An Outbreak of Invasive Pneumococcal Disease in a Long-Term Care Facility

An Outbreak of Invasive An Outbreak of Invasive Pneumococcal Disease in a Pneumococcal Disease in a

Long-Term Care FacilityLong-Term Care Facility

Sherif Ibrahim, MD, MPHSherif Ibrahim, MD, MPHDivision of Infectious Disease EpidemiologyDivision of Infectious Disease Epidemiology

02/18/201002/18/2010

ObjectivesObjectives

Background information on pneumoniaBackground information on pneumonia

Review the unique characteristics of the Review the unique characteristics of the population in LTCFpopulation in LTCF

Epidemiology of streptococcus pneumoniaeEpidemiology of streptococcus pneumoniae

Outbreak investigation and timeline of eventsOutbreak investigation and timeline of events

Outbreak descriptive analysis and results Outbreak descriptive analysis and results

Limitations of the studyLimitations of the study

What Went Wrong? ConclusionsWhat Went Wrong? Conclusions

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Background: Pneumonia Background: Pneumonia

An inflammation of the lung tissues due to either An inflammation of the lung tissues due to either infectious or non-infectious agents infectious or non-infectious agents

Commonly associated with predisposing factors and Commonly associated with predisposing factors and triggerstriggers

Annually, in the U.S., 2-3 million people develop Annually, in the U.S., 2-3 million people develop pneumoniapneumonia

In 2006, pneumonia caused 1.2 million hospitalizations In 2006, pneumonia caused 1.2 million hospitalizations and 55,477 deaths in the U.S.and 55,477 deaths in the U.S.

High risk groups (who is at risk?)High risk groups (who is at risk?)

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Background: Pneumonia Cont.Background: Pneumonia Cont.

Clinical Picture:Clinical Picture: fever, chills, productive cough, pleuritic fever, chills, productive cough, pleuritic chest pain, dyspnea, tachypnea, and tachycardiachest pain, dyspnea, tachypnea, and tachycardia

VaccinesVaccines: : several types of pneumonia can be prevented several types of pneumonia can be prevented by vaccinesby vaccines

ClassificationClassification: : according to the anatomical site of the according to the anatomical site of the lung, causative organism, and the setting in which it lung, causative organism, and the setting in which it developsdevelops

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Background: Pneumonia Cont.Background: Pneumonia Cont.

Hospital-acquired: Hospital-acquired: 48 hours after hospitalization. 48 hours after hospitalization.

Pathogens:Pathogens: gram-negative bacilli and staph. gram-negative bacilli and staph. (Drug -resistant organisms are of main concern)(Drug -resistant organisms are of main concern)

Community-acquired: Community-acquired: no contact with medical institutions no contact with medical institutions Pathogens:Pathogens: Streptococcus pneumoniae, Haemophilus Streptococcus pneumoniae, Haemophilus

influenzae and atypical organismsinfluenzae and atypical organisms

Long-Term Care Facility (LTCF) -acquiredLong-Term Care Facility (LTCF) -acquired

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LTCF-Acquired PneumoniaLTCF-Acquired Pneumonia

LTCF: institutions provide health care to people who are unable to manage independently in the community. LTCF include nursing homes, assisted living, rehab, etc.

Nursing home is a licensed facility that has organized professional staff and inpatient bed to provide health services to individuals who are not in acute phase of an illness

In the U.S. about 2.5 millions resides in LTCF and 1.5 millions in over 16,000 nursing homes

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LTCF-Acquired PneumoniaLTCF-Acquired Pneumonia

22ndnd most common cause of infection and leading cause of most common cause of infection and leading cause of death from infections in LTCFdeath from infections in LTCF

LTCF residents develop pneumonia almost 10 times more LTCF residents develop pneumonia almost 10 times more frequently than their peers in the community and they have frequently than their peers in the community and they have hospitalization rate of nearly 30 times higherhospitalization rate of nearly 30 times higher

Etiologic agents (bacterial)Etiologic agents (bacterial)– StreStreptococcus pneumoniae ptococcus pneumoniae – Haemophilus influenzaeHaemophilus influenzae– Staphylococcus AureusStaphylococcus Aureus– Moraxella catarrhalis Moraxella catarrhalis – Gram-negative bacilliGram-negative bacilli– LegionellaLegionella

