Love can be good or bad! Ayesha Iqbal MBBS MPH St Louis County Department of Health 02/14/2014

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1 Love can be good or bad! Ayesha Iqbal MBBS MPH St Louis County Department of Health 02/14/2014

2 Bad Love Germs LOVE to attack a host causes disease or If more than 1 host - outbreak

3 Number of Outbreaks 25 St Louis County Outbreak by Setting 2006 through 2014 YTD Year LTC Childcare Community Food School Other

4 The two most common outbreaks in the Long term care facilities (LTC) Acute Gastroenteritis (AGI) or (Norovirus) Respiratory

5 Number of Outbreaks St Louis County Outbreaks in LTC by Cause 2006 through 2014 YTD Year AGI Norovirus ARI FLU

6 NOROVIRUS

7 Most common Questions? What is an outbreak? Should I contact the Health Department (HD)? How does the HD help? Recommendations by the HD New admissions? Discharge patients? Labs, who pays, why 3 samples? Outbreak over? Control measures why we do what we do?

8

9 Why Noro Loves LTC? What enables norovirus to spread rapidly through confined populations. The ease of its transmission. A very low infectious dose. A short incubation period. Environmental persistence, and Lack of durable immunity following infection. Source:

10 Implications Healthcare facilities managing outbreaks of norovirus gastroenteritis may experience significant costs relating to: Isolation precautions. Personal protective equipment. Ward closures. Supplemental environmental cleaning. Staff cohorting or replacement, and sick time. Elderly - hospitalization due to severe dehydration. Source:

11 What is an outbreak? Suspect outbreak: 2 or 3 cases within 48 hours on the same unit, floor, room Outbreak: The onset of NVD, vomiting alone, or diarrhea alone in a number of residents and/or staff within 1-3 day period Both are reportable to the Health Department. SOURCE:

12 Chain of Transmission Host Aerosolized Person-to-person Food Surfaces Water Environment Agent

13 Chain of Transmission Aerosolized Vomitus Diarrheal accidents Environmentally stable (due to capsid): Resists heating to 60 C Resistant to commonly used disinfectants

14

15 Control measures Wear masks when cleaning Wear gloves when cleaning Do not vacuum carpets

16 Person to person Spread

17 Spread

18 Residents Staff Food handlers Custodian Caretakers Other Visitors Family members Control Measures

19 Control Measures: Residents Cohort/Isolation Symptomatic residents stay in their rooms until symptom-free for 72 hours. Discontinue group activities until the outbreak is over. If possible, move symptomatic residents a room with a resident with the same symptoms. Do not transfer residents (symptomatic or not) from outbreak-affected to unaffected units until the outbreak is over, unless it s medically urgent to do so.

20 Norovirus cycle 7 days Day 1, 2 (24 48) Incubation 3, 4 (24 48) Symptoms 5, 6, 7 (24 72) Symptom free Infectivity

21 Recommendations: New admissions No new admissions until 7 days after last case onset Hrs Day Incubation Symptoms Symptom free hrs hrs hrs Peak infectivity Last case onset No new admissions

22 Recommendations: Discharge patients Do not discharge patients until 3 days symptoms free Hrs Day Incubation Symptoms Symptom free hrs hrs hrs Peak infectivity Patient : symptoms resolved Discharge

23 Cohort nursing: Control Measures: Staff Maintain the same staff to resident assignments (cohort nursing). Discontinue floating staff from the outbreak-affected to unaffected units. Exclude non-essential personnel from outbreak-affected units. Contact precautions: Use contact precautions with all incontinent or diapered patients with diarrhea. Wear gloves and masks and possibly a disposable gown when caring for a patient after a vomiting or diarrhea accident. Remove before leaving the room and wash hands immediately. Hand hygiene: Do not use alcohol-based hand sanitizers - wash hands thoroughly and often.

