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Anatomy of An Outbreak

Anatomy of An Outbreak. Donald Allegra, MD NNJAPIC March 28, 2012 Mountainside Hospital Montclair, NJ. Epidemic: “An increase over the expected occurrence of an event.” -APIC Famous Outbreaks: 1918 Influenza pandemic: killed more people than WWI

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Anatomy of An Outbreak

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  1. Anatomy of An Outbreak Donald Allegra, MD NNJAPIC March 28, 2012 Mountainside Hospital Montclair, NJ

  2. Epidemic: “An increase over the expected occurrence of an event.” -APIC • Famous Outbreaks: • 1918 Influenza pandemic: killed more people than WWI • Zaire Ebola virus outbreak, 1976, Yambuku, Zaire: case fatality rate 90%. Transmission attributed to reuse of unsterilized needles • (other important outbreaks and dates…?)

  3. Steps in an Outbreak • Initial Investigation: • Confirm Presence • Alert Key people (administration, local public health) • Perform Current Literature reviews and research guidelines (CDC, NJDHSS, OSHA, etc)- talk here about possible discrepencies between these) • Establish (Preliminary) Case Definition • Develop[ methodology for case finding • Prepare Line list and Epidemic Curve • Observe patient/ employee care activities • Consider Environmental sampling • IMPLEMENT initial control measures

  4. Steps in an Outbreak • Follow-Up Investigation • Refine the Case Definition (true case vs. background noise) • Continue case findings and definitions • Regularly review control measures with key people • Consider analytic studies

  5. Norovirus • A group of related, single stranded RNA, non-enveloped viruses • Previously Norwalk Like Vurus; often called Viral Gastroenteritis, Stomach flu; causes acute inflammation of the stomach and intestines • Clinical Presentation: incubation period is usually 24 to 48 hours, with median of 36 hours) • Presents as • acute-onset vomiting • watery non-bloody diarrhea with abdominal cramps • nausea. • Low-grade fever also occasionally occurs, and diarrhea is more common than vomiting in children. • Most Commonly reported outbreak settings are healthcare facilities (including hospitals, nursing homes)

  6. Norovirus • Transmission • primarily through the fecal-oral route, either by consumption of fecally contaminated food or water or by direct person-to-person spread. • Environmental and fomite contamination may also act as a source of infection. • Good evidence exists for transmission due to aerosolization of vomitus that presumably results in droplets contaminating surfaces or entering the oral mucosa and being swallowed. • No evidence suggests that infection occurs through the respiratory system.

  7. Norovirus • Transmission • Noroviruses are highly contagious and as few as 10 viral particles may be sufficient to infect an individual. • During outbreaks of norovirus gastroenteritis, several modes of transmission have been documented; • for example, initial foodborne transmission in a restaurant, followed by secondary person-to-person transmission to household contacts. • Although pre-symptomatic viral shedding may occur, shedding usually begins with onset of symptoms and may continue for 2 weeks or more after recovery. • It is unclear to what extent viral shedding over 72 hours after recovery signifies continued infectivity

  8. Kaplan Criteria • In absence of labs, clinicians can use Kaplan criteria: • 1) a mean (or median) illness duration of 12 to 60 hours, • 2) a mean (or median) incubation period of 24 to 48 hours, • 3) more than 50% of people with vomiting, and • 4) no bacterial agent found

  9. Norovirus Outbreak in Local Communitty Hospital 2012 • Timeline: • Jan 9th, 2011: IP alerted that 13 staff called out in the past week re: GI symptoms. Predominant unit is 2W, where four patients have GI symptoms. • Stools collected on all four patients, sent to state. • Housekeeping notified to increase bleach cleaning in departments involved. • Jan 10th: Local health department was notified. Communication to executive staff. Bleach cleaning extended to entire building as precautionary measure. • Jan 11th: Thorough Chart review conducted on patients involved. Index case possibly identified: 83 yo male pt admitted with diarrhea on 12/31/11. • Case Definition identified: nausea with vomitting and/ or diarrhea • Daily rounds included speaking to staff, and giving out containers of bleach wipes with instructions. • Email sent out to all email users from Director of Operations

