Outbreaks 2009 HAI

							                Maria del Rosario, MD, MPH
Division of Infectious Disease Epidemiology
                       WVDHHR/BPH/OEPS

                            February 2010




                                              1
   Describe 2009 outbreaks of healthcare-
    associated infections (HAIs).

   Review the lessons learned from
    outbreaks of HAIs.




                                             2
TRUE or FALSE:

1.   In a healthcare facility outbreak, when physicians
     clinically diagnose the cause of the outbreak, there
     is NO need to obtain specimens for laboratory
     testing.

2.   In general, local health departments (LHDs) do not
     need to worry about HAI outbreaks because
     Infection Preventionists (IP) in the facility can
     usually address the problem.

                                                            3
What is HAI?
Health care-associated infections (HAIs) are infections that
 patients get while receiving treatment for another
 condition in some type of health care facility*, i.e.
 hospitals and outpatient surgical centers, clinics and
 LTCFs


Healthcare-Associated Infection (HAI) Outbreak
   Increase in the incidence of infection (or presumed
   infection) among people associated with a healthcare
   setting

__
*AHRQ


                                                               4
   Annual disease burden
      More than 1.7 million infections
      99,000 deaths


 75% of HAIs
     Catheter-associated UTI (CAUTI)
     Surgical site infection (SSI)
     Central Line-Associated Blood Stream Infection
      (CLABSI)
     Ventilator-associated pneumonia (VAP)

                                                       5
•   1996 to 2005 - 110 % rise in the number of ambulatory clinics

•   2004 to 2008 - 44% HAI outbreak investigations (with CDC) in
    non-hospital setting

•   Related to:
    failure to adhere to basic safe practices (e.g., syringe re-
      use) – HBV and HCV
    patients contracting S. aureus, K. pneumoniae, etc.


•   The overall burden of HAI…. significant problem…resulting
    from very basic infection control failures.
                                                                    6
   About 30% of all 2009 disease outbreaks
    are HAI-related
            Setting           Count   Percent
Long-term Care Facility        29       90%

Hospital                        1       3%

Outpatient clinic               2       7%
(dental, medical, surgical)

   At least 18 WV counties
                                                7
           Type                 Count   Percent
Enteric                          17      55%
Respiratory                      11      32%
Rash                              1       3%
Other                             3      10%
(MSSA, Hep B, Conjunctivitis)




                                                  8
40 Reports of HAI outbreaks
    • 32 Confirmed outbreaks
    • 8 Not an outbreak (after review)




                                         9
   Disease outbreaks – report immediately (64CSR-7)

   2008 WV Legislative Session – WV Healthcare
    Authority created HAI Advisory Panel to assist
    and guide hospital HAI reporting, effective July
    2009.

   2009 HAI Prevention Grant to WVDHHR/BPH



                                                       10
WV Hospitals – July 2009

•   CLABSI
    • All ICUs
    • Report at National Healthcare Safety Network (NHSN)


•   HC Personnel Flu vaccination
    • All acute care hospitals
    • Report to WV Healthcare Authority


                                                            11
 Recovery Act funds targeting HAI
 Tied to Preventive Block Grant
 WV developed HAI Plan, report to CDC:
 • Tier 1 Focus – Hospitals
 • HAI Priority Areas:
       Catheter-Associated Urinary Tract Infection (CAUTI)
       Central Line-Associated Blood Stream Infection (CLABSI)
       Surgical Site Infection (SSI)
       Ventilator-Associated Pneumonia (VAP)
       MRSA
       Clostridium difficile (CDI)


                                                                  12
WVDHHR HAI Infrastructure

   Multidisciplinary advisory group
   Build PH workforce – HAI Prevention Coordinator
   HAI surveillance, prevention and control - coordination
    among agencies and organizations
   NHSN: internet-based surveillance system




                                                              13
1.   Prepare for field work.
2.   Establish existence of an outbreak.
3.   Verify the diagnosis.
4.   Construct a working case definition.
5.   Find cases systematically and record
     information.
6.   Perform descriptive epidemiology.
7.   Develop hypothesis.
                                            14
8.  Evaluate hypothesis epidemiologically.
9. As necessary, reconsider, refine, and re-
    evaluate hypothesis.
10. Compare and reconcile with laboratory
    and/or environmental studies.
11. Implement control and preventive
    measures.
12. Initiate or maintain surveillance.
13. Communicate findings.

