Maria del Rosario, MD, MPHDivision of Infectious Disease Epidemiology

WVDHHR/BPH/OEPS

February 2010

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Describe 2009 outbreaks of healthcare-associated infections (HAIs).

Review the lessons learned from outbreaks of HAIs.

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TRUE or FALSE:  

1. In a healthcare facility outbreak, when physicians clinically diagnose the cause of the outbreak, there is NO need to obtain specimens for laboratory testing.

2. 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.

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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

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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)

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• 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.

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About 30% of all 2009 disease outbreaks are HAI-related

At least 18 WV counties

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Setting Count PercentLong-term Care Facility 29 90%

Hospital 1 3%

Outpatient clinic (dental, medical, surgical)

2 7%

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Type Count Percent Enteric 17 55%

Respiratory 11 32%

Rash 1 3%

Other (MSSA, Hep B, Conjunctivitis)

3 10%

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40 Reports of HAI outbreaks• 32 Confirmed outbreaks• 8 Not an outbreak (after review)

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

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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

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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)

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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

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1. Prepare for field work.2. Establish existence of an outbreak.3. Verify the diagnosis.4. Construct a working case definition.5. Find cases systematically and record

information.6. Perform descriptive epidemiology.7. Develop hypothesis.

8. Evaluate hypothesis epidemiologically. 9. As necessary, reconsider, refine, and re-

evaluate hypothesis.10. Compare and reconcile with laboratory

and/or environmental studies.11. Implement control and preventive

measures.12. Initiate or maintain surveillance.13. Communicate findings.

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Verify the diagnosis.

Establish existence of an outbreak.

Implement control and preventive measures.

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1919

PROCESS OUTCOME

Verify the diagnosis. Vanco-susceptible; reducing

Establish existence of an outbreak. No

Control and preventive measures. Contact precautions, no contact tracing.

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?

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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.

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Case Study 2 – cont. Case Study 2 – cont.

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?

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So, what was the outcome?

Causes of rash illness in elderly• Shingles• Scabies• Contact Dermatitis• Staph. aureus

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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…

About 18 residents with vomiting, diarrhea, cramps

Going on for about 5 days 62-bed facility

What do you do next?

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Verify the diagnosis. Establish existence of an outbreak. Construct a working case definition. Find cases systematically. Perform descriptive epidemiology.

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You review the (complete) linelist and saw that the list is growing steadily. It is Friday!

What else needs to be done?

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Develop hypothesis. Implement control and preventive

measures Reconcile information – epi, lab,

environmental Maintain surveillance Communicate Findings

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Source: SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility, 2008

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

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TRUE or FALSE:  

1. 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

2. 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

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Questions?