Strengthening Infection Control and Vaccine Effectiveness to Improve Public Health & Hospital Safety

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Daniel Simon, MD: Hello everyone, this is your Science@UH host, Dr. Dan Simon. Today I am happy to be joined by Dr. Elie Saade, Medical Director of the Infection Control program at University Hospitals and Associate Professor of Medicine at Case Western Reserve University School of Medicine. Welcome, Elie.

Elie Saade, MD, MPH: Hello Dan, thank you for having me.

Daniel Simon, MD: So, Dr. Saade, before we dive into your latest research, can you share a bit about your journey into infection control and public health? What led you to specialize in these areas?

Elie Saade, MD, MPH: I became interested in infectious disease and public health fairly during medical school. What drew me to infectious disease is the sheer variety and complexity of infections. There's countless pathogens, each with different presentation, each with a different treatment, each with a different epidemiology. Differential diagnosis is always very rich, so it's like guesswork, like a puzzle that you have to put together, making every case a challenge. Also, infectious disease and public health are very deeply intertwined, and public health allows for interventions that can impact entire populations. For example, vaccines, proper sanitation, plumbing which impacted cholera and others, mosquito control which impacted malaria in the United States, and most recently, the COVID-19, which wreak havoc until it was controlled with the help of vaccines but also needed a lot of other public health interventions as well.

So, vaccines play a huge role in people's lives as well as other infection control methods play a huge role in patients' life and that really the possibility of making a big impact with small intervention is something that fascinates me.

Daniel Simon, MD: That's really terrific. I think obviously as you mentioned, our whole lives from 2020 through 2022 were defined by this new infection, you know COVID. So, you became our best friends because you got us through this in the hospital and congratulations and thank you to you and your team for doing that.

So, you've been the medical director for infection prevention and control at University Hospitals Cleveland Medical Center since 2019. Can you walk us through some of the key initiatives that you've led and their impact on patient safety? I mean, tell us you know, of course, I have to wash my hands now when I go in the room and when I come out of the room and we are very diligent about doing that So, tell us about the things that you've put into place that have made it better for patients with patient outcomes.

Elie Saade, MD, MPH: Leading the Function Prevention and Control at University Hospitals, a big hospital with many different hospitals/clinics and where we added also additional hospitals during the pandemic was a big challenge and it was done with a big team, which Dr. Simon you led in addition to Dr. Megerian and late Bob Salata. So, under your leadership, we were able to stand up this Infection Control Committee, which became a big part of the hospital operations for a while. So, the intervention that we do in infection prevention, that would not work unless we have a commitment from everyone, pretty much everyone, and so, that's why this impacted a lot of people from the administration to nurses at the bedside, to cleaning worker, environmental staff, physicians and everyone else. And we learned a lot of lessons, not only on the control of pandemics, but also at the control of crisis and the crisis keep coming, but we built a lot of resilience to help address those with, in addition to COVID, the hospital related infections remain a part of our lives and actually became worse for some time during the COVID pandemic.  But in infection prevention, small interventions, for example, dressing changes or controlling how we do our blood tests or our urine tests can have big impacts, but they need to be scaled. So, in infection prevention we always have a need to have a lot of interdisciplinary intervention, a lot of interdisciplinary work, big communities that span the whole hospital system, and these are necessary to make anything work. And we have to also leverage technology such as EPIC, using clinical decision support, and there's always a duty to look into how we can generalize these interventions and generalize our knowledge and our information so we can benefit from but also others can benefit from it.

Daniel Simon, MD: So, Elie, you know, let's try to make this simple for the lay audience. You come into the hospital, you get a central line, or you get a Foley catheter because you can't urinate. So as soon as you put a central line in or you put a Foley catheter in, you're at risk for an infection and that infection leads to a lot of complications, prolongs your hospital stay. It can lead to serious blood borne infections, and it's also very expensive.

Tell us, in something really simple like Foley catheter, where you now have units that have gone more than 12 months without a Foley catheter infection, how do you tell them what to do? What’s the key thing about preventing those infections?

Elie Saade, MD, MPH: The most important part is not to have a catheter or if you have it, or if they need it to, remove it as soon as possible. Removing a catheter will decrease the risk of infection but also taking care of how we place the catheter. Doing it in a very clean and sterile way and then doing a close maintenance every day making sure that the basics are met, having the appropriate antiseptics used every day and also making sure to remove it as soon as we don't need it.

So those look like simple intervention, but we do need to scale them up and to scale them up we have...a large collaboration across all the hospital system which we call the fractal management system, where the changes start at the bedside and go up until like all levels... until the administration, until the chief quality officers and the C suites like the chief medical officer, chief nursing officers. So, the information flows from top down, but also from the bottom up, where we adopt interventions that are successful in some units. We take them to spread them to other units or to other hospitals. And we also learn from each other, so nurses learn from other nurses and other hospitals, doctors learn from other doctors and so forth. And in addition, information is very important in this situation. We still have dashboards where we can follow in real time information that is very important to this. Like for example, the patient to have like they're dressing we can monitor every patient, how much, if they got their dressing changes, for example, and we can address that pretty quickly. So, this is like the part of implementation science, which is also, you know, very important part to apply to anything today in a big hospital.

Daniel Simon, MD: Well, I think Elie, the other thing that still always wins is nothing like good competition. And if you publish, everybody's, as we say, central line infection rates and they're fully catheter infection rates, it drives better performance. I know that you and your partner, Dr. Hoyen, follow that very, very closely. And it is always nice to hear about units that have had zero CLABSI infections and zero CAUTI infections over the past 12 months.