                                               15
16
   Verify the diagnosis.

   Establish existence of an
    outbreak.

   Implement control and preventive
    measures.
                                       17
18
PROCESS                               OUTCOME
Verify the diagnosis.                 Vanco-susceptible; reducing

Establish existence of an outbreak.   No

Control and preventive measures.      Contact precautions, no
                                      contact tracing.




                                                                    19
You receive a call from a LTCF:

   4 residents diagnosed (by facility doctor) with
    shingles

   4 more residents with symptoms…looks like
    shingles, awaiting diagnosis of doctor

What do you do next?


                                                      20
   Verify the diagnosis.
     Review clinical presentation
     Review mode of transmission
   Establish existence of an outbreak.
   Construct a working case definition.
   Find cases systematically and record
    information.


                                           21
Case Study 2 – cont.




                       22
Shingles
•   Rash on one side of body

•   Blisters scab after 3 to 5 days,
    clears within 2 to 4 weeks

•   Before rash - pain, itching, or
    tingling in the rash area

•   Other symptoms: fever, headache,
    chills, and upset stomach

•   Transmission?

    So, what was the outcome?
                                       23
Causes of rash illness in elderly
• Shingles
• Scabies
• Contact Dermatitis
• Staph. aureus




                                    24
It is Thursday afternoon, 3pm. You are finishing up on your
     paperwork and can’t wait till Saturday. You are leaving for a 10-
     day cruise early Saturday morning.

Your thoughts were suddenly interrupted by a tap on your shoulder.
   “I’m forwarding a call to you,” said your receptionist.

On the other line, the caller informs you about TLC Geriatric Home --
   ‘it has closed it’s doors to visitors because of some illness going
   on’. You listened, you took a deep breath , and…




                                                                         25
   About 18 residents with vomiting, diarrhea,
    cramps
   Going on for about 5 days
   62-bed facility



What do you do next?


                                                  26
   Verify the diagnosis.
   Establish existence of an outbreak.
   Construct a working case definition.
   Find cases systematically.
   Perform descriptive epidemiology.




                                           27
28
29
   You review the (complete) linelist and saw that the list
    is growing steadily. It is Friday!



What else needs to be done?




                                                               30
               18                   Employee
               16
               14                   Resident
No. of Cases




               12
               10
                8
                6
                4
                2
                0




                    Date of Onset

                                               31
   Develop hypothesis.
   Implement control and preventive
    measures
   Reconcile information – epi, lab,
    environmental
   Maintain surveillance
   Communicate Findings


                                        32
                            Source: SHEA/APIC Guideline: Infection Prevention and Control in the
                            Long-Term Care Facility, 2008



Respiratory                                   Other Infections
•   Influenza                                 •   Methicillin-resistant
•   Tuberculosis                                  Staphylococcus aureus (MRSA)
•   S. pneumoniae                             •   Vancomycin-resistant
                                                  Enterococcus (VRE)
•   Chlamydia pneumoniae
                                              •   Group A Streptococcus
•   Legionella spp.
                                              •   Scabies
                                              •   Conjunctivitis
Gastrointestinal
•   Viral gastroenteritis (norovirus,
    etc.)
•   Clostridium difficile
•   Salmonellosis
•   E. coli 0157:H7 colitis


                                                                                                   33
   Identify and establish regular contact with Infection
    Preventionist and other key contacts

   Inquire about facility’s
      Disease identification, surveillance system,
      Data analysis and reporting
      Infection control policies and procedures

   Assess training and education needs

   Information sharing


                                                            34
TRUE or FALSE:

1.   In a healthcare facility outbreak, when physicians
     clinically diagnose the cause of the outbreak, there is
     NO need to obtain specimens for laboratory testing.
     Answer: False

2.   In general, local health departments (LHDs) do not need
     to worry about HAI outbreaks because infection control
     practitioners (ICP) in the facility can usually address the
     problem. Answer: False


                                                                   35
Questions?




             36