Public Health Outbreaks, Responses: focus --Cough...
Transcript of Public Health Outbreaks, Responses: focus --Cough...
for for MUSCMUSC
Public HealthPublic Health
InterInter--disciplinary disciplinary
CourseCourse
Feb. 2011Feb. 2011
Public Health Outbreaks, Public Health Outbreaks, Responses: focusResponses: focus
Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant/ Epidemiologist, SC DHECInfectious Disease Consultant/ Epidemiologist, SC DHEC
CoCo--Chair, SC Pandemic Influenza Ethics Chair, SC Pandemic Influenza Ethics
MUSCMUSC
Public HealthPublic Health
disciplinary disciplinary
CourseCourse
Feb. 2011Feb. 2011
Public Health Outbreaks, Public Health Outbreaks, Responses: focusResponses: focus-- Cough CootiesCough Cooties
R. Ball, MD MPH FACP
Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant/ Epidemiologist, SC DHECInfectious Disease Consultant/ Epidemiologist, SC DHEC
Chair, SC Pandemic Influenza Ethics Chair, SC Pandemic Influenza Ethics TaskforceTaskforce
1. Confirm the Diagnosis/ What is the true Dx?
2. Organize data: time, place, person = line listing,
with demographics & risk factors
3. Make an epi-curve, look for more cases
4. Ask relevant Qs of Pts, generate an hypothesis
5. Develop a (broad) case definition
6. Collect (additional) samples (not
7. Define controls (? case-
8. Refine hypothesis, data, studies… etc…
Cluster/ Outbreak InvestigationCluster/ Outbreak Investigation
R. Ball, MD MPH FACP
Confirm the Diagnosis/ What is the true Dx?
Organize data: time, place, person = line listing,
with demographics & risk factors
curve, look for more cases
Ask relevant Qs of Pts, generate an hypothesis
Develop a (broad) case definition
Collect (additional) samples (not nec. to test all)
-control study)
Refine hypothesis, data, studies… etc…
Cluster/ Outbreak InvestigationCluster/ Outbreak Investigation
TERMINOLOGY: “EXPOSURE” …TERMINOLOGY: “EXPOSURE” …
“EXPOSUREEXPOSURE” = a behavioral event/ incident
(ie, needlestick, mucous membrane splash)
“INFECTIONINFECTION” = a biologic/ immunologic event
(ie, growth of organism, antibody response
“DISEASEDISEASE” = a clinical event
(ie, symptoms and/or signs of the infection)
R. Ball, MD MPH FACP
TERMINOLOGY: “EXPOSURE” …TERMINOLOGY: “EXPOSURE” …
= a behavioral event/ incident
, needlestick, mucous membrane splash)
= a biologic/ immunologic event
, growth of organism, antibody response
= seroconversion)
= a clinical event
, symptoms and/or signs of the infection)
Cluster v. Outbreak v. Epidemic ?Cluster v. Outbreak v. Epidemic ?
“CLUSTERCLUSTER” ~ an increase in cases above
baseline, at one point in time, usually focal
“OUTBREAK” ~ an ongoing cluster (+ time),
usually with growing # of cases among contacts
“EPIDEMIC” ~ an ongoing outbreak, with #s of
cases far exceeding baseline, over a longer span
of time, and beyond the immediate contactsR. Ball, MD MPH FACP
Cluster v. Outbreak v. Epidemic ?Cluster v. Outbreak v. Epidemic ?
~ an increase in cases above
baseline, at one point in time, usually focal
~ an ongoing cluster (+ time),
usually with growing # of cases among contacts
~ an ongoing outbreak, with #s of
cases far exceeding baseline, over a longer span
of time, and beyond the immediate contacts
School nurse vs. pediatricianSchool nurse vs. pediatrician
�� A school nurse calls DHEC A school nurse calls DHEC some children have severe cough some children have severe cough illness, but the pediatricians allow illness, but the pediatricians allow the children to return the children to return
What would you What would you
�� DHEC: DHEC: make Dx, notificationmake Dx, notificationtracing, tracing, PEP the contacts, PEP the contacts, indigent Ptindigent Pt. ? private . ? private provider roles. provider roles. What about HIPAA, etc?What about HIPAA, etc?