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LTCF-Acquired PneumoniaLTCF-Acquired PneumoniaPopulation Characters:Population Characters:

Several predisposing factorsSeveral predisposing factors: : Old ageOld age

Poor cognitive and functional statusPoor cognitive and functional status

Difficulty swallowing and tube feedingDifficulty swallowing and tube feeding

Inadequate oral careInadequate oral care

Immune system dysfunction due to multiple Immune system dysfunction due to multiple underlying chronic conditions, malnutrition, etcunderlying chronic conditions, malnutrition, etc

PolypharmacyPolypharmacy

Invasive devicesInvasive devices

Frequent hospitalizationsFrequent hospitalizations88


Triggering factorsTriggering factors: :

Upper respiratory tract viral infection (influenza, Upper respiratory tract viral infection (influenza, parainfluenza & Respiratory Syncytial Virus)parainfluenza & Respiratory Syncytial Virus)

Atypical clinical pictureAtypical clinical picture SymptomsSymptoms:: anorexia, weakness, restlessness anorexia, weakness, restlessness

and agitation, falling, incontinence, dyspneaand agitation, falling, incontinence, dyspnea SignsSigns: : altered mental status, diminished or absent altered mental status, diminished or absent

responsiveness, fever, tachycardia, tachypnea, responsiveness, fever, tachycardia, tachypnea, wheezes or crackles, and decrease in Owheezes or crackles, and decrease in O22 Sat Sat

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Institutional factors:Institutional factors:Larger facilities with a single nursing unit or Larger facilities with a single nursing unit or multiple units with a shared nursing staffmultiple units with a shared nursing staff

Heterogeneous populationsHeterogeneous populations

Closed environment & group activitiesClosed environment & group activities

Low immunization rates (staff and residents)Low immunization rates (staff and residents)

Excessive use of antibioticsExcessive use of antibiotics

Widespread colonization of residents with Widespread colonization of residents with antimicrobial-resistant organismsantimicrobial-resistant organisms

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Epidemiology of Streptococcus pneumoniaeEpidemiology of Streptococcus pneumoniae

Lancet-shaped, gram-positive, anaerobic Lancet-shaped, gram-positive, anaerobic bacteriabacteriaHas polysaccharides capsule which acts as a Has polysaccharides capsule which acts as a primary basis for its pathogenicityprimary basis for its pathogenicitySeveral serotypes have been identified Several serotypes have been identified Commonly colonizes the nasopharynx of 5-70% Commonly colonizes the nasopharynx of 5-70% of healthy adultsof healthy adultsRates and duration of asymptomatic carriage Rates and duration of asymptomatic carriage vary with age, environment and the presence of vary with age, environment and the presence of URTIURTI

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Epidemiology of Streptococcus pneumoniae Epidemiology of Streptococcus pneumoniae Cont.Cont.

Major clinical syndromeMajor clinical syndrome: : Pneumonia, Meningitis, and BacteremiaPneumonia, Meningitis, and BacteremiaTransmissionTransmission: :

1.1. Direct person-to-person via droplets. Direct person-to-person via droplets. 2.2. Autoinoculation in persons carrying the bacteria Autoinoculation in persons carrying the bacteria

in their URTin their URT

Season: Season: winter and early springwinter and early springIncubation Period: Incubation Period: 1-3 days1-3 daysCommunicability: Communicability: unknown unknown

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Is the most common cause of community-Is the most common cause of community-acquired pneumonia (accounts for 25-30%)acquired pneumonia (accounts for 25-30%)

Causes an estimated 40,000 deaths annuallyCauses an estimated 40,000 deaths annually

Incidence of invasive disease vary with age Incidence of invasive disease vary with age

More than 90 serotypes may cause invasive More than 90 serotypes may cause invasive disease. The 23-valent polysaccharide vaccine disease. The 23-valent polysaccharide vaccine (adult) covers 88% of these serotypes(adult) covers 88% of these serotypes

Who should get the pneumococcal vaccine?

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Indications for pneumococcal vaccination:People who are 65 years of age or olderPeople 2 years of age or older who have a chronic illness such as cardiovascular or pulmonary (lung) disease, sickle cell disease, etc.People 2 years of age or older with a weakened immune system due to illnesses, medications, etc.People 2 to 64 years of age who are living in LTCFPeople 19-64 years of age who smoke cigarettes or have asthma

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Outbreak of Streptococcus Pneumonia in a LTCFOutbreak of Streptococcus Pneumonia in a LTCFTimeline of The OutbreakTimeline of The Outbreak

Feb 18, 2009Feb 18, 2009 Two Lab reports indicating positive blood culture Two Lab reports indicating positive blood culture

for streptococcus pneumoniae sent to LHDfor streptococcus pneumoniae sent to LHD (Do you have an outbreak? Do you have a diagnosis)(Do you have an outbreak? Do you have a diagnosis)

Reported to and consulted with state health Reported to and consulted with state health officialsofficials

Site visit by local Health officialsSite visit by local Health officials (Field work: What would you need with you?)(Field work: What would you need with you?)

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Timeline of The Outbreak Cont.Timeline of The Outbreak Cont.The Facility The Facility

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Timeline of The Outbreak Cont.Timeline of The Outbreak Cont.

Immediate actions taken:Immediate actions taken:

Initial chart reviewInitial chart review Developing a provisional Developing a provisional case definitioncase definition Creating a line list of casesCreating a line list of cases Request immunization records (residents & staff) Request immunization records (residents & staff) Request staff attendance and illness historyRequest staff attendance and illness history Active case finding: Active case finding: clinical evaluation, CXR, CBC, clinical evaluation, CXR, CBC,

blood & sputum culture, NP swap for viral studiesblood & sputum culture, NP swap for viral studies Implementing infection Implementing infection control & prevention measurescontrol & prevention measures

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Infection control and prevention measures:

Standard Precautions: Hand-hygiene Hand-hygiene Personal Protective Equipment (PPE)Personal Protective Equipment (PPE) Cough etiquetteCough etiquette Environmental controlEnvironmental control Needles and sharpsNeedles and sharps Soiled patient-care equipmentSoiled patient-care equipment Safe injection practiceSafe injection practice

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Droplet Precautions:Droplet Precautions:A single patient room if possible A single patient room if possible

Cohorting patients and staff Cohorting patients and staff

Maintain a distance > 3 feet and drawing a curtain between bedsMaintain a distance > 3 feet and drawing a curtain between beds

Practice good hand hygiene, cough etiquette, and use PPEPractice good hand hygiene, cough etiquette, and use PPE

Patients to wear a mask if they leave their roomsPatients to wear a mask if they leave their rooms

Limit social gathering for patientsLimit social gathering for patients

Implement visitor policy Implement visitor policy

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Feb 20, 2009Feb 20, 2009 - Site visit by state and local health officials- Site visit by state and local health officials - Reviewing infection control log and chart review- Reviewing infection control log and chart review - Revising the case definition- Revising the case definition - Reviewing and implementing infection control- Reviewing and implementing infection control measuresmeasures

Feb 24, 2009Feb 24, 2009- Consultation with CDC by state and local health - Consultation with CDC by state and local health officials officials

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Deaths by Month and YearDeaths by Month and Year

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Pneumonia Cases by Month and YearPneumonia Cases by Month and Year

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Illness Onset of Residents, n=34Illness Onset of Residents, n=34

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Timeline of The Outbreak Cont.Timeline of The Outbreak Cont.Feb 26, 2009Feb 26, 2009- Site visit by the state licensing agency- Site visit by the state licensing agency

- Closing the facility for new admissions- Closing the facility for new admissions - Antibiotic prophylaxis for all residents- Antibiotic prophylaxis for all residents - Update all residents pneumococcal vaccination (> 5 Years)- Update all residents pneumococcal vaccination (> 5 Years) - Continue to implement infection control measures- Continue to implement infection control measures

Feb 27, 2009Feb 27, 2009 - Site visit by state and local health officials- Site visit by state and local health officials

- Specimen collection. NP swabs, urine, and serum samples- Specimen collection. NP swabs, urine, and serum samples - Reviewing infection control measures- Reviewing infection control measures

March 11, 2009March 11, 2009 - End of illness investigation analysis time period- End of illness investigation analysis time period - Reopen the facility for new admission- Reopen the facility for new admission - In-service training provided by state and local health officials - In-service training provided by state and local health officials

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Descriptive Analysis – MethodDescriptive Analysis – MethodDescriptive EpidemiologyDescriptive Epidemiology

