Outbreak Management

Wisconsin Department of Health Services

Heather Kloth RN, BSN

Infection Preventionist, HAI Prevention Program

Wisconsin Division of Public Health (DPH)

August 10, 2017

After the presentation, attendees will be able to:

Identify an outbreak and be prepared to manage the outbreak

List the necessary steps to contain and manage an outbreak

Name resources available to assist with outbreak management and investigation

Identify common outbreak management errors

Objectives

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Is This REALLY an outbreak?

3

Respiratory Outbreak:

Three or more residents AND/OR employees from the same unit

With similar illness onset within 72 hours of each other

Who have an Acute Respiratory Illness (ARI), such as pneumonia, or lab-confirmed viral or bacterial infection, including influenza

Is this really an outbreak?

4

Gastrointestinal (GI) Outbreak:

Three or more residents AND/OR employees

Who develop new onset of vomiting and/or diarrhea

Onset dates are within 1-2 days

5

Is this really an outbreak?

Scabies Outbreak:

Two or more positive scrapings

One positive scraping and two clinically suspect cases

At least two clinically suspect cases in anyone (employees, visitors, or residents)

During a two-week period

Is this really an outbreak?

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Two or more of the following symptoms:

Fever

Cough

Rhinorrhea or nasal congestion

Sore throat

Myalgia

Common ARIs include pneumonia, influenza, Respiratory Syncytial Virus (RSV), and many others

Clinical Signs and Symptoms (S/Sx)

of Acute Respiratory Illness (ARI)

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Sudden onset of vomiting and/or diarrhea, which may also include:

Headache

Fever

Chills

Abdominal cramps

Common viral GI illnesses include norovirus, rotavirus, and sapovirus

Clinical S/Sx of Viral GI Illness

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Norovirus

Acute-onset watery, non-bloody diarrhea

Acute-onset vomiting

Stomach cramps

Chills

Fatigue

Short incubation period and highly infectious

Common “outbreak” organism

C. Difficile

Frequent, foul-smelling watery stool

Stomach cramps

Stool usually contains blood and/or mucous

Commonly associated with antibiotic usage

Not a typical “outbreak” organism

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Norovirus Versus C. Difficile

An illness of the skin characterized by a papular, extremely pruritic rash and:

Is often burrow-like

Itching is predominantly worse at night

Typical locations?

Clinical S/Sx of Scabies

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Encourage and educate

Staff call-ins

Walking rounds

Working line list

Recognition and Confirmation

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Swift, effective management of the outbreak will be the key to your success.

Where appropriate, a prophylactic plan should already be in place with MD approval.

12

Recognition and Confirmation

Confirm presence of outbreak

Alert key partners about investigation

Literature review

http://text.apic.org/toc/epidemiology-surveillance-performance-and-patient-safety-measures/outbreak-investigations#book_section_17256

Fundamental Components of

Preliminary Investigation

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Establish a preliminary case definition

Develop a methodology for case finding

Fundamental Components of

Preliminary Investigation

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Prepare line list and mapping

Observe and review potentially implicated patient care activities

Consider environmental sampling when appropriate

Implement control measures

Fundamental Components of

Preliminary Investigation

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https://docs.legis.wisconsin.gov/code/admin_code/dhs/110/145/III/15

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Category I

Disease: must

be reported

immediately

https://www.dhs.wisconsin.gov/disease/diseasereporting.htm

Current guidance for outbreak management:

Annual reporting, prevention, and control of acute respiratory illness outbreaks in long-term care facilities https://www.dhs.wisconsin.gov/influenza/ltc-respiratory-

memo.pdf

Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities https://www.dhs.wisconsin.gov/publications/p0/p00653.pdf

Healthcare Infection Control Practices Advisory Committee https://www.cdc.gov/hicpac/pubs.html

Outbreak Management

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Droplet Precautions Contact Precautions

Influenza X

RSV X

Parainfluenza X

Rhino/Enterovirus X

Coronavirus X

Human Metapneumovirus

X

Adenovirus X X

Unknown Etiology X X

CDC Recommendations for

Common ARIs

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F441 – §483.80 (a) states that “Written standards…must

include…When and how isolation should be used for a resident;

including, but not limited to: Type and duration of isolation and requirement

that isolation be least restrictive possible…under the circumstances”.

Isolation: Is it necessary?

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Evaluation

Observation

Being Prepared in an Outbreak

Situation

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Lack of situational awareness

Failure to recognize outbreak

Sick staff

Failure to initiate appropriate precautions

Improper use or lack of use of personal protective equipment (PPE)

Common Outbreak Management Errors

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Policies and procedures

Hand hygiene related to the “Five Moments”

Lack of appropriate environmental cleaning https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants

Failure to notify your local health department https://www.dhs.wisconsin.gov/disease/diseasereporting.htm

Lack of knowledge of line lists and why/how they are used

Common Outbreak Management Errors

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Initials Rm # Age Sex Date

of

Onset

Resolution

Date

Type of

Precaution

Date

Precaution

Ended

N V D A Lab spec Result ABX

MM 102 70 M 12/1 12/3 Contact 12/5 X X X Stool + Noro N

DD 104 81 M 12/2 12/5 Contact 12/7 X X X X Stool +Noro N

PB 101 67 F 12/2 12/4 Contact 12/6 X X X Stool +Noro N

EF 107 90 M 12/3 12/6 Contact 12/8 X X Stool +Noro N

JJ 106 85 F 12/3 12/4 Contact 12/6 X Stool (-) N

RP 100 68 M 12/4 12/7 Contact 12/9 X X X Stool +Noro N

GY 103 78 F 12/4 12/6 Contact 12/8 X X Stool +Noro N

Example of Line List for GI

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*N = Nausea ; V = Vomiting ; D = Diarrhea ; A = Abdominal cramping Notes: Unit “quarantined” on 12/2. DPH notified on 12/2 of outbreak of Norovirus. Staff education provided regarding outbreak, hand hygiene, PPE use, and environmental cleaning. Signs posted re: outbreak and precautions. MD notified and blanket order obtained to test symptomatic residents for Norovirus. No floating of staff allowed as of 12/2.

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Norovirus

Outbreak in a

Nursing Home

Foodborne

Best practices for identification and management of an outbreak

Resources

Staying ahead of the game!

Questions?

Conclusion

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