24 Control Measures: Staff Cleaning/disinfecting surfaces: Clean up vomiting and diarrhea accidents promptly and follow Norovirus Long-Term Care Cleaning and Disinfection Procedures For routine cleaning during a norovirus outbreak (in areas without vomiting and diarrhea accidents) use a 1000 ppm bleach solution (1/3 cup bleach to 1 gallon water, freshly made within 24 hours) or other disinfectants EPA-registered for noroviral disinfection.

25

26 Control measures: Visitors Ask family members and visitors with vomiting and/or diarrhea to stay home until symptom free for 72 hours or more. Discourage visitors, especially to sick residents, until the outbreak is over. Do not allow children to enter the facility until the outbreak is over.

27

28 Attention Visitors!!! We presently have a number of ill residents. Please wash your hands before visiting and before leaving. You may wish to reconsider visiting at this time. If you have any questions, please contact either the Administrator or Director of Nursing Thank you.

29 When is the Outbreak over? No new cases and Min of 2 incubation period after the last case onset or No new cases for at least 1 week after the last case onset Hrs Day Incubation Symptoms Symptom free hrs hrs hrs Peak infectivity Last case onset Min of 2 incubation periods Max 1 week

30 INFLUENZA

31 Influenza Highly infectious viral illness of respiratory tract In the US, flu season peaks in the fall and winter Between 1976 and 2006, CDC estimates that flu-associated deaths ranged between 3,000 and 49,000 in the US

32 Groups at High Risk for Influenza Children < 5 y/o, especially those <=2 y/o Adults >= 65 y/o Pregnant American Indians/Alaskan Natives Persons with certain medical conditions: Asthma Morbidly Obese Heart Disease Lung Disease Weakened immune systems, e.g. HIV or AIDS

33 Implications Flu seasons are unpredictable due to Antigenic Drift small changes antibodies against older strains do not recognize reason why new seasonal vaccine every year Antigenic Shift Major changes new strain causes pandemic as no immunity Mild to severe illness with complications or death among residents. Source:

34

35 Chain of Transmission Host Chain of Transmission Person-to-person Droplet transmission Environment Agent

36 Flu cycle >7 days Day 1-4 (1-4 days) Incubation Day 5 11 (3-7 days) Symptoms (>7days) Symptom free Infectivity Ref:

37 Control Measures Vaccinate TIV Trivalent Inactivated Vaccine (TIV). The Centers for Medicare and Medicaid Services (CMS) - all residents. CDC and the Advisory Committee on Immunization Practices (ACIP), recommend that all health care personnel. Surveillance If in the community start surveillance Testing Any suspicion on ill residents

38 What is it an Outbreak? When 2 or more ill residents or 1 lab confirmed and other with similar signs and symptoms in one unit. Notify LHD if suspect outbreak.

39 Residents Staff Food handlers Custodian Caretakers Other Visitors Family members Control Measures

40 Control Measures: Residents Standard precautions Wearing gloves Wearing a gown Changing gloves and gowns after each encounter Perform hand hygiene before and after touching the resident, the resident s environment, or after touching the resident s respiratory secretions.

41 Control Measures: Residents Droplet precautions Cohort residents Facemask : Upon entering the resident s room. Remove it when leaving the resident s room Dispose it in a waste container. Have a resident wear one if transport is necessary. Communicate information about patients with suspected, probable, or confirmed influenza to appropriate personnel before transferring them to other departments.

42 Control Measures: Residents Antiviral and chemoprophylaxis All eligible, unvaccinated personnel or residents should receive it. Be Aware of the Possibility of a Drug-Resistant Virus - Infection-control mea sures are especially important for patients who are immunocompromised to reduce the risk for transmission of oseltamivir-resistant viruses. Notify the health department if a resident develops influenza while on or after receiving antiviral chemoprophylaxis.

43 Control Measures: Staff Restrict personnel movement from areas of the facility having illness to areas not affected by the outbreak. Monitor personnel absenteeism due to respiratory symptoms. Exclude those with influenza-like symptoms from work until at least 24 hours after they no longer have a fever.

44 Control Measures: Visitors Avoid new admissions or transfers to wards with symptomatic residents. Limit visitation and restrict visitation by children during community outbreaks of influenza. Exclude ill persons from visiting the facility via posted notices.

