Sherif Ibrahim, MD, MPHDivision of Infectious Disease Epidemiology

WVDHHR, BPH, OEPSNovember 17th, 2010

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Example of a line list (1)

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Example of a line list (2)

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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

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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

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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

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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

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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

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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

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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)

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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

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Questions Case Study

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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

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