OUTBREAKS 2009: Healthcare-Associated Infections (HAIs)

1. OUTBREAKS 2009:Healthcare-Associated Infections(HAIs) Maria del Rosario, MD, MPH Division of Infectious Disease Epidemiology WVDHHR/BPH/OEPS February 2010

2. Objectives • Describe 2009 outbreaks of healthcare-associated infections (HAIs). • Review the lessons learned from outbreaks of HAIs.

3. Pre-test Questions TRUE or FALSE:   In a healthcare facility outbreak, when physicians clinically diagnose the cause of the outbreak, there is NO need to obtain specimens for laboratory testing. In general, local health departments (LHDs) do not need to worry about HAI outbreaks because Infection Preventionists (IP) in the facility can usually address the problem.

4. Introduction What is HAI? Health care-associated infections (HAIs) are infections that patients get while receiving treatment for another condition in some type of health care facility*, i.e. hospitals and outpatient surgical centers, clinics and LTCFs Healthcare-Associated Infection (HAI) Outbreak Increase in the incidence of infection (or presumed infection) among people associated with a healthcare setting __ *AHRQ

5. HAI in Hospital Settings (U.S.) • Annual disease burden • More than 1.7 million infections • 99,000 deaths • 75% of HAIs • Catheter-associated UTI (CAUTI) • Surgical site infection (SSI) • Central Line-Associated Blood Stream Infection (CLABSI) • Ventilator-associated pneumonia (VAP)

6. HAI in Non-Hospital Setting (U.S.) • 1996 to 2005 - 110 % rise in the number of ambulatory clinics • 2004 to 2008 - 44% HAI outbreak investigations (with CDC) in non-hospital setting • Related to: • failure to adhere to basic safe practices (e.g., syringe re-use) – HBV and HCV • patients contracting S. aureus, K. pneumoniae, etc. • The overall burden of HAI…. significant problem…resulting from very basic infection control failures.

7. HAI in West Virginia • About 30% of all 2009 disease outbreaks are HAI-related • At least 18 WV counties

8. 2009 Outbreaks of HAIWest Virginia, N=32

9. 2009 Reports of HAI West Virginia • 40 Reports of HAI outbreaks • 32 Confirmed outbreaks • 8 Not an outbreak (after review)

10. West Virginia’s Response to HAI • Disease outbreaks – report immediately (64CSR-7) • 2008 WV Legislative Session – WV Healthcare Authority created HAI Advisory Panel to assist and guide hospital HAI reporting, effective July 2009. • 2009 HAI Prevention Grant to WVDHHR/BPH

11. 2008 West Virginia Legislation WV Hospitals – July 2009 • CLABSI • All ICUs • Report at National Healthcare Safety Network (NHSN) • HC Personnel Flu vaccination • All acute care hospitals • Report to WV Healthcare Authority

12. 2009 HAI Prevention Grant • Recovery Act funds targeting HAI • Tied to Preventive Block Grant • WV developed HAI Plan, report to CDC: • Tier 1 Focus – Hospitals • HAI Priority Areas: • Catheter-Associated Urinary Tract Infection (CAUTI) • Central Line-Associated Blood Stream Infection (CLABSI) • Surgical Site Infection (SSI) • Ventilator-Associated Pneumonia (VAP) • MRSA • Clostridium difficile(CDI)

13. West Virginia’s HAI Plan WVDHHR HAI Infrastructure • Multidisciplinary advisory group • Build PH workforce – HAI Prevention Coordinator • HAI surveillance, prevention and control - coordination among agencies and organizations • NHSN: internet-based surveillance system

14. Steps of an Outbreak Investigation Prepare for field work. Establish existence of an outbreak. Verify the diagnosis. Construct a working case definition. Find cases systematically and record information. Perform descriptive epidemiology. Develop hypothesis.

