emerging issues in infection control: the …...emerging issues in infection control: the continuum...
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Emerging Issues in Infection Control:The Continuum From the Hospital to
Global Health
Jay C. Butler, MDDeputy Director for
Infectious Diseases
Alaska Infection Control ConferenceAnchorage, AK
October 7, 2019
• Healthcare-associated pathogens
• Data on infection control practices and tools
• Non-traditional settings for infection control
• Issues in the community• Global health concerns
So, What’s New?
Hospital
Other facilities
Community
Global
Realms of Infection Control
Candida auris• 2009: isolated from ear canal of patient in
Japan• Bloodstream and intra-abdominal infections• Leading cause of candidemia in some
hospitals:• South Africa• India• Kenya• Spain
• Unlike other Candida species:• Colonizes healthcare environment• Transmitted through facility networks• Highly drug resistant
Vallabhaneni S, et al. Ann Intern Med 2019;171(6):432-433
Candida auris Drug Resistance
Azoles90%
Polyenes40%
Echinocandins2%
• 33% resistant >1 class• 3 pan-resistant strains
in 2019• Resistance emerged
during treatment• No transmission
documented• Resistance maintained
after treatment stopped
Vallabhaneni S, et al. Ann Intern Med 2019;171(6):432-433
C. Auris Affects the Sickest of the Sick
• Tracheostomy• Long-term mechanical ventilation• PEG tube• Colonization with other multidrug resistant organisms• Recent exposure to broad-spectrum antibiotics and antifungals• Multiple healthcare facilities and stays
States Reporting Candida auris, as of July 31, 2019
• >720 clinical isolates• >2,000 clinical or
screening isolates• 11 cases linked to
healthcare abroad
Outbreak of C. auris Neuro ICU Oxford Hospital, London, Feb 2015-Aug 2017
• Predictors of infection/ colonization:
• Reusable axillary temperature probes (OR 6.8, 95% CI 3.0-15.6)
• Fluconazole exposure (OR 10.3, 95% CI 1.6-65.2)
• Infection rates fell after probe use discontinued
Eyre DW, et al. N Engl J Med 2018;379(14):1322-1331
Outbreak of C. auris Neuro ICU Oxford Hospital, London, Feb 2015-Aug 2017
Eyre DW, et al. N Engl J Med 2018;379(14):1322-1331
New York Times, April 6, 2019
Odds of Lab-Confirmed Influenza Among Healthcare Providers: N95 vs Medical Mask
Radonovich LJ, et al. JAMA 2019;322(9):824-833
• Cluster randomized pragmatic trial• 4 years during 12-week peak influenza season• 137 outpatient study sites• 7 US medical centers
• Staff at centers randomized• N-95• Medical mask
• N=2862 HCPs• 5180 HCP-seasons
Odds of Lab-Confirmed Influenza Among Healthcare Providers: N95 vs Medical Mask
Intention to Treat Cohort
Per-protocol Cohort
Adjusted*
Adjusted*
Unadjusted
Unadjusted
* Adjusted for: age, gender, race, number of household members aged <5 years, categorical occupation risk level, influenza vaccination status, etc
Odds Ratio (95% CI) for Influenza with N-95
Radonovich LJ, et al. JAMA 2019;322(9):824-833
Lab-confirmed influenza: • N-95: 207; 8.2% of HCP seasons• Medical mask: 7.2% of HCP seasons
Risk of Invasive Streptococcal Infection Among PEH, Anchorage, 2002-2015
Mosites E, et al. Emerg Infect Dis 2019;25(10):1903-1910
Widespread Hepatitis A Outbreaks, March 2017-Sept 27, 2019
• 26,276 cases• 15,819 hospitalizations• 268 deaths• Risk factors
• Homelessness• Drug use• Recent incarceration• MSM• Chronic liver disease
Measles, US, October 2018-October 2019
Patel M, et al. MMWR Early Release Oct 4,2019
0.6 0.60.7
0.8 0.80.7
0.8 0.8 0.8
1.1
0
1
2
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
HP2020 Goal: <1%
Very few US toddlers receive no vaccines at all, but this group is increasing
*Source: National Immunization Survey, MMWR October 12, 2018, 19-35 months at time of survey
Percentage of 0 Dose children
For more information please contact the Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
As of Oct 4, 2019: 3,087 confirmed cases/114 probable, 2,137 deaths
Ebola outbreak in conflict zone Infected HCWs and nosocomial spread once again important (6% of cases) Currently, <60% of cases appropriately isolated
Renewed efforts at community engagement Trust building extremely challenging
Systematic evaluation of multiple new therapeutics Vaccines are available Global preparedness improved
Ebola, DRC, 2018-19
Risk of Transmission of Ebola
Utilization of Ebola Vaccine: Ring Vaccination
Ebola Case
Contact Case
Contact Contact
August 2019: • Tertiary contacts• Pregnancy women, after 1st trimester
Ebola Treatment, 2019Investigational Agents:• ZMapp:
• combination of three humanized monoclonal antibodies• evaluated in the PREVAIL II trial in West Africa• trend in benefit but missed the primary endpoints due to the declining
number of cases. • Remdesivir (GS-5734): antiviral drug• REGN-EB3 (Regeneron):
• combination of three, fully human, monoclonal antibodies• efficacy equivalent to ZMapp in non-human primates
• mAb114: • single human monoclonal antibody• protects NHPs with 1 dose given 5d after challenge
• Favipiravir: broad-spectrum polymerase inhibitor
Improved Domestic Preparedness: Ebola Treatment Centers
Lessons Learned from Ebola:Human Factors Engineering
• Doffing of PPE• Study of healthcare worker removing PPE artificially contaminated:
• Fluorescent lotion• Bacteriophage MS2
Tomas M, et al. JAMA Intern Med 2015;175(12):1904-1910
Lessons Learned from Ebola:Human Factors Engineering
Drews FA, et al. Clin Infect Dis 2019;69(S3):S199-S205
Thinking Holistically to Protect Patients
Protecting Across the Patient Care Spectrum
• Faster diagnostic tools
• Sepsis
• Implement current recommendations
• Innovation
• Antibiotic Stewardship
Appropriate Treatment Early DetectionPrevent Infections
• Emerging Resistant Bacteria• Inter-facility Transmission
CDC Strategic Priorities
End epidemics
Eliminate diseases
Secure global health and ensure domestic
preparedness
CDC is Science-based, Data-driven, Service-oriented
InfluenzaAntibiotic resistance
Opioid misuseDiabetes
HIV/AIDSHepatitis C
Vaccine-preventable diseases
Pandemic contagionsVector-borne diseases
Terrorism preparedness