R. Ball, MD MPH FACP
School nurse vs. pediatricianSchool nurse vs. pediatrician
A school nurse calls DHEC A school nurse calls DHEC Epi:Epi:some children have severe cough some children have severe cough illness, but the pediatricians allow illness, but the pediatricians allow the children to return the children to return to to class.class.
What would you What would you do?do?
make Dx, notificationmake Dx, notification, contact , contact PEP the contacts, PEP the contacts, even Tx if even Tx if . ? private . ? private & public health & public health
What about HIPAA, etc?What about HIPAA, etc?
Q: What’s the most pQ: What’s the most pcommunicable infectious disease?communicable infectious disease?
�In the viral kingdom ?�In the bacterial kingdom ?
Inf.Dis.: CommunicabilityInf.Dis.: Communicability
�� A: A: ViralViral: measles > : measles > several several herpesvirusesherpesviruses�� A: A: BacterialBacterial: pertussis > ?staph.: pertussis > ?staph.
�� Q: Are there any more Q: Are there any more �� A: yesA: yes-- CoxsiellaCoxsiella burnettiburnetti
R. Ball, MD MPH FACP
Q: What’s the most pQ: What’s the most p--p contagious/ p contagious/ communicable infectious disease?communicable infectious disease?
kingdom ?
Inf.Dis.: CommunicabilityInf.Dis.: Communicability
: measles > : measles > varicellavaricella > > herpesvirusesherpesviruses > > flu > othersflu > others
: pertussis > ?staph.: pertussis > ?staph.
Q: Are there any more Q: Are there any more transmissabletransmissable organisms?organisms?burnettiburnetti (Q fever)(Q fever)-- 1 organism1 organism
Pertussis Dx, Tx, & PEPPertussis Dx, Tx, & PEP
�� Suspect if paroxysmal or prolonged Suspect if paroxysmal or prolonged cough illness (seldom see whoop), cough illness (seldom see whoop), especially if especially if >>1 other family/ friend ill1 other family/ friend ill
�� Dx: NP swab for PCRDx: NP swab for PCR�� Tx: azithromycinTx: azithromycin�� PEP: azithromycinPEP: azithromycin�� DHEC assists in PEPDHEC assists in PEP
R. Ball, MD MPH FACP
Pertussis Dx, Tx, & PEPPertussis Dx, Tx, & PEP
Suspect if paroxysmal or prolonged Suspect if paroxysmal or prolonged cough illness (seldom see whoop), cough illness (seldom see whoop),
1 other family/ friend ill1 other family/ friend ill
Dx: NP swab for PCRDx: NP swab for PCR
PEP: azithromycinPEP: azithromycinDHEC assists in PEPDHEC assists in PEP
Pertussis: Clinical & Epi FeaturesPertussis: Clinical & Epi FeaturesIncubation Period: 6-21 days, average 7
Symptoms: Catarrhal Stage (URI)
Stage with cough, usu. lasting 6
Transmission: large respiratory droplets ~6’ radius
(sneezing, coughing, kissing, sharing…)/1
Communicability: high (attack rates up to 80% of
nonimmune household contacts)
CONTAGIOUS BACTERIAL INFECTION KNOWN
Complications: pneumonia, encephalopathy, rib
seizures, apneic episodes, death (often < 1yo)R. Ball, MD MPH FACP
Pertussis: Clinical & Epi FeaturesPertussis: Clinical & Epi Features21 days, average 7-10 d.
