There and Back Again: Relearning Infection Control

1. There and Back Again: Relearning Infection Control Matthew J. Arduino, M.S., Dr.P.H. Division of Healthcare Quality Promotion National Center for Preparedness, Detection and Control of Infectious Diseases Coordinating Center for Infectious Diseases The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention

2. Outline • Introduction • Bloodborne Pathogens • Hepatitis B • Hepatitis C • Hepatitis D • Human Immunodeficiency Virus (HIV) • Tuberculosis • Drug Resistant Microorganisms (MRSA, VRE, VISA, VRSA) • Dialysis Unit Precautions

3. Background • October 20, 1972 Richard Nixon signed the Social Security Amendments of 1972; Extended Medicare coverage to patients with chronic renal failure. • July 1973 patients became eligible for Medicare. • Conditions of Coverage, first established in 1976 • AAMI End Stage Renal Disease and Detoxification Committee formed in 1981

4. Hemodialysis Numbers, 1982-2002 Number of Dialysis Facilities Number of patients

5. So where are we today as related to infection control? • Infection Control added to conditions for coverage • Incident transmission of hepatitis C and B (anti-HCV screening is not recognized by CMS as an infection control issue) • Dialysis patients are sentinel population for antimicrobial resistance • Prevalence of MRSA and VRE is unknown • Dialysis patients have an extremely high incidence of invasive MRSA, more than 100-fold greater than the general U.S. population.

6. Breaks in Infection Control • Not cleaning blood spills or splatters; including prime buckets on side of machine • Not cleaning or disinfecting commonly touched environmental surfaces between patients (e.g. machine, chair or station) • Sharing equipment and supplies that were not disinfected; shared multidose vials placed on the top of the machines • Sharing a common medication cart

7. Bacterial/Fungal Infections • Vascular access related • Contaminated machines • Reuse related • Contaminated IV medications

8. Contaminated Machines:Waste Handling Option • Several outbreaks since 1995 (U.S., Canada, and Israel) • Enterobacter cloacae, Pseudomonas aeruginosa, Escherichia coli, Candida parapsilosis • Recent cluster in Chicago Phialemonium curvatum (two patients sequentially on the same machine became fungemic, WHO port was removed prior to the investigation); Phialemonium was isolated in the water feeding the machine

9. Reuse Related Bacteremia/Fungemia • Organisms: Burkholderia cepacia complex, Ralstonia pickettii, Ralstonia mannitolytica, Stenotrophomonas maltophilia, Candida parapsilosis • Today most reuse related infections are associated with header removal “Header-sepsis” • In the past, most were associated with either poor water quality, or manual reuse

10. Drug Resistance an Emerging Infectious Disease Emergency • Resistance to antibiotics is becoming an increasing problem in healthcare delivery systems • Organisms with major public health importance include: • Methicillin resistant Staphylococcus aureus (MRSA) • Multiply Drug Resistant Mycobacterium tuberculosis • Penicillin resistant Streptococcus pneumoniae • Vancomycin Resistant Enterococci (VRE) • Vancomycin Resistant Staphylococcus aureus (VISA)

11. Vancomycin Intermediate-Resistant S. aureus (VISA) State, YearSitePD/HD* Michigan, 1997 Peritonitis Chronic PD New Jersey, 1997 Blood Recent PD New York, 1998 Blood Chronic HD Illinois, 1999 Endocarditis Chronic HD Minnesota, 2000 Bone Chronic HD Nevada, 2000 Liver ----- Maryland Blood ----- PD=peritoneal dialysis HD=hemodialysis Fridkin Clin Infect Diseases 2001

12. First Case of Vancomycin - Resistant S. aureus (VRSA) • First fully vancomycin resistant clinical isolate of S. aureus • Michigan, June 2002 • 40-year old black female with diabetes mellitus, peripheral vascular disease,on chronic hemodialysis • VRSA from foot ulcer and catheter exit site • During the 6 months preceding VRSA: • patient experienced 6 hospitalizations, totaling 18 days • patient received multiple antimicrobial therapy, including • 5.5 weeks of vancomycin Chang S et al, New England J of Med 2003; 348:14,1342-3447

13. Vancomycin Resistant S. aureus • 9 cases of VRSA since 2002 (7 in Michigan, 1 PA, 1 NY) • Two were dialysis dependent (Including index case) • Most patients diabetics • Infected wounds • MIC vancomycin > 16µg/mL • Acquisition of VanA gene: many cases shown to have a VRE donor and MRSA recipient ZhuW, et al. Vancomycin-Resistant Staphylococcus aureus Isolates Associated with Inc18-Like vanA Plasmids in Michigan. Antimicrob Agents Chemother 2008;52(2):452-7.

