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Public Health: Whatcom County

Public Health: Whatcom County. Infectious Disease Update Protecting the Protectors Emergency Response. Presented by Joni Hensley, R.N, BSN Whatcom County Health Dept March 31, 2005. Infectious Disease Update. Organism that is transmissible Method of transmission Susceptible host.

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Public Health: Whatcom County

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  1. Public Health: Whatcom County • Infectious Disease Update • Protecting the Protectors • Emergency Response Presented by Joni Hensley, R.N, BSN Whatcom County Health Dept March 31, 2005

  2. Infectious Disease Update • Organism that is transmissible • Method of transmission • Susceptible host

  3. Diseases Du Jour • Enteric diseases transmitted by fecal/oral route • Respiratory diseases transmitted through respiratory droplets or airborne particles • Organisms can include • Viruses • Bacteria • Mycoplasms • Fungii • Ameboas • Others

  4. Enteric Diseases • Bacteria • E.coli • Viruses • Noro-like viruses

  5. Enteric Infectious Diseases in Whatcom County • “The most common” enteric diseases : e.coli 0157:H7 campylobacter salmonella norovirus Rate= # cases/100,000 population

  6. Ecoli 0157:H7 • Not the same bacteria that normally inhabits the human gut. (It is found in cattle & other domestic animals) • A certain species of e.coli that can form a cytotoxin (Shiga toxin 1 & 2) • Hemolytic Uremic Syndrome (HUS) • Thrombcytopenic purpura (TPP) It is very dangerous for young children

  7. E.coli 0157:H7 cont • Cytotoxins: cell killers • The structural genes for the toxins are found on chromosomally encoded bacteriophages • Chromosomal pathogenicity island containing multiple virulence genes • These encoding proteins cause attaching & effacing lesions

  8. Bacteriophage • Virus that has a specific affinity for and infects bacteria • Protein coat (capsid) enclosing genetic material, DNA or RNA • Injected into the bacterium

  9. Evolving Bacteria • Bacteriophages • Genetic mutations • Inheriting resistance genes from forerunners • Sharing resistance genes with other bacteria (plasmids)

  10. Enteric Disease (cont) Norovirus Or Norwalk-type viruses • Vomiting & diarrheal disease (stomach flu) highly contagious (cruise ship fame) (vomitus, stool & fomites) • Resistant to some disinfectants* Not a reportable disease condition in WA State but 10 outbreaks occurred in Nov/Dec last year

  11. The Evolution (hypothetical) • Norovirus has resistance to quaternary ammonia disinfectants • E.coli 0157: H7 is currently susceptible to quaternary disinfection • Genes are shared between norovirus and e.coli and now the quaternary products don’t work

  12. Environmental Sanitizers • Gluteraldehyde*** • Hydrogen peroxide*** • Peracetic Acid*** • Bleach (chlorine)** • Iodine** • Phenols** • Quaternary Ammonia* Pro's & Con's EPA-registered hospital disinfectants ***High-level use; **Intermediate-level use; *Low-level use

  13. Kills organisms so they cannot spread disease Keeps environment clean and appealing Inadequate sanitizing can lead to stronger germs Mutations can occur with too frequent use What about the “Germ Theory” Pro's & Con's

  14. Recommendations for Enteric Exposures • Handle vomitus & feces with great caution • Use gloves & mask • Use goggles (maybe, if patient is vomiting) • Disinfect your equipment • Discard contaminated clothing • WASH YOUR HANDS ( use alcohol-based hand sanitizers) Be Careful Out There!

  15. Handwashing Public Health Message #1: Wash your hands Wash your hands Wash your hands

  16. Alcohol-Based Hand Sanitizers • 1995: HICPAC: • “recommends use of antimicrobial soap or waterless antiseptic agent for cleaning hands upon leaving rooms of patients with MRSA or VRSA” HICPAC: Healthcare Infection Control Practices Advisory Committee

  17. Alcohol-Based Hand Sanitizers • 2002: CDC: “If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in clinical situations: CDC: MMWR Recommendations & Reports Oct 25, 20002

  18. When to “decontaminate hands” • Before direct contact with patient • After contact with patients’ intact skin • After contact with body fluids, excretions, mucous membranes, non-intact skin, wound dressings • After contact with inanimate objects in immediate vicinity of patient • After removing gloves 2002 CDC recommendations

  19. Caution! • Alcohol-based hand rubs have a flash point range from • 21 – 24 degrees C • Or 69.8 – 75.2 degrees F • So, store away from high heat or flames

  20. Skin Infections • Can be caused by bacteria • Staph (MRSA, VRSA) • Strep (Gr. A, Gr B) • Can be caused by viruses • Chickenpox • Can be caused by fungi • Athletes foot

  21. MRSA & VRSA • Remember that Norovirus infections are not reportable • MRSA is also not a reportable condition in WA State Notifiable Conditions & The Health Care Provider The following diagnoses are notifiable to local health authorities in Washington in accordance with WAC 246-101. Timeframes for notification are indicated in footnotes. Immediately notifiable conditions are indicated in bold and should be reported when suspected or confirmed ______________________________________________________________ Animal Bites HIV infectino Arboviral disease Immunization reactions Botulism Legionellosis Brucellosis Leptosporosis Chamylobacterosis Listeriosis Chncroid Lyme disease Chlamydia trachomatis Lymphogranuloma Colera Malaria Cryptosporidiosis Measles Cyclosporosis Meningococcal disease Dipththeria Mumps Disease of suspected bioterrorism origin Paralytic shellfish poisoning Anthrax Pertussis Smallpox Plague Disease of suspected foodborne origin Poliomyelitis Methicillin Resistant Staph Aureus & Vancomycin Resistant Staph Aureus

  22. Notifiable Conditions (WA State) • Reporters Include: • Health Care Providers • Laboratories • Hospitals • Some diseases are immediately notifiable such as botulism, brucellosis, pertussis, Hepatitis A There have been some recent changes to the posters including reporting Arboviral diseases such as West Nile virus

  23. What Is MRSA? Why Is It Important? • MRSA is a type of staphlococcus aureus bacteria • It has mutated so that it is resistant to the b-lactam antibiotics (penicillins,methicillin, oxacillin, nafcillin) & cephalosporins. • It is one of the most common nosocomial infections.

  24. Campaign to PreventAntimicrobial Resistance Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare Quality Promotion Clinicians hold the solution! • Link to: Campaign to Prevent Antimicrobial Resistance Online • Link to:Federal Action Plan to Combat Antimicrobial Resistance

  25. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Antimicrobial Resistance among Pathogens Causing Hospital-Onset Infections Vancomycin-resistant enterococci Non-Intensive Care Unit Patients Intensive Care Unit Patients Source: National Nosocomial Infections Surveillance (NNIS) System • Link to:NNIS Online at CDC

  26. Resistant Bacteria Mutations XX Resistance Gene Transfer New Resistant Bacteria Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Emergence of Antimicrobial Resistance Susceptible Bacteria

  27. Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Resistant StrainsRare Antimicrobial Exposure Resistant Strains Dominant x x x x x x x x x x x x Selection for antimicrobial-resistant Strains

  28. Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Antimicrobial-ResistantPathogen Prevent Infection PreventTransmission Infection Antimicrobial Resistance Effective Diagnosis & Treatment Optimize Use Antimicrobial Use Antimicrobial Resistance:Key Prevention Strategies Susceptible Pathogen Pathogen

  29. 1. Vaccinate 2. Get the catheters out 3. Target the pathogen 4. Access the experts 5. Practice antimicrobial control 6. Use local data 7. Treat infection, not contamination 8. Treat infection, not colonization 9. Know when to say “no” to vanco 10. Stop treatment when infection is cured or unlikely 11. Isolate the pathogen 12. Break the chain of contagion 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Use Antimicrobials Wisely Prevent Infection Diagnose and Treat Infection Effectively Prevent Transmission

  30. Manifestations of Illness • Impetigo • Generalized infection • Sepsis • Toxic Shock Syndrome

  31. Impetigo • Bacterial skin infection • Red • Erythematous • Pustular • Regional, not disseminated • Oozing • Patient generally well

  32. MRSA terminology & stats • CA-MRSA: Community-acquired MRSA • HA-MRSA: Hospital-acquired MRSA • Incidence of MRSA has increased in WA State from • 12% in 1999 • 30% in 2003 • (Whatcom County as of Nov 04 had 40% of S.aureus isolates that were + for MRSA) (MRSA is not reportable in the State.)