  10. Email to staff, Jan 12th 2012 • We have had an increase in callouts throughout the building related to gastrointestinal upset (symptoms are a combination of  vomiting/ nausea/ diarrhea/ headaches/ fever) in the past week and a half. • It is imperative that anyone calling out MUST report to Employee Health or call the EH hotline to report an illness (973.579.8989) in addition to calling his/ her supervisor. • Employees who display or report any of these symptoms while at work must go home immediately and NOT return to work until they are 24 hours symptom- free. • Housekeeping has been vigilant about cleaning affected areas with bleach products; in addition Infection Prevention and Employee Health has been rounding to reiterate hand hygiene and to regularly wipe down surfaces and equipment. • There needs to be NO food/ beverage in ANY clinical areas. Please wipe down all surfaces with bleach- based products (order Dispatch Wipes, PMM # 171766); this includes keyboards, phones, desk surfaces, etc.     • This is a time when appropriate handwashing is a necessity to prevent further spread of this illness.

  11. Timeline continued… • Jan 13th: County epidemiologist visited facility • Results from state: all four patients tested positive for norovirus • Updated email sent out to staff; reiterated strict hand washing with soap and water; • Employees cannot return to work until 24 hours symptom free • Staff callouts continue to increase • Jan 16th: Formal meeting with ID chair, ICP, CNO, Employee Health, marketing • Continue isolations of all GI patients • Memo to all Medical staff with directions for patient care and discharge (cannot D/C to any LTC until patients are 48 hours symptom free)

  12. Timeline • Jan 18th: Updated memo to all staff • Plan to contain GI patients to one unit; unsuccessful due to layout of the second floor, and too many patients with GI for one unit. • ICP and Nursing Leaders conducted individual staff meetings to all inpatients; gave handouts • Weekly conference calls with key leaders • Jan 19th • Visitors restrictions activated: family members only, and must be 18yo or older to visit. • Salad bar in staff cafeteria closed down until further notice. • Posters/ signage throughout the hospital reiterating visitor restriction and hand hygiene with soap and water.

  13. Timeline • Jan 21st weekend • Snow Storm… staff callouts GI vs. Snow • Continue all measures and chart reviews • Week of January 23rd • ED visits continue to peak • Continue measures due to community increase • 5 additional hospital-acquired infections identified • Staff callouts begin to decrease to baseline • Week of Jan 27th • Highest peak in the ED • Staff callouts back to baseline

  14. Feb 15th; restrictions lifted • Visitor restrictions: resume normal visitation policies. • Continuous house-wide bleach cleaning: we will return to normal cleaning with hospital approved ammonia compound with exception of isolation rooms due to GI where bleach will continue to be used. • Closure of salad bar in cafeteria; we will reopen the salad bar. • Employees are required to stay home for at least 48 hours symptom free: they now can return to work when they feel well and when cleared by employee health. • Ill patients not transferred to rehab or nursing home until 48 hours after being free of GI symptoms; this will revert to our usual policy of transferring once patients are asymptomatic.

  15. Norovirus Outbreak in Local Communitty Hospital 2012 • Over 80 employees on the line list c/o GI symptoms since 1/1/12; only two were tested, both positive • Peaked January 13th • Interventions placed on Jan. 10th; Restrictions Jan.17th • Restrictions placed on January 17th; Discontinued on Feb 14th • Lab Results: • 37 negative results • 16 positives (6 healthcare-acquired) • Last positive 2/19/12 (ED) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

  16. Gastroenteritis in staff callouts NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

  17. GI Visits in the Emergency Department (vomiting +/_ diarrhea)

  18. Lab Results Norovirus

  19. Staff Callouts r/t GI symptoms

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