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Acute Disease Service:
Hot Topics in Infectious Diseases
in Oklahoma
Laurence Burnsed & Becky Coffman
Oklahoma State Department of Health
Acute Disease Service
Communicable Disease Division
1000 Northeast Tenth Street
Oklahoma City, OK 73117-1299
Acute Disease Service: Background
• Mission
– Prevention and control of communicable diseases via
application of epidemiologic methods
• Primary program activities
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Epidemiologist-on-Call system (24/7/365)
Surveillance and investigation of notifiable diseases
Prevent transmission/secondary cases
Outbreak response
OK-HAN: Partner notification of urgent/important
health events
– Education of internal/external partners and public
Acute Disease Service:
Program Activities
• Epidemiologist-on-Call
– Available 24/7/365 for infectious disease consultation
– Resource for questions/concerns posed for communicable
disease issues (exception HIV/STDs)
– Investigation of urgent events
• Investigation, implementation of control measures
– Determine exposed, susceptible contacts
– Implement control measures (isolation, exclusion, active
monitoring of contacts, prophylaxis)
Why are some diseases
reportable?
• Uncommon but severe disease
• Disease for which there is a public health
intervention to prevent the spread of disease
• Enhance ability to detect clusters or outbreak
of a disease
• New disease that we are trying to learn more
about its epidemiology
Example Disease Investigations
• Measles
– Cases suspected on clinical presentation
immediately investigated
– Laboratory testing coordinated to confirm
– Identify susceptible contacts, implement control
measures
• Meningococcal Disease
– Cases investigated immediately upon report
– Identify exposed contacts, recommend postexposure prophylaxis
External Partners
Acute Disease Service works with external partners during
disease investigations and provides disease consultation
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Hospital personnel (Infection Preventionists)
Laboratory personnel
Healthcare Providers (physicians, nurses, PA’s, etc.)
Veterinarians
City officials
School officials
State and Federal Agencies
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Department of Environmental Quality
Department of Agriculture
Department of Education
Food & Drug Administration
US Department of Agriculture
Centers for Disease Control and Prevention
Novel Influenza Viruses
• What makes an influenza strain novel?
– It’s a different subtype from the currently circulating
human influenza A H1 or H3 viruses
– It’s an influenza A subtype that originated from a nonhuman species
– It’s an influenza A subtype from a genetic reassortment
between animal and human influenza viruses
Influenza A H3N2v
– 2010: First identified in U.S. pigs
• The H3N2v virus had genes from pig, bird, and human
influenza viruses and had the 2009 H1N1 pandemic
virus M gene.
– 2011 – 2013 human cases detected
• 2011: 12 cases (IN, IA, ME, PA)
• 2012: 309 cases in 12 states
• 2013 to date: 17 cases (IN, IL, MI, OH)
– No cases confirmed among OK residents to date!
Summary of H3N2v Symptoms and
Exposure Information
• Symptoms are consistent with seasonal influenza:
– Fever, cough, sore throat, myalgia, fatigue
– CDC clinical guidance posted to the OSDH influenza A H3N2v
web page: http://www.ok.gov/health/index.html
– Antivirals recommended for high-risk groups
– Susceptible to oseltamivir and zanamivir
– Rapid antigen tests may not detect flu A H3N2v, negative does
not exclude infection with this strain
• Severity is also similar to other circulating flu strains
– 16 (5%) of 335 cases hospitalized, 1 death
– All had underlying medical conditions
Influenza A H3N2v and Agricultural
Fairs
• Why is there concern with Ag venues?