Descriptive analysis of case-patients Descriptive analysis of case-patients characteristicscharacteristics

Case definition: Case definition: Residents with invasive pneumococcal infection Residents with invasive pneumococcal infection or radiographically confirmed pneumonia with an or radiographically confirmed pneumonia with an illness onset between January 11 and March 11, illness onset between January 11 and March 11, 20092009

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Descriptive Analysis-ResultsDescriptive Analysis-Results28 cases:28 cases:- Mean age: 83 years (M) and 85 years (F) - Mean age: 83 years (M) and 85 years (F) - 3 cases (11%) had invasive pneumococcal infections- 3 cases (11%) had invasive pneumococcal infections- 25 (89%) had pneumonia- 25 (89%) had pneumonia

The attack rate, calculated using an average daily The attack rate, calculated using an average daily census, was 52.4%census, was 52.4%

22 (79%) cases had previously received the 22 (79%) cases had previously received the pneumococcal vaccinepneumococcal vaccine

15 (54%) hospitalizations and 7 (25%) deaths15 (54%) hospitalizations and 7 (25%) deaths

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Descriptive Analysis-Results Cont.Descriptive Analysis-Results Cont.

22 (79%) cases had an onset of illness prior to outbreak 22 (79%) cases had an onset of illness prior to outbreak notificationnotification

Streptococcus pneumoniae serotype 19a was isolated Streptococcus pneumoniae serotype 19a was isolated from all cases with invasive pneumococcal infectionfrom all cases with invasive pneumococcal infection

2 cases of respiratory syncytial virus by PCR2 cases of respiratory syncytial virus by PCR

NP swabs were negative for influenza and urine samples NP swabs were negative for influenza and urine samples were negative for Legionella were negative for Legionella

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Limitations of the StudyLimitations of the Study This was a case series study that describes This was a case series study that describes

clinical/epidemiological characteristics of a group of clinical/epidemiological characteristics of a group of individuals with certain disease in a given time. individuals with certain disease in a given time.

Limitations:Limitations:

Incomplete documentation Incomplete documentation

Exclusion of cases that did not match the case Exclusion of cases that did not match the case definitiondefinition

Delay in collecting specimen for testingDelay in collecting specimen for testing

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What Went Wrong?What Went Wrong?

Delay in interpretation of the surveillance data Delay in interpretation of the surveillance data failure of early detection of the outbreak failure of early detection of the outbreak delay delay in implementing control & prevention measures in implementing control & prevention measures

Excessive use of empiric antibioticsExcessive use of empiric antibiotics

Physician’s standing orders for symptomatic Physician’s standing orders for symptomatic treatmenttreatment

Missteps in clinical evaluation and managementMissteps in clinical evaluation and management

Gaps in documentation of clinical dataGaps in documentation of clinical data

Staffing issuesStaffing issues

Lack of adequate infection control trainingLack of adequate infection control training3232

Descriptive Analysis-ConclusionsDescriptive Analysis-Conclusions

An outbreak, likely caused by S. pneumoniae, occurred An outbreak, likely caused by S. pneumoniae, occurred among residents of the long-term care facilityamong residents of the long-term care facility

Co-infection with RSV may have contributed to illness Co-infection with RSV may have contributed to illness severityseverity

Proper infection control, including droplet precautions Proper infection control, including droplet precautions and investigative methods, was delayed by late outbreak and investigative methods, was delayed by late outbreak notificationnotification

Outbreak detection could be improved by providing staff Outbreak detection could be improved by providing staff of long-term care facilities with training focused on of long-term care facilities with training focused on disease surveillance and appropriate clinical evaluation disease surveillance and appropriate clinical evaluation of such populationof such population

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Acknowledgment WVDHHR WVDHHR

Dee BixlerDee Bixler

Maria Del RosarioMaria Del Rosario

Rachel RadcliffeRachel Radcliffe

Thein ShweThein Shwe

Lillie ClayLillie Clay

OLSOLS

Christi ClarkChristi Clark

MOVHDMOVHD

Richard WittbergRichard Wittberg

CDCCDC

Chris Van Beneden Chris Van Beneden

The Team at the Respiratory Diseases Branch The Team at the Respiratory Diseases Branch 3434

QuestionsQuestions

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An Outbreak of Invasive Pneumococcal Disease in a Long-Term Care Facility

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