional booster shot for adults who are parents or caregivers of infants less than 12 months of age—the idea being that if the adults are vaccinated they are less likely to get pertussis and pass it on to susceptible infants in their care. Health care providers, especially the front-line staff of nurses, are included in this recommendation. This approach of targeting pertussis vaccination to the main caregivers of infants is called cocooning.

I’ve been monitoring the news coverage of Washington State’s pertussis epidemic. The Seattle Times published an article, “Whooping cough epidemic declared in Wash. State” (Donna Gordon Blankenship, 5-10-12). In her article, Ms. Blankenship emphasized the need for adults to get vaccinated as a way to protect infants, and quoted a CDC official calling this a “cocoon of protection.” She also quoted this same CDC official as stating that Washington State’s current pertussis epidemic has nothing to do with the anti-vaccination movement, and instead attributed it to better disease surveillance, the cyclical nature of pertussis infections, and an aging population with waning immunity as the vaccine wears off. That all made sense to me—except for the matter of it not being related to the antivaccination movement. How could it not be at least partially responsible for the current epidemic?

A New York Times article “Cutbacks hurt a state’s response to whooping cough” (Kirk Johnson, 5-12-12) emphasized Washington State’s budget crisis and recent cuts to the public health infrastructure as contributing factors to our states’ current pertussis epidemic. He pointed out that changes in the vaccine to make it have less side effects have also made it less effective over—immunity tends to wane faster. He included quotes from a school nurse (yeah school nurses!) in Skagit County, north of Seattle, which is the hardest hit county so far. He referenced the fact that Washington State has the highest percentage of parents who voluntarily exempted their children from vaccines out of fear of side effects or for philosophical reasons. Studies have shown that vaccine refusers tend to cluster, are often middle-class, college educated white people with antigovernment, anti-establishment views. They like living in the Eco-topia of Puget Sound.

A related topic I find fascinating is the seemingly rising trend of antivaccination sentiments among nurses—and the fact that an astonishingly low percentage of pediatric nurses get the booster vaccine for pertussis, despite CDC recommendations for them being part of the ‘cocooning’. I’ll deal with that issue in a follow-up post next week—unless I come down with pertussis thanks to my airplane seatmates. (I have had the pertussis booster so am counting on it working.)

The state of the state regulation of health professions

The Seal of Washington, Washington's state seal.
Image via Wikipedia

Washington State is among the best states for nurse practitioner scope of practice. I knew this, of course, and it is one of the reasons I moved here 16 years ago. Therefore, I assumed that Washington State had to be that much better than Virginia when it came to the regulatory system for health professions. However, according to the results of the 2007 Performance Audit Report, Department of Health, Health Professions Quality Assurance Report by Brian Sonntag, Washington State Auditor, this is not the case. Governor Christine Gregoire requested this audit, largely as a result of media coverage of sexual abuse of patients by Washington state licensed health care providers. In 2005/2006 The Seattle Times published a investigative reporting series by Mike Berens called “License to Harm,” and in it he concluded that Washington State had a deficient health regulatory system that fostered abuse through weak and inefficient regulation.

One of the main problems as pointed out in the Performance Audit Report is the confusing government structure for Washington State health professions regulation. Whereas most all other states in the US have independent agencies regulating health professions, Washington State has an umbrella structure. Within the Department of Health there is Health Professions Quality Assurance (HPQA), which directly oversees 23 professions, but also provides support to 16 other boards and commissions. These boards and commissions are authorized by law to adopt their own rules and standards. Although HPQA is responsible for overseeing credentialing and discipline of health care professionals, it does not have responsibility or authority to direct boards and commissions in matters relating to case resolution and disciplinary actions. The report states that this divided governance structure does not provide for clear lines of performance management and accountability with regard to operations of the boards and commissions. In addition, it results in significant inconsistencies in disciplinary practices across professions.

Another interesting fact mentioned in the Audit Report is that since 2005, HPQA has taken steps to address public demand for more severe sanctions against health care providers. They do not specify how they have addressed this public demand for more severe sanctions, except by highlighting Governor Gregoire’s mandate to promptly investigate—without—exception—all allegations of sexual misconduct by all health professionals. They note that between 1995 and 2006, there was an 83% increase in the number of all complaints filed against health care providers in Washington State. The authors of the report recommended ways to increase public awareness about their right to file complaints against health care providers; however, the written response of HPQA to this recommendation was that they didn’t want to do this since they were inadequately staffed to handle the increased number of complaints.

So, in the past four years since this audit was done and recommended changes given to the Department of Health, the Governor and the State Legislature, what progress has been made? Since there was no follow-up report available on the HPQA website, I decided to call and e-mail them to find some answers to my questions. I’m happy to report that I got further with this line of inquiry than I did with comparable government personnel in Virginia. I spoke with Steve Hodgson in the Assistant Secretary’s Office of HPQA. He told me he had forwarded on my list of questions to Kristi Weeks, Director, Office of Legal Services, HSQA, and that they would get back with me with the answers by the end of the week this past week. In response to my ‘easy’ question, “What’s the difference between a board and a commission within HPQA?” he said that it boiled down to a difference of payment structure. That the board members of the four health professions’ boards (medicine, nursing, dentistry and chiropractic) receive $250/day in compensation for their board duties, whereas all commission members only get $50/day.

Here are some updates. There have been no changes in the umbrella/divided government structure of the health professions regulatory system in Washington State. In May 2006, the Secretary of Health adopted Uniform Sanctioning Guidelines as a tool for all of the boards and commissions to consistently impose similar sanctions for similar violations. The various health regulatory boards and commissions were not mandated to adopt these guidelines, and voluntarily adopted them at different times. As of this year, all boards and commissions have adopted them. However, as the results of the 2007 audit found, interpretation and implementation of such guidelines varies widely by professional group commission/board. All of the boards and commissions are now annually reporting performance measures to the HPQA. A planned follow-up audit of the health regulatory system in 2010 was canned due to lack of funds. However, Kristi Weeks writes, “The Legislature has mandated a report by December 15, 2013 that will evaluate, among other things, medical and nursing’s regulatory activities, including timelines, consistency of decision making, and performance levels in comparison to other disciplining authorities.” She did write that this is all subject to public disclosure and said I should feel free to share it.

A lingering question: Assuming the 2010 health regulatory system audit had been funded, what, if anything, would have been different in the cases of Kim Hiatt and the other Children’s hospital nurses recently charged by the Nursing Commission for misconduct?