Emerging and Re-emerging Infectious Diseases

INFECTION PREVENTION AND CONTROL IN EMERGING INFECTIOUS DISEASES

Mark Kristoffer U. Pasayan, MD, FPCP, DPSMID

Internal Medicine – Infectious Diseases

SOUTHEAST ASIA IS AN EID HOTSPOT

EMERGING INFECTIONS IN THE PHILIPPINES Ebola Reston in monkeys (Reston, Virginia)

2006

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1998

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2002

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2003

2005

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Serological Surveillance ABLV

West Nile Virus Pseudo outbreak (RITM as Referral Laboratory)

SARS Outbreak

Pandemic A H1N1

1989

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Bioterrorism threat using Bacillus anthracis as biological weapon

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Meningococcemia outbreak in CAR2004

2001

20082009 ▼ Ebola Reston in pigs and humans/ Leptospirosis/ Salmonella typhi

2007

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Resistant Shigella flexneri 2a in Cavite, Bohol and Cotabato

2010

▼ Dengue2011

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Chikungunya2012

Leptospirosis

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No H5N1, H7N9,

Ebola in PH2013 Pertussis, Measles

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2014

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Measles, MERS CoV, Henipah

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1992

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1996

Ebola Reston in monkeys (Sienna, Italy)

Ebola Reston in monkeys (US)

2015 MERS CoV, Ebola Reston

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EMERGING AND RE-EMERGING INFECTIOUS DISEASES

Middle East respiratory syndrome coronavirus (MERS-CoV)

1,638 laboratory confirmed cases of MERS-CoV infection, globally

587 MERS-CoV – related deaths since September 2012

26 countries have reported cases of MERS-CoV since September 2012

WHO, as of February 16, 2016

A 35-year-old male was tested positive for MERS-CoV on October 12 in South Korea.

WHO, as of February 14, 2015

Between January 22 and 27 2016, KSA notified WHO of 5 additional cases of MERS-CoV infection

One laboratory-confirmed case from the Philippines, reported on July 6, 2015

On 24 January 2016, Thailand notified WHO of 1 laboratory case of MERS-CoV infection

What is the mode of human-to-human transmission of MERS - Coronavirus?

AIRBORNE

DROPLET

CONTACT

VECTOR-BORNE

MERS-CoV, like other coronaviruses,

is thought to spread from an infected

person’s respiratory secretions, such

as through coughing. However, the

precise ways the virus spreads are

not currently well understood.

Ebola Virus Disease

28, 639 cases of Ebola virus disease and 11,316 deaths as of 31 January 2016

WHO, as of January 31, 2016

On 7 November 2015 , WHO declared that Ebola virus transmission had been stopped in Sierra Leone; on 90-day period of enhance surveillance

On 14 January 2016, a new confirmed case was reported in Sierra Leone

28, 639 cases of Ebola virus disease and 11,316 deaths as of January 31, 2016

WHO, as of January 31, 2016

Human-to-human transmission linked to the most recent cluster of cases in Liberia was declared to have ended on 14 January 2016

Guinea was declared free of Ebola transmission on 29 December 2015

What is the mode of human-to-human transmission of Ebola virus?

AIRBORNE

DROPLET

CONTACT

VECTOR-BORNE

Ebola among healthcare personnel and other people

is associated with DIRECT CONTACT with

symptomatic people with Ebola (or the bodies of

people who have died from Ebola) and DIRECT

CONTACT with body fluids from Ebola patients.

Airborne transmission of Ebola virus among humans

has never been demonstrated in investigations that

have described human-to-human transmission,

although hypothetical concerns about aerosol

transmission of Ebola virus have been raised

Best Defense Strategy:

GOOD BASIC INFECTION

CONTROL PRACTICE

Yes No Yes, with reservation

IPC and EID

Emerging infections associated with healthcare

depends on the full implementation of the core

components of IPC programs.

Healthcare institutions are advised to consider

reinforcing a service for the oversight of HCW’s health

to ensure a safe environment for patients and HCW’s

HCWs are provided with the best locally available

protection for caring for patients infected with an EID,

and are followed up if exposure has occurred.