Catarrhal Stage (URI)→ Paroxysmal
Stage with cough, usu. lasting 6-10 weeks
: large respiratory droplets ~6’ radius
(sneezing, coughing, kissing, sharing…)/1 hr.in room
high (attack rates up to 80% of
household contacts)- MOST
CONTAGIOUS BACTERIAL INFECTION KNOWN
pneumonia, encephalopathy, rib Fx,
episodes, death (often < 1yo)
Stages of Classic PertussisStages of Classic Pertussis
Day 0 7 14 21 28 35 56 63
Incubation Period
7-10 days
(range 5-21 days)
Catarrhal stageCatarrhal stage
2-7 days
(range 7-14 days)Exposure
Paroxysmal cough stageParoxysmal cough stage
~56 days (PCR still +, cultures neg.)~56 days (PCR still +, cultures neg.)(range: min.1, avg. 6(range: min.1, avg. 6
Duration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to Others~21 days without approp.antibiotics~ 5 days once approp. antibiotics started
Date of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onset: : : : : : : : “pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”
R. Ball, MD MPH FACP
Stages of Classic PertussisStages of Classic Pertussis
Day 0 7 14 21 28 35 56 63 70
Paroxysmal cough stageParoxysmal cough stage
~56 days (PCR still +, cultures neg.)~56 days (PCR still +, cultures neg.)(range: min.1, avg. 6(range: min.1, avg. 6--10, max.16 weeks)10, max.16 weeks)
Recovery (“100 day cough”)Recovery (“100 day cough”)
Toxin damage to
tracheobronchial tree
Modified from slide viaS. Jankelevich MD
Duration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to Others~21 days without approp.antibiotics~ 5 days once approp. antibiotics started
“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”
A Family Member is the Source of Pertussis in
75% of cases
Nearly 50% of the Time, Infants are Infected by Their Parents
Adult-to-infant transmission has been well
Bisgard, K. et al. Ped Infect Dis J.
2004; 23:985-989. R. Ball, MD MPH FACP7
A Family Member is the Source of Pertussis in
75% of cases
Nearly 50% of the Time, Infants are Infected by Their Parents
infant transmission has been well-documented for decades
Source:Mom or Dad
in 47% of cases
n PCR: Polymerase chain reaction – rapid, very sensitive and specific, high predictive value
n Culture: Isolation of Bordetella Pertussis
– preferred test, but fastidious growth of organism make it very difficult to isolate, slower turnPCR and DFA, confounded by prior antibiotic use
Pertussis Testing (DHEC Districts)Pertussis Testing (DHEC Districts)
nDFA: Direct fluorescent antibody (ceased 8/8/03)
– rapid & cheap, but low sensitivity and variable specificity, with low positive predictive value
R. Ball, MD MPH FACP
PCR: Polymerase chain reaction rapid, very sensitive and specific, high predictive value
Bordetella Pertussis
preferred test, but fastidious growth of organism make it very difficult to isolate, slower turn-around than PCR and DFA, confounded by prior antibiotic use
Pertussis Testing (DHEC Districts)Pertussis Testing (DHEC Districts)
DFA: Direct fluorescent antibody (ceased 8/8/03)
rapid & cheap, but low sensitivity and variable specificity, with low positive predictive value
simple Dacron NP swabs
Pertussis Tx & PEP:Pertussis Tx & PEP:
• Azithromycin: Z-pack (
& convenient, cost ~ $70, has least side effects
• Erythromycin: cheaper, but QID dosing x 14
days, side effects →→→→ suboptimal compliance
• Clarithromycin: BID OK, but more expensive
• Others: TMP/ SMX (but NOT
Isolate case 1Isolate case 1ststR. Ball, MD MPH FACP
Pertussis Tx & PEP:Pertussis Tx & PEP:>> 3 antibiotics3 antibiotics
pack (5 days) most available
& convenient, cost ~ $70, has least side effects
Erythromycin: cheaper, but QID dosing x 14
suboptimal compliance
Clarithromycin: BID OK, but more expensive
Others: TMP/ SMX (but NOT ß-lactams like amoxicillin!)
5 days of Rx !5 days of Rx !
