Transcript OUTBREAKS-What’s next, what’s now.

OUTBREAKSWhat’s Now, What’s Next.
Carol Shenold, RN, CIC
Deaconess Hospital, Oklahoma City
2006
“Mold Control and Remediation in Healthcare”
“The Infection Control Trainer’s Toolkit”
“The CDC’s Tuberculosis Guidelines: Strategies for Compliance”
What’s the next outbreak?
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SARS-carried by humans, cats ???
“Mad Cow Disease”
Bird Flu - spread by wild birds and…
Botulinum Toxin A - contaminated carrot
juice - 2006 September
E coli 0157 - fresh spinach-2006-September
West Nile - mosquitoes
New Food Groups
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Can’t eat beef - Mad Cow
Can’t eat chicken and eggs - salmonella
Can’t eat spinach - E. coli 0157
Can’t drink carrot juice - botulism
No fish - mercury poisoning
I believe that leaves wine and chocolate!
Pets and People
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Are we at risk from our animals?
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Chickens - Bird Flu
Cats - toxoplasmosis-don’t scoop
Deer Mice - Hanta Virus
Birds - histoplasmosis
In the United States, we have 139 million cats
and dogs as pets and 569,774 Iguanas.
And now with the bird flu thing
Pets and People cont.
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We have pet therapy for children’s hospitals, nursing homes,
regular hospitals, behavioral health and as therapy animals.
What if a pet, or several pets carried a mutated virus or just a
more deadly form of campylobacter. Track that outbreak.
58.3% of U.S. households have pets
62 million dogs, 69 million cats, 10 million birds
3 million reptiles.
I DID NOT SAY GET RID OF YOUR PETS!
Just be aware, use good hand hygiene and etc.
Pandemics
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Avian Flu - need person to person
transmission
Pandemic Flu - One that flu vaccine
might not slow down and is
transmitted person to person (Why
avian flu could be scary if it mutated.)
Bioterrorism
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The usual suspects
– Plague
– Anthrax
– Small Pox
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Not on the front page as much due to the
Weapons like planes, trains and automobile
weapons.
Viral Agents
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Small Pox(Variola)
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Wiped Out 1980
highly contagious
kills 20% of exposed
dangerous vaccine
No chemotherapy
Isolation with droplet and
airborne precautionsN95 masks-gowns and
glovesDispose of or destroy
bed linens and clothing
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Pre-event vaccination at
issue in many states at
this time
Some hospitals are
opting for the formation
of a team but not preevent vaccinating.
Screening and
reimbursement issues as
well as worker’s
compensation
Fear of side-effects for
family.
Viral Agents cont.
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Viral Hemorrhagic fever
– Ebola, Marburg, Lassa
– Mortality rates 56-92%
– Supportive care for major blood loss
– Ribivirin being used
– No real vaccine in use
– Contact precautions, strict barrier nursing
– Decontamination of double-bagged spec.
– Disinfection excreta
Bioterrorism continued
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Geographically unusual
disease
high disease rate among
exposed
Vector borne disease in
wrong area
More than one epidemic at
once
Higher morbidity/mortality
than usual
Rapidly increasing incidence
in healthy population
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Epidemic curve rising and
falling In short period of time
Unusual increase in people
with fever or resp. symptoms
seeking treatment
Epidemic disease at unusual
time
Clusters of patients from
single locale
Presentation with pulmonary
anthrax, tularemia or plague
Case Definition
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We already have case definitions. For
example, we know the definition of CAMRSA involves a skin lesion or cellulitis with
abscess, purulent drainage, a positive
culture for MRSA, in a young healthy
person with no history of contact with
hospital acquired MRSA.
Case Definition continued
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We have many more
case definitions like
those for Community
Acquired Pneumonia
or Ventilator
Associated
Pneumonia
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When you see a
cluster of infections
and suspect an
outbreak, decide on
your case definition
so you know what you
are looking for.