Core component for IPC programs

Organization of IPC programs

Technical guidelines

Human resources (training, staffing, occupational health)

Surveillance of diseases and of compliance with IPC

practices

Microbiology laboratory support

Clean and safe environment

Monitoring and evaluation of IPC program

Links with public health and other services

Principles of Infection Prevention and Control Strategies Associated with Health Care

CONTROLS

Administrative

Environmental and Engineering PPE

Administrative Controls

■ Clinical triage

■ IPC infrastructures and activities

■ Education of HCWs

■ Prevention of overcrowding in waiting areas

■ Providing dedicated waiting areas for the ill and placement of

hospital patients

■ Organization of health-care services for adequate provision and

use of supplies

■ Policies and procedures for all facets of occupational health

■ Monitoring of HCW compliance

Administrative ControlsInfrastructure of Policies and Procedures

■ Prevent, detect, and control infections– from first point of patient encounter at triage through discharge

■ Implement occupational health policies and procedures– e.g. Exclude ill health care personnel from facility

■ Implement source control measures– e.g. change ventilator circuits between patients

– One-time use of oxygen delivery devices

– Sufficient PPE available at all times

■ Organize health care service delivery – e.g. Postponement of elective procedures if necessary

– Restrict visitors

Administrative ControlsManagement of PUIs/Confirmed Cases■ Timely and Effective Patient Triage

– Prevent overcrowding in (dedicated) waiting areas

– Avoid admitting patients with no risk factors

■ Admitted patients

– Place in one ward, when possible

– Minimum of 1 meter distance between patients with ARI

– Cohorting policies

■ Drafting and access to specific case and clinical management

protocols

■ Safe transport or discharge home


CONTROLS

Administrative


Engineering Controls: Objective

Reduce exposures at the source and reduce the

spread of pathogens during health care delivery

using basic health-care facility infrastructure

Engineering Controls: Examples

■ Physical barriers or partitions to guide

patients through triage areas

■ Appropriate environmental ventilation

– At least 12 air changes per hour

– Keep doors and windows open onto

well ventilated corridors

– If available, ensure air-handling

systems (with appropriate directionality,

filtration, exchange rate, etc.) are

properly maintained

Engineering Controls: Examples

■ Curtains between shared areas

■ Regular and proper technique for

environmental cleaning

■ Closed systems for airway suctioning in

intubated patients


CONTROLS

Administrative


Personal Protective Equipment

■ Rational and consistent use of available PPE and

appropriate hand hygiene

PPE is the strongest in the hierarchy of IPC measures to

prevent transmission of EIDs?

Yes No Yes, with reservation


■ Rational and consistent use of available PPE and

appropriate hand hygiene

■ PPE is the last and weakest in the hierarchy of IPC

measures AND should not be relied upon as a primary

prevention strategy.

■ In the absence of effective administrative and

engineering controls, PPE HAS LIMITED BENEFIT


■ Workers must receive training on and demonstrate an

understanding of:

– When to use PPE

– What PPE is necessary

– How to properly don and doff PPE

– How to properly dispose of or disinfect and maintain PPE

– Limitations of PPE

■ Any reusable PPE must be properly cleaned, decontaminated,

and maintained after and between uses.


PPE use is based on risk assessment of potential exposure and non-intact skin and

should be applied during all potential exposure times, removed correctly and

does not eliminate need for hand hygiene

Recommended Personal Protective Equipment

■ Goggles or face shield

■ Fit-tested N95 mask (or P100)

■ Impermeable gown

■ Gloves

■ Shoe cover

■ Additional: cap


■ General sequence to donning for respiratory

pathogens: gown, respirator, goggles or face

shield, gloves.

■ General sequence to doffing: gloves, goggles

or face shield, gown, then respirator.


Except for respirator, remove PPE at doorway or in anteroom.

Remove respirator after leaving patient room and closing

door.

Careful attention should be given to prevent contamination of

clothing and skin during the process of removing PPE.

Perform hand hygiene as described above immediately before

putting on and after removing all PPE.

Infection prevention and control (IPC) precautions

■ Standard precautions – cornerstone for

providing safe healthcare, reducing the risks

of further infection and protecting HCWs,

should always be applied in all health care

settings for all patients.

