1. Methods of Epidemiological investigation

2. Epidemiology is the scientific process applied to the control of infections in the healthcare setting.

3. Origin of the term ‘epidemiology’ epi - ‘on, upon, at, by, near, over, on top of, against, among’ demos - ‘common people or citizenry’ ology - ‘the study of’ epidemiology =‘Study of disease among the population’

4. Epidemiology is about Populations Groups of people not individuals It answers population questions –aetiology of disease –prevention of disease –Extent/distribution of disease (allocation of effort & resources in health facilities and communities)

5. Epidemiology and Clinical Medicine Relationship between Studies/Assessments Prevention Evaluation Planning Diagnosis Treatment Cure Care

6. Examples of Epidemiological Studies Link between smoking and lung cancer Doll & Hill, 1964

7. Examples of Epidemiological Studies Water fluoridation: Communities that had low natural water fluoride levels had high levels of dental caries Communities that had high natural water fluoride levels had low levels of dental caries

9. Uses of Epidemiology(Gordis, 2000) Identifies aetiology or causes of disease including the risk factors for the disease. Determine the extent of the disease in the community Examines natural history of disease and prognosis of disease Investigates and controls disease outbreaks

10. Uses of Epidemiology(Gordis, 2000) Describes and monitors the population health and the patterns of disease Evaluates new preventive and therapeutic interventions and modes of health care delivery Provides information to inform public policy decisions

11. Key components of epidemiological studies Study Population/ Sample Exposure to a study factor Outcome Unexposed Exposed Target Population

12. Key components of epidemiological studies Target population is the population a researcher wants to make generalizations about Study population is the group a researcher wishes to study (sometimes the same as the target population) Study sample is a group of subjects chosen for study to represent the study population

13. Key components of epidemiological studies Study factor –is a element that is being investigated to see if it is a determinant of a particular health problem –or if it reduces the impact of a particular health problem. –Study factors can include risk factors for a health problem, interventions (therapeutic or preventative) to ameliorate a health condition, diagnostic tests or techniques and environmental exposures.

14. Exposure is contact with or possessing a particular study factor Exposed group is a group whose members have had contact with or possess a study factor

15. Key components of epidemiological studies Unexposed group is a group that has not had contact with a cause of, or possess a characteristic that is a determinant of, a particular health problem. Outcome is any or all of the possible results that may stem from an exposure or study factor.

16. How is Hospital Epidemiology different from Healthcare Epidemiology? Healthcare Epidemiology extends the practice into the outpatient areas.

17. History of infection control and hospital epidemiology in the USA Pre 1800: Early efforts at wound prophylaxis 1800-1940: Nightingale, Semmelweis, Lister, Pasteur 1940-1960: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus 1960-1970’s: Documenting need for infection control programs, surveillance begins 1980’s: focus on patient care practices, intensive care units, resistant organisms, HIV 1990’s: Hospital Epidemiology = Infection control, quality improvement and economics 2000’s: ??Healthcare system epidemiology modified from McGowan, SHEA/CDC/AHA training course

18. Why do we need infection control?? Hospitals and clinics are complex institutions where patients go to have their health problems diagnosed and treated But, hospitals, clinics, and medical/surgical interventions introduce risks that may harm a patient’s health

19. Additional morbidity Prolonged hospitalization Long-term physical, developmental and neurological sequelae Increased cost of hospitalization Death Consequences of Nosocomial Infections

20. What is healthcare epidemiology? The fundamental roles of healthcare epidemiology are to: –Identify risks –Understand risks –Eliminate or minimize risks

21. What is the role of healthcare epidemiology? Identify risks to patient’s health Find nosocomial infections –surveillance Identify and study risk factors for nosocomial infections –understand epidemiologic principles and methods –understand nosocomial pathogens –what is it about healthcare institutions that increases risk?

22. What is the role of healthcare epidemiology? Eliminate or minimize risks to a patient’s health organize care to minimize risk –eliminate risk factors –work around risk factors –develop improved policies and procedures educate physicians and nurses regarding risks study risk factors to learn more about them and how to eliminate them

23. Responsibilities of the Infection Control Program Surveillance of nosocomial infections Outbreak investigation Develop written policies for isolation of patients Develop written policies to reduce risk from patient care practices Cooperation with occupational health Education of hospital staff on infection control Ongoing review of all aseptic, isolation and sanitation techniques Eliminate wasteful or unnecessary practices

24. Areas of interest to a healthcare epidemiologist Surveillance for nosocomial infection Patterns of transmission of nosocomial infections Outbreak investigation Isolation precautions Evaluation of exposures Employee health Disinfection and sterilization Hospital engineering and environment –water supply –air filtration Reviewing policies and procedures for patient care

25. Organizing for Infection Control Requires cooperation, understanding and support of hospital administration and medical/surgical/nursing leadership There is no simple formula: –Every facility is different –Every facility’s problems are different –Every facility’s personnel are different The facility must develop its own unique program

26. Organizing for Infection Control Main elements –Establish policies and regulations to reduce risks Develop with clinicians (physicians and nurses) –Develop and maintain a program of continuing education for hospital personnel –Use scientific (epidemiologic) methods to study problems and test hypotheses

27. Disease Transmission Leave original host Survive in transit Be delivered to a susceptible host Reach a susceptible part of the host Escape host defenses Multiply and cause tissue damage To cause disease, a pathogenic organism must: Disease