Employee surveillance
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One way to spot an in-house outbreak is by
surveillance of employee call-in/illness
patterns. If you see a cluster of GI disease
among employees, do they all work on the
same unit? Is there a patient on that unit
with GI symptoms? Or did that group all
attend the same event? Can the symptoms
be passed on to the patient population?
Employee patient surveillance
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Patient
Diarrhea, nausea, vomiting,
especially bloody diarrhea.
Illness with fever, rash, sore
throat, temperature, chills
headache, fatigue,
decreased appetite, change
in mental status.
Influenza-like syndromes
Acute respiratory distress
syndromes.
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Employee
Clusters of employees
reporting
diarrhea/nausea/vomiting
Clusters of employees
reporting illness with fever,
rash,
sore throat with white or
yellow membrane, red
swollen lymph nodes
Increased absenteeism or
unusual sick leave pattern.
Employee surveillance continued
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Even without a cluster, one employee
can make a difference.
– OKC 2006-one nurse with active TB, small
hospital, over 150 patients, visitors and
employees tested so far in Sept. 2006.
Mass Exposure
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Diseases with Mass Exposure Potential
*Starred Diseases require only one case to start investigation
*Anthrax
Resistant Organisms (MRSA,VRE,VISA, VRSA
Botulism
Respiratory Syncytial Virus
Chickenpox
Rubella
Hepatitis A
Scabies
Influenza A or B
*Small Pox
Legionnaires Disease
Tuberculosis
*Measles
Tularemia
Meningococcal Meningitis
Viral Conjuntivitis
Pertussis
Viral Gastroenteritis
(Rotavirus, Norwalk)-cruise
*Plague
Viral Hemorrhagic Fevers
*Polio
SARS
Is it really an outbreak?
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General definitions of an outbreak includes:
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Two or more linked cases of the same illness or an increase in
the number of observed cases over expected cases
Two or more persons with same illness after exposure to
common source
Any time you have several people exposed at a mass event
who then become ill, be suspicious. The same would apply to
multiple cases of influenza when it’s not flu season. Several
cases of c.difficile where you rarely see any cases.
Investigation of an Outbreak
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Control ongoing outbreak
Detect and separate
implicated source
Identify specific risk factors
Prevent future outbreaks
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Date of onset, duration
severity
Proximity to other patients
Common factors-same Dr.,
same unit, same surgery,
same organism, common
risk factors.
Laboratory confirmation
Basic Steps
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Establish a case definition
Identify cases
Data Analysis
Who is at risk?
Prevention measures
Environmental testing, only if indicated
Controlling an Outbreak
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The goal is to control the source (if
known), control transmission and
protect at-risk groups. Look at
interventions.
If, for example, you see an outbreak of
c.difficile you will take multiple actions.
Control continued
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Proximity of patients to one another,
same room, hall, unit, physician,
diagnosis.
Proper isolation techniques
Hand Hygiene-soap & water-no alcohol
Antibiotics used
Housekeeping processes
Modifications of patient activity.
Patient Surveillance
Outpatient procedures increasing.
How do we track them and potential infections?
Phone
Letters
Physician self reporting
ER Visits-chart review
Evaluating Data
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Once the outbreak is over, you can look at
everything related to the outbreak and present data
to Infection Control Committee, Patient Care
Services and other involved committees. That’s
where the bar graphs, pie charts, new process and
procedures come into the picture. What have you
learned from the outbreak? Is there anything you
can do to prevent the next one?
Epidemic curve
C. Diff Incidence
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The epidemic curve can give
you a pattern of spread,
magnitude of outbreak, outliers,
time trend, exposure and
disease incubation period.
When making the graph, put
reported cases on y axis, day or
time of symptoms on x axis,
make sure the time interval
works, label clearly and add
other info as needed, i.e. unit,
organism
Number of cases
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Date Identified
Presumptive Hypothesis
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The common factor in a multiple case outbreak
of e. coli 0157 was all patients eating bagged,
organic baby spinach therefore: The outbreak
was caused by eating contaminated spinach.
