Outbreak Investigations CHS 446 Communication Skills for the Healthcare Professional Mohammed S. Alnaif, Ph.D. alnaif@ksu.edu.sa 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Epidemic refers to the outbreak of a disease in a localized group of people; it can be infectious and spread from one person to another. Epidemic nosocomial infections are defined as hospital-acquired infections that represent an increase in incidence over expected rates. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Outbreaks: The basics Goals of an outbreak investigation: To identify the source of illness To guide public health intervention Ways to recognize an outbreak: Routine surveillance activities Reports from clinicians and laboratories Reports from affected individuals 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Epidemic associated infections usually are clustered temporally or geographically, suggesting that infections are from common source or are secondary to increased person-to-person transmission. These outbreaks are often associated with specific procedures or devices. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Epidemics are important because they account for substantial percentage of nosocomial infections. Approximately 5% of nosocomial infections occur in epidemics. Most of these infections occur in small clusters of two to three patients. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations If infection control personnel thoroughly investigate nosocomial epidemics, they may identify new agents, reservoir, or mode of transmission. To accomplish these goals, infection control personnel must evaluate data obtained from epidemiologic studies and from microbiologic and molecular studies. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Recognizing Outbreaks Epidemiology determines questions to ask Laboratory provides answers EPI and LAB together “solve” most outbreaks (especially true for outbreaks in healthcare facilities) 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Surveillance cultures Environmental samples Culture ID Susceptibility testing Isolate typing Surveillance Provides first evidence of outbreak Often detected by microbiology Line list of cases Epi-curves Case-Control study Exposure risks Epidemiologic Studies A hospital outbreak usually begins when ongoing surveillance signals a clusters of unusual infections. ADVANCE This provides the first evidence of an outbreak, and is often picked up by the microbiology lab. Epidemiologist in the field then help define the outbreak by providing a line-list of cases, an epi-curve which shows the distribution of cases over time, and perhaps results of a case-control study, which can give clues to exposures that are related to the disease in question. But it usually work done in the laboratory that confirms the suspicions raised by epidemiology. This may involve: collection of surveillance cultures to see if the outbreak is ongoing, collection and identification of environmental samples and clinical isolates, susceptibility testing of organisms and molecular typing to see if they are related. Many hospital outbreaks end once the organism and its transmission dynamics have been determined. This usually results in local interventions such as isolation of patients, a change in disinfection protocol, or even suspension of an implicated procedure or closure of a unit until new cases cease to arise. Confirmatory Studies Patient isolation Enhanced disinfection Suspend procedure or close unit Local Interventions Adapted from Ostrowsky and Jarvis Efficient Management of Outbreak Investigations

Outbreak Investigations Recognizing Outbreaks Hospitals must have reliable, sensitive surveillance systems that allow the infection control personnel to detect increased infection rates in a defined time period and geographic area, suggestive of epidemic transmission. Sometimes outbreaks are easy to recognize. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Recognizing Outbreaks Sometimes outbreaks are easy to recognize. Fore example, even one episode of an uncommon infection, such as group A streptococcal surgical site infection, can indicate an out break. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Recognizing Outbreaks Sometimes outbreaks are easy to recognize. In other cases, an increased incidence of infection caused by unusual organisms, such as multidrug-resistant Mycobacterium tuberculosis, indicate epidemic transmission. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Steps in Outbreak Investigation Preliminary Investigation and descriptive Study Review existing information Determine the nature, location, and severity of the disease problem Verify the diagnosis Establish a case definition Find and ascertain case-patients. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Steps in Outbreak Investigation Preliminary Investigation and descriptive Study Request that the laboratory save isolates from affected patients and from suspected sources or vehicles Draw an epidemic curve Summarize data in a line-listing Establish the existence of an outbreak Institute or assess adequacy of emergency control measures. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Steps in Outbreak Investigation Comparative Study and Definitive Investigation Review records of existing case-patients Develop hypotheses Test hypotheses in comparative (case-control or cohort) studies Conduct microbiologic or other laboratory studies and surveys Conduct additional studies, including observational studies, surveys, or experiments, to confirm the mode of transmission 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Emergency Measures Once the outbreak is confirmed we decide immediately whether to: Conduct a full epidemiological study Obtain cultures from equipment or suspected vehicles Call local, or central agencies Institute emergency control measures 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Emergency Measures When making these decisions we should consider the following factors: The mortality associated with the epidemic The public health importance of the outbreak The frequency of infection versus colonization The possibility of a common source The size of the outbreak The characteristics of the pathogen Local and government regulation that may require healthcare facilities to report epidemics 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Closing the Ward The epidemiology staff must weight carefully the benefits of closing a ward or a unit against the risk of decreased access to care. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Reporting Outbreaks Epidemiology ICP should report to the local health officials all outbreaks that have potential public health implications at the local or national level. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Reporting Outbreaks In addition, ICP should report suspected intrinsic contaminations, infections caused by contaminated blood transfusion reactions, infections associated with defective devices to the hospital infections programs, and local health officials. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Conducting an Epidemiologic Study Reviewing the Line-Listing Before conducting a comprehensive epidemiologic study, ICP should review line- listing and the epidemic curve, because these tools may suggest the cause of the outbreak. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Comparative Studies In many outbreaks, a putative risk factor can be confirmed only if it meets certain criteria. First the risk factor must have been present before the onset of the disease. Second the risk factor generally will be associated with the condition statistically. 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Comparative Studies To confirm the second point, epidemiology staff must either compare affected patients with patients who did not acquire the condition (control) or compare the rate of the condition among patients with certain putative risk factor to the rate among patients without the risk factors (a cohort study). 6/10/2018 Dr. Mohammed Alnaif

Outbreak Investigations Observational Studies ICP should observe health care workers perform procedures, particularly patient-care techniques that might be related to outbreaks. 6/10/2018 Dr. Mohammed Alnaif

Chapter 14 Outbreak Investigations Culture Surveys Organisms that cause nosocomial outbreaks can be isolated frequently from nonsterile environmental sources or from staff. 6/10/2018 Dr. Mohammed Alnaif

Chapter 14 Outbreak Investigations Demonstrating Biological Plausibility The investigators should design and conduct additional studies to confirm that the reservoir and the mode of transmission are biologically plausible. 6/10/2018 Dr. Mohammed Alnaif

Chapter 14 Outbreak Investigations Acting on Results ICP should focus their interventions on the immediate cause of an outbreak and should institute the simplest measures that will correct the problem. ICP should develop a plan and timeline for implementing the control measures. ICP must determine whether the measures are effective. 6/10/2018 Dr. Mohammed Alnaif

THANK YOU 6/10/2018 Dr. Mohammed Alnaif