45 STL CO DOH and LTC COMMON GOAL COMMON GOAL Protect the health of our citizens. Minimize illness, hospitalization and death. Control the outbreak. Prevent future recurrence of similar nature.

46 Role of STL CO DOH Surveillance Applied Research Epidemiologic Investigation Prevention Measures 46

47 Role of STL CO DOH 1. Establish the existence of an outbreak 2. Confirm the diagnosis or develop a case definition 3. Relate the outbreak to person, place and time 4. Formulate tentative hypothesis 5. Plan a detailed epidemiologic investigation 6. Conduct the investigation 7. Analyze data 8. Test hypothesis 9. Formulate conclusions 10. Implement control measures 11. Make report / applied research 47

48 Establish the existence of an outbreak Initial phone call/interview with the ICN Total residents at the facility Total staff at the facility Number ill residents / staff Calculate Attack Rate number ill / total at risk Residents Staff Ill Total Attack Rate 53% 16% 48

49 Confirm the diagnosis Exclude bacterial cause Encourage samples for lab Free NORO testing by the State Lab Could be stools or vomitus Can be stored in the refrigerator for a week Need min 3, max 10 samples < 3 is insufficient for outbreak survey > 10 would be unnecessary/costly testing 49

50 Develop a case definition A resident or staff member of XXX facility experiencing NVD, or diarrhea alone, or vomiting alone, after XXX date. 50

51 Surveillance 3. Relate the outbreak to person, place and time 4. Formulate tentative hypothesis 5. Plan a detailed epidemiologic investigation 6. Conduct the investigation 7. Analyze data 8. Test hypothesis 9. Formulate conclusions 51

52 Surveillance Collection Utilization HEALTH DATA (eg. Line list) Analysis Dissemination Interpretation

53 Last Name First Name DOB Age Gender Resident Employee Nausea Vomiting Diarrhea Fever Abdominal Pain Other Hospitalized? test Floor/Ward/unit/buildi ng Onset Duration Line list Person Place Time

54 1/6 1/8 1/10 1/12 1/14 1/16 1/18 1/20 1/22 1/24 1/26 1/28 1/30 2/1 2/3 2/5 2/7 2/9 2/11 2/13 2/15 2/17 2/19 2/21 2/23 2/25 2/27 3/1 Number of cases Epi Curve n= Date of onset

55 5, 4% Symptoms n=122 24, 20% 93, 76% NVD Diarrhea Vomiting

56 Number of cases 60 Age groups n= Unknown Age groups

57 Role of STL CO DOH Surveillance Applied Research Epidemiologic Investigation Prevention Measures 57

58 The National Outbreak Reporting System (NORS) A web-based platform designed to support reporting to CDC Health departments, researchers, and public health policy makers use outbreak data to: Better understand the human health impacts of outbreaks Understand settings where outbreaks occur Evaluate the causes and contributing factors of outbreaks Determine major modes of transmission for agents that cause illness Help evaluate the burden of waterborne and enteric illness outbreaks in the United States and its territories Develop guidance and recommendations for preventing future outbreaks Source:

59 Good Love LTC workers love Hand washing

60 References Missouri Department of Health and Senior Services NOROVIRUS OUTBREAK CONTROL GUIDELINES FOR LONG-TERM CARE FACILITIES Norovirus Gastroenteritis CDC Management of outbreaks in healthcare settingshttp:// Resources: Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, A Norovirus Outbreak Control Resource Toolkit for Healthcare Settings Prevention toolkit:

61 Thank You Ayesha Iqbal MBBS MPH

62 Questions??

63

64 Seasonal Influenza Vaccine Trivalent (3 different flu types) & Quadrivalent (4 different flu types) Offers protection against two types of influenza A (one H1 and one H2) and one type of influenza B (Quadrivalent two B strains) Three basic flu shots : Intramuscular, intradermal (18-64 y/o), and high dose (65+) Nasal spray (2 to 49 y/o) CDC recommends seasonal influenza vaccine for all persons >= 6 mos old

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