R. Ball, MD MPH FACP
10.20.1010.20.10
CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10
R. Ball, MD MPH FACP
CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10
PERTUSSIS WEBCAST DR. CHERRY 10.6.10
R. Ball, MD MPH FACP
PERTUSSIS WEBCAST DR. CHERRY 10.6.10
R. Ball, MD MPH FACP
R. Ball, MD MPH FACP
Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10
R. Ball, MD MPH FACP
Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10
R. Ball, MD MPH FACP
R. Ball, MD MPH FACP
R. Ball, MD MPH FACP
R. Ball, MD MPH FACP
http://www.llr.state.sc.us/pol/medical/
R. Ball, MD MPH FACP
http://www.llr.state.sc.us/pol/medical/
PEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SC
* and Epi-Treatment of STDs, including Expedited Partner Therapy
*
R. Ball, MD MPH FACP
PEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SC
Treatment of STDs, including Expedited Partner Therapy
R. Ball, MD MPH FACP
Respiratory Illnesses in a FacilityRespiratory Illnesses in a Facility
�� A hospital ICP calls A hospital ICP calls Several admissions for fever, cough, Several admissions for fever, cough,
and pneumonia from a facility. and pneumonia from a facility. Limited testing nonLimited testing nonSome response to antibiotics, but…Some response to antibiotics, but…
�� DHEC: DHEC: make a Dx, notificationmake a Dx, notificationcontact tracing, contact tracing, PEP the contacts, PEP the contacts, Tx if indigent PtTx if indigent Pt. ? Roles . ? Roles public health public health providers.providers.
R. Ball, MD MPH FACP
Respiratory Illnesses in a FacilityRespiratory Illnesses in a Facility
A hospital ICP calls A hospital ICP calls DHEC DHEC Epi:Epi:Several admissions for fever, cough, Several admissions for fever, cough,
and pneumonia from a facility. and pneumonia from a facility. Limited testing nonLimited testing non--contributory. contributory. Some response to antibiotics, but…Some response to antibiotics, but…
make a Dx, notificationmake a Dx, notification, , PEP the contacts, PEP the contacts, even even . ? Roles . ? Roles of private & of private &
providers.providers.
R. Ball, MD MPH FACP
InfluenzaInfluenza-- Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned
� Learn from history of pandemics� Providers MUST keep up constantly with medical
information explosion (articles etc = TNTC)� Descriptive, Epi (US,state,local), & Clinical Mx/ Tx guidance� You can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]
�Vaccines: seasonal/pandemic: +/�Testing: types/methods, +/�Antiviral Tx & PEP: meds, guidance, supplies OK…� Guidelines freq. “updated”, ~confusing (eg: N95s)�Communication: w/ peers, patients, public = poor
Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned
history of pandemics (or else repeat…)Providers MUST keep up constantly with medical information explosion (articles etc = TNTC)Descriptive, Epi (US,state,local), & Clinical Mx/ Tx guidanceYou can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]
: seasonal/pandemic: +/- guidance, supplies: types/methods, +/- guidance, supplies OKTx & PEP: meds, guidance, supplies OK…freq. “updated”, ~confusing (eg: N95s)
: w/ peers, patients, public = poorR. Ball, MD MPH FACP
R. Ball, MD MPH FACP
Pandemic nH1N1: Transmissibility Pandemic nH1N1: Transmissibility
(Attack Rate) vs. Morbidity/Mortality(Attack Rate) vs. Morbidity/Mortality
Transmissibility
(Attack Rate)
Qs: what are the determinants of these Qs: what are the determinants of these influenza virus characteristics,influenza virus characteristics,
and do they apply to all/ most viruses ?and do they apply to all/ most viruses ?R. Ball, MD MPH FACP
Pandemic nH1N1: Transmissibility Pandemic nH1N1: Transmissibility
(Attack Rate) vs. Morbidity/Mortality(Attack Rate) vs. Morbidity/Mortality
Severity/ Virulence
(Morbidity/ Mortality)
Qs: what are the determinants of these Qs: what are the determinants of these influenza virus characteristics,influenza virus characteristics,
and do they apply to all/ most viruses ?and do they apply to all/ most viruses ?
