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

 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 % rise in the number of ambulatory clinics 2004 to % 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  At least 18 WV counties 7 SettingCountPercent Long-term Care Facility2990% Hospital13% Outpatient clinic (dental, medical, surgical) 27%

8 TypeCountPercent Enteric1755% Respiratory1132% Rash13% Other (MSSA, Hep B, Conjunctivitis) 310%

9 40 Reports of HAI outbreaks 32 Confirmed outbreaks 8 Not an outbreak (after review)

 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 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

14 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.

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

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17  Verify the diagnosis.  Establish existence of an outbreak.  Implement control and preventive measures.

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19 PROCESSOUTCOME Verify the diagnosis.Vanco-susceptible; reducing Establish existence of an outbreak.No Control and preventive measures.Contact precautions, no contact tracing.

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

22 Case Study 2 – cont.

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? 23 So, what was the outcome?

Causes of rash illness in elderly Shingles Scabies Contact Dermatitis Staph. aureus 24

25 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…

 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

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30  You review the (complete) linelist and saw that the list is growing steadily. It is Friday! What else needs to be done?

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 Develop hypothesis.  Implement control and preventive measures  Reconcile information – epi, lab, environmental  Maintain surveillance  Communicate Findings 32

33 Source: SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility, 2008 Respiratory Influenza Tuberculosis S. pneumoniae Chlamydia pneumoniae Legionella spp. Gastrointestinal Viral gastroenteritis (norovirus, etc.) Clostridium difficile Salmonellosis E. coli 0157:H7 colitis Other Infections Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-resistant Enterococcus (VRE) Group A Streptococcus Scabies Conjunctivitis

 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

35 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

36 Questions?