Expert Doctor’s Showcase Infection at the work place – we can

prevent it!

Dr Leong Hoe Nam Infectious Diseases Physician

Raffles Hospital, Singapore hoe_nam@yahoo.com.sg

Unrestricted Educational Grant from

Financial Declaration

• Advisory Board

– Pfizer

– GlaxoSmithKline

– Sanofi-Pasteur

– MSD

• Site Principal Investigator

– Sanofi-Pasteur – Dengue Vaccine Trial

Unrestricted Educational Grant from

Infection in the Workplace is PREVENTABLE

Begins with

PERSONAL RESPONSIBILITY

Stephen Covey’s 7 Habits of Highly Effective People

SILVER WORKFORCE

• Co-morbidities

– Diabetes Mellitus, Chronic Obstructive Airway Disease, Asthma, Heart Disease, etc

• Reduced Immunity

• Same medical condition – HIGHER MORTALITY

INFECTIONS

GERMS

Listeriosis Contaminated Cantaloupes

E Coli Haemolytic Uraemic Syndrome

BACTERIA

FUNGI

HIV / AIDS

Viruses

RECENT EPIDEMICS / PANDEMICS

• Spread Fast

• Made use of Airport Routes

www.airliners.net

RECENT EPIDEMICS / PANDEMICS

• Humans were the carrier

• SINGAPORE – major airport hub

• Spread Fast

• Made use of Airport Routes

RESPIRATORY ROUTE!

Germany E Coli O104, Beansprout

FAECAL ORAL TRANSMISSION

INFECTIONS

• Risk of infection higher in the immunocompromised host. Cancer patients

• Diabetes mellitus type 2. Good control helps

“sugar to the white cells is like brandy to an alcoholic”

The pleasure of it all makes them not want to work.

Two main modes of transmission of Illness

• FAECAL ORAL

• RESPIRATORY

balkris.blogspot.com

Faecal Oral Transmission

粪便口头传输 Viral infection (Rotavirus, Enteroviruses) Salmonella (Typhoid fever), Shigellosis Hepatitis A - diarrhoea.

Chong Kneas — a floating village over Tonle Sap Great lake in Cambodia. A child refills lake water into her drinking bottle.

Faecal Oral Transmission

粪便口头传输

Spot the Difference

Straits Times Nov 3, 2011

What do I do?

• Keeping the environment clean

– Clearing / wiping down table.

– Eating at the office table

• Cover for keyboard.

• Who used the keyboard previously?

What do I do?

• Keeping the environment clean

– Clearing / wiping down table.

– Eating at the office table

• Nothing in the mouth except FOOD!

• Washing Hands

• Good toileting habits

• Ovaries of Hens

• Bacteria enters egg prior to

egg shell formation

Salmonella enteritidis

Source: salmonellablog.com Topnews.in

• Faecal contamination

Fresh eggs go through the same vent as faeces

PATIENTS with CANCER /

IMMUNOCOMPROMISED – TAKE

NOTE!

Faecal Oral Transmission 粪便口头传输

It’s all about….. 1. Personal hygiene 2. Personal responsibility 3. Using some common sense….

Unwell 1. Seek treatment 2. Rest at home 3. Strict handwashing

Respiratory (呼吸)

Influenza / Tuberculosis / Pertussis

Biggest burden – Influenza (流行性感冒) Spread by Droplet (通过飞沫传播) Other respiratory viruses Respiratory syncytial virus (RSV), parainfluenza, enteroviruses, adenovirus, coronaviruses, bocavirus, metapeumovirus Other bacterial infections Streptococcus pneumoniae, Haemophilus influenzae, Moxarella catarrhalis

Respiratory

Spread by droplets - minimise exposure - cover cough - dispose of dirty tissue - no spitting - hand hygiene - surgical mask SEE A DOCTOR! Stay at home. Influenza Vaccinations for those with chronic Illnesses Option of antiviral therapy <48hrs for influenza

Surgical Masks – THEY WORK!

THEY PROTECT THE WEARER!

THEY PROTECT OTHERS!

PREVENTION OF INFECTION

Johnson et al. Clin Infect Dis. (2009) 49 (2): 275-277.

INFLUENZA

COUGH!

20cm

PREVENTS Transmission

Myths on Influenza

• It is a whimpy virus

• It doesn’t kill

• There is no influenza in Singapore

• The influenza vaccination doesn’t work

Two FLU SEASONS in SINGAPORE

• BIMODAL APRIL – JULY

NOVEMBER – JANUARY

Follows the Southern and Northen hemispheres

Greater PEAK – APRIL – JULY

Angela Chow et al. EID. Vol 12. No.1 Jan 2006

A

Angela Chow et al. EID. Vol 12. No.1 Jan 2006

All Cause Death

Underlying Pneumonia and Influenza

Underlying Circulatory and Respiratory Deaths

Influenza – excess death

INFLUENZA is responsible for DEATH in TROPICS

Angela Chow et al. EID. Vol 12. No.1 Jan 2006

Every peak of excess death paralleled Influenza peaks (except 1)

An experiment in TTSH

• ALL patients admitted over 48 hour period tested for influenza

• 10% were positive for influenza by PCR

• 60% had “Influenza-like illness”

• “underrecognition and underdiagnosis of influenza in hospitals. “

Leo YS et al. Lancet Inf Dis. August 2009

An experiment in TTSH

• ALL patients admitted over 48 hour period tested for influenza

• 10% were positive for influenza by PCR

• 60% had “Influenza-like illness”

• “underrecognition and underdiagnosis of influenza in hospitals. “

Leo YS et al. Lancet Inf Dis. August 2009

INFLUENZA in the AT-RISK POPULATIONS

RR Hospitalisation

• Non-epidemic years 1.1 (1977) 1.0 (1979)

• Epidemic years 5.7 (1976) 6.2 (1978)

• 5 X Increase risk of HOSPITALISATION • Pneumonia RR 25.6

• Death RR 30.9 (1977) 91.8 (1978)

• .

The adjusted rates of excess influenza-associated hospital admissions for the three diagnoses combined amounted to 58.5, 20.0, 29.2, and 13.4 per 10,000 populations aged 65 years in 1998, 1999, 2000, and 2001, respectively.

Pneumonia / Diabetes Mellitus / Heart + INFLUENZA

= BAD NEWS

What about children…..?

www.colourtown.com

• The risk of INFLUENZA on HOSPITALISATIONs

<6 mo 103.8 1-3y 18.6 5-15y – 4.1

6 – 12 mo 49.6 3-5y 8.6 Excess/10K chn/yr

Relationship within the family

Children

Grandparents Parents

Children gives “multiple doses” (exposures) to grandparents

• 1 child can give

multiple doses

The Good News…..

We have a vaccine…….

In Singapore A vaccine is just dead vaccine lightly salted….

Effectiveness of the Vaccine

• COPD

• Decrease in ARI / Hospitalisation / Mechnical Ventilation

MILD

MODERATE

SEVERE

ALL

• Part of PRISMA Study (Prevention of Influenza, surveillance and management Study). 75,000

• 1999-2000 Influenza A

• Vaccine : Control 1:4

Reduction in Death / Hospitalisation

BURDEN OF INFLUENZA…. BEYOND THE PATIENT…..

The burden of respiratory illness…

• All respiratory illnesses can result in visits, prescriptions, lost school and work days…

• BUT – INFLUENZA – had more of them…..

Burden of Influenza vs Others

• More transmissibility in family

• More prescriptions

• More medical visits

• More lost work / school days

Vaccinating the YOUNG to save the OLD

• Mandatory Flu vaccination in Children – 1962-87

• Laws relaxed 1987

• Repealed in 1994

• VACCINATION of CHILDREN PROTECTS ELDERLY

COMPULSORY

Vaccine Effectiveness

Adults / Children with Asthma

>65 yo

713, 872 person-years observation. VACCINATION

27% reduction HOSPITALISATION (for pneumonia / influenza (OR 0.73, CI 0.68-0.77)

48% reduction in Risk of Death. (OR 0.52 CI 0.5 – 0.55)

• Vaccine effectiveness repeated in Taiwan…..

Cost EXcluding Operating Income

PRODUCTIVITY RATE 70 50 30

Cost INcluding Operating Income

PRODUCTIVITY RATE 70 50 30

Vaccine Safety

Generally safe…

Pain / Ache site of infection

Limited fever post vaccination

MOH guidelines on Influenza Vaccination • Persons aged 65 years and older; • Residents of nursing homes and other chronic care facilities; • Adults and children who have chronic disorders of the lungs

or heart, including asthma; • Adults and children who have required regular medical

follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), kidney or blood disorders, or lowered immunity caused by medications or by the Human Immunodeficiency Virus (HIV);

• Children and teenagers aged 6 months to 18 years who are receiving long-term aspirin therapy;

• Women who are in the second or third trimester of pregnancy.

INDIVIDUALs in contact with patient

INDIVIDUAL To Protect!

INFECTIONS are transmitted by those around the patient

Vaccinations must include the OUTER PERIMETER – the patients’ contacts!

5- to 19-year-olds are expected to suffer the

highest incidence during the initial epidemic phase of an emerging infection

Mossong et al. PLoS Med. 2008 Mar 25;5(3):e74.

Lessons on influenza

• Children transmit the viruses

• Children pass the infection to others

(YOUR EMPLOYEE / YOURSELF)

Manhours, medical leave.

• Vaccinating the children of your employee helps

Impact of Annual Influenza Epidemics

• No. of workdays lost

1.5 – 4.9 days / person

lab-confirmed influenza.

Keech and Beardsworth. Pharmacoeconomics. 2008;26(11):911-24

• Lost of productivity

“reduced capacity to work”

5 - 6.2 days

Kavet. Am J Public Health. 1977;67:1063-1070

Economics of Workplace Vaccination

• Cost savings….($15 to $995) per vaccinated employee)

(20% attack rates)

Bruce lee at al. Vaccine. 2010 August 23; 28(37): 5952–5959

TWO LARGE RANDOMISED CONTROL TRIALS TWO WELL RECOGNISED JOURNALS

But there are detractors….

• “vaccines are undoubtedly the best preventive means for clinical influenza in healthy adults.”

• “low effectiveness and high incidence of trivial local adverse effects that the trade-of is unfavourable”

• “most cost-effective option is not to take any action”

Demicheli V et al. Vaccine. 2000 Jan 6;18(11-12):957-1030. Review

How much vaccination is enough?

• In an epidemic of influenza

• Computer Modelling

• 20% compliance – MAXIMUM GAIN!

Vaccine Cover Attack Rates

100% 0.5%

50% 0.6%

20% 0.7%

0% 2.8%

60 Days to complete vaccination

Vaccine Cover Attack Rates

100% 1.5

50% 1.5%

20% 1.8%

0% 3.8%

120 Days to complete vaccination

Lee et al. Am J Prev Med. 2010 March ; 38(3): 247–257

Physical Barriers Help

Respiratory Infections

• Influenza biggest burden

• Vaccination helps! $23-25

– Hospitalisation / Deaths

• Influenza has two peaks in Singapore

• Surgical masks can help prevent infections.

Barriers to Vaccination

1. Doctor’s Recommendations

2. Perceived benefits

3. Previous vaccinations

4. Convenience to vaccinations eg. Vaccination programme at workplace, at GP consultation

Some parting words

• “If there is any conceivable way a germ can travel from one species to another, some microbe will find it,”

William McNeill

Plagues and Peoples

The END

Infection in the Workplace is PREVENTABLE

Begins with

PERSONAL RESPONSIBILITY (CORPORATE RESPONSIBILITY)

Annual Impact of Seasonal Influenza - USA

• 2003 US population 294 million

• 610,660 life years lost

• 3.1 million hospitalised days

• 31.4 million outpatient visits

• Direct medical costs $10.4 billion

• Lost earnings $16.3 billion

• Total Economic Burden $87.1 billion

INDIVIDUALs in contact with patient

INDIVIDUAL To Protect!

INFECTIONS are transmitted by those around the patient

Vaccinations must include the OUTER PERIMETER – the patients’ contacts!

How much vaccination is enough?

• In an epidemic of influenza

• Computer Modelling

• 20% compliance – MAXIMUM GAIN!

Vaccine Cover Attack Rates

100% 0.5%

50% 0.6%

20% 0.7%

0% 2.8%

60 Days to complete vaccination

Vaccine Cover Attack Rates

100% 1.5

50% 1.5%

20% 1.8%

0% 3.8%

120 Days to complete vaccination

Lee et al. Am J Prev Med. 2010 March ; 38(3): 247–257

Difficulty in Studying Influenza

INFLUENZA INFLUENZA-LIKE ILLNESSES

Lab-confirmed Clinically suspected

low sensitivity Other viruses responsible.

Characteristic features (50%)

URTI only (30%)

No Symptoms (20%)

Costly!

INFLUENZA A, B

Parainfluenza 1,2,3 Respiratory Syncytial Virus, Adenovirus, Enterovirus, Coronaviruses, Mycoplasma

Risk of Guillain Barre Syndrome

• Incidence GBS – 4-10/ 1,000,000

• Flu – 15-20% of the cases.

• “the attributable rate of GBS would be 0.71 per 100,000 person-years, corresponding to an attributable risk of 0.8 excess cases of GBS per 1 million vaccinations.“

Impact of Annual Influenza Epidemics

• No. of workdays lost

1.5 – 4.9 days / person

lab-confirmed influenza.

• Lost of productivity

“reduced capacity to work” Keech and Beardsworth. Pharmacoeconomics. 2008;26(11):911-24