14. Resurgence of HBV outbreaks in the mid 1990s • Failure to review lab results; HBsAg+ patients treated with susceptible patients • Failure to isolate HBsAg+ patients • Sharing of staff, equipment, medications, and supplies among patients • Failure to vaccinate susceptible patients against hepatitis B

15. CDC. Hepatitis-Control measures For hepatitis B in dialysis centers. Viral hepatitis and Control Series, November 1977. HEW Publ No (CDC) 78-8358

16. What we have learned from our annual surveillance • In 2002, the incidence of HBV infection was higher among patients in centers where injectable medications were prepared on a medication cart or medication area located in the treatment area compared to a dedicated medication room. • Centers that used a disposable container versus a nondisposable container for priming the dialyzer had a significantly lower incidence of HCV.

17. Blood Contaminating a PressureTransducer Filter

18. Have we forgotten the basics?

20. Bloodborne Pathogens • Hepatitis B, C, and D Viruses • Human Immunodeficiency Virus (HIV/AIDS) HBV HCV HIV

21. Estimates of Acute and Chronic DiseaseBurden for Viral Hepatitis, United States HAV HBV HCV HDV Acute infections (x 1000)/year* 125-200 140-320 35-180 6-13 Fulminant deaths/year 100 150 ? 35 Chronic 0 1-1.25 3.5 infections million million 70,000 Chronic liver disease deaths/year 0 5,000 8-10,000 1,000 * Range based on estimated annual incidence, 1984-1994.

22. Relative Infectivity of HBV, HCV, and HIV *Can persist on environmental surfaces for at least 7 days ** Can persist for 24 hrs (CDC unpublished data)

23. Hepatitis B HBV is a vaccine preventable Disease

24. Outbreaks of HBV in the Hemodialysis • Blood leaks • Transducer protectors • cross-contamination of environmental surfaces, supplies, medications, or equipment • simultaneous provision of care to both HBV-infected and susceptible patients by the same staff members • multiple dose medication vials

25. Extra Precautions for HBV • Can remain infectious on surfaces for at > 7 days • high titer of HBV • Blood can be diluted to below visible levels and still contain enough infectious particles that indirect transmission can still occur • 3.3% of centers reported >1 patients with newly acquired (incident) HBV infection • 24.1% of centers reported >1 patients with chronic (prevalent) HBV infection • 25.5% of centers reported >1 patients with either acute or chronic HBV infection.

26. Hepatitis B by Year, United States, 1966 - 2000 HBsAg screening of pregnant women recommended Infant Immunization recommended Vaccine licensed 1977 CDC Recs for Dialysis OSHA Rule enacted Adolescent Immunization recommended Decline among injecting drug users Decline among MSM & HCWs Source: NNDSS

27. Incidence and Prevalence of Hepatitis B in the United States, 1976-2002 1977 CDC Recommendations 2001 CDC Recommendations Vaccine

28. Incidence of HBsAg in Hemodialysis Patients, by use of Hepatitis B Vaccine, 1996 P<0.05 compared with reference group

29. Hepatitis C Virus • Most efficiently transmitted by direct percutaneous exposure to infectious blood • Risk factors: history of blood transfusions, volume of blood transfused, and years on dialysis (≥5 years) • No significant differences in HCV incidence or prevalence in centers that reused dialyzers compared to those who did not reuse dialyzers • Decline in prevalence may be attributable in part to a decline in new infections among patients as a result of increased awareness of the potential for HCV transmission in this setting.