28. Routes of Transmission Contact: Infections spread by direct or indirect contact with patients or the patient-care environment (e.g., shigellosis, MRSA, C. difficile) Droplet: Infections spread by large droplets generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis, pertussis, influenza) Airborne (droplet nuclei): Infections spread by particles that remain infectious while suspended in the air (TB, measles, varicella, variola)

30. Precautions to Prevent Transmission of Infectious Agents Standard Precautions Apply to ALL patients Transmission-based Precautions Used in addition to Standard Precautions Contact Droplet Airborne http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf

31. Standard Precautions Hand hygiene Respiratory hygiene and cough etiquette Personal protective equipment (PPE) Based on risk assessment to avoid contact with blood, body fluids, excretions, secretions Safe injection practices Environmental control Patient placement

33. PPE for Standard Precautions Gloves – when touching blood, body fluids, secretions, excretions, mucous membranes, non- intact skin, contaminated items Gowns – during procedures or patient-care activities when anticipating contact with blood, body fluids, secretions, excretions Mask, eye protection (goggles or face shield) – during procedures or patient care activities likely to generate splashes or sprays

34. Transmission-based Precautions

35. Contact Precautions Patient placement –Single room or cohort with patients with same infection –If neither is possible, ensure patients are separated by at least 3 ft (1 m) *Change PPE and perform hand hygiene between patient contacts regardless of whether one or both are on contact precautions

36. Contact Precautions Environmental measures/patient care equipment –Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces (bed rails, bedside tables, lavatory surfaces, blood pressure cuff, equipment surfaces). –Use dedicated equipment if possible (e.g., stethoscopes, bp cuffs) PPE  Gown and gloves  Don upon entry to room  Remove and discard before leaving the room  Perform hand hygiene after removal

37. Droplet Precautions Patient placement –Single room or cohort with patients with same infection –If neither is possible, ensure patients are separated by at least 3 ft (1 meter) –Surgical mask on patient when outside of patient room –Negative pressure or airborne isolation rooms not required PPE surgical mask Don upon entry into room Eye protection (goggles or face shield) if needed according to standard precautions

38. Airborne Isolation  Airborne infection isolation room (AIIR)*  Monitored negative air pressure in relation to corridor  6-12 air exchanges/hour  Air exhausted outside away from people or recirculated by HEPA filter  Surgical mask on patient when not in AIIR (limit movement)  PPE – filtering facepiece respirator  For all personnel inside negative pressure room * Natural ventilation alone or combined with mechanical ventilation may be a practical alternative in some settings. http://www.who.int/csr/resources/publications/AI_Inf_Control_Guide_10May2007.pdf

39. TYPES OF NOSOCOMIAL INFECTION BY SITE 1.Urinary tract infections (UTI) 2.Surgical wound infections (SWI) 3.Lower respiratory infections (LRI) 4.Blood stream infections (BSI)

40. EPIDEMIOLOGICAL INTERACTION Intrinsic host susceptibility Age, Poor nutritional status, Co morbidity, severity of underlying disease Agent factors varieties of organisms Institutional and human Reservoirs & their virulence Environmental factors hospital location, diagn procedures, immunosuppressive, chemotherapy, antibiotics, med & surgical devices, exposure to infected patients or health workers, asymptomatic carriers

41. MODES OF TRANSMISSION A) BY CONTACT 1) Direct - between Patients and between patient care personnel 2) Indirect - contaminated inanimate objects in environment (Endoscopes etc) 3) Droplet infections by large aerosols B)THRO COMMON VEHICE like Food, Blood & blood products, Diagnostic reagents, Medications C)AIRBORNE e.g. legionellosis, aspergillosis D)VECTORBORNE – by flies

42. Why surveillance? NCI cause of morbidity and mortality One third may be preventable Surveillance = key factor –an infection control measure –overview of the burden and distribution of NCI –allocate preventive resources Surveillance is cost-efficient!!

43. The surveillance loop Event Action Data Information Health care system Surveillance centre Reporting Feedback, recommendations Analysis, interpretation

44. Objectives Reducing infection rates Establishing endemic baseline rates Identifying outbreaks Identifying risk factors Persuading medical personnel Evaluate control measures Satisfying regulators Document quality of care Compare hospitals’ NCI rates

45. Who All hospitals? All departments? All specialties? Other health institutions?

46. Surveillance of one or more types of NCI Urinary tract infections Lower respiratory tract infections Surgical site infections Bloodstream infections Conjunctivitis Others…

47. Targeted surveillance Special patient population (surgical, medical, paediatric, intensive) Diagnostic and therapeutic procedures (endoscope, haemodialysis, catheterization, blood transfusion) Specific pathogens (staphylococcus aureus, MRSA, clostridium difficile, norovirus)

48. Variables Administrative data –Id, address, dates of admission, discharge.. Patient related factors: –Age, sex, severity of underlying disease Procedures –Surgery –Devices (e.g. catheters) Treatment, diagnosis –Use of antibiotics

49. When? During hospital stay? –Frequency of data collection After discharge? –When and how?

50. How? Two main surveillance methods –incidence –prevalence Variations within these methods

51. Methodological issues Definitions NCI –Cut off 48 or 72 hours? –Criterias from Centers for Disease Control and Prevention (hospital) –McGeer (long-term care facilities) Risk variables Case finding –Active or passive –By whom? –After discharge? –Prospective or retrospective?

52. SURVEILLANCE Important means of monitoring HAI Early detection of trends outbreaks 1. Laboratory Based Microbiology Laboratory lists +ve organisms ICN reviews ‘Alert organisms’ reported 2. Ward Based Ward staff monitor patients ICN reviews ICN visits wards