– Pigs from multiple places come in close contact with other
pigs and people
– Asymptomatic swine can shed the virus
• Greater than 90% of cases have occurred in people who
had close contact with pigs while exhibiting or helping to
exhibit pigs at fairs
– The majority of cases have occurred in persons ≤18 yrs of age
Enhanced Public Health Surveillance
for Influenza A H3N2v
• OK-HAN distributed to:
– Hospital IPs, labs, EDs, clinicians statewide
• Enhanced surveillance activities:
– Advise clinicians to consider H3N2v in patients
with ILI who report direct contact with swine or
attending a swine exhibit
• Report suspected cases to ADS
• Collect respiratory specimen for testing at OSDH PHL
Influenza A H7N9 Background
• April 2013: First reported in China
– Avian influenza strain
– Cases in 8 Chinese provinces, one case in Taipei with
history of travel to affected Chinese province
– Cases reported contact with poultry or live animal markets
– Sharp decline in incidence after live animal market
closures in affected provinces
– No evidence of sustained person-to-person transmission
– Note: No cases detected in US to date!
Summary of H7N9 Clinical
Information
• Confirmed cases: present with severe respiratory
illness:
– High fever, non-productive cough, dyspnea, hypoxia,
evidence of lower respiratory tract disease (infiltrates,
opacities)
– Complications: septic shock, respiratory failure, acute
respiratory distress syndrome, acute renal dysfunction,
encephalopathy
• As of August 30: 135 human cases, 44 (33%)
deaths
Enhanced Public Health Surveillance
for Influenza A H7N9
• OK-HAN distributed to:
– Hospital IPs, labs, EDs, clinicians statewide
• Enhanced surveillance activities:
– Advise clinicians to consider H7N9 in patients with
respiratory illness and appropriate travel or exposure
history
– Report suspected cases to ADS Epi-on-Call (24/7/365)
– Collect respiratory specimen for testing at OSDH PHL
• Focus testing on several respiratory illness cases requiring
hospitalization
Oklahoma Influenza and Respiratory
Virus Sentinel Surveillance Program
• Sentinel physicians and labs are located in each of
the 8 regions of OK
– Submit influenza-like illness & lab info weekly
– Conducted year round
• Influenza season occurs from the beginning of
October to the end of April
– The peak of influenza season occurs approximately at the
beginning of February
www.ok.gov/health/Disease,_Prevention,_Preparedness/Acut
e_Disease_Service/Disease_Information/OK_Flu_View.html
Respiratory Hygiene/Cough Etiquette
Prevents spread of respiratory infections at the first point of
contact in a healthcare setting
Who: Any employee, patient or visitor in a healthcare facility
with signs of a cold or respiratory infection
How:
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Separate people with respiratory symptoms in waiting areas
Ask symptomatic persons to wear a surgical mask
Provide tissues and trash receptacles
Perform hand hygiene after coughing, sneezing or touching
respiratory secretions
Signage/Education
2013-2014 Influenza Vaccine
MERS CoV Background
• Middle East Respiratory Syndrome
Coronavirus
– Viral respiratory disease first identified in
Saudi Arabia during 2012
– Caused by a novel coronavirus
• Distinct from coronavirus associated with SARS
– Source not clearly understood yet.
