outbreaks- what’s now, what’s next. outbreaks- what’s now, what’s next. carol shenold, rn,...
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OUTBREAKS-OUTBREAKS-What’s Now, What’s Next.What’s Now, What’s Next.
Carol Shenold, RN, CICDeaconess 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?What’s the next outbreak?
• 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 GroupsNew Food Groups
• 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 PeoplePets and People• Are we at risk from our animals?
– 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 thingAnd now with the bird flu thing
Pets and People cont.Pets and People cont.• 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.
PandemicsPandemics
• 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.)
BioterrorismBioterrorism
• The usual suspects– Plague– Anthrax– Small Pox
• Not on the front page as much due to the Weapons like planes, trains and automobile weapons.
Viral AgentsViral Agents
• Small Pox(Variola)– Wiped Out 1980– highly contagious– kills 20% of exposed– dangerous vaccine– No chemotherapy– Isolation with droplet and
airborne precautions-N95 masks-gowns and gloves-
– Dispose of or destroy bed linens and clothing
– Pre-event vaccination at issue in many states at this time
– Some hospitals are opting for the formation of a team but not pre-event vaccinating.
– Screening and reimbursement issues as well as worker’s compensation
– Fear of side-effects for family.
Viral Agents cont.Viral Agents cont.• 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 continuedBioterrorism continued• 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
• 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 DefinitionCase Definition• We already have case definitions. For
example, we know the definition of CA-MRSA 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 continuedCase Definition continued
• We have many more case definitions like those for Community Acquired Pneumonia or Ventilator Associated Pneumonia
• 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 surveillanceEmployee surveillance
• 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 surveillanceEmployee patient surveillancePatient
• 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.
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 continuedEmployee surveillance continued
• 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 ExposureMass Exposure• 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?Is it really an outbreak?
• General definitions of an outbreak includes:– 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 OutbreakInvestigation of an Outbreak• Control ongoing outbreak• Detect and separate
implicated source• Identify specific risk factors • Prevent future outbreaks
• 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 StepsBasic Steps
• Establish a case definition• Identify cases• Data Analysis• Who is at risk?• Prevention measures• Environmental testing, only if indicated
Controlling an OutbreakControlling an Outbreak
• 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 continuedControl continued• 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 SurveillancePatient SurveillanceOutpatient procedures increasing.How do we track them and potential infections?
PhoneLetters
Physician self reportingER Visits-chart review
Evaluating DataEvaluating Data
• 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 curveEpidemic curve• 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
C. Diff Incidence
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Date Identified
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Presumptive HypothesisPresumptive Hypothesis• 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.
HypothesisHypothesis• 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 ControlsEnvironmental Controls
• 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.
Planning for the impossible, improbable and life in general.
• Outbreak Management Plan• Johns Hopkins Hospital-Outbreak
Investigation Management Team.– 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 PlanForming a PlanOutbreak 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 PlanA 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?What should I plan for?• 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 includeWho to include
• 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…JCAHO says…• 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-1Disaster Planning-1• 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-2Disaster Planning-2• Plan for efficient evaluation and discharge of
patients• Develop discharge instructions for non-
infectious 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 ChangesPolicy Changes• 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?
ProphylaxisProphylaxis
• 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.Educate, educate, educate.
• 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
– Type of isolation– Incubation– Transmission– Keep audience in mind
FEARFEAR
• Effective communication and education will help allay fears and prevent unnecessary rumors and panic.
