Tag Archives: public health

Root Cause Analysis

CDC provides guidance for states to respond to Zika cases

By ThinkReliability Staff

The first Zika cases related to the current outbreak were found in Brazil in May 2015, along with a dramatic increase in microcephaly in babies born in that year. (See our previous blog about the possible link – now verified – between Zika and microcephaly.) Microcephaly is a serious birth defect that impacts many children whose mothers contract Zika while pregnant.

Active Zika transmission currently exists in nearly all of South and Central America, the Caribbean, and some Pacific Islands. 934 people in the US have been infected with Zika; 287 of those infected are pregnant women. Most of these people were infected outside the country and then traveled to the US. Zika is primarily spread by mosquitos, but can also be transmitted through blood transfusion, laboratory exposure and sexual contact.

While no cases of transmission by mosquito have yet been reported in the continental US, the Centers for Disease Control and Prevention (CDC) has released a blueprint for states to respond to locally transmitted cases of Zika. A visual diagram outlining the steps to be taken from the blueprint (a Process Map) can be helpful. (To view the Process Map for the CDC’s interim Zika response process, click on “Download PDF”.)

The CDC’s plan involves four stages. The first stage is implemented during mosquito season. This stage involves surveillance for suspected locally transmitted infections (i.e. persons with “symptoms compatible with Zika virus infection who do not have risk factors for acquisition through travel or sexual contact”, with pending test results). Upon a suspected infection, state officials and the CDC should be notified. State or local officials will open an epidemiological investigation (including ongoing surveillance) and begin implementing controls, involving both reducing mosquito populations and continuing public outreach, with CDC assistance as needed.

Stage 2 occurs upon confirmation of a locally transmitted infection. At this point, notification expands to include local blood centers as well as others required by International Health Regulations. The CDC will assist with an expanded investigation, surveillance, and communication, including deployment of an emergency response team (CERT) if desired. Once Stage 2 has been reached, stand down will only occur after 45 days (3 mosquito incubation periods) without additional infections or when environmental conditions no longer permit transmission.

If there is confirmed Zika in two or more persons whose movement during the exposure period overlaps within a one-mile diameter, Stage 3 (widespread local transmission) is entered. First, local officials will attempt to determine the transmission area, the “geographic area in which multiperson local transmission has occurred and may be ongoing”. Communication, surveillance, testing and controls are enhanced and expanded. Interventions for blood safety and vulnerable populations (including pregnant women) are implemented.

Once the infection has spread outside a county, it enters Stage 4 (widespread multijurisdictional transmission). All steps taken in previous stages are expanded and enhanced. The CDC will evaluate whether local capacity is adequate for response, and will assist as needed. Stage 4 actions will be continued until the criteria for stand down is met.

Based on previous experience with two mosquito-transmitted diseases, chikungunya & dengue fever, the CDC does not believe Stage 4 will be reached within the United States. However, as Dr. Tim F. Jones, an epidemiologist for the State of Tennessee, says, “Even though the percentages and the likelihoods are incredibly low, the outcome is awful.” Risk is a function of probability and consequence. Even with a low probability, the high consequence makes the risk from Zika considerable, and worth planning for.

To view the Process Map, click on “Download PDF” above. Or, click here to view the CDC’s interim guidance.

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Root Cause

The end of the Guinea worm?

By Kim Smiley 

Guinea worm disease is poised to become the second human disease to be eradicated (after smallpox). In the 1980s, there were millions of cases of Guinea worm disease each year and the number has plummeted to only two confirmed cases so far in 2016, both believed to have been contained before the disease had a chance to spread. This accomplishment is particularly impressive considering that there is no cure or vaccine for Guinea worm disease. In fact, the most effective “cure” for the disease used today is the same one that has been used for thousands of years – to wrap the worm around a stick and slowly pull it out. (Read our previous blog “Working to Eradicate a Painful Parasite” to learn more about the problems caused by Guinea worm disease.)

So how has this horrible disease been fought so effectively?  We need to understand how the disease spreads to understand how the cycle was broken.  (Click on “Download PDF” to see a Process Map of the Guinea worm lifecycle.) The Guinea worm is a human parasite that spreads from host to host through the water supply.  The (rather disgusting) lifecycle begins with Guinea worm embryos squirming and wiggling in a freshwater pond, hoping to attract the attention of unsuspecting water fleas.  Once consumed by a water flea, the Guinea worm embryos drill out of the water flea’s digestive tract, move around the body cavity and feed on the water flea.  When a human then drinks the water containing the infected water flea, the lifecycle continues.

The water flea is dissolved by digestive juices in the human’s stomach and the Guinea worm embryo drills out of the intestines and crawls into the abdominal blood vessels, remaining in the body for several months until it reaches sexual maturity.  If the human is unlucky enough to be hosting both a male and female Guinea worm, the parasites will mate.  The male then die and millions of embryos grow in the female.  The female worm will usually make her way to the host’s leg or foot, pierce the skin and release an irritant that creates a painful blister.

Human hosts will often put the fiery blister into water to soothe the pain.  The female worm senses the water and releases thousands of embryos from her mouth.  She doesn’t release all her embryos at once, but will continue to release embryos when she senses water over a period of time.  If the embryos happen to land in a pond with water fleas, the whole painful process can start anew.

Once the lifecycle of the Guinea worm was understood, communities and aid organizations were able to use the information to disrupt the lifecycle and prevent the Guinea worm from spreading.  Some aid organizations helped provide access to clean drinking water or straws with filters that removed water fleas and prevented Guinea worm infections. In other places, the Guinea worm larvae were killed by treating the water with larvicide. But the most effective solution has been simply keeping infected people out of the water supply.  Once most people understood the consequence of putting Guinea worm blisters in drinking water they simply (if painfully) avoided the ponds used for drinking water, but some communities also implemented new laws and fines or posted guards at water holds to ensure that no infected individuals went into the water. These methods have proven very effective and the Guinea worm is now one of the most endangered animals on the planet.

The key to fighting the Guinea worm was education. The most effective solutions were simple and low-tech. No modern vaccine or modern medical knowledge was needed to prevent Guinea worm infections, just knowledge about how the disease spread. Guinea worms have been infecting people for millions of years (they have even been seen in Egyptian mummies), and the lifecycle could have been broken long ago if it had been better understood.

Root Cause Analysis

Particulate Matter Closes Operating Rooms at VA Hospital

By ThinkReliability Staff

On February 17, 2016, the 5 operating rooms at a New York Veterans Affairs (VA) hospital were closed due to particulates falling from the air ducts. An internal email from the engineer & safety officer to administrators at the hospital described the problem as this: “The dust is depositing on HVAC registers, ceilings, walls, and on medical equipment. Maintenance continues to clean the surfaces but, as the staff has observed, the dust reappears within a short time. At least three staff members have indicated their concern that this environment has affected them. They have been sent to employee health and to their individual physicians.”

The information related to this issue determined as part of the incident investigation can be captured within a Cause Map, a visual form of root cause analysis. The first step of the process is to determine the impacts to the goals. In this case, both patient and employee safety are impacted due to the risk of illness from exposure to the particulates. The environmental goal is impacted because of the release of the particulates into the facility. Patient services are impacted because patients are being sent to other facilities as sterile procedures are not being performed (an impact to the production/ schedule goal). The labor and time required for an investigation is also an impact to the goal.

The second step of the process is the analysis: determining why these goals were impacted. The release of the particulates into the facility is because there are particulates within the air ducts, and the air ducts open into the facility to provide heating, ventilation and air conditioning. In order to determine where the particulates come from, first it must be determined what they are composed of. An environmental analysis determined that the particulates were rust, crumbling concrete, fiberglass fibers, and cladosporium (a common mold).

The analysis also identified that rust in air systems typically results from aged equipment exposed to moisture. Cladosporium also results from exposure to moisture. The air duct system pulls in outside air, including humidity, resulting in the system being exposed to moisture. The VA hospital is 45 years old, which actually makes it one of the “newer” VA facilities. (According to the VA, about 60% of its facilities are more than 60 years old.) While it’s unclear what maintenance or replacements have been performed on these components over the life of the facility, deferred maintenance is a general problem at VA facilities. According to the VA inspector general, there is a $10-12 billion maintenance backlog at the department.

Once the causes of the problems (or impacted goals) have been determined, the last step is to implement action items to reduce the risk of the problem recurring. There are two parts to this step: brainstorming possible solutions, and determining which will be most effective to meet the organization’s needs. The hospital considered bringing in mobile surgical units and installing high efficiency particulate air filters in the vents in the operating rooms. The cost of the mobile surgical units (over $70,000 per month) led the hospital to select only the solution of the air filters. At least one operating room is expected to be ready to return to service June 1st.

To view a one-page downloadable PDF of the incident investigation, including the impacted goals, analysis with evidence, and possible solutions, please click on “Download PDF” above.

Root Cause Analysis

Multiple Factors Contributing to Health Care Crisis in Venezuela

By ThinkReliability Staff

Venezuela is facing a health care crisis of massive proportions. Since 2012, the infant mortality rate has skyrocketed from 0.02% to more than 2%. (The latest numbers are from 2015, so this is a hundred-fold increase within 3 years.) The mortality rate for new mothers increased almost 5 times over the same period. Everyone else isn’t doing too well either. Says Dr. Yamila Battaglini, a surgeon at J. M. de los Ríos Children’s Hospital, “There are people dying for lack of medicine, children dying of malnutrition and others dying because there are no medical personnel.” That doesn’t even cover all of the problems facing Venezuela right now, which include:

Rolling blackouts: The government has announced official “rolling” blackouts of at least 40 days. That includes hospitals and other medical facilities. (Doctors are reporting having to work in the dark.) At least one hospital has a generator that doesn’t work. One reason electricity is being rationed is that even though money has been allocated to building new power plants, the plants aren’t online, and the money hasn’t been accounted for. (Unfortunately this kind of potential theft/ corruption is much too common in Venezuela). Another reason is . . .

Drought: The Guri hydroelectric dam provides 75% of the nation’s electricity, and currently has extremely low levels due to drought. The drought, caused by El Niño, has also resulted in a general lack of water, which is now being rationed. The combination means that the hospital doesn’t have adequate water supplies, resulting in . . .

Lack of sanitation: Without water, sanitation suffers. Doctors have reported performing surgery after a quick rinse from a water bottle, and no rinsing down of surgical beds or instruments before the next surgery, or procedure. But the people who are getting surgery or procedures are lucky, because many hospitals are also suffering from . . .

Shortages of medical personnel: Many medical professionals have left Venezuela during the severe ongoing economic issues (such as inflation, currently pegged at 700%) due to both the decreasing price of oil (Venezuela’s main export) and what have been called “disastrous” government policies. Says Ricardo Hausmann, Professor at the Kennedy School of Government (and Venezuela native), “Venezuela’s problems are a consequence of the craziest economic policy ever in a country or in the world. It’s a country that has gone through its longest and highest oil boom in its history, and ended that period over-indebted, with a destroyed productive capacity, and now it cannot face the reduction in the price of oil.” Doctors that remain face exhaustion – without water and power, many are attempting to save lives by manually operating equipment (such as respirators for newborns). Even this can’t save lives with . . .

Shortages of drugs and equipment: The Pharmaceutical Federal of Venezuela estimates that the country is lacking ~80% of needed basic medical supplies. Price controls in Venezuela resulted in official selling prices lower than manufacturing costs. This made it financially infeasible to provide many products. The government can’t afford to import drugs, and individuals have difficulty doing so because official currency exchange isn’t available. (Even if it was, Venezuelan money is virtually worthless at this point, as the government keeps printing more.) Theft and corruption have also resulted in the loss of some equipment. And as if this all weren’t enough, the country is also suffering from . . .

Zika outbreak: To a country that lacks almost all ability to provide health care, add an ongoing outbreak (see our previous blog) for which there is currently no cure, and you end up with a situation where “some come here healthy, and they leave dead.” (Dr. Leandro Pérez, Luis Razetti Hospital)

With this many (and this severe) problems, there are no easy answers. Making the situation even worse is the government’s denial that there IS a problem. Says President Nicolás Maduro, “I doubt that anywhere in the world, except in Cuba, there exists a better health system than this one.” This is preventing other countries from providing aid, sometimes because they are unaware the extent of the need. At least one country, India, is offering drugs for oil, though that may be mainly to recoup funds they are already owed, not for providing new medication.

In order to see the multitude of causes that have resulted in the health care crisis in Venezuela laid out in a visual cause-and-effect format, click on “Download PDF” above. Or click here to read more.

Hospital Acquired Condition

“Desensitization” Process Improves Compatibility of Donor Kidneys

By ThinkReliability Staff

Many patients with advanced and permanent kidney failure are recommended for kidney transplants, where a donor kidney is placed into their body. Because most of us have two kidneys, donor kidneys can come from either living or deceased donors. If a compatible living donor is not found, a patient is placed on the waiting list for a deceased donor organ. Unfortunately, there are about 100,000 people on that waiting list. While waiting for a new kidney, patients must undergo dialysis, which is not only time-consuming but also expensive.

Researchers estimate that about 50,000 people on the kidney transplant waiting list have antibodies that impact their ability to find a compatible donor kidney. Of those, 20,000 are so sensitive that finding a donor kidney is “all but impossible” . . . .until now.

A study published March 9, 2016 in the New England Journal of Medicine provides promising results from a procedure that alters patients’ immune systems so they can accept previously “incompatible” donor kidneys. This procedure is called desensitization. First, antibodies are filtered out of a patient’s blood. Then the patient is given an infusion of other antibodies. The immune system then regenerates its own antibodies which are, for reasons as yet unknown, less likely to attack a donated organ. (If there’s still a concern about the remaining antibodies, the patient is treated with drugs to prevent them from making antibodies that may attack the new kidney.)

The study examined 1,025 patients with incompatible living donors at 22 medical centers and compared them to an equal number of patients on waiting lists or who received a compatible deceased donor kidney. After 8 years, 76.5% of the patients who were desensitized and received an “incompatible” living donor kidney were alive compared to only 43.9% of those who remained on the waiting list and did not receive a transplant.

The cost for desensitization is about $30,000 and a transplant costs about $100,000. However, this avoids the yearly life-long cost of $70,000 for dialysis. The procedure also takes about two weeks, so patients must have a living donor. The key is that ANY living donor will work, because the desensitization makes just about any kidney suitable, even for those patients who previously would have had significant trouble finding a compatible organ. Says Dr. Krista L. Lentin, “Desensitization may be the only realistic option for receiving a transplant.”

The study discusses only kidney transplants but there’s hope that the process will work for living-donor transplants of livers and lungs. Although the study has shown great success, the shortage of organ donations – of all kinds – is still a concern.

To view the process map for kidney failure without desensitization, and how the process map can be improved with desensitization, click on “Download PDF” above. To learn more about other methods to increase the availability of kidney donations, see our previous blog on a flushing process that can allow the use of kidneys previously considered too damaged for donation.

 

Root Cause Analysis

More than 2,700 babies are born with microcephaly in 2015 in Brazil

By Kim Smiley

In 2014, fewer than 150 babies were born with microcephaly in Brazil, but the number dramatically increased in 2015 with more than 2,700 cases.  Microcephaly is a neurological disorder where the growth of the head is stunted with reduced brain function in 90 percent of cases.  Infants with microcephaly often have reduced life spans and require significant long-term care.  The spike in microcephaly is so alarming that some doctors and health officials are encouraging women in the regions with a high concentration of microcephaly cases to avoid becoming pregnant at this time.

Health officials are still working to understand exactly what caused the increase in microcephalic babies, but many believe Zika virus is contributing to the problem.  Zika virus is a mosquito-borne virus and the symptoms are similar to many other mosquito-borne viruses such as dengue and chikungunya.  Latin America reported their first Zika virus cases in 2014 and the spread of Zika virus matches the timing of the increase in microcephaly cases.  Additionally, many mothers of babies with microcephaly report having symptoms associated with Zika virus early in their pregnancies.

A Cause Map, a visual root cause analysis, can be built to illustrate what is known about this issue as this time.  As more information becomes available the Cause Map can easily be expanded to incorporate new information.  A Cause Map is built by asking “why” questions and laying out all the causes that contribute to an issue to show the cause-and-effect relationships. Understanding all the causes that contribute to an issue can aid in development of effective solutions.

In this example, more evidence is needed to confirm that Zika virus is responsible for the microcephaly increase in babies.  (A box with a question mark on a Cause Map indicates areas where more information is required.) The timing of the increase in microcephaly cases and the spread of Zika virus is certainly suspect, but additional data will be needed to ensure that other factors aren’t involved as well.  An autopsy on a baby born with microcephaly revealed the presence of Zika virus, which is another data point, but again isn’t enough to conclusively prove the connection between Zika virus and microcephaly.

Tracking cases of Zika virus is difficult for several reasons.  Many people infected with Zika virus have no symptoms so it is difficult to determine exactly how many have been infected, including pregnant woman.  Zika is spread by mosquitos so everyone in the region is potentially exposed.  Only a few labs in Brazil have the capability to test for Zika virus which makes researching the virus more difficult.  Scientists are working on solving this mystery as quickly as they can, but reality is it will likely be some time before the connection between Zika virus and microcephaly is definitively proven or disproven.

Health officials are working to reduce the number of mosquitos in Brazil, even going door-to-door to look for potential breeding locations.  Reducing the number of mosquitos should hopefully reduce the number of cases of microcephaly if the suspicion about the involvement of Zika virus is correct.  Additionally, pregnant women are encouraged to stay indoors and wear plenty of insect repellant to prevent mosquito bites.  And of course, woman may want to avoid pregnancy as recommended until the mystery is solved, but this obviously isn’t always possible or practical.

To view an initial Cause Map of this issue, click on “Download PDF” above.

Root Cause Analysis

Handwashing is effective at fighting disease – so why doesn’t it happen more?

By ThinkReliability Staff

Global Handwashing Day is October 15. It’s very clear that handwashing can prevent disease – one study showed that it resulted in a 30% reduction in episodes of diarrhea; another study showed it could reduce the risk of respiratory infections by 16%. Yet proper handwashing is still not happening in many places. It’s estimated that the rate of handwashing is less than 20% in some developing countries.

There are multiple reasons that effective handwashing may not be occurring. We can look at these issues, as well as some of the solutions that have been suggested or implemented to increase the rates of handwashing, in a Cause Map, or visual root cause analysis. This method, like other problem-solving methods, involves three steps to define the problem(s), analyze the issues that may cause the problems, and brainstorm solutions that will reduce the risk of the problem(s) recurring.

In Cause Mapping, the problem is defined as the impact to an organization’s goals. In this case, the goals are broad and impact the population of most of the world. The risks of increased disease (particularly diarrhea and respiratory infection) impact the public safety goal. Contamination of handwashing water is an impact to the environmental goal.

The cause-and-effect analysis begins with the impacted goals. Asking “why” questions allows us to determine the causes that resulted in the impacted goals (or effects). It has been established (by the previously mentioned studies, as well as others) that the public safety impacts of increased risk of disease result from ineffective handwashing (or no handwashing at all).

Proper handwashing involves 3 things: clean water, soap, and time. Lathering with soap for about twenty seconds detaches oils and microbes from the skin and water washes it away. Removing any one of these things results in an ineffective wash, and there are multiple reasons why this could occur.

If no soap is available, washing won’t be able to remove disease-causing microbes. Obtaining soap may be difficult due to cost or availability. If soap is obtained, it may be eaten by goats (seriously, goats eat everything) or may not be used if it doesn’t smell good. Solutions suggested include making a protective cover to protect the soap from goats, finding less expensive soap supplies, or creating hand soap out of laundry soap and water. Hardening soap in the sun can help it last longer. Some groups have also started developing nicer-smelling, inexpensive soap or allowing donation of leftover pieces of soap from hotel use.

Even with soap, washing for a period of time (about twenty seconds) is required to give it time to fully remove germs and oils. Various versions of handwashing jingles (songs about the importance of handwashing that last at least the required amount of time) have been developed and are being spread across many areas of the world.

Lastly, even if handwashing involves lathering with soap for at least twenty seconds, if the soap is then rinsed off using contaminated water, the contamination will spread to the just-washed hands. In areas where there is no running water, water used for handwashing can be contaminated when dirty hands or ladles are dipped into the water. To reduce the risk of contamination, many areas use plastic containers that contain a tap that drips out water to use for handwashing.

Even with these difficulties, handwashing remains the most effective, inexpensive way to prevent disease across the globe. No matter where you live, it’s important to wash your hands properly and frequently, to fight the spread of disease.

To view the Cause Map and solutions related to this issue, click “Download PDF” above. Or, click here to read more.

 

Root Cause Analysis

Smoke from wildfires in West may impact public health across the US

By ThinkReliability Staff

A significant portion of the United States is currently being affected by wildfires. The Valley and Butte fires in California, two of the worst in that state’s history, have killed five (all civilians found dead in their homes). The Tassajara Fire has resulted in another civilian fatality. The Rough Fire (also in California) has burned more than 141,000 acres. The US Wildfire Activity Public Information Map and National Wildlife Coordinating Group Incident Information System shows dozens more fires across the Western United States.

The wildfires are also impacting the population in areas not directly impacted by the fires. Public safety has been impacted by the deaths and risk for injury. Worker safety has been impacted as well; four firefighters were burned in the Valley fire. Even animal safety has been impacted; animals were left to fend for themselves in many areas that were evacuated rapidly due to changing conditions, leading to risk of injury or death. Tens of thousands of people have been evacuated. Hundreds of thousands of acres have been burned and thousands of buildings destroyed, causing a potential long-term impact on area businesses. More than 15,000 workers have been deployed to assist in fighting the fires.

The wildfires are also affecting air quality in areas not directly impacted by the fires. The smoke from these wildfires is causing environmental and health issues including asthma, chronic lung disease and even heart attacks. Janice Nolan, the assistant vice president for national policy at the American Lung Association says of recent air quality, “It’s really bad. I hadn’t seen ‘code maroon’ days, which is the most hazardous air quality, in years.” (The Air Quality Index reports the quality of outdoor air in color categories. Maroon, or “hazardous” represents a level of air pollution that means the entire population is likely to experience serious health effects. Lower categories indicate when members of more sensitive groups may experience health concerns.)

Health issues can occur when smoke is breathed in and enters the respiratory system. The organic particles that make up smoke can be so small they can bypass the body’s natural defenses (such as mucus and hair in the nose). The particles can even enter the bloodstream. This occurs any time a person is exposed to smoke. Says Sylvia Vanderspek, the chief air quality planner for the California Air Resources Board, “If you can smell smoke, then basically you’re breathing it.”

An average person can breathe in about 35 micrograms of particulate matter for only 24 hours before experiencing health problems. Unfortunately, the California air quality board has measured levels of particulate matter up to 34 micrograms in a day . . . and the fires have been burning for weeks and may continue for weeks more. Weather conditions impact not only the wildfires themselves but also where the smoke from those fires goes. Weather conditions this summer have meant that smoke issues have been seen into the Midwest.

The only really effective protection against health impacts from smoke is to stay inside with air conditioning on recirculate if in an affected area (based on the local air quality index). This has meant schools are holding indoor recess and sports practices and outdoor festivals have had to cancel performances. Idaho is considering establishing clean air shelters so the population can avoid breathing in smoke. Regrettably, most air masks won’t help, as they don’t protect against the tiny particles of concern. Instead, health officials reiterate that if the air quality in your area is poor, stay indoors to protect your health.

Root Cause Analysis

Child Paralyzed by Vaccine-Derived Polio

By Kim Smiley

There has been amazing progress in the effort to eradicate polio, but recent cases of the disease are a harsh reminder that the work isn’t complete and now isn’t the time to be complacent.  Public health officials are planning three mass vaccination rounds in less than 120 days after a child was recently paralyzed by polio in Mali.  In addition to this case, the World Health Organization (WHO) announced that two children in western Ukraine were also paralyzed by polio.

The last case of polio was detected in Mali in 2011.  A Cause Map, a visual root cause analysis, can be used to analyze how the child contracted polio as well as help in understanding the overall impacts of this case.  The first step in a Cause Map is to fill in an outline with the basic background information, including listing how the issue impacts the different overall goals.  This issue, like most, impacts more than a single goal.  For example, the child being paralyzed is an impact to the patient safety goal, but the potential for an outbreak of polio is an impact to the public safety goal.

Once the impacts to the goals are defined, the Cause Map itself is built by asking “why” questions and including the answers in cause boxes.  The Cause Map visually lays out all the cause-and-effect relationships that contributed to an issue.  So why was the child paralyzed?  The child was infected with vaccine-derived polio because he was exposed to the disease and wasn’t immune to it, likely because he didn’t receive all four of the required doses of vaccine.  Vaccine rates in Guinea, where the child was from, dropped during the Ebola outbreak.

In this region of the world, oral polio vaccine is used and it contains weakened, but live, strains of polio virus.  After being administered oral polio vaccine, a child will excrete live virus for a period of time.  The live virus can replicate in the environment and there is the potential for it to mutate into a more dangerous form of polio, which is what causes vaccine-derived polio.

Cases of vaccine-derived polio are very rare, but are a known risk of using oral polio vaccine.  The injectable vaccine uses dead polio virus that cannot mutate, but there are other important factors that come into play.  The oral polio vaccine is cheaper and is simpler to administer than the injectable vaccine because medical professionals are needed to give injections.

The use of oral vaccines also eliminates the risk of spreading blood borne illnesses.  Because there are no needles involved, there is no risk of needles being shared between patients.  The oral vaccine also provides greater protection for the community as a whole, especially in regions with poor sanitation.  When a child is fully immunized with the oral polio vaccine this ensures immunity in the gut so that the polio virus is not excreted after exposure.  This is not true with the injectable polio vaccine; an immunized child exposed to “wild” polio would not be infected, but may still excrete polio virus after exposure and potentially spread it to others.  One negative of using the oral polio vaccine is that in rare cases (estimated to be about one in about 2.7 million) the weakened polio virus can cause paralysis in a child receiving their first dose of the vaccine.  Concern over paralysis is one of the reasons that developed nations generally use the injectable polio vaccine.

Polio is highly contagious and public health officials are planning an aggressive vaccine campaign to reduce the risk of an outbreak now that a case of polio has been verified in Mali. The plan is to have three mass vaccination rounds in less than 120 days, a level of effort aided by the many World Health Organization and United Nations staff that are still in the area as part of the response to the Ebola outbreak.  Thankfully, Guinea has not reported any cases of Ebola for several months so officials can devote significant resources to the mass polio vaccine effort.

Root Cause

Cuba Eliminates Transmission of HIV from Mother to Child

By ThinkReliability Staff

On June 30, 2015, the World Health Organization (WHO) declared mother-to-child transmission (MTCT) of HIV in Cuba eliminated. Clearly, this is fantastic news. Says Dr. Margaret Chen, WHO Director-General, “Eliminating transmission of a virus is one of the greatest public health achievements possible. This is a major victory in our long fight against HIV and sexually transmitted infections, and an important step towards having an AIDS-free generation.” The fight against HIV continues, with a global target of less than 40,000 new child infections per year by 2015.   (In 2013, there were 240,000 children born with HIV worldwide.) It’s hoped that the progress made in Cuba can be extended to the rest of the world.

How did Cuba do it? Root cause analysis can be used to determine causes of positive impacts as well as negatives. Here we will use a Cause Map, or visual root cause analysis, to determine the causes that resulted in Cuba being declared free of MTCT of HIV. Instead of defining the “problem” in a problem outline, we will define the success using the same format. In this case, the elimination of transmission of HIV from mother to child is the success we’ll be looking at. This success impacts goals as well, though positively. The child safety goal is impacted because it is now very rare (only 2 in 2013) for children to receive HIV from their mothers. The maternal safety goal is impacted because mothers are receiving effective treatment for HIV. Other goals are impacted because of the decreased need for services for children who might otherwise have been infected with HIV.

Beginning with an impacted goal, we can ask Why questions. Why is it rare for children to receive HIV from their mothers? Because the risk of passing HIV from mother to child has been lessened. Why? Because when children are born to HIV-infected mothers, there is decreased exposure to infants from their mother’s bodily fluids, and both mothers and children are being treated effectively for HIV. Decreased exposure to bodily fluids has been accomplished by the use of Cesarean sections and substitution for breastfeeding. Effective HIV treatment results from awareness of the presence of HIV infection from testing performed by healthcare providers, seen as part of a five-year initiative that gave universal healthcare coverage and access. That same access allowed treatment for infected moms and their children with antiretrovirals.

Although this Cause Map is presented as a positive impact to the goals, it could also be presented as an analysis of the problem of HIV transmission from mother to child. The causes would be baby’s exposure to mom’s body fluids, and lack of effective treatment due to lack of knowledge of infection and/or lack of access. The solutions to that Cause Map are the causes presented here in the positive Cause Map. (For example, use of Cesarean sections and substitutions for breastfeeding are solutions to the cause of baby being exposed to mom’s body fluids.)

In order to receive validation from WHO of the elimination of MTCT of HIV, Cuba had to meet very specific indicators for a defined period of time. These indicators do not just measure the overall success of the program (impact indicators), but also measure the success of the initiatives meant to achieve those goals (process indicators). Impact indicators included reducing MTCT of HIV to less than 50 cases per 100,000 live births, less than 5% in breastfeeding populations, and less than 2% in non-breastfeeding populations for at least 1 year. Process indicators included more than 95% of all pregnant women receiving at least one antenatal visit, more than 95% of pregnant women knowing their HIV status, and more than 95% of HIV-positive pregnant women receiving antiretroviral drugs for at least 2 years.

With implementation of similar initiatives across the world, it is hoped that MTCT of HIV will continue to decrease rapidly.

To view the outline, Cause Map, and indicators, click on “Download PDF” above. Click here to read the release from the WHO.