  33. HA= hospital acquired Recent (within 1 yr) hospitalization, procedure or residency in healthcare setting Victims usually have weakened immune systems Usually manifests as wound, bloodstream infections or pneumonia CA= community acquired Not recently hospitalized or residing in healthcare setting No recent medical procedure (dialysis, surgery,etc) Victims usually healthy Usually manifests as skin infection HA vs CA MRSA

  34. HA vs CA MRSA • Outbreaks of MRSA in community • Have occurred in athletic settings, military establishments, other close quarters • At least 3 different strains id • Some are exhibiting “unique properties” • Some suggestion that biologic properties (virulence factors) may be helping spread

  35. Factors associated with transmission of MRSA • Close skin to skin contact • Openings in the skin such as cuts or abrasions • Contaminated items and surfaces • Crowded living conditions • Poor hygiene

  36. Recommendations for MRSA Exposures • Handle skin lesions with caution • Use gloves • Cover any skin breaks that you might have • Disinfect your equipment • Discard contaminated clothing • WASH YOUR HANDS (use alcohol-based hand sanitizers) Be Careful Out There!

  37. Recommendations for Sanitizing to Prevent MRSA transmission • Clean non-critical medical equipment surfaces with EPA-registered detergent/disinfectant • Do not use alcohol to disinfect large environmental surfaces (it is flammable) • Use barrier-protective coverings for difficult to clean surfaces, areas likely to become contaminated with blood or body substances “Good” bactericidal properties listed for chlorine,iodine, chlorhexidine, 70% alcohol, oxidizing agents, phenol, quaternary ammonium.

  38. Bloodborne Pathogens • Hepatitis B (HBV) • Hepatitis C (HCV) • HIV (AIDS) Organism capable of being transmitted in “blood, body fluids containing visible blood, semen and vaginal secretions.” CDC: June 29, 2001 MMWR RR 50

  39. Other potentially infectious fluids • CSF • Synovial fluid • Pleural fluid • Peritoneal fluid • Pericardial fluid • Amniotic fluid “Risk for transmission of HBV, HCV, HIV infection from these fluids is unknown” CDC 2001

  40. Relative Risk of Getting BBP from needlestick • Hepatitis B 1/3 • Hepatitis C 1/30 • HIV 1/300 Re: There is a vaccine to prevent Hepatitis B

  41. Hepatitis B Virus Anatomy Hepatitis Virus

  42. Viral Hepatitis - An Overview Some Consequences of Hepatitis Infections Type of Hepatitis AB C D E 80% Chronic None 10% adult 80% newborn Yes None infection Significant with existing liver disease 30 % develop liver disease > 60 % of liver cancer cases Risk to PG women Morbidity Prevention blood donor screening Ensure safe food & drinking water Pre/post - exposure immunization pre/post- Exposure Immunization pre/post- Exposure B immunization Ensure safe food & drinking water [--------- risk behavior modification ---------]

  43. Hep B Rates

  44. Rates of AIDS, Hep B in Whatcom County 1999 - 2003

  45. AIDS & HIV Cases ReportedWhatcom County Cumulative 1983-2002 9/99 * * HIV reportable WA St since 9/1999 Whatcom Co. Health Dept

  46. Bloodborne Pathogen Prevention • “Occupational exposures should be considered urgent medical concerns”** • Universal precautions • Use proven products for barrier-protection and clean-up **CDC: Updated U.S Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Post Exposure Prophylaxis : MMWR June 29, 2001

  47. BBP Exposure Notes • HBV survived in dried blood at room temperature for at least 1 wk. • Recommendations: • Pre-exposure vaccination • Standard precautions • HBIG within 1 wk of percutaneous exposure (75% protection)

  48. BBP Exposure Notes • HCV survival in environment is uncertain. • HCV is not transmitted efficiently through occupational exposures to blood* • Recommendation: • Perform baseline test for anti-HCV • Follow-up testing 4 – 6 months post-exposure

  49. BBP Exposure Notes • HIV survival in environment is uncertain but probably very low. • HIV transmission • related to percutaneous exposure = .3% • Related to mucous membrane exposure = .09% • Recommendation: • Perform baseline test for HIV • Refer immediately for evaluation and to consider PEP within 36 hours of exposure if possible. • Make sure of follow-up for care

  50. Summary for BBP • Have protocol in place • Review with staff • Stress importance of • Hep B vaccination • Tetanus vaccination • Cleaning wounds • Immediate reporting • Adequate follow-up • Cleaning of contaminated equipment

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