1. Hospital Outbreaks Allison McGeer Mount Sinai Hospital 416-586-3118 amcgeer@mtsinai.on.ca

2. Outbreaks Anything out of the ordinary An increase in the occurrence of a complication or disease above the background rate A statistically significant increase in the incidence of an infection

3. Why are hospitals a problem? PATHOGENS –They concentrate virulent pathogens ACCESS –By hands on care, they allow transmission of these pathogens –By devices & parenteral therapy, they permit access HOSTS –They admit susceptible hosts (elderly, immunocompromised) –They make them more susceptible (chemotherapy, surgery)

4. Hospital Outbreaks 1 in 8 patients in Canadian hospitals acquire an infection as a result of their hospital stay –5-10% of these are part of outbreaks Rate: 1/10,000 admissions (Wenzel, 1981) 1/12,000 admissions (Haley, 1985) at least an equal number of “clusters”

5. Outbreaks to be prepared for: MRSA/VRE; S. aureus (nurseries); S. pneumoniae; GAS P. aeruginosa, Serratia, Salmonella; resistant gram negs (ICU) Legionella, Mycobacteria, C. difficile Scabies Candida, Aspergillus Influenza, Hepatitis A/B/C, SREV, Adeno

6. Outbreaks to be prepared for: MRSA/VRE; S. aureus (nurseries); S. pneumoniae; GAS P. aeruginosa, Serratia, Salmonella; resistant gram negs (ICU) Legionella, Mycobacteria, C. difficile Scabies Candida, Aspergillus Influenza, Hepatitis A/B/C, SREV, Adeno PEOPLE ARE THE RESERVOIR TRANSMISSION FROM PERSON TO PERSON IS THE PROBLEM

7. “Other” hospital outbreaks E. coli O157:H7 in a salad served to patients, and in cafeteria Legionella pneumophila in water supply Pseudomonas aeruginosa from water/sinks Ralstonia picketii from contaminated normal saline Aspergillus fumigatus from an air conditioner Serratia marcescens blood infections from propofol Candida spp. from vacuum seals in equipment for preparation of TPN

8. Hospital vs. Community Outbreaks Reservoir/propagation –Reservoir is people (usually patients) –Propagation is person to person We provide medical care to patients, as well as outbreak management –Easier to get medical/laboratory information –Differences between goals more evident

9. Preparing for outbreaks - Prevention Physical structure Private rooms Adequate space – between patients, for cleaning Adequate ventilation Enough handwashing sinks, well-placed Design in purchased equipment Glucometers Needleless IV systems Monitors for negative pressure rooms Machines for cleaning/disinfecting endoscopes/ endoscopes themselves Cleaning/disinfection/sterilization Adequate policies Adherence to policies

10. Preparing for outbreaks - Prevention Handwashing –Accessibility –Programs for compliance Education –Aseptic technique –Handwashing –Isolation precautions –Surveillance/reporting

11. Preparing for outbreaks Detection –surveillance, awareness –culture, lab processing protocols –thresholds, time frames Preservation of samples/isolates (typing)

12. Preparing for outbreaks Lines of communication –awareness among administrative staff –media relations Funding –microbiology lab services Policies for outbreak management

13. Goals of outbreak investigation/management

14. Outbreak types Cause unknown Control uncertain Disease severe/many cases Something to learn Cause is known Exposure/transmission known Control measures effective Small number/non-severe cases “Nothing to learn” ManagementInvestigation

15. Outbreak investigation Verify diagnosis Confirm the outbreak Develop a case definition Obtain descriptive epidemiology Develop a hypothesis Test the hypothesis Refine hypothesis/additional studies Implement control and prevention measures Communicate findings

16. Hospital outbreak investigation Verify diagnosis Confirm outbreak Perform literature review/call experts Develop a case definition Obtain descriptive epidemiology Open lines of communication Implement control measures Consider definitive investigation

17. Initial Investigation 1Verify diagnosis 2Confirm the existence of a problem -confirm the diagnosis -review existing data (surveillance records, interviews, microbiology records, charts) 3Perform a literature review/ call experts -reservoirs, mode of transmission -things that went wrong

18. Initial Investigation 4Develop a case definition -microbiology -other lab, radiology -clinical signs/symptoms -other (e.g. skin testing for TB) -set time/place parameters 5Identify, count, describe cases -line listing -time/place person -describe nature and severity -plot epidemic curve

19. Initial Investigation 6Open lines of communication -consider media strategy -ensure all isolates/potential isolates are saved 7 Implement control measures -enforce existing measures -supplement

20. Initial Investigation 8 Consider definitive investigation -formulate hypotheses -case control/cohort studies -cluster analysis

21. Problem #1 3 candidemias on 14th level at MSH in one month 14th level is gi medicine/general surgery –68 beds –large oncology/IBD population –25 pts per month on TPN

22. Problem #2

23. Invasive GAS disease, LTCFs

24. Other presentations/articles http://www.idready.org/slides/03outbreak- slides.pdfhttp://www.idready.org/slides/03outbreak- slides.pdf http://www.dsf.health.state.pa.us/health/lib/ health/Outbreak_Investigation.ppthttp://www.dsf.health.state.pa.us/health/lib/ health/Outbreak_Investigation.ppt http://www.wvdhhr.org/idep/PPTs/Outbreak Investigation.ppt http://www.cdc.gov/ncidod/eid/vol4no1/rei ngold.htm