On the road to a stronger public health workforce: visual tools to address complex challenges.

The public health workforce is vital to protecting the health and safety of the public, yet for years, state and local governmental public health agencies have reported substantial workforce losses and other challenges to the workforce that threaten the public's health. These challenges are complex, often involve multiple influencing or related causal factors, and demand comprehensive solutions. However, proposed solutions often focus on selected factors and might be fragmented rather than comprehensive. This paper describes approaches to characterizing the situation more comprehensively and includes two visual tools: (1) a fishbone, or Ishikawa, diagram that depicts multiple factors affecting the public health workforce; and (2) a roadmap that displays key elements-goals and strategies-to strengthen the public health workforce, thus moving from the problems depicted in the fishbone toward solutions. The visual tools aid thinking about ways to strengthen the public health workforce through collective solutions and to help leverage resources and build on each other's work. The strategic roadmap is intended to serve as a dynamic tool for partnership, prioritization, and gap assessment. These tools reflect and support CDC's commitment to working with partners on the highest priorities for strengthening the workforce to improve the public's health.

Public health surveillance workforce of the future.

Although electronic data systems that monitor for health threats are becoming increasingly automated, human expertise is, and always will be, critical to recognizing potential cases of disease, diagnosing disease, reporting diseases or conditions, analyzing and interpreting data, and communicating results to all stakeholders. For this reason, the nation's health professionals from all disciplines and at all levels are fundamental to sustaining and enhancing public health surveillance capacity.

West Nile virus encephalitis in a child with left-side weakness.

West Nile virus typically causes self-limited fever with flulike symptoms; pediatric cases are rare. We report a unique case involving a 7-year-old girl with left-side weakness and focal temporal lobe findings resembling herpes encephalitis.

Vancomycin use in hospitalized pediatric patients.

OBJECTIVES: To assess vancomycin utilization at children's hospitals, to determine risk factors for vancomycin use and length of therapy, and to facilitate adapting recommendations to optimize vancomycin prescribing practices in pediatric patients. METHODS: Two surveys were conducted at Pediatric Prevention Network hospitals. The first (Survey I) evaluated vancomycin control programs. The second (Survey II) prospectively reviewed individual patient records. Each hospital was asked to complete questionnaires on 25 consecutive patients or all patients for whom vancomycin was prescribed during a 1-month period. RESULTS: In Survey I, 55 of 65 (85%) hospitals reported their vancomycin control policies. Three quarters had specific policies in place to restrict vancomycin use. One half had at least 3 vancomycin restriction measures. In Survey II, personnel at 22 hospitals reviewed 416 vancomycin courses, with 2 to 25 (median = 12) patients tracked per hospital. Eighty-two percent of the vancomycin prescribed was for treatment of neonatal sepsis, fever/neutropenia, fever of unknown origin, positive blood culture, pneumonia, or meningitis. In an additional 6% (26/416), vancomycin was prescribed for patients with beta-lactam allergies and in 13% (56/416) for prophylaxis. Median duration of prophylaxis was 2 days (range: 1-15 days). Almost half (196, 47%) of the patients who received vancomycin were in intensive care units; 27% of the vancomycin courses were initiated by neonatologists and 19% by hematologists/oncologists. The predominant risk factor at the time of vancomycin initiation was the presence of vascular catheters (322, 77%); other host factors included cancer chemotherapy (55, 13%), transplant (30, 7%), shock (24, 6%), other immunosuppressant therapy (17, 4%), or hyposplenic state (2, <1%). Other clinical considerations were severity of illness (96, 23%), uncertainty about diagnosis (51, 12%), patient not responding to current antibiotic therapy (40, 10%), or implant infection (13, 3%). When vancomycin was initiated, blood cultures were positive in 85 patients (20%); cultures from other sites were positive in 45 (11%), and Gram stains of body fluids were positive in 37 (9%). In 29 (7%) patients, organisms sensitive only to vancomycin were isolated before vancomycin initiation. Reasons for discontinuing vancomycin included: therapeutic course completed (125, 30%), negative cultures (106, 25%), alternative antibiotics initiated (75, 18%), illness resolved (14, 3%), or patient expired (13, 3%). Final results of blood culture isolates resistant to beta-lactam antibiotics included 48 coagulase-negative staphylococcus, 5 Staphylococcus aureus, and 10 other species. CONCLUSIONS: At children's hospitals, vancomycin is initiated for therapy in patients who have vascular catheters and compromised host factors. Only 7% had laboratory-confirmed beta-lactam-resistant organisms isolated at the time vancomycin was prescribed. Efforts to modify empiric vancomycin use in children's hospitals should be targeted at intensivists, neonatologists, and hematologists. Initiatives to decrease length of therapy by decreasing the number of surgical prophylaxis doses and days of therapy before laboratory results may decrease vancomycin exposure.

Expanding the infection control team: development of the infection control liaison position for the neonatal intensive care unit.

Neonatal survival has risen progressively during the past 30 years. As the limits of viability continue to decline, the challenges of providing care to infants at the lowest extremes of gestational age and birth weight continually increase. Nosocomial infections in this very fragile population can be devastating. The complexity of care of these premature infants requires specialized knowledge of the neonate, infectious disease processes, and methods to reduce infection risks in the neonatal intensive care unit. The role of infection control liaison has been established in our institution as an adjunct to meeting this challenge by providing a line of communication between staff, neonatologists, and the infection control team. This article describes the role of the infection control liaison and its overall impact on the infection control program in an 87-bed level II, III, and IV neonatal intensive care unit from 1995 to 1999.

A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States.

OBJECTIVE: To determine the prevalence of intensive care unit-acquired infections, a major cause of morbidity in pediatric intensive care unit (PICU) patients. METHODS: Pediatric Prevention Network hospitals (n = 31) participated in a point-prevalence survey on August 4, 1999. Data collected for all PICU inpatients included demographics, infections, therapeutic interventions, and outcomes. RESULTS: There were 512 patients in 35 PICUs. The median age was 2.2 years (range, <1 day-35.4 years). Seventy-five PICU-acquired infections occurred among 61 (11.9%) patients. The most frequently reported sites were bloodstream (31 [41.3%]), lower respiratory tract (17 [22.7%]), urinary tract (10 [13.3%]), or skin/soft tissue (6 [8.0%]). The most frequent pathogens were coagulase-negative staphylococci (in 16 [21.3%] infections), Candida spp. (13 [17.3%]), enterococci (10 [13.3%]), Staphylococcus aureus (9 [12.0%]), or Pseudomonas aeruginosa (8 [10.7%]). Age-adjusted risk factors for infection included central intravenous catheters (relative risk [RR], 4.1; 95% confidence intervals [CI], 2.4-7.1), arterial catheters (RR, 2.4; 95% CI, 1.5-3.9), total parenteral nutrition (RR, 5.5; 95% CI, 3.6-8.5), or mechanical ventilation (RR, 3.9; 95% CI, 2.2-6.8). Infection was associated with higher age-adjusted risk of death within 4 weeks of the survey (RR, 3.4; 95% CI, 1.7-6.5). CONCLUSIONS: This national multicenter study documented the high prevalence of PICU-acquired infections. Preventing these infections should be a national priority.