R. Ball, MD MPH FACP
Global Air TravelGlobal Air Travel--
Thanks to Mike Schmidt, PhD R. Ball, MD MPH FACP
-- 1 day, mid1 day, mid--20092009
Thanks to Mike Schmidt, PhD- MUSC for this graph
R. Ball, MD MPH FACP
Pandemic mortality curves: 1918, othersPandemic mortality curves: 1918, othersTaubenberger. EID 1Taubenberger. EID 1--0606
R. Ball, MD MPH FACP
Pandemic mortality curves: 1918, othersPandemic mortality curves: 1918, others
“Cytokine Storm”“Cytokine Storm”
10%
90%
Graph F: U.S. Percentage of Seasonal Flu Deaths Among People on Average
Seasonal Influenza DeathsSeasonal Influenza Deaths
R. Ball, MD MPH FACP
Graph F: U.S. Percentage of Seasonal Flu Deaths Among People ≥65 Years Old Each Year on Average
0-64 Yrs ≥65 Yrs
Seasonal Influenza DeathsSeasonal Influenza Deaths
2009 H1N1 Deaths
1,230
8,980
CDC Estimates of 2009 H1N1 Deaths by Age Group in the United States (n=11,690)
(April 2009 –January 16, 2010)
R. Ball, MD MPH FACP
2009 H1N1 Deaths
1,480
CDC Estimates of 2009 H1N1 Deaths by Age Group in the States (n=11,690)
January 16, 2010)
0-17 Yrs
18-64 Yrs
≥65 Yrs
R. Ball, MD MPH FACP
InfluenzaInfluenza-- Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned
�Learn from history of pandemics� Providers MUST keep up constantly with medical
information explosion (articles etc = TNTC)� Descriptive, Epi (US,state,local� You can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]
�Vaccines: seasonal/pandemic: +/�Testing: types/methods, +/�Antiviral Tx & PEP: meds, guidance, supplies OK…� Guidelines freq. “updated”, ~confusing (�Communication: w/ peers, patients, public = poor
R. Ball, MD MPH FACP
Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned
history of pandemics (or else repeat…)Providers MUST keep up constantly with medical information explosion (articles etc = TNTC)
US,state,local), & Clinical Mx/ Tx guidanceYou can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]
: seasonal/pandemic: +/- guidance, supplies: types/methods, +/- guidance, supplies OKTx & PEP: meds, guidance, supplies OK…freq. “updated”, ~confusing (eg: N95s)
: w/ peers, patients, public = poorR. Ball, MD MPH FACP
• AA (H3N2)/ (H3N2)/ Perth/16/2009
• A A (H1N1)/(H1N1)/ California/2009
• BB / Brisbane/60/08 (same as last year)
Myths/misconceptions we must combat:Myths/misconceptions we must combat:“Flu shots give me the flu.” (rare S.E. are “Flu shots give me the flu.” (rare S.E. are natural immune reaction: Tx= E&R, NSAIDs)natural immune reaction: Tx= E&R, NSAIDs)“The flu shots are dangerous/ untested…”“The flu shots are dangerous/ untested…”“I’m not in a ‘risk group’ & won’t get it”“I’m not in a ‘risk group’ & won’t get it”
etc…etc…
Inactivated Trivalent Influenza Vaccine (ITIV):
3 Components for 2010
R. Ball, MD MPH FACP
Perth/16/2009-like
California/2009-like [“swine”]
/ Brisbane/60/08 (same as last year)
Myths/misconceptions we must combat:Myths/misconceptions we must combat:“Flu shots give me the flu.” (rare S.E. are “Flu shots give me the flu.” (rare S.E. are natural immune reaction: Tx= E&R, NSAIDs)natural immune reaction: Tx= E&R, NSAIDs)“The flu shots are dangerous/ untested…”“The flu shots are dangerous/ untested…”“I’m not in a ‘risk group’ & won’t get it”“I’m not in a ‘risk group’ & won’t get it”
Inactivated Trivalent Influenza Vaccine (ITIV):
3 Components for 2010-2011, selected 2.10
R. Ball, MD MPH FACP
R. Ball, MD MPH FACP
CDC 8.13.10
R. Ball, MD MPH FACP
Influenza vaccination:Influenza vaccination:2 main reasons to get vaccinated2 main reasons to get vaccinated� Greatly ↓ chance (by 3/4) of influenza (& transmitting
� Even if a person gets vaccinated and still catches influenza, vaccination will greatly ↓ the chance of (eg, hospitalization, pneumonia, & death)
R. Ball, MD MPH FACPR. Ball, MD, MPH
Influenza vaccination:Influenza vaccination:2 main reasons to get vaccinated2 main reasons to get vaccinated
chance (by 3/4) of catching transmitting to others)
Even if a person gets vaccinated and still catches influenza, vaccination will
the chance of complications(eg, hospitalization, pneumonia, & death)
Good reasons why people benefitGood reasons why people benefit
from influenza vaccination: summaryfrom influenza vaccination: summary1. Efficacy studies suggest the vaccine will prevent about
75% of influenza infections.
