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Management of Respiratory Disease Outbreaks in Long-Term Care Facilities (First 48 Hours)

Management of Respiratory Disease Outbreaks in Long-Term Care Facilities (First 48 Hours). Sherif Ibrahim, MD, MPH Division of Infectious Disease Epidemiology WVDHHR, BPH, OEPS November 17 th , 2010 . Objectives . Describe LTCF populations and risk factors

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Management of Respiratory Disease Outbreaks in Long-Term Care Facilities (First 48 Hours)

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  1. Management of Respiratory Disease Outbreaks in Long-Term Care Facilities(First 48 Hours) Sherif Ibrahim, MD, MPH Division of Infectious Disease Epidemiology WVDHHR, BPH, OEPS November 17th, 2010

  2. 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 Study

  3. 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

  4. Population Characters • In the U.S there are 1.8 million Americans residing in the nation’s 16,500 NHs • Average length of stay 835 days (2.4 years) • Average age of residents is 80 YO • 88% > are 65 YO and 45% are > 85 YO • Over 70% of residents are females • 50% of the residents takes >9 medications /day CDC statistics

  5. Population Characters Cont. • One in four people aged 65 or more will spent some times in a LTCF • In 2030, 70 million US citizens will be > 65 YO • With 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

  6. 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

  7. Risk Factors for Infection in LTCFs:Residents Factors • Old age • Poor cognitive and functional status • Difficulty swallowing and tube feeding • Inadequate oral care • Immune system dysfunction • Polypharmacy (prescribing multiple meds) • Invasive devices • Frequent hospitalization

  8. 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 staff • Heterogeneous populations • Closed environment & group activities

  9. Risk Factors for Infections in LTCFs:Institutional Factors Cont. • Low immunization rates (staff and residents) • Pathogen exposure in shared living spaces • Common air circulation • Direct/indirect contact with health care personnel/visitors/other residents • Direct/indirect contact with equipment used to provide care

  10. 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

  11. Challenges of Respiratory Disease Outbreaks Investigation • Challenges in finding baseline disease rates • Seasonality: cyclical changes • Wide range of pathogens can cause similar clinical syndromes • Outbreaks may involve multiple pathogens • Potential new pathogens (H1N1, Human metapneumovirus) • Limited lab resources and diagnostic capacity

  12. Why Should Respiratory Disease Outbreaks Be Investigated ? • Vulnerable populations • High morbidity and mortality rates • Infections and fever are the most common cause of hospitalization of LTCF residents • Pneumonia is the leading cause of death and hospitalization • Some respiratory diseases are preventable • Prevent overuse of antibiotics

  13. 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 rates • Advance knowledge and lessons learned

  14. Initial Outbreak Notification Notification call: what do you need to know? • Who: (ills and total population at-risk) • Where: facility, unit • When: date of onset • What: Clinical information, lab studies • Interventions already in-place • Administrative issues

  15. 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

  16. 1) Establish the Existence of a Respiratory Disease Outbreak • Determine the endemic rate or the base line of the disease • Use facility’s surveillance data • Review the case definition of respiratory syndromes: • URTI (Upper Respiratory Tract Infection) • ILI (Influenza-Like Illness) • LRTI (Lower Respiratory Tract Infection) • Pneumonia

  17. 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 issues • Management and operational issues

  18. 3- Develop an Initial Case Definition • 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

  19. 4- Start a Line list • Include 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

  20. Example of a line list (1)

  21. Example of a line list (2)

  22. 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

  23. 6- Initiate Active Surveillance • Active 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

  24. 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 status • Applies to staff who provide direct patient care • Involve 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

  25. 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

  26. Initial Infection Control Measures Cont. Implement respiratory hygiene & cough etiquette • Post visual alerts • Provide tissues or masks to symptomatic residents and visitors • Provide tissues and alcohol-based hand rubs in common areas and waiting rooms • Ensure enough handwashing facilities & supplies • Encourage social distancing • Ill residents should be discouraged from using common areas where feasible

  27. 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 admissions • Evaluate and exclude ill staff until recovered

  28. Differential Diagnosis Clues • Principle and case definition of respiratory diseases • Review the most common pathogens encountered in LTCFs • Population characteristics • Season • Exposures

  29. Summary of Investigation steps in the First 48 Hours • Establish the existence of a respiratory disease outbreak • Verify the diagnosis / Field investigation • Develop an initial case definition • Start a line list • Draw an epidemic curve • Initiate active surveillance • Implement initial infection control measures

  30. 8- Follow Up Beyond 48 Hours • Continue active surveillance • Organize and re-evaluate your data • Perform descriptive epidemiology • Confirm diagnosis (lab confirmation) • Develop hypothesis • Re-evaluate your case definition • Re-evaluate infection prevention measures and keep a balance with residents’ psychosocial needs • Communicate findings • Lessons learned and measures to prevent future outbreaks

  31. Recent advances in Diagnostics • Multiple Pathogens Assays MPAs • Based on PCR technology • Allows convenient testing for several agents in a short period of time • Immediate use in emergencies • CDC 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)

  32. Conclusions • Respiratory 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

  33. Questions Case Study

  34. Resources • DIDE: Division of Infection Diseases Epidemiology • Website: www.wvidep.org • Phone # 304-558-5358 or 800-423-1271 • Fax: 304-558-8736 • Office of Laboratory Services 304-558-3530

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