Understanding Skin Infections and Prevention in Alaska Native Communities

1. Skin Infection Knowledge, Attitudes, and Practices Among Alaska Native People — Three Rural Alaska Communities, 2012 Michael Bruce, MD, MPH Arctic Investigations Program 6th Annual Water and Sanitation Innovations for the Arctic February 5th 2016 National Center for Emerging and Zoonotic Infectious Diseases Division of Preparedness and Emerging Infections

2. Skin and Soft Tissue Infections • Boil: an infection under the skin that causes a painful, pus-filled lump • Furuncle: deep infection of the hair follicle • Carbuncle: a collection of furuncles

3. Staphylococcus aureus • Common cause of skin infection • Spread by direct contact • Colonizes skin and nasal sinuses • Antibiotic resistance, emerging public health concern • MRSA: Methicillin-resistantStaphylococcus aureus • MSSA: Methicillin-sensitiveStaphylococcus aureus

4. Investigation Links Steambaths to Boils • Numerous studies 1996-2000 on Boils • Risk factors for boils: • Traditional sauna or “Steambath” use • Crowded steambaths • Not sitting on a protective barrier • Household member with boil • Antimicrobial drug use within previous 12 months • MRSA colonized steambaths

5. Public Health Response at the time • Standardized treatment guidelines • Emphasized incision and drainage • Adjusted antibiotic regimens • Educational messages developed: • Disinfect steambathswith bleach after use • Use barriers while seated in steambaths • Limit crowding in steambaths • Avoid using steambathwith skin infections • Avoid sharing towels

6. ICD-9 Codes for Skin Infections — YK Health Corporation, January 2008 – May 2012

7. Knowledge, Attitudes and Practices (KAP) Survey (2012) • Epi-Aid called to assist Medical Director in Investigation of Reported Increase in Boils • Three communities included with highest rates: • Chefornak • Toksook Bay • Kwethluk • Three teams conducted interviews of persons aged ≥18 years to determine: • knowledge of boils and risks • attitudes to potential prevention strategies • current prevention practices

8. What did we learn?

9. Knowledge

10. Knowledge, Attitudes, and Practices Survey — Chefornak, Kwethluk, Toksook Bay, 2012 (N=492) • Have you ever had a boil? • Do you know anyone with a boil? • Are boils a big problem in your village? 84% • 95% • 64%

11. Existing Knowledge • Can a boil be cured? • By lancing • By bandage and ointment • By specific medications • Can a boil be prevented? • By washing clothing and bedding • By healthy eating • By steams • Can a boil be acquired? • By touching other people’s boils • By touching other people • By sharing clothing or towels • From insects 47% 26% 27% 90% 74% 59% 85% 47% 88% 61%

12. Attitudes

13. How Serious Is It To Get a Boil? “it can enter tissue … and it might go to the heart” “It is going to spread … usually 2 others will appear” “It can get in your blood and you can die, my cousin died from Staph in the blood”

14. How Serious Is It To Get a Boil? “it can enter tissue … and it might go to the heart” “It is going to spread … usually 2 others will appear” “It can get in your blood and you can die, my cousin died from Staph in the blood”

15. practices

16. How Often is Laundry Done? • Laundry is done more often when piped water is available (P <0.001)

17. Danby Water Recycling • Concerns about unsafe water conservation practices noted early in investigation • water “recycling”

18. Danby Water Recycling • Concerns about unsafe water conservation practices noted early in investigation • water “recycling”

19. How Many Loads Are Washed Before the Water is Changed? • Water is recycled more often in villages without running water (P <0.001)

20. Hand Washing Practices • ~10 hand washes per water change

21. Interventions Willing to Try 58% • Willing to change habits? • Willing to use disposable towel? • Willing to sit on a barrier? • Willing to clean steam after use? 68% 87% 88%

22. Summary • Knowledge • No major misconceptions • Prior public health educational messages were understood and accepted • Attitudes • Communities believe boils are a problem • Motivated to prevent boils “because [boils] can cause sepsis and kill”

23. Summary • Practices • Identification of practices that can be improved • Hand washing • Laundry • Steamhouse cleaning • Sharing hygiene items

24. Plan of Action for Reducing Skin and Soft Tissue Infections in Rural Southwest Alaska

25. Thank you

26. Next Steps • Expand descriptive epidemiology • Microbiological data • Develop educational materials for: • Laundering practices • Hand washing • Steambath/Washeteria cleaning • Diminish barriers to implement practice • Laundry service access (e.g., dryer tokens) • Hand sanitizer • Bleach / cleaning supplies

27. Next Steps (2) • Role for environmental testing • Laundry machines • Hand washing basins • Sinks • Public showers

28. Acknowledgements • The Residents of Chefornak, Toksook Bay, and Kwethluk • YK Tribal Health Corporation • Alaska Division of Health • Alaska Native Tribal Health Consortium • Arctic Investigations Program • EIS Officers & Scientific Education and Professional Development Office

29. Thank you For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Preparedness and Emerging Infections

30. ICD9 Coded Skin Infection Encounter Rates by Community, Year (per person-year)

31. Participant Demographics by Village

32. Life in Southwestern Alaska • 25,000 residents • 85% Alaska Native People • Largest community (~6,000 people) • Boats, small aircraft used to reach surrounding region • Ice road in winter for automobiles, snow machines • 49 smaller villages (20 –1,100 people) • Traditional subsistence lifestyle common • Employment scarce; limited cash economies

33. Alaska Native Health System Regions

34. Traditional Sauna

35. Village Water Sources • Piped water service