Upload
eric-booker
View
224
Download
0
Tags:
Embed Size (px)
Citation preview
Sherif Ibrahim, MD, MPHDivision of Infectious Disease Epidemiology
WVDHHR, BPH, OEPSNovember 17th, 2010
1
Objectives • Describe LTCF populations and risk factors• Describe the initial steps of investigation and
control of respiratory disease outbreak• Review the case definition of common
respiratory diseases• Review the different isolation precautions
used to prevent/control transmission of infectious agents in LTCFs
• Review the most common encountered respiratory pathogens in LTCFs
• Case Study2
Long-Term Care Facilities (LTCFs)Institutions that provide health care to persons
who cannot function independently in the community
LTCFs encompass a diverse residential settings
Nursing home (NHs) is a licensed facility that has organized professional staff and inpatient beds to provide health services to individuals who are not in acute phase of an illness
3
Population CharactersIn the U.S there are 1.8 million Americans
residing in the nation’s 16,500 NHsAverage length of stay 835 days (2.4 years)Average age of residents is 80 YO88% > are 65 YO and 45% are > 85 YOOver 70% of residents are females50% of the residents takes >9 medications
/day CDC
statistics
4
Population Characters Cont.One in four people aged 65 or more will
spent some times in a LTCFIn 2030, 70 million US citizens will be > 65
YOWith the continuous expansion of alternative
grouped quarter living opportunities (e.g. assisted living facilities, home care)
The demographic characteristics of nursing home residents have shifted to the oldest adults
5
Population Characters Cont.More than 50% of all residents are either
totally or partially dependent on assistance in activity of daily living (ADL)
Altered clinical manifestations to infection may delay early diagnosis and treatment
Challenges in balancing infection control measures and psychosocial needs of the residents
6
Risk Factors for Infection in LTCFs:Residents Factors
Old agePoor cognitive and functional statusDifficulty swallowing and tube feedingInadequate oral careImmune system dysfunction Polypharmacy (prescribing multiple meds)Invasive devicesFrequent hospitalization
7
Risk Factors for Infections in LTCFs:Institutional Factors
Excessive use of empiric antibiotics Widespread colonization with MDROs
(Multidrug-resistant organisms)Low technology setting limited diagnostic
tools Larger facilities with a single nursing unit or
multiple units with a shared nursing staffHeterogeneous populationsClosed environment & group activities
8
Risk Factors for Infections in LTCFs:Institutional Factors Cont.
Low immunization rates (staff and residents)Pathogen exposure in shared living spacesCommon air circulationDirect/indirect contact with health care
personnel/visitors/other residentsDirect/indirect contact with equipment used
to provide care
9
Outbreaks in LTCFs, West VirginiaEpidemiologic Data
There are 130 NHs that house almost 10,895 residents.
In 2009, 99 confirmed outbreaks were reported
Healthcare facilities reported 33 outbreaks (33%)
LTCFs reported 29 (88%) of all healthcare-associated outbreaks
10
11
12
Challenges of Respiratory Disease Outbreaks Investigation
Challenges in finding baseline disease ratesSeasonality: cyclical changesWide range of pathogens can cause similar
clinical syndromesOutbreaks may involve multiple pathogensPotential new pathogens (H1N1, Human
metapneumovirus)Limited lab resources and diagnostic
capacity
13
Why Should Respiratory Disease Outbreaks Be Investigated ?
Vulnerable populationsHigh morbidity and mortality ratesInfections and fever are the most common
cause of hospitalization of LTCF residentsPneumonia is the leading cause of death and
hospitalizationSome respiratory diseases are preventablePrevent overuse of antibiotics
14
Why Should Respiratory Disease Outbreaks Be Investigated ? Cont.
Outbreaks are disruptive to the facility and stressful to staff, residents, administration
Financial burden Early detection and immediate interventions
decreased morbidity and mortality ratesAdvance knowledge and lessons learned
15
Initial Outbreak Notification Notification call: what do you need to know? Who: (ills and total population at-risk)Where: facility, unitWhen: date of onsetWhat: Clinical information, lab studiesInterventions already in-placeAdministrative issues
16
What Defines a Respiratory Disease Outbreak?
Outbreak Definition: an increase in the number of cases of a respiratory disease over and above the expected number of cases for a given time and location
Influenza Outbreak: three or more cases of (ILI) influenza-like illness in a single nursing home unit within a 3-day period OR one case of a confirmed influenza by any testing method
17
1) Establish the Existence of a Respiratory Disease Outbreak
Determine the endemic rate or the base line of the disease
Use facility’s surveillance dataReview the case definition of respiratory
syndromes:
URTI (Upper Respiratory Tract Infection) ILI (Influenza-Like Illness) LRTI (Lower Respiratory Tract Infection) Pneumonia
18
URTI Influenza LTRI/Pnuemonia
Fever May or may not ≥100°F / 37.8°C fever ≥100.4°F / 38° C,
Symptoms &Signs
New onset of at least 2 of the following: -Runny nose/sneezing-Stuffy nose/congestion -Sore throat/ hoarseness- Dry cough- Cervical LN
ANDCough (and/or)Sore throat
Three of the following:New or increased coughNew or increased sputum pleuritic chest painNew or increased Physical finding on chest examOne indication of change in status or breathing difficulty (SOB, RR> 25/m, confusion)
R/O allergy R/O other causes of fever
Positive chest-X ray and two of the above = pneumonia
Lab studies NP swabs (nasopharyngeal)
NP swabs NP swabs, CBC, blood and sputum culture, sputum gram stain, CXR
Treatment Supportive Antiviral if influenza is confirmed
Antibiotics based on clinical and lab findings
19
20
21
2- Verify The Diagnosis / Field Investigation
Clinical info, lab studies, number of Ill, and total population.