The common factor in a multiple patient
outbreak of c.diff is one caregiver who did not
use appropriate hand hygiene. The outbreak
was caused by one caregiver failing to follow
proper procedures.
Hypothesis
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Avian Flu can be found in
water fowl.
Donald Duck is a water
fowl who lives in Disney
world.
You’ll catch Avian Flu if you
visit Disney World
Environmental Controls
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When looking at results of an outbreak
investigation-don’t forget to look at any
environmental controls you could put in
place like disease specific cleaning
procedures, UV light units in waiting rooms
likely to have active TB patients, additional
isolation rooms, especially negative
pressure.
Planning for the impossible,
improbable and life in general.
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Outbreak Management Plan
Johns Hopkins Hospital-Outbreak
Investigation Management Team.
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Could include IC, associate IC, IC Manager, IC
director, Risk Management, Pharmacy, nursing
management, microbiologist, disease specialist.
Routine hospital outbreak in a moderate to small
hospital, ICP, ID Dr., others as needed.
Forming a Plan
Outbreak Plan
This is a general plan for
investigating an
outbreak and can be
used to look at large
and small clusters of
disease. Not all
outbreaks would be
large enough to involve
all aspects of the plan
Disaster Plan
A larger plan for handling
any disaster but should
include a plan for
handling a large influx
of contagious and could
involve the outbreak
investigation model
depending upon the
disease involved.
What should I plan for?
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Everything? You can’t. Keep it simple. Your plan for
investigating outbreaks, large or small, should be
the same. Remember your IC Risk Assessment? It
is tailored for your facility. Use those perceived
risks to form your outbreak investigation plan.
Keep in mind that you may not have Johns Hopkins
resources and your team may be you, your ID
doctor and a lab technician.
Who to include
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When formalizing your plan involve the
Infection Control Committee because the
make-up of that committee is the same
players that will be involved in a small
outbreak on one unit or a large outbreak
involving a city, county, state or country.
JCAHO says…
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IC.6.10
The hospital prepares to respond to an influx, or risk of
influx, of infectious patients.
Small or large
City-wide influenza, Bioterrorism, county-wide
pertussis etc.
Incorporate into over-all disaster plan, move away from
the disease specific boutique plans-Smallpox, SARS,
Avian Flu.
Disaster Planning-1
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Establish communication networks and lines of
authority
Plan for cancellation of non-emergency
services and procedures
Identify sources able to supply vaccines,
immune globulin, antibiotics, and anti-toxins
Determine the ability to handle a sudden
increase in the number of cadavers on site
Determine the ability to lock down the facility
Disaster Planning-2
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Plan for efficient evaluation and discharge of
patients
Develop discharge instructions for noninfectious patients
Determine sources for additional medical
equipment and supplies
Plan allocation of scarce equipment
Determine ability to isolate large numbers of
patients.
Determine the ability to increase security
Policy Changes
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Like, when riding the mower, always watch the road
ahead.
After the outbreak, look at the overall incident and
determine if process was part of the issue and what
could be done to change the way things are done.
If you have several surgical site infections and only
half the patients received prophylactic antibiotics
within 1 hr of cut time, do you need pre-printed
orders?
Prophylaxis
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Side-note: In making plans for the
influx of infectious patients, involve
employee health in case prophylaxis
of employees is called for and/or
prophylaxis of families or other
exposed individuals.
Educate, educate, educate.
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Educate staff, employees, visitors.
If processes change, educate.
If they stay the same, educate
Must know what role is in disaster
Need to understand disease dynamics of the outbreak
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Type of isolation
Incubation
Transmission
Keep audience in mind
FEAR
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Effective
communication and
education will help
allay fears and
prevent
unnecessary rumors
and panic.