Well, let's shift gears for a second and I know this is an area that really excites you, which is the US Flu Vaccine Effectiveness Network and your collaborative research. I think the people listening don't realize that we have infection control royalty with us. You are the principal investigator of an over $18 million grant, looking at flu vaccine effectiveness in how multidisciplinary collaborations come into play. Tell us a little bit about this grant,  what you're trying to do and how it improves public health.

Elie Saade, MD, MPH: We are a part of the US Flu Vaccine Effectiveness Network. It's a network of eight hospitals across the United States and this is one of the networks that the CDC uses to monitor the effectiveness of flu vaccines every year. We contribute data to this network by recruiting patients at our urgent cares and emergency rooms at Case student health center, at the VA, and this year we started also collaborating with Metro Health to recruit patients at Metro Health.

We contribute information in an anonymous way about flu vaccines and illness to the CDC, and in addition to contributing blood samples and contributing virus samples as well that helps us calculate vaccine effectiveness every year and throughout the season. We just had our mid-season publication yesterday, actually, and the NWR, which showed that this year vaccines have been effective in reducing outpatient visits or doctor visits by around 50%. So, despite a low uptake of vaccines, so if we have a higher uptake, that will definitely lead to more prevention.

In addition, we collect the virus samples which are sequenced and that contributes to deciding on next year's vaccine composition. When it's joined with our partners as well and in addition to that, we have the chance to perform immunology study with our partner at Case and that's something that we are unique for in the network where we, with the help of Dr. Kennedy and Dr. Cameron at Case Western, we perform immunology studies to help understand the impact of natural immunity and the impact of the vaccines on illness.

Daniel Simon, MD: So the frustration with our annual flu vaccine is that we have to guess the strains very far in advance because most of the vaccines’ technology still uses, as you would say, old fashioned egg cultures, and it takes time to vaccinate millions and millions of people in this way.  What do you think about the future of, and I know that we've participated in trials of mRNA technology similar to Moderna and Pfizer for COVID, for flu so that we can learn about the strains from the Southern Hemisphere faster and have changes to vaccines that would be more effect because a vaccine that's 50% effective is not what we really like, we'd like a vaccine that was 70 to 90% effective. So, tell us a little bit about how you think the technology might change over time.

Elie Saade, MD, MPH: One of the biggest problem with the flu vaccines is that their effectiveness is not as good as some of the other vaccines where, for example, measles vaccine, their effectiveness in the mid to high 90s, while with flu vaccines, it's usually around 40 to 50% when it's a good effectiveness year. Of course, the effectiveness on hospitalization and on severe disease is usually higher, nevertheless, we do need to change the strains and the vaccine every year because of how fast the virus mutates and about how these mutations are important in the immunity response. So, we have to decide on which strains to be used early enough during the season to be able to produce these big quantities of vaccines and most of the times they are produced using egg cultures, which still take time and have other problems like this year for example, when we have the avian flu. Which effects egg production that can lead to problems also in producing eggs for the following season but now, with the emerging technology that we learn to scale up during COVID and to use a lot during COVID, which is the MRNA technology that will accelerate the production of vaccines so that will make the selection of strains closer to the actual need for the vaccine. So, if we are giving the vaccine starting in September, we can select the strain translate as May or June or July we don't really know yet how that will work and that will be closer to the actual vaccine that will circulate the closest we have now is recombinant technology, where we produce the proteins or the antigens in the lab. However, the problem with scaling is real and the technology these vaccines are not yet as good as we want them to be. So, the MRNA technology is really what made a big difference in that.

Daniel Simon, MD: You know, I think that the lay audience doesn’t realize that high risk groups really need these vaccines. If you have heart failure, heart disease, lung disease. If you're advanced in age, there are still 35 to 50,000 plus flu deaths a year in the United States.  And if you come to our hospital, we are swamped with patients in the emergency room and on the inpatient because people with underlying asthma, COPD, and heart failure it can be a very, very serious illness, so the need for improved effectiveness of vaccines is greater than ever.

Let me ask you a final question. So, for our trainees, our residents and our fellows in our career physicians who aspire to make a difference in infectious disease, in public health, what guidance would you give them? What advice? I mean we have a lot of people going into infectious disease because of the pandemic now, so what's your advice to our young people?

Elie Saade, MD, MPH: Hmm, that's a very important question for infectious disease. Of course, our first recommendation is to go into infectious disease, a very interesting and very exciting field. Theres a lot of variety, it touches on people's lives every day and there's a big potential for a big impact with interventions and it's a very exciting field where there's always something new like over the last five years. Since COVID, for example, we've had m-pox, we've had a resurgence of Ebola, and we have now the avian flu. And we don't know what will be coming next. In addition to that, we have the other existing problems, such as the hospital acquired infection, the super bugs, which are a big crisis as well, even though it's one that is in slow motion, so it doesn't feel as big or as exciting or as interesting, but It is also a big challenge, so, I would say to seek collaboration and seek a broad collaboration and to keep yourself flexible and open to what is coming.

So, when I went into this field, no one knew about COVID, of course, but then, you know, COVID came and that's something that I embarked on and I'm helping with the control at many different scales. And also, to seek mentors that are as passionate as you. I'm lucky to have had my mentor, Dr. Salata and currently continue to have other mentors which are also passionate about what they do and in helping me and other young investigators to, to advance.

Daniel Simon, MD: Well, thank you so much for joining us today. I think that Dr. Salata would be so proud of you and this entire infectious disease team. You rose to a great challenge.

Elie Saade, MD, MPH: Thank you and it's with your support and your leadership.

Daniel Simon, MD: We are indebted to you. You saved many lives in Cleveland. So, thank you.

To learn more about research at University Hospitals, please visit UHhospitals.org/UHResearch

Thank you so much for joining us, Elie.