15. Steps of an Outbreak Investigation – cont. • Evaluate hypothesis epidemiologically. • As necessary, reconsider, refine, and re-evaluate hypothesis. • Compare and reconcile with laboratory and/or environmental studies. • Implement control and preventive measures. • Initiate or maintain surveillance. • Communicate findings.

16. Case Study 1

17. Case Study 1 – What’s next? • Verify the diagnosis. • Establish existence of an outbreak. • Implement control and preventive measures.

18. Case Study 1

19. Case Study 1 – Outcome of Investigation • PROCESSOUTCOME • Verify the diagnosis. Vanco-susceptible; reducing • Establish existence of an outbreak. No • Control and preventive measures. Contact precautions, no contact tracing. 19

20. Case Study 2 You receive a call from a LTCF: • 4 residents diagnosed (by facility doctor) with shingles • 4 more residents with symptoms…looks like shingles, awaiting diagnosis of doctor What do you do next?

21. Case Study 2 – cont. • Verify the diagnosis. • Review clinical presentation • Review mode of transmission • Establish existence of an outbreak. • Construct a working case definition. • Find cases systematically and record information.

22. Case Study 2 – cont.

23. Case Study 2 So, what was the outcome? Shingles • Rash on one side of body • Blisters scab after 3 to 5 days, clears within 2 to 4 weeks • Before rash - pain, itching, or tingling in the rash area • Other symptoms: fever, headache, chills, and upset stomach • Transmission?

24. Case Study 2 Causes of rash illness in elderly • Shingles • Scabies • Contact Dermatitis • Staph. aureus

25. Case Study 3 It is Thursday afternoon, 3pm. You are finishing up on your paperwork and can’t wait till Saturday. You are leaving for a 10-day cruise early Saturday morning. Your thoughts were suddenly interrupted by a tap on your shoulder. “I’m forwarding a call to you,” said your receptionist. On the other line, the caller informs you about TLC Geriatric Home --‘it has closed it’s doors to visitors because of some illness going on’. You listened, you took a deep breath , and…

26. Case Study 3 • About 18 residents with vomiting, diarrhea, cramps • Going on for about 5 days • 62-bed facility What do you do next?

27. Case Study 3 – cont. • Verify the diagnosis. • Establish existence of an outbreak. • Construct a working case definition. • Find cases systematically. • Perform descriptive epidemiology.

28. (Partial) Line list of Sick Residents at TLC Geriatric Home

29. Line list of Sick Employees at TLC Geriatric Home

30. Case Study 3 – cont. • You review the (complete) linelist and saw that the list is growing steadily. It is Friday! • What else needs to be done?

31. Cases of Gastroenteritis by Onset of Illness (N=48)

32. Case Study 3 – cont. • Develop hypothesis. • Implement control and preventive measures • Reconcile information – epi, lab, environmental • Maintain surveillance • Communicate Findings

33. Common Long-Term Care Facility Epidemics Source: SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility, 2008 • Respiratory • Influenza • Tuberculosis • S. pneumoniae • Chlamydia pneumoniae • Legionella spp. • Gastrointestinal • Viral gastroenteritis (norovirus, etc.) • Clostridium difficile • Salmonellosis • E. coli 0157:H7 colitis • Other Infections • Methicillin-resistant Staphylococcus aureus(MRSA) • Vancomycin-resistant Enterococcus(VRE) • Group A Streptococcus • Scabies • Conjunctivitis

34. Lessons learned • Identify and establish regular contact with Infection Preventionist and other key contacts • Inquire about facility’s • Disease identification, surveillance system, • Data analysis and reporting • Infection control policies and procedures • Assess training and education needs • Information sharing

35. Post-Test TRUE or FALSE:   • In a healthcare facility outbreak, when physicians clinically diagnose the cause of the outbreak, there is NO need to obtain specimens for laboratory testing. Answer: False • In general, local health departments (LHDs) do not need to worry about HAI outbreaks because infection control practitioners (ICP) in the facility can usually address the problem. Answer: False

36. THANK YOU Questions?