MERS CoV: Symptoms and Transmission
• Symptoms and care
– Fever, cough, shortness of breath
– Most develop severe respiratory disease
– Supportive care only
• Transmission
– Person-to-person, close contacts
– Eight clusters identified in six countries among close,
person contacts
– One cluster involving healthcare personnel caring for
a MERS CoV case
MERS CoV Case Count
• Case count as of September 5, 2013
– 108 cases, 50 (46%) deaths
– 8 countries
• All cases have a direct or indirect link to one of four
countries: Saudi Arabia, Qatar, Jordan, United
Arab Emirates
– Onsets: April 2012 – May 2013
– Median age of cases is 56 years
– No confirmed cases detected in the US
MERS CoV Investigation
• Similar to novel flu, investigations coordinated
by OSDH ADS
– Initial investigation: clinical history, exposures
– Specimen collection by clinician or CHD for
confirmation (via CDC)
– Investigation of contacts, testing symptomatic
– Implement disease prevention and control
measures
Healthcare-Associated Infections
(HAIs)
• Any condition caused by an
infectious agent that
– occurs in a patient in a hospital and
– was not present (or incubating)
when the patient was admitted to
the hospital
Financial Burdens of HAIs
• Direct medical costs in the United
States are estimated* to range**
from:
– Between $5.7 – $31.5 billion
– Every year
*Using Consumer Price Index (CPI)
**Ranges of costs due to estimation
Source: The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits
of Prevention. March 2009. www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf -
Estimated Costs of Top Five
HAIs: $9.8 Billion per Year
Zimlichman, E., Henderson, D., Tamir, O., et. al. Health Care–Associated Infections: A Meta-analysis of
Costs and Financial Impact on the US Health Care System. JAMA Intern Med. Published online
September 02, 2013. http://archinte.jamanetwork.com/article.aspx?articleid=1733452
Social Burdens of HAIs
• Direct Hospital Costs
– Fixed costs: buildings, utilities, equipment, technology, labor
– Variable costs: medications, food, consultations, treatments,
procedures, devices, lab tests, radiographic tests, supplies
• Indirect Costs
– Lost wages, diminished productivity, short/long term morbidity,
mortality, income lost by family members, forgone leisure time,
time spent by family for hospital visits, travel costs
• Intangible Costs
– Psychological costs (anxiety, grief, disability), pain & suffering,
change in social functioning
Source: The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits of Prevention.
March 2009. www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf
Prevention of HAIs
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Hand hygiene
Use of personal protective equipment
Removal of invasive lines ASAP
Pre-op antibiotics: short-term
Appropriate pre-op prep
Cleaning and disinfection of equipment
and environment
• Timely reporting of organisms by lab
CDC’s Isolation Precautions
• Recommendations for acute
care hospitals, home health
care, ambulatory care, and
long-term care settings
• New topics:
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Increase in MDRO’s
Change in populations at risk
New therapies and procedures
Bioterrorism
New pathogens
www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Two Categories of
Precautions
• Standard Precautions
• Transmission Based Precautions
– Empiric Precautions (proactive
application of Transmission Based
Precautions)
Hand Hygiene
• “The single most
effective action to
prevent spread of
disease”
• CDC recommends the
use of alcohol-based
handrubs by health care
personnel
Hand Hygiene Products
• Soap and water
– when hands are visibly soiled
– when working with patients who
have spore-forming organisms
(such as C. difficile or B. anthracis)
– after using the restroom or
changing a diaper
• Alcohol-based hand rubs
– when hands are visibly clean
– towelettes are not as effective so
should not be used in healthcare
settings
www.who.int
www.cdc.gov/injectionsafety/
Unsafe injection practices and
circumstances that likely resulted in
transmission of hepatitis C virus (HCV)
at clinic A — Nevada, 2007
http://www.cdc.gov/mmwr/PDF/wk/mm5719.pdf
Personal Protective Equipment
(PPE)
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Gloves
Masks
N-95 Respirators