30. Hemophilia Injecting drug users Hemodialysis STD clients Gen population adults Surgeons, other HCWs Pregnant women Military personnel HCV Prevalence by Selected Groups United States Average Percent Anti-HCV Positive

31. Hepatitis C Virus • Flavivirus (single stranded RNA, enveloped virus) • Multiple HCV genotypes; in addition within genotypes there are closely related genotypes or quasi species • Antibody elicited by infection with one genotype fails to cross-neutralize virus of another genotype. • Prior infection does not produce immunity

32. Estimated Incidence of Acute Hepatitis C United States, 1982-2000 Surrogate testing of blood donors 20 Anti-HCV test (1st generation) licensed 18 16 14 12 Anti-HCV test (2ndgeneration) licensed Cases per 100,000 10 8 6 Decline among injection drug users 4 Decline among transfusion recipients 2 0 83 87 91 93 84 89 92 94 95 96 99 82 85 86 88 90 97 98 2000 Source: Sentinel Counties

33. Nosocomial Hepatitis C TransmissionHemodialysis Units • Prevalence increases with increasing years on dialysis • Annual incidence is only 1-2% • Transmission probably results from poor infection control practices • Prevalence in patients is approximately 10% • Prevalence in Staff members is 2%

34. Tuberculosis

35. ESRD Patients With Active Tuberculosis

36. Tuberculin Skin Testing of ESRD Patients • ESRD Patients are at increased risk for developing TB- A survey in New Jersey (1994) • 7.9% of all U.S. dialysis patients treated at least one patient with known active TB (CDC-1995 Survey) • Individual dialysis centers treating a high proportion of minority and foreign born patients, have reported higher incidences of TB

37. Guidelines for Skin Testing • Test groups with either: • high rate of TB (substance abusers; residents of correctional facilities, nursing homes, and other congregate settings; medically under served populations; high risk racial or ethnic/minority populations; children exposed to high risk categories) • medical risk factors that increase risk of disease progression

38. Tuberculin Skin Testing in Hemodialysis Patients • All patients with ESRD should receive at least one tuberculin test to identify latent infection. • If exposure to persons with active TB is likely, periodic rescreening is indicated • ESRD patients who are contacts of a person with infectious TB should be retested • A recent study of anergy in patients uninfected patients found only 18% of ESRD patients to be anergic

39. General Recommendations for Tuberculosis in the Hemodialysis Setting • CDC. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 2005. MMWR 2005;54 (No. RR-17). http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf • Patients with ESRD who need chronic dialysis should have at least one test for M. tuberculosis infection to determine the need for treatment of LTBI • Annual re-screening is indicated if ongoing exposure of ESRD patients to M. tuberculosis is probable. • Easier to treat patients with active pulmonary tuberculosis in an acute setting where TB isolation rooms, appropriate engineering controls, and respiratory protection programs are available • Patients can be admitted back to the unit when on appropriate therapy and are considered non-infectious.

40. Tuberculosis • All patients with compromised immunity should be tested at least once for latent TB infection. • Consider skin testing as part of patient intake process • Staff should be tested at time of hire • For patients who test positive a refer for medical follow up and treatment plan development • Patients and staff with latent TB should be offered prophylaxis and monitored regularly for signs of active infection • Patients with active pulmonary disease should be treated in the acute setting in an airborne isolation room until considered noninfectious Haddad MB, Arduino MJ. Is tuberculosis a serious health risk for hemodialysis patients? Nephrology Incite 2004;17:21-23

41. Infection Control Practices

42. CDC. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50 (RR5):1- 43 http://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf

45. Interpretation of serologic test results for hepatitis B virus infection

46. Patients Who Might Be At Increased Risk For Transmitting Pathogenic Bacteria Uncontained wound drainage, fecal incontinence or diarrhea uncontrolled with personal hygiene measures. a) staff members treating the patient should wear a separate gown over their usual clothing and remove the gown when finished caring for the patient and b) dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the unit).

47. Safe Injection Practices • Use aseptic technique to avoid contamination of sterile injection equipment. Category IA • Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient. Category IA • Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set. Category IB • Use single-dose vials for parenteral medications whenever possible. Category IA • Do not administer medications from single-dose vials or ampoules to multiple patients or combine leftover contents for later use. Category IA • If multidose vials must be used, both the needle or cannula and • syringe used to access the multidose vial must be sterile. Category IA • Do not keep multidose vials in the immediate patient treatment area • and store in accordance with the manufacturer’s recommendations; • discard if sterility is compromised or questionable. Category IA • Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients. Category 1B

48. CDC Guidelines and Recommendations and the New Conditions of Coverage • CDC. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50 (RR5):1- 43 http://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf • Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 http://www.cdc.gov/ncidod/dhqp/gl_isolation.html • Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002 http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html • Guideline for Hand Hygiene in Healthcare Settings – 2002 http://www.cdc.gov/ncidod/dhqp/gl_handhygiene.html

49. There and Back Again