Hand Hygiene

PPE

Prevention Needle-

stick Injury

Safe Waste

CDS

Environment

Respiratory Hygiene

■ The use of PPE does not eliminate the need

for hand hygiene. Hand hygiene is also

necessary while putting on and especially

when taking off PPE.

■ Ensure that cleaning and disinfection

procedures are followed consistently and

correctly

■ Cleaning environmental surfaces with water

and detergent and applying commonly used

disinfectants is an effective and sufficient

procedure.

What is the most common mode of transmission of infection in the healthcare settings?

Contact Transmission

Droplet Transmission

Airborne Transmission

Inoculation

Additional IPC precautions…

■ In addition to Standard Precautions…

– Use a medical mask when in close contact and

upon entering the room or cubicle of the patient

– Perform hand hygiene before and after touching the

patient and his or her surroundings and

immediately after removal of a medical mask

IPC precautions for aerosol-generating procedures

■ There is a consistent association between pathogen

transmission and tracheal intubation

■ There is an increased risk of infection associated with

tracheostomy, non-invasive ventilation and manual

ventilation before intubation

When caring for patients with probable or confirmed EID…

■ Place patients in adequately ventilated single rooms or

‘Airborne Precaution’ rooms

■ When single rooms are not available, place confirmed

patients together and separate them from probable

patients

■ If this is not possible, place patient beds at least 1m

apart

■ Limit the number of HCWs, family members and visitors

in contact with a patient

When caring for patients with probable or confirmed EID…

■ If possible, use either disposable equipment or

dedicated equipment

■ If equipment needs to be shared among patients, clean

and disinfect it after each patient use

■ Avoid the movement and transport of patients out of

barrier nursing room or area unless medically

necessary. If transport is required, use routes of

transport that minimize exposures of staff, other

patients and visitors.

Duration of barrier nursing precautions

■ Fact: duration of infectivity of (some) EIDs is unknown

■ While Standard Precautions should always be applied,

additional barrier nursing precautions should be used

for the duration of symptomatic illness, and continued

for 24 hours after the resolution of symptoms

■ Testing for viral shedding should assist decision-making

when readily available.

Collection and handling of laboratory specimens from patients EIDs of potential concern

■ Ensure that HCWs who collect specimens use

appropriate PPE

■ Ensure that personnel who transport specimens are

trained in safe handling practices and spill

decontamination procedures

■ Ensure that healthcare facility laboratories adhere to

appropriate biosafety practices and transport

requirements

■ Need for comprehensive strategy to

enhance IPC

– Efforts directed to EIDs must be

aggregated and efficient to build IPC

capacity in the country

■ Need for integrated approach

– WHO: improved liaison/collaboration

among IPC-related initiatives

– DOH: vertical programs

■ Creation of national resources centers that

can foster country capacity building

■ Political will + combination of efforts =

WORKS!

EBOLA VIRUS DISEASE MERS-CoV

Emerging Threats■ A new variant of a fatal neurologic illness, Creutzfeldt-Jakob disease, appeared

in the United Kingdom and was possibly transmitted by ingestion of beef from

animals afflicted with bovine spongiform encephalopathy, also known as "mad

cow disease."

■ A new and virulent strain of influenza in Hong Kong raised fears of a global

pandemic

■ The United States had several multistate foodborne outbreaks, including

outbreaks caused by Cyclospora parasites; hepatitis A virus; and Escherichia

coli O157:H7

■ Staphylococcus aureus with reduced susceptibility to vancomycin was

reported for the first time in the United States and Japan

■ A new strain of tuberculosis (strain W), which is multidrug-resistant and

appears more frequently in persons with HIV infection, has become endemic

in New York

In recent years, we have seen the emergence and re-emergence of

many infectious diseases.

EID outbreaks highlight the shortcomings in our understanding of the

complexities of infectious diseases.

The reasons for emergence and re-emergence are multiple and

complex.

Clearly, human activities are a key factor for driving disease emergence

and current knowledge of the various emerging viruses is far from

complete.

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It could be said that the current global

situation favors disease emergence,

and we may be faced with MORE

outbreaks or pandemics of EIDs in the

FUTURE

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Thank you for listening

Emerging and Re-emerging Infectious Diseases

Healthcare

Transcript of Emerging and Re-emerging Infectious Diseases