Notify and collaborate with your partners
Determine if field investigation is needed
Prepare for field investigation: Scientific and investigative issuesManagement and operational issues
22
3- Develop an Initial Case DefinitionCase Definition Element
Description
Who Residents / Staff
Where Facility/ unit/wing
When Date of onset ( first case)
What Clinical data (symptoms and signs)Laboratory data, CXR
Loose / sensitive Vs. narrow / specific case def. It helps to determine who should be in the line list It can be modified throughout the outbreak
23
4- Start a Line listInclude all ill persons (residents and staff)
Update throughout the outbreak.
Rapid assessment of the extent and nature of the outbreak
Use to draw your epidemic curve
Use the line listing to track the progress of the outbreak and to adjust your control measures
24
Example of a line list (1)
25
Example of a line list (2)
26
27
5- Draw An Epidemic Curve
Graphic (histogram) depiction of the outbreak
Plot the number of cases at y-axis and date of onset at x-axis
Help to differentiate between a common source, propagated (person-to-person) or mixed outbreaks
28
6- Initiate Active SurveillanceActive case findings
Use your initial case definition
Make sure all ill residents are evaluated by a physician
Collect nasopharyngeal swabs (recent onset of illness)
Blood and sputum culture, if indicated, before initiating antibiotic
29
7- Implement Initial Infection Control Measures Strict hand hygiene: single most important
practice to reduce the transmission of infections in healthcare settings
Standard precautions: Group of infection prevention practices that apply
to all residents regardless of infection statusApplies to staff who provide direct patient careInvolve hand hygiene and using personal
protective equipments (PPEs) (gloves, gowns, etc.) when anticipate contact with respiratory secretions or other body fluids
Safe injection procedures Respiratory hygiene/cough etiquette
30
Initial Infection Control Measures Cont.
Droplet Precautions: Place ill residents in private rooms. If a private
room is not available Cohort If cohorting is not possible use a curtain
between residents (> 3 feet )Cohort staff Wear a mask upon entering & remove it upon
leaving the resident’s room Limit ill residents movement or transport. If
indicated have the resident wear a mask
31
Initial Infection Control Measures Cont. Implement respiratory hygiene & cough
etiquette Post visual alertsProvide tissues or masks to symptomatic
residents and visitorsProvide tissues and alcohol-based hand rubs in
common areas and waiting rooms Ensure enough handwashing facilities &
suppliesEncourage social distancingIll residents should be discouraged from using
common areas where feasible 32
Initial Infection Control Measures Cont.
Apply the following restrictions when indicated:
Restrict ill residents to their rooms/units Notify visitors and restrict visitations Restrict group activities, such as dining,
recreation or rehabilitation Restrict new admissionsEvaluate and exclude ill staff until recovered
33
Differential Diagnosis Clues
Principle and case definition of respiratory diseases
Review the most common pathogens encountered in LTCFs
Population characteristics
Season
Exposures34
Summary of Investigation steps in the First 48 Hours
Establish the existence of a respiratory disease outbreak
Verify the diagnosis / Field investigationDevelop an initial case definitionStart a line listDraw an epidemic curveInitiate active surveillanceImplement initial infection control
measures35
8- Follow Up Beyond 48 Hours Continue active surveillance Organize and re-evaluate your dataPerform descriptive epidemiologyConfirm diagnosis (lab confirmation)Develop hypothesisRe-evaluate your case definition Re-evaluate infection prevention measures
and keep a balance with residents’ psychosocial needs
Communicate findingsLessons learned and measures to prevent
future outbreaks 36
Recent advances in Diagnostics Multiple Pathogens Assays MPAsBased on PCR technology Allows convenient testing for several agents in a short
period of timeImmediate use in emergenciesCDC uses Taqman Low-Density Array (TLDA) cards
detect up to 24 respiratory viruses and bacteria WV Office of Laboratory Services (new technology that
will allow detection of 21 targets)
(COCA, 2009)
37
ConclusionsRespiratory disease outbreaks in LTCFs are
common, challenging and sometimes associated with high morbidity and mortality rates
Your response in the first 48 hours is crucial
Investigation requires all-level-collaborations
Integrate epidemiologic and lab response
Ongoing surveillance system in LTCFs is essential in identifying and controlling outbreaks
38
Questions Case Study
39
ResourcesDIDE: Division of Infection Diseases
EpidemiologyWebsite: www.wvidep.orgPhone # 304-558-5358 or 800-423-1271Fax: 304-558-8736Office of Laboratory Services 304-558-3530
40