Gowns
Eye protection
Transmission-Based
(Expanded) Precautions
• Use in addition to standard precautions
when pathogen is known or suspected
• Based on routes of transmission:
– Contact
– Droplet
– Airborne Infection Isolation (AII)
Contact Transmission
• Organisms spread by direct contact or
contact with items in the patient's
environment (indirect)
• Examples:
– Herpes simplex
– Staph infections
– Many gastroenteritis agents
– MDRO’s such as MRSA
Contact Isolation
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Private room
Wear gloves when entering the room
Wear a gown if soiling is likely
Dedicate equipment to stay in the
room until discharge when possible
• Pay special attention to disinfection
of contaminated surfaces
Spencer, Maureen. Environmental Technology: Practical Implications , presented at APIC 2011, Baltimore MD
Droplet Transmission
• Organisms that are spread by large
particle droplets > 5
• Examples:
– Influenza
– Bacterial meningitis
– Whooping cough
– Mumps
– Pneumocystis carinii pneumonia
Droplet Isolation
• Private room
– Or separate from others by at least 3 feet
• Wear a standard surgical mask
when entering the room
• Patient follows Respiratory
Hygiene/Cough Etiquette
Airborne Transmission
• Organisms transmitted by very
small airborne droplet nuclei <5
• Examples:
– Tuberculosis
– Chickenpox
– Measles
– Smallpox
Airborne Infection Isolation
• Place patient into a negative airflow room
• Don a fit-tested and fit-checked N-95
“mask” when entering the room
– If the organism is known, susceptible people
should not enter the room (measles, varicella)
• Minimize patient movement
• Place surgical mask on patient if necessary
to leave the room
Airborne Infection Isolation (AII)
Rooms
• Air is ventilated to outside, away from
windows and doors
• Continuous negative air pressure
• Door of the room must be kept closed
• Test airflow regularly (> daily when
occupied)
• Six air changes per hour (ACH) required
for existing buildings, newly constructed
rooms must be >12 ACH
Empiric Precautions
• Use precautions based on symptoms when
diagnosis is still unknown:
Symptom
Diarrhea
Precautions
Contact
Wound infections
Rash
Cavitary lung disease
Contact
Droplet/Airborne
Airborne
Respiratory infections
Meningitis
Droplet/Contact
Droplet/Contact
Antibiotic Resistance
• MRSA (methicillin-resistant Staph aureus)
– VISA and VRSA
• VRE (vancomycin-resistant Enterococcus)
• Acinetobacter baumanii
• Drug-resistant Mycobacterium tuberculosis
• Clostridium difficile (due to aby overuse)
• Carbapenem-resistant Enterobacteriaceae
www.cdc.gov/HAI/organisms/organisms.html
Carbapenem-resistant
Enterobacteriaceae (CRE)
• CRE = carbapenem-resistant and
carbapenemase-producing Enterobacteriaceae.
• Klebsiella pneumoniae carbapenemase (KPC) is
the most common type of carbapenemase in the
US.
• It is usually found in wounds or in the stool.
• Effective antibiotics are limited. Triple-drug
combinations are often used for bacteremia.
Epidemiology of CRE
• Enterobacteriaceae are normal flora of the
respiratory and GI tract
– Also nasopharynx, the respiratory tract, and the
urinary tract
• Transmission from person-to-person occurs
through the hands of healthcare staff
• Colonization rates vary
– May persist up to several months
• Some strains may be transmitted more easily
• Environment thought to play a lesser role
CRE: Who’s at risk?
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Patients with long hospitalizations
Long-term acute care residents
Immunocompromised patients
Invasive tubes or devises
Unhealed open wounds
People can be “colonized”, meaning
CRE is not causing illness, but can still
be spread.
Outbreaks of CRE
• KPC outbreak at National Institutes of Health
(NIH) for 6 months, starting in June 2011.
– Total of 18 patients: transmission to 17 patients, 8
developed bloodstream infections (BSIs), and 6
attributable deaths.
www.sciencetranslationalmedicine.org, 22 Aug. 2012, Vol 4., Issue 148
• KPC (CRKP) outbreak in an acute-care
hospital in Denver, starting in May 2012.
– Total of 8 patients: three were infected, five were
colonized. No deaths.
MMWR, Feb. 15, 2013, Vol. 62, No. 6, p 108
Outbreaks of CRE continued
• KPC (CRKP) outbreak in an acute care
hospital in West Virginia, from April
2009 – February 2011.