2. Those who are protected will not transmit to others (e.g.,
family, co-workers, patients).
3. For the 25% of vaccinees who may get the flu, the
chances of complications, hospitalization or death are
much less. (Efficacy preventing hospitalization
R. Ball, MD MPH FACP
Good reasons why people benefitGood reasons why people benefit
from influenza vaccination: summaryfrom influenza vaccination: summaryEfficacy studies suggest the vaccine will prevent about
75% of influenza infections.
Those who are protected will not transmit to others (e.g.,
workers, patients).
For the 25% of vaccinees who may get the flu, the
chances of complications, hospitalization or death are
much less. (Efficacy preventing hospitalization > 90%)
Influenza Vaccine: Priority GroupsInfluenza Vaccine: Priority Groups
& 2005& 2005--08 Vaccination Coverage Rates08 Vaccination Coverage Rates
SHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USHCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !
How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?
CDC. MMWR July 24, 2009 / Vol. 58 ER
R. Ball, MD MPH FACP
Influenza Vaccine: Priority GroupsInfluenza Vaccine: Priority Groups
08 Vaccination Coverage Rates08 Vaccination Coverage Rates
SHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USHCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !
How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?
Influenza nonInfluenza non--HCWs: Adverse EffectsHCWs: Adverse Effects
� HCWs w/ flu are contagious ~1 day prior to Sx, 5+ days after, & still try to work with Sx!
�→ Increased employee illness & absenteeism: (50% more sick days shortages, medical errors)
�→ Increased #s Pt cases/outbreaks in facilities
�→ Increased facility’s & HCW health care costs
--Vaccination in Vaccination in HCWs: Adverse EffectsHCWs: Adverse Effects
HCWs w/ flu are contagious ~1 day prior to Sx, 5+ days after, & still try to work with Sx!
Increased employee illness & absenteeism: (50% more sick days →coworker illnesses & shortages, medical errors)
Increased #s Pt cases/outbreaks in facilities
Increased facility’s & HCW health care costsR. Ball, MD MPH
R. Ball, MD MPH FACP
Mandatory Influenza Mandatory Influenza Vaccination for HCWs?Vaccination for HCWs?
Some hospital systems now mandate HCW influenza Some hospital systems now mandate HCW influenza
vaccination as a condition of employment.vaccination as a condition of employment.
(eg, UNC, Johns Hopkins, Duke, others, & growing)
eg, in SC: Georgetown Hosp.System
SCHA: 18 hosp. report 24-99.8% (
R. Ball, MD MPH
Mandatory Influenza Mandatory Influenza Vaccination for HCWs?Vaccination for HCWs?
Some hospital systems now mandate HCW influenza Some hospital systems now mandate HCW influenza
vaccination as a condition of employment.vaccination as a condition of employment.
(eg, UNC, Johns Hopkins, Duke, others, & growing)
eg, in SC: Georgetown Hosp.System→→→→99.8% compliance
99.8% (55%) HCW H1N1 vax.rates
HCW Pushback counterHCW Pushback counter
• As an absolute condition of employment, we (your
employer) have the right to inject into your arm a PPD
test- which offers you no immune protection at all, is
simply a test of LTBI/ TB ,and can inflame your arm.
You do NOT have a right to refuse if you want this job.
• As a absolute condition of employment, you must take a
3-shot HBV vaccination series which offers high (but
not perfect) protection and consent to a blood test.
IF you refuse, you MUST sign a R. Ball, MD MPH
HCW Pushback counterHCW Pushback counter--strategiesstrategies
As an absolute condition of employment, we (your
employer) have the right to inject into your arm a PPD
which offers you no immune protection at all, is
simply a test of LTBI/ TB ,and can inflame your arm.
You do NOT have a right to refuse if you want this job.
As a absolute condition of employment, you must take a
shot HBV vaccination series which offers high (but
not perfect) protection and consent to a blood test.
you refuse, you MUST sign a declination form…
R. Ball, MD MPH FACP
October 2010
SCHA- DHEC article by Drs. Eric Brenner & R. Muhammed 11.10
R. Ball, MD MPH FACP
DHEC article by Drs. Eric Brenner & R. Muhammed 11.10
nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009
Wise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timelimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resources
R. Ball, MD MPH FACP
nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009
Wise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of time--------limited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resources
Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 R. Ball, MD MPH FACP
July 2008July 2008July 2008July 2008
Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 →→→→ 2010201020102010 →→→→ 2011201120112011
For 2010-2011:- everyone > 6 mos.- no priority groups- ~distribution = rationing
Flu: Rapid Tests, PCR & CulturesFlu: Rapid Tests, PCR & Cultures
•• Rapid tests occas. false (+) or false (Rapid tests occas. false (+) or false (
• Some (+) rapid tests do not differentiate
between seasonal influenza A & B.
• (+) rapid tests, and (-) tests (in the presence
of clinical ILI Sx, or meeting the “evolving”
case definition) should be accompanied by
2nd swab for Culture with PCR (DHEC).Culture with PCR (DHEC).
• Specimen technique is important (NP,
throat, and/or bronchial washings) !
• Doubtful if current rapid tests can detect H5
(N1) or new “swine” flu H1 (April 2009)
• HCW MUST WEAR PPE !R. Ball, MD MPH
Flu: Rapid Tests, PCR & CulturesFlu: Rapid Tests, PCR & Cultures
Rapid tests occas. false (+) or false (Rapid tests occas. false (+) or false (--).).
Some (+) rapid tests do not differentiate
) tests (in the presence
of clinical ILI Sx, or meeting the “evolving”
case definition) should be accompanied by
Culture with PCR (DHEC).Culture with PCR (DHEC).
Specimen technique is important (NP,
Doubtful if current rapid tests can detect H5
(N1) or new “swine” flu H1 (April 2009)
HCW MUST WEAR PPE !
Seasonal: NP better yieldSeasonal: NP better yieldSeasonal: NP better yieldSeasonal: NP better yieldH5N1 Flu: throat or bronch.H5N1 Flu: throat or bronch.H5N1 Flu: throat or bronch.H5N1 Flu: throat or bronch.H1N1: Either site is OK.H1N1: Either site is OK.H1N1: Either site is OK.H1N1: Either site is OK.
R. Ball, MD MPH FACPSlide courtesy: R. Wenzel MD
Zanamivir “Relenza” & Oseltamivir “Tamiflu”Zanamivir “Relenza” & Oseltamivir “Tamiflu”treat & prevent most Influenza A & B infectionstreat & prevent most Influenza A & B infections(& cover most strains of A(& cover most strains of A
Influenza Antivirals:Influenza Antivirals:For Treatment AND PreventionFor Treatment AND Prevention
MMWR July 31, