Federal crackdown hits hospitals in pocketbook for facility-related infections, injuries

December 24th, 2014by Kate Belzin Local Regional NewsRead Time: 4 mins.

How they scored

Penalties for hospital-acquired conditions:
Medicare is penalizing hospitals with high rates of potentially avoidable mistakes that can harm patients, known as “hospital-acquired conditions.” To determine penalties, Medicare ranked hospitals on a score of 1 to 10, with 10 being the worst, in three categories: 1. Central-line-associated bloodstream infections, or CLABSIs. 2. Catheter-associated urinary tract infections, or CAUTIs. 3. Serious complications, which is based on eight types of injuries, including blood clots and falls. Hospitals with a score above 7 will be penalized.
CHI Memorial Health Care System — No Penalty
Serious complications score — 1
CLABSI score — 10
CAUTI score — 9
Total score — 6.525

Erlanger Health System — Penalty
Serious complications score — 10
CLABSI score — 8
CAUTI score — 10
Total score — 9.35

Hutcheson Medical Center — Penalty
Serious complications score — 10
CLABSI score — 1
CAUTI score — 10
Total score — 7.075

Parkridge Health System — No Penalty
Serious complications score — 4
CLABSI score — 7
CAUTI score — 9
Total score — 6.6
Source: Kaiser Health News

Infections and injuries sustained at hospitals have hurt millions of patients. Now those injuries are hurting hospitals’ bottom lines.

Last week, the federal government announced it will cut payments to 721 hospitals for having high rates of infections and other patient injuries in 2013.

Erlanger Health System and Hutcheson Medical Center, the area’s two public hospitals, both made the list.

An analysis released by Kaiser Health News called the move “the toughest crackdown yet on medical errors.” The report shows one out of every seven hospitals in the nation will have its Medicare payments lowered by 1 percent over the next year — a total of $373 million, Medicare estimates. Erlanger and Hutcheson will be in the company of some of the country’s most renowned hospitals, such as the Cleveland Clinic in Ohio and Brigham and Women’s Hospital in Boston.

The penalty system was created under the Affordable Care Act. The goal was to rein in health costs and slowly shift payment models from straight fee-for-service toward health outcomes. The law also penalizes hospitals for high rates of patient readmissions.

The penalties for “hospital-acquired conditions” include infections caused by central line catheters, which doctors use to pump fluids and medicines into patients’ veins; infections from urinary catheters; and “avoidable” medical injuries like blood clots, bedsores, surgical tears and broken bones from falls in the hospital. The study looked just at Medicare patients, who are mostly 65 or older.

Erlanger officials said the penalty will cost the hospital about $1 million. The hospital has put a renewed focus on these measures, said chief quality officer Dr. Woods Blake, and more up-to-date statistics will reflect that when they are released.

“We have a push for everyone hospitalwide to be engaged on this issue, from the board all the way to the bedside,” Blake said.

The penalties are hitting academic medical centers and public hospitals — Erlanger is both — especially hard. Roughly half the nation’s academic hospitals were penalized, as were a fourth of public hospitals, the Kaiser report found.

“It is a challenge for academic teaching institutions because we take all comers,” Blake said, noting that Erlanger is a Level 1 trauma center and a stroke center.

“Many of these people are not well when they come in, and in many cases we see high rates of co-morbidities,” which means a patient has two or more diseases or conditions, he said.

Hutcheson CEO Farrell Hayes said he and his staff question whether the numbers are accurate. The hospital was “just a whisker” past the threshold to warrant a penalty, he said.

But Hayes said infection control has become “a big focus” of the hospital in recent years.

“A lot of it is training, and really focusing on these issues,” Hayes said. “We’ve really put forth a big effort. I think when the next report comes out you will see much better numbers.”


Dr. Kevin Lewis, chief medical officer at CHI Memorial, said that while the hospital was not penalized this year, “you have be on your guard.”

“We’re never really satisfied, because at the end of every statistic is a patient,” he said, adding that this year Memorial set a goal to cut its rate of hospital-acquired infections in half within two years. “The incentives are tied to the right thing, which is doing right by the patient.”


Hospitals have struggled to lower chronic infection and injury rates for years, especially after a 1999 U.S. Institute of Medicine report called “To Err is Human” revealed that as many as 100,000 people died across the nation each year from preventable medical errors.

But the ACA added new pressure to the fight. Hospital-acquired infections were no longer par for the course.

That new pressure, health experts say, could help decrease massive waste in health care spending while significantly improving patient outcomes.

Over the past three years, hospital readmission rates — the number of Medicare patients who return to the hospital less than a month after being discharged — have fallen 17 percent, a report from the U.S. Department of Health and Human Services released earlier this month showed.

The drop translates to 50,000 lives and $12 billion saved just through hospital improvements, the federal agency said.

“People can debate these penalties all they want, but they are working to move the numbers,” said Lewis.

Local hospitals say different quality programs have grown in importance over the past two years. For example, Blake said Erlanger recently created a team that makes regular rounds to determine whether patients with urinary catheters still need them. Cutting down on unnecessary catheters can greatly reduce the number of infections.

If there is an infection, a team investigates, asking whether the catheter was inserted carefully, how it was cleaned and any other related factors that may have contributed to infection. A new computer system more closely tracks hospital-acquired infections.

“Last year we improved 20 percent with catheter-associated infections,” Blake said.

Memorial also has rinstituted a policy to reduce catheter use. Falls are reported and investigated daily in the hospital’s updated protocol. There are “Wound Wednesdays,” where the health care workers will take turns surveying each other’s patients’ skin more carefully to check for signs of infection.

And as Medicare plans to add more types of injuries and infections to its criteria soon, Lewis said hospitals will have to strategize even more.

“This is just the beginning of what’s going to be a fairly large and complex system of rewards and penalties around patient and safety and outcome,” said Lewis. “I think we’re seeing the tip of the iceberg.”

Contact staff writer Kate Harrison Belz at kbelz@timesfreepress.com or 423-757-6673.

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The fight against nursing home acquired infections…

Nursing Homes’ Residents Face Health Risks From Antibiotics’ Misuse

Antibiotics are prescribed incorrectly to ailing nursing home residents up to 75 percent of the time, the nation’s public health watchdog says.

The reasons vary — wrong drug, wrong dose, wrong duration or just unnecessarily – but the consequences are scary, warns the Centers for Disease Control and Prevention.  Overused antibiotics over time lose their effectiveness against the infections they were designed to treat. Some already have. And some antibiotics actually cause life-threatening illnesses on their own.

Closeup of elderly man on wheelchair in hospitalThe CDC last month advised all nursing homes to do more – immediately – to protect more than 4 million residents from hard-to-treat superbugs that are growing in number and resist antibiotics.

Antibiotic-resistant infections threaten everyone, but elderly people in nursing homes are especially at risk because their bodies don’t fight infections as well. The CDC counts 18 top antibiotic-resistant infectionsthat sicken more than 2 million people a year and kill 23,000. Those infections contribute to deaths in many more cases.

The CDC is launching a public education campaign for nursing homes aimed at preventing more bacterial and viral infections from starting and stopping others from spreading. A similar effort was rolled out for hospitals last year. “One way to keep older Americans safe from these superbugs is to make sure antibiotics are used appropriately all the time and everywhere, particularly in nursing homes,” said CDC Director Tom Frieden in announcing the initiative.

Studies have estimated antibiotics are prescribed inappropriately 40 percent to 75 percent of the time in nursing homes.

Here’s why that worries the CDC: Every time someone takes antibiotics, sensitive bacteria are killed but resistant bacteria survive and multiply – and they can spread to other people. Repeated use of antibiotics promotes the growth of antibiotic-resistant bacteria. Taking antibiotics for illnesses the drugs weren’t made to treat – such as flu and common colds – contributes to antibiotic resistance.

Antibiotics also wipe out a body’s good infection-fighting bacteria along with the bad. When that occurs, infections like Clostridium difficile can get out of control. C. diff. leads to serious diarrhea that each year puts 250,000 people in the hospital and kills 15,000. If precautions aren’t taken, it can spread in hospitals and nursing homes.

Health care facilities already have infection control procedures in place, such as providing private rooms and toilets for infected individuals. But the CDC is pushing them to do more on the prescribing side, advising nursing homes to track how many and what antibiotics they prescribe monthly and what the outcomes were for patients, including any side effects. Other recommendations include placing someone, such as a consulting doctor or a pharmacist, in charge of antibiotics policies and training other staff in following them.

Some of the CDC’s suggestions could challenge nursing homes’ culture and how staffs, residents and their families interact. While nursing home residents and staff are among the people most at risk for the flu, annual shots aren’t mandatory. Nor do homes always track who gets them.

That’s starting to change at Evangelical Lutheran Good Samaritan Society, a nonprofit that provides a spectrum of senior care services in many states. Starting this year, it will collect data on staff vaccinations at one of its 167 nursing homes and share the pilot project’s results with other homes, said Victoria Walker, chief medical officer.

But better handling of antibiotics in nursing homes may also require tactful communication with residents’ families and nursing home doctors accustomed to treating antibiotics as a default remedy.

“There’s a real fear of under-treatment and that it is better to err on the safe side, and that means treating with antibiotics but forgetting about all the harms. But giving antibiotics can be just as harmful as not,” said Walker.

Family members may push for an antibiotic treatment when they visit a loved one in a nursing home who seems sick, even if they don’t know precisely what’s wrong. Doctors and nurses may go along because they don’t know either and it’s easier to treat than not. “The family will check in and ask what the doctor did and the nurse will say ‘nothing’ because they don’t see monitoring as doing anything,” said David Nace, director of long term care at the University of Pittsburgh, who contributed to the CDC guidelines.

“Practitioners are guilty of saying, ‘it’s just an antibiotic’ … We don’t appreciate the real threat,” he said.

Antibiotics are routinely prescribed to treat urinary tract infections, which are common in nursing homes, but too often when a UTI is only suspected, not confirmed, studies have found. The Infectious Disease Society of America is developing guidelines to help institutions implement programs to better manage antibiotics.

In addition to fostering antibiotic resistant bacteria and causing C. diff infections, antibiotics also can produce allergic reactions and interfere with other drugs a nursing home resident is taking. Those risks aren’t always fully considered, says researcherChristopher Crnich, who has published articles on antibiotic overuse. He is a hospital epidemiologist at William S. Middleton Veterans Hospital in Madison, Wis.

“Bad antibiotic effects don’t come until weeks or months later, and frankly all we [prescribers] see is the upside when we’re dealing with a sick mom or dad,” Crnich said.

CATEGORIES: Aging, Cost and Quality, Public Health, Syndicate


Health Department Resources for LTCFsThe resources on this page were developed by state health departments to assist healthcare personnel with preventing infections in nursing homes, assisted living facilities and other long-term care facilities.


The resources on this page were developed by state health departments to assist healthcare personnel with preventing infections in nursing homes, assisted living facilities and other long-term care facilities.

State Resources by Program

The following links are examples of resources that outline infection prevention and antibiotic stewardship information and provide educational material on training programs created for clinicians within long-term care facilities. The state links listed below may not be a comprehensive list of all of the resources available for long-term care.

Antibiotic Stewardship
Massachusetts http://www.macoalition.org/evaluation-and-treatment-uti-in-elderly.shtml
Minnesota http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/index.html


Healthcare Associated Infections
Arizona http://www.azdhs.gov/phs/oids/hai/advisory-committee/long-term-care.htm
California http://www.cdph.ca.gov/programs/hai/Pages/LongTermCareFacilities(LTCF).aspx
Iowa http://www.idph.state.ia.us/hai_prevention/
Massachusetts http://www.mass.gov/eohhs/gov/departments/dph/programs/id/epidemiology/providers/infection-control.html
North Carolina http://spiceducation.unc.edu/nursing-home-modules/
Vermont http://healthvermont.gov/prevent/HAI/residential_care.aspx
Virginia https://www.vdh.virginia.gov/Epidemiology/Surveillance/HAI/longterm.htm
West Virginia http://www.dhhr.wv.gov/oeps/disease/HAI/Pages/WVBPHHAIResources.aspx
Wisconsin https://www.dhs.wisconsin.gov/regulations/nh/hai-resources.htm


General Long-Term Care Information
Delaware http://dhss.delaware.gov/dhss/dsaapd/services.html
DC http://dcoa.dc.gov/book/long-term-care-planning-guide
Florida http://www.floridahealthfinder.gov/reports-guides/long-term-care.aspx
Illinois http://dph.illinois.gov/topics-services/health-care-regulation/nursing-homes
Maine http://www.maine.gov/dhhs/long_term_care.shtml
Maryland http://mhcc.maryland.gov/consumerinfo/longtermcare/Default.aspx
New York http://www.health.ny.gov/facilities/long_term_care/
Oklahoma http://www.ok.gov/health/Protective_Health/Long_Term_Care_Service/Long_Term_Care_Programs_In_Oklahoma/index.html
Oregon http://www.oregon.gov/dhs/spwpd/Pages/ltc/main.aspx
Rhode Island http://www.health.ri.gov/nursinghomes/about/choosing
Utah https://health.utah.gov/myhealthcare/longterm.htm
Washington https://www.dshs.wa.gov/adult-care
Wisconsin https://www.dhs.wisconsin.gov/long-term-care-support.htm


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Common infections in nursing homes: a review of current issues and challenges



Common infections in nursing homes: a review of current issues and challenges Ana Montoya1 and Lona Mody* 1University of Michigan, Division of Geriatrics, MI, USA Abstract Over 1.5 million people live in 16,000 nursing homes in the USA and experience an average of 2 million infections a year. Infections have been associated with high rates of morbidity and mortality, rehospitalization, extended hospital stay and substantial healthcare expenses. Emerging infections and antibiotic-resistant organisms in an institutional environment where there is substantial antimicrobial overuse and the population is older, frailer and sicker, create unique challenges for infection control. This review discusses the common infections, challenges, and a framework for a practical infection prevention program. Keywords antibiotic-resistant organisms; infection control program; infection prevention; infections; multidrug-resistant organisms; nursing home Impact of infections in nursing homes Over 1.5 million people live in 16,000 nursing homes (NHs) in the USA, according to the 2004 National Nursing Home Survey. More than 88% of these people are 65 years of age and older, and 45% are age 85 years and older [1]. It is estimated that the number of people who will require NH care in the USA will reach 5.3 million by 2030 [2]. The acuity of illness in this population has increased substantially in the last decade, as has the risk of acquiring new infections. Although recent estimates are lacking, approximately 2 million infections occur in US NHs each year [3]. In addition, a point prevalence survey revealed that the prevalence of NH-associated infections on the day of the survey was 5.2% in Veterans Administration (VA) Community Living Center (CLC) facilities in the USA [4]. Internationally, a 3-year study in The Netherlands reported a prevalence of healthcareassociated infections of 6.7% in 2007, 7.6% in 2008 and 7.6% in 2009, ranging from 0 to 32.4% between NHs [5]. Infections in the NH population have been associated with high rates of morbidity and mortality, rehospitalization, extended hospital stay and substantial healthcare expenses. Risk factors that predispose older adults to infections have been well described and include the presence of indwelling devices, recent admission to an acute care facility, functional *Author for correspondence: University of Michigan, Division of Geriatrics and Geriatrics Research Education and Clinical Center, Veteran Affairs Ann Arbor Healthcare System, 11-G Geriatrics Research Education and Clinical Center, 2215 Fuller Rd, Ann Arbor, MI 48105, USA, Tel.: +1 734 845 3072, Fax: +1 734 845 3298, lonamody@umich.edu. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. No writing assistance was utilized in the production of this manuscript. NIH Public Access Author Manuscript Aging health. Author manuscript; available in PMC 2012 December 20. P

The body-count: Drug-resistant infections, estimated to kill more than 700,000 people each year

UN meeting tackles the ‘fundamental threat’ of antibiotic-resistant superbugs
All 193 UN member states have agreed to combat the proliferation of drug-resistant infections, estimated to kill more than 700,000 people each year

The UN secretary general, Ban Ki-moon, said antimicrobial resistance is a “fundamental threat” to global health and safety at the first general assembly meeting on drug-resistant bacteria.

It is only the fourth time the general assembly has held a high-level meeting for a health issue.

“If we fail to address this problem quickly and comprehensively, antimicrobial resistance will make providing high-quality universal healthcare coverage more difficult if not impossible,” said Ban. “It will undermine sustainable food production. And it will put the sustainable development goals in jeopardy.”

Just before world leaders convened for the meeting, all 193 member states agreed in a declaration signed on Wednesday to combat the proliferation of antibiotic resistance.

The declaration routes the global response to superbugs along a similar path to the one used to combat climate change. In two years, groups including UN agencies will provide an update on the superbug fight to the UN secretary general.

It is estimated that more than 700,000 people die each year due to drug-resistant infections, though it could be much higher because there is no global system to monitor these deaths. And there has been trouble tracking those deaths in places where they are monitored, like in the US, where tens of thousands of deaths have not been attributed to superbugs, according to a Reuters investigation.
Resistance isn’t futile – how to tackle drug-resistant superbugs
Read more
Scientists have known for more than half a century that patients could develop resistance to the drugs used to treat them – one of the first people to sound the alarm was Alexander Fleming, who is credited with creating the first antibiotic, penicillin, in 1928. He cautioned of the impending crisis while accepting his Nobel prize in 1945: “There is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

But scientific innovation, and increased awareness, has shown the severity of the threat. The World Bank announced this week that without containment, the economic impact of the crisis makes it unlikely for the UN to reach its sustainable development goals for 2030.


“The scale and nature of this economic threat could wipe out hard-fought development gains and take us away from our goals of ending extreme poverty,” said the World Bank president, Jim Yong Kim. “We must urgently change course to avert this potential crisis.”

There has also been considerable advocacy by health officials, like Sally Davies, chief medical officer of the UK.

“Drug-resistant infections are firmly on the global agenda but now the real work begins,” Davies said in a statement. “We need governments, the pharmaceutical industry, health professionals and the agricultural sector to follow through on their commitments to save modern medicine.”

The World Health Organization director general, Margaret Chan, said on Wednesday that it was imperative for consumers and medical providers to rely less on antibiotics for disease treatment.

“On current trends, a common disease like gonorrhea may become untreatable,” Chan said. “Doctors facing patients will have to say, ‘I’m sorry – there’s nothing I can do for you.’”

Margaret Chan, director general for the World Health Organization, speaking at another UN event on refugees and migrants.
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Margaret Chan, director general for the World Health Organization, speaking at another UN event on refugees and migrants. Photograph: Julie Jacobson/AP
She also called for more innovation in antibiotic development, noting that only two new classes of antibiotics reached the market in the past half century. “The emergence of bacterial resistance is outpacing the world’s capacity for antibiotic discovery,” Chan said.

She warned specifically about gram-negative bacteria, which causes infections like pneumonia, wound or surgical site infections and meningitis in healthcare settings, and is proving increasingly resistant to antibiotics.

“With few replacement products in the pipeline, the world is heading to a post-antibiotic era in which common infections, especially those caused by gram-negative bacteria, will once again kill.”

Signatories to the UN declaration committed to encouraging innovation in antibiotic development, increasing public awareness of the threat and developing surveillance and regulatory systems on the use and sales of antimicrobial medicine for humans and animals.

Only three other health issues have been the subject of general assembly high-level meetings: HIV/Aids, non-communicable diseases and Ebola.

Mark Woolhouse, professor of infectious disease epidemiology at the University of Edinburgh, said he was encouraged that unlike with HIV/Aids and Ebola, the UN is addressing this health crisis before it has spun out of control.

“It’s very serious indeed – it’s killing people around the world at the rate of hundreds of thousands of year and we all expect it to get worse if something isn’t done now,” Woolhouse said. “But the UN is coming in at just the right time, in a sense.”

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Could intentional commercial misuse of strategic antibiotics be a form of “Depraved Indifference” ?

NY Court of Appeals Issues an Opinion on Depraved Indifference

POST WRITTEN BY:Prof. Peter Widulski, Assistant Director of the First Year Legal Skills Program and the Coach of International Criminal Moot Court Team at Pace Law School.

The New York State Penal Code provides serious penalties in situations where a defendant’s reckless conduct toward others manifests “depraved indifference to human life” and exposes a victim to “a grave risk of death.” When these elements can be proven and the victim dies as a result, a defendant can be subject to conviction for second-degree murder, pursuant to N.Y. Penal Law § 125.25(2) (McKinney 2015). When the victim does not die, the defendant can be subject to conviction for reckless endangerment in the first degree, pursuant to N.Y. Penal Law § 120.25 (McKinney 2015).

In an opinion issued on February 19, 2015, the N.Y. Court of Appeals addressed the latter situation in the case of People v. Williams, 2015 N.Y. Slip Op. 01486 (Feb. 19, 2015). In this case, a prosecutor pursued a first-degree reckless endangerment charge against Mr. Williams because he did not disclose the fact that he knew he was HIV positive to a male partner with whom he had unprotected anal intercourse on several occasions and because Mr. Williams responded affirmatively to his partner’s questions about whether it was safe to engage in unprotected sex. The defendant’s partner subsequently became very ill, was diagnosed as HIV positive, and was put on a lifetime regimen of medications to stave off AIDS.

As noted in my previous post, in recent years the Court of Appeals has restricted the application of depraved indifference charges, finding that prosecutors often pursued such charges when not merited. Of particular relevance to the recent Williams case is this Court’s decision in People v. Suarez, 6 N.Y.3d 202, 844 N.E.2d 721, 811 N.Y.S.2d 267 (2005) holding that when a defendant’s reckless conduct endangers only one person, a prosecutor must show that the defendant exhibited “wanton cruelty, brutality or callousness directed against a particularly vulnerable victim, combined with utter indifference to the life or safety of the helpless target of the perpetrator’s inexcusable acts.”

In Williams, the grand jury returned an indictment on one count of first-degree reckless endangerment, N.Y. Penal Law § 120.25, and on one count of third-degree assault, N.Y. Penal Law § 120.00(2) (McKinney 2015). Upon defendant’s motion to dismiss both counts arguing legally insufficient evidence, the Supreme Court denied the motion as to the assault charge but reduced the reckless endangerment charge from first degree to second degree. The prosecutor appealed and the Appellate Division, Fourth Department, affirmed holding that viewing the evidence in the light most favorable to the prosecution, (1) the evidence was legally insufficient to support proof of the mental state requirement of depraved indifference and (2) given favorable medical advances in treatment of HIV positive patients, the defendant’s conduct did not expose the victim to a grave risk of death.

On further appeal, several civil rights, public health, and HIV advocacy organizations submitted, or joined in, amicus briefs supporting the defendant. The Center for HIV Law and Policy, on behalf of itself and several other groups, argued in its brief that “[u]sing the criminal law to prosecute and penalize people living with HIV for conduct that would be legal if they did not get tested or know their status reinforces prejudice and undermines important government-funded HIV testing, treatment, and prevention efforts.”

The Court of Appeals affirmed the Fourth Department’s decision and held that although it had no doubt that “defendant’s conduct was reckless, selfish and reprehensible,” the evidence presented to the grand jury was insufficient to support a prima facie case that the defendant acted with depraved indifference. Reviewing the testimony presented to the grand jury, the Court found that there was no evidence that “defendant exposed the victim to the risk of HIV infection out of any malevolent desire for the victim to contract the virus, or that he was utterly indifferent to the victim’s fate.”

Given its holding on the failure of proof regarding the required mental state element, the Court of Appeals explicitly declined to address the “grave risk” element of whether, in light of modern medical science, HIV infection creates a grave risk of death.

Related Reading:

Zika marches on, can neoliberal US state governments stop it?


Volume 22, Number 10—October 2016


Culex pipiens and Aedes triseriatus Mosquito Susceptibility to Zika Virus

Suggested citation for this article

To the Editor: Zika virus, genus Flavivirus, has spread nearly uncontrolled since its introduction into the Western Hemisphere; autochthonous spread has occurred in >39 countries and territories, including several US territories. Transmission of Zika virus is usually by the bite of infected mosquitoes, and potential for emergence in areas with competent mosquito vectors is high (1). Future spread of Zika virus is unpredictable; however, eventual local spread in the United States is possible. As of July 13, 2016, a total of 1,306 travel-associated cases had been reported (ArboNET, https://www.cdc.gov/zika); substantial populations of Aedes (Stegomyia) aegypti(Linnaeus) mosquitoes exist in >16 states in the eastern, southeastern, and southwestern United States; and Ae. (Stegomyia) albopictus (Skuse) mosquitoes inhabit >28 states and continued expansion throughout the northern United States is probable (2). Mosquitoes of these 2 species have demonstrated the ability to transmit Zika virus (1).

The recent epidemic spread of Zika virus suggests that Ae. aegypti mosquitoes are the main vector; however, information about the role of other species in driving and maintaining Zika virus transmission is lacking. Of particular concern this summer (2016) is emergence and establishment of Zika virus in previously unaffected geographic areas; with the advent of mosquito season commencing in most of the continental United States, the likelihood of mosquitoborne transmission of Zika virus in states without populations of Ae. aegypti and Ae. albopictus mosquitoes remains unknown. To understand the potential risk for spread of Zika virus in temperate US states, we compared the relative abilities of Culex pipiens and Ae. triseriatus mosquitoes to transmit Zika virus in the laboratory. We used Ae. aegyptiand Ae. albopictus mosquitoes as positive controls.

Laboratory colonies of mosquitoes used in this study were maintained at the University of Wisconsin–Madison, and vector competence for Zika virus was evaluated by using established procedures (3,4). Mosquitoes from each group were incapacitated (exposed to trimethylamine); legs were removed and collected. Salivary secretions were collected in capillary tubes containing a 1:1 ratio of fetal bovine serum and 50% sucrose. Mosquitoes were then placed in individual tubes; their bodies and legs were homogenized, clarified by centrifugation, and screened for virus infection. Dissemination was indicated by virus-positive legs, and transmission potential was indicated by virus-positive salivary secretions. All samples were screened by plaque assay on Vero cells. Mosquitoes were exposed to Asian lineage Zika virus strain PRVABC59 (GenBank accession no. KU501215) (5) by feeding on Zika virus-infected Ifnar−/−mice (4). Mice (n = 4/replicate) yielded infectious blood meal concentrations of 6.02 log10 PFU/mL ± 0.67 (mean ± SD; biological replicate no. 1), 4.74 log10PFU/mL ± 0.06 (replicate no. 2), and 6.83 log10 PFU/mL ± 0.45 (replicate no. 3). Blood meal concentrations in mice were consistent with viremia concentrations of humans in the field (4).

All samples from Cx. pipiens mosquitoes and all replicates were negative for Zika virus by plaque assay (Table). In contrast, Ae. triseriatus mosquitoes were susceptible to infection when exposed to mice with the highest viremia concentrations (Table). However, none of these infected mosquitoes disseminated virus and none were capable of transmitting the virus. Data from Ae. albopictus and Ae. aegypti mosquitoes that had been exposed to the same mice demonstrated that the viremia concentrations used could productively infect mosquitoes. Of note, Ae. albopictus mosquito infection rates were dose dependent (i.e., infection rates increased with blood meal titer). Furthermore, data generated from exposure to the same mice demonstrated productive mosquito infection with these viremia concentrations (4). It therefore seems likely that if Zika virus circulation in the United States occurs, it will be driven by Ae. albopictus or Ae. aegypti mosquitoes (6). However, we cannot rule out that anthropophilic mosquitoes of other species in this country could be competent vectors.

These data argue for continued studies (experimental and epidemiologic) assessing interactions between differing mosquito–Zika virus combinations in the United States because of geographic variations that may exist in oral susceptibility of mosquitoes of the same or different species. The few vector competence studies conducted to date have focused primarily on Ae. aegypti and Ae. albopictus mosquitoes (8), but mosquitoes of other species may be vectors, depending on geographic location. We focused on Cx. pipiens mosquitoes because they are ubiquitous (7), they are considered one of the principal vectors of West Nile virus in the northern half of the United States, and a recent report from Brazil suggests Cx. quinquefasciatus mosquitoes as potential Zika virus vectors (8). We chose Ae. triseriatus mosquitoes because they are the natural vector and overwintering host of La Crosse virus, they are extremely tolerant to a range of temperatures, they are distributed from Florida to eastern Canada (9), and they have been implicated as potential enzootic vectors for West Nile virus (10). To determine the risk for Zika virus transmission in the United States, surveillance of different human-biting mosquito species will be paramount. Although we expected that Cx. pipiens and Ae. triseriatus mosquitoes would not be competent Zika virus vectors, our experimental verification helps exclude uncertainties surrounding the potential vectors of this emerging pathogen.

Matthew T. AliotaComments to Author , Stephen A. Peinado, Jorge E. Osorio, and Lyric C. Bartholomay
Author affiliations: University of Wisconsin, Madison, Wisconsin, USA


  1. Musso D, Gubler DJ. Zika virus. Clin Microbiol Rev. 2016;29:487524. DOIPubMed
  2. Kraemer MU, Sinka ME, Duda KA, Mylne AQ, Shearer FM, Barker CM, The global distribution of the arbovirus vectors Aedes aegypti and Ae. albopictus. Elife. 2015;4:e08347.DOIPubMed
  3. Aliota MT, Walker EC, Uribe Yepes A, Dario Velez I, Christensen BM, Osorio JE. The wMel strain of Wolbachia reduces transmission of chikungunya virus in Aedes aegypti. PLoS Negl Trop Dis. 2016;10:e0004677. DOIPubMed
  4. Aliota MT, Peinado SA, Velez ID, Osorio JE. The wMel strain of Wolbachia Reduces Transmission of Zika virus by Aedes aegypti. Sci Rep.2016;6:28792 .DOIPubMed
  5. Lanciotti RS, Lambert AJ, Holodniy M, Saavedra S, Signor LDCC. Phylogeny of Zika virus in Western Hemisphere, 2015. Emerg Infect Dis.2016;22:9335. DOIPubMed
  6. Chouin-Carneiro T, Vega-Rua A, Vazeille M, Yebakima A, Girod R, Goindin D, Differential susceptibilities of Aedes aegypti and Aedes albopictus from the Americas to Zika virus. PLoS Negl Trop Dis. 2016;10:e0004543. DOIPubMed
  7. Farajollahi A, Fonseca DM, Kramer LD, Marm Kilpatrick A. “Bird biting” mosquitoes and human disease: a review of the role of Culex pipiens complex mosquitoes in epidemiology. Infect Genet Evol. 2011;11:157785. DOIPubMed
  8. Franca RFO, Neves MHL, Ayres CFJ, Melo-Neto OP, Filho SPB. First International Workshop on Zika Virus held by Oswaldo Cruz Foundation FIOCRUZ in Northeast Brazil March 2016—a meeting report. PLoS Negl Trop Dis. 2016;10:e0004760. DOIPubMed
  9. Darsie RF, Ward RA. Identification and geographical distribution of the mosquitoes of North America, North Mexico. Gainesville (FL): University Press of Florida; 2005.
  10. Erickson SM, Platt KB, Tucker BJ, Evans R, Tiawsirisup S, Rowley WA. The potential of Aedes triseriatus (Diptera: Culicidae) as an enzootic vector of West Nile virus. J Med Entomol. 2006;43:96670. DOIPubMed


Suggested citation for this article: Aliota MT, Peinado SA, Osorio JE, Bartholomay LC. Culex pipiens and Aedes triseriatus mosquito susceptibility to Zika virus [letter]. Emerg Infect Dis. 2016 Oct [date cited]. http://dx.doi.org/10.3201/eid2210.161082

DOI: 10.3201/eid2210.161082

Related Links

Table of Contents – Volume 22, Number 10—October 2016

Cuba,a high-risk area,has no cases of Zika. Why?

Zika virus: Aggressive public health efforts keep Cuba safer than other tropical areas


Preventing Zika: Why Does Cuba Do A Better Job Than Hawaii?

Hawaii and Cuba, both islands in tropical regions, are at risk for Zika. Cuba, surrounded by dozens of other countries in the Caribbean and Latin America that have already had cases and outbreaks, is particularly vulnerable.

Hawaii recently had its first cases — involving people who had been traveling abroad. Cuba, meanwhile, has remained one of the only vulnerable countries in our hemisphere tocompletely avoid Zika cases. How is this possible?

Cuba has performed aggressive door-to-door mosquito spraying. It is using 9,000 soldiersin the spraying to decrease the mosquito species that spreads the virus. Cuba is about 42,500 square miles, or 10 times larger than the Big Island.

Bill Cullum aims his Stihl backpack sprayer during demonstration in Honaunau. Cullum was infected with the Dengue virus in November and experienced terrible fevers, loss of apetite, joint pain and skin peeling with rash.

After he recovered from the dengue virus, Big Island resident Bill Cullum got his own sprayer and enlisted in the war on mosquitoes that spread dengue and potentially Zika. Why isn’t the state doing more spraying?

Cory Lum/Civil Beat

In Hawaii, meanwhile, spraying has been much more limited. This means Zika will likely come to Hawaii, and people may die. Why has a developing nation with extremely limited resources been able to conduct much stronger public health strategies than the state of Hawaii in the richest country on Earth?

While I’m writing this article, numerous other places in our hemisphere are recording their first Zika cases — one in Missouri, 16 in Florida.

Cuba remains one of the last places in the Western Hemisphere free of Zika. The fact that it is also one of the poorest places in the hemisphere, and one with almost no trade relations, means that its efforts are even more impressive. We could learn a lot from them.

Cuba has always taken public health seriously. It did with the HIV virus, and always had one of the lowest rates for HIV in the entire world. How did it accomplish that? By offering free testing.

Hawaii has not taken the Zika threat seriously, just as it failed to do with dengue. The result will inevitably be sick people, and perhaps deaths. And it could spread even further because of what we know about Zika’s capacity to spread via sexual activity.

The question remains: Why haven’t we sprayed more?

It becomes a question of motivation and awareness. Why should a country like Cuba be leading the world in public health efforts?

It is a shame that our government does not learn lessons from our past, or from the good work of other places. Hawaii should have sprayed the entire state.

Our stubbornness could cost lives. We ought to demand that our government explain its inaction. What excuse could it possibly have?

It seems that every time there is a public health threat in Hawaii, the state does nothing. Officials just throw their hands up in the air and hope that nothing serious happens. It is why there have been hundreds of dengue cases, and why there may be hundreds of Zika cases.

It is embarrassing when a country as wealthy as America fails so comprehensively in matters like this. We know the biology of Zika. We know how it spreads. We know that it can be prevented through spraying, as Cuba has thoroughly demonstrated.

It is like our government does not care about the welfare of its citizens. Is it our arrogance and ego and recalcitrance that prevent us from doing something simple like thorough spraying?

Our attitude seems to be: Let’s just wait and see what happens. Anybody with any intelligence will know exactly what will happen. The same as happened with dengue.

We have an opportunity to prevent Zika from taking hold in Hawaii. All we have to do is follow the lead of Cuba. Is that so hard? In this case, it doesn’t take a public health expert or fancy equipment or tons of research. Buy the chemicals, pay people to spray, go spray. Then people won’t get sick and die.

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Ohio Hospitals on Top 102 CMS 5 Stars List



Here are the 102 hospitals that received five-star ratings from CMS’ new Overall Hospital Quality Star Rating, which combines 64 measures that are already public on Hospital Compare into one consumer friendly rating.

This listing reflects how hospitals are ordered on the Hospital Compare site. For a state-by-state breakdown of the five-star hospitals, click here. Read more about the star rating system here.

1. Fresno (Calif.) Surgical Hospital
2. Mercy St. Anne Hospital (Toledo, Ohio)
3. Scripps Memorial Hospital La Jolla (Calif.)
4. Orthopaedic Hospital at Parkview North (Fort Wayne, Ind.)
5. Mayo Clinic Health System Eau Claire (Wis.)
6. Methodist Stone Oak Hospital (San Antonio)
7. Hoag Orthopedic Institute (Irvine, Calif.)
8. Premier Surgical Institute (Galena, Kan.)
9. Straub Clinic and Hospital (Honolulu)
10. Crystal Clinic Orthopaedic Center (Akron, Ohio)
11. Advocate Condell Medical Center (Libertyville, Ill.)
12. The Orthopaedic Hospital of Lutheran Health Network (Fort Wayne, Ind.)
13. Banner Heart Hospital (Mesa, Ariz.)
14. Main Line Hospital Paoli (Pa.)
15. Community Hospital of the Monterey (Calif.)
16. North Central Surgical Center (Dallas)
17. Texas Orthopedic Hospital (Houston)
18. Hospital for Special Surgery (New York City)
19. Memorial Hermann Hospital System (Houston)
20. Northside Medical Center (Columbus, Ga.)
21. Mayo Clinic (Jacksonville, Fla.)
22. Avera Heart Hospital of South Dakota (Sioux Falls)
23. OrthoIndy Hospital (Indianapolis)
24. Black Hills Surgical Hospital (Rapid City, S.D.)
25. Sauk Prairie Hospital (Prairie Du Sac, Wis.)
26. UHHS Memorial Hospital of Geneva (Ohio)
27. Sarasota (Fla.) Memorial Hospital
28. St. Catherine Hospital (East Chicago, Ind.)
29. Kansas Spine & Specialty Hospital (Wichita, Kan.)
30. Gordon Hospital (Calhoun, Ga.)
31. Dunes Surgical Hospital (Dakota Dunes, S.D.)
32. Quail Creek Surgical Hospital (Amarillo, Texas)
33. Orthopaedic Hospital of Wisconsin (Glendale, Wis.)
34. Oaklawn Hospital (Marshall, Mich.)
35. Chester County Hospital (West Chester, Pa.)
36. Sutter Maternity & Surgery Center of Santa Cruz (Calif.)
37. Specialists Hospital Shreveport (La.)
38. Texas Health Harris Methodist Hospital (Fort Worth)
39. Mayo Clinic Hospital (Phoenix)
40. Bon Secours-St. Francis Xavier Hospital (Charleston, S.C.)
41. Arkansas Surgical Hospital (Little Rock, Ark.)
42. Kansas Surgery & Recovery Center (Wichita)
43. McLaren-Northern Michigan (Petoskey)
44. Novant Health Medical Park Hospital (Winston-Salem, N.C.)
45. Hill Country Memorial Hospital (Fredericksburg, Texas)
46. Lincoln (Neb.) Surgical Hospital
47. Memorial Hospital and Health Care Center (Jasper, Ind.)
48. GHS Patewood Memorial Hospital (Greenville, S.C.)
49. Lakeland Community Hospital (Haleyville, Ala.)
50. Community Hospital (Oklahoma City)
51. Roper Hospital (Charleston, S.C.)
52. Franciscan St. Francis Health – Mooresville (Ind.)
53. Goleta Valley Cottage Hospital (Santa Barbara, Calif.)
54. Mercy Regional Medical Center (Durango, Colo.)
55. Baptist Medical Center East (Montgomery, Ala.)
56. Mercy Hospital (Iowa City)
57. Nebraska Orthopaedic Hospital (Omaha)
58. Coordinated Health Orthopedic Hospital (Bethlehem, Pa.)
59. Ohio Valley Medical Center (Springfield, Ohio)
60. Carolina East Medical Center (New Bern, N.C.)
61. IU Health West Hospital (Avon, Ind.)
62. The Heart Hospital Baylor Plano (Texas)
63. Memorial Hermann Memorial City Medical Center (Houston)
64. Mount Carmel New Albany (Ohio) Surgical Hospital
65. Midwest Surgical Hospital (Omaha, Neb.)
66. Moses H. Cone Memorial Hospital (Greensboro, N.C.)
67. Sioux Falls (S.D.) Specialty Hospital
68. CHI Health Nebraska Heart (Lincoln)
69. Scripps Green Hospital (La Jolla, Calif.)
70. New England Baptist Hospital (Boston)
71. OSS Orthopaedic Hospital (York, Pa.)
72. Central Louisiana Surgical Hospital (Alexandria)
73. Dublin (Ohio) Methodist Hospital
74. Mayo Clinic Hospital Rochester (Minn.)
75. St. Luke’s Regional Medical Center (Boise, Idaho)
76. Surgical Hospital at Southwoods (Youngstown, Ohio)
77. Fairview Hospital (Cleveland)
78. St. Joseph’s Hospital (Breese, Ill.)
79. Schneck Medical Center (Seymour, Ind.)
80. Institute for Orthopaedic Surgery (Lima, Ohio)
81. Baylor Medical Center at Upton (Dallas)
82. St. David’s Medical Center (Austin, Texas)
83. Avera Queen of Peace (Mitchell, S.D.)
84. UnityPoint Health – Meriter (Madison, Wis.)
85. Texas Spine and Joint Hospital (Tyler)
86. Methodist Hospital of Southern California (Arcadia)
87. McBride Clinic Orthopedic Hospital (Oklahoma City)
88. Kansas Heart Hospital (Wichita)
89. Citizens Medical Center (Victoria, Texas)
90. GHS Greer (S.C.) Memorial Hospital
91. Avera St. Luke’s (Aberdeen, S.D.)
92. St. Mary’s Hospital (Madison, Wis.)
93. Oklahoma Surgical Hospital (Tulsa, Okla.)
94. North Carolina Specialty Hospital (Durham, N.C.)
95. Holland (Mich.) Community Hospital
96. Santa Barbara (Calif.) Cottage Hospital
97. Oklahoma Heart Hospital (Oklahoma City)
98. Shawnee Mission (Kan.) Medical Center
99. Mosaic Life Care at St. Joseph (Saint Joseph, Mo.)
100. South County Hospital (Wakefield, R.I.)
101. St. Joseph Mercy Chelsea (Mich.)
102. Oakleaf Surgical Hospital (Altoona, Wis.)

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