– 40 total cases identified
– Spread among 14 acute care hospitals, 2
LTACHs, and 10 nursing homes
Clinical Infectious Diseases, Volume 53, Issue 6, p. 532-540
Summary of Prevention
Strategies
• Core measures:
1. Hand hygiene
2. Contact Precautions
3. Healthcare personnel
education
4. Minimizing device use
5. Patient and staff cohorting
6. Lab notification
7. Promote antimicrobial
stewardship
8. CRE screening
• If transmission occurs in
the facility:
1. Active surveillance
2. Chlorhexidine bathing
www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html
When You Have a Patient With CRE
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Contact precautions
Active surveillance may be performed
Lab results will be verified with CDC
Communicate with facilities when transferring
patients
• Use the transfer form on CDC website for all
transfers:
• www.cdc.gov/HAI/toolkits/InterfacilityTransfer
CommunicationForm11-2010.pdf
Use the transfer form on CDC
website for all transfers:
• www.cdc.gov/HAI/toolkits/InterfacilityTransferC
ommunicationForm11-2010.pdf
What the Health Department is
Doing
• Health Alert distributed to providers and IPs
• Reporting is voluntary, and encouraged
• Survey of hospitals performed:
– Of 58 responses, 10 hospitals reported having at
least one CRE in 2012
• Epidemiologists facilitate confirmatory testing
• Consultation regarding control measures on a
case-by-case basis “24/7”
Acute Disease Service: 405-271-4060
Appropriate Antibiotic Use
• Be Smart: Know When Antibiotics
Work
– Antibiotics don’t cure viral infections
– Most respiratory infections are caused
by viruses
– Don’t pressure your healthcare
provider for antibiotics
– When you are prescribed antibiotics,
take exactly as instructed
www.cdc.gov/getsmart/
Fewer New Antibiotics
• From 1983 to 2010, FDA approval of new
antibiotics declined from four to less than
one antibiotic per year
– Less profitable in comparison with other drug
classes for chronic or lifestyle conditions
– FDA approval takes approximately 8 years,
therefore there is little likelihood of a new
antibiotic before 2015
Antibiotic Stewardship
• Antibiotics are the only drug where
use in one patient can affect the
usefulness in another
• As much as 50% of antibiotic use
is unnecessary
• Antibiotic stewardship programs
limit inappropriate use of
antibiotics and promote
appropriate use
• www.cdc.gov/getsmart/healthcare
Environmental Cleaning
• The inanimate environment plays a role in
facilitating transmission of organisms.
• Cleaning and disinfection reduces the numbers
of microorganisms in the environment.
• Cleaning not always seen as a high priority.
• Germs can survive for days → weeks → months
on surfaces.
• Cleaning/disinfecting priorities might be upsidedown (high-touch vs. low-touch).
Environmental Contamination
X’s = culture- positive sites
BBP Exposure in a Healthcare
Setting in OK
• In March 2013, OSDH and the Board of
Dentistry inspected and found numerous
deficiencies in a Tulsa oral surgeon’s office.
• Patient with no other risk factors became
HCV positive.
• Issues included inappropriate use of multidose vials, misuse of the autoclave, and
misguided corrosive cleaning of instruments.
Next Steps
• Press conferences held to inform the public.
• Notification letters sent to 7000 patients.
• HIV, hepatitis B and hepatitis C tests provided
at OCCHD and TCCHD sites. Educational
materials were provided .
• To date, 4087 people were tested, and:
– HCV positive =
– HBV positive =
– HIV positive =
82
5
4
In Progress
• Patients with negative test results who had
dental procedures in the 6 months before it
closed, need to return for follow-up testing at
least 6 months past the last dental clinic date.
• Analysis of data obtained from chart reviews.
• Identification of high-risk situations.
• Linking likelihood of exposure via Dr. H’s
office using genotyping.
• Determining how many infected may have
had different (non-dental) exposures.
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In Summary:
• Patients, visitors and employees all have a part
in healthcare-associated infections
• The environment can lays an important part in
infection control and prevention
• Use of antibiotics affects your community
• Infections can be prevented through the use of
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Standard and transmission-based precautions
Environmental cleaning
Vaccination
Communication
Remember!
• Protect yourself
• Protect your
patients
• Protect your
coworkers
• Protect your
family, friends
and community
Questions?
Thank you!
Call Acute Disease Service
“24/7”
405-271-4060
http://ads.health.ok.gov
Presenter Contact Information
Laurence Burnsed MPH
Administrative Program Manager
[email protected]
Becky Coffman MPH, RN, CIC
Epidemiologist
[email protected]
Acute Disease Service
405-271-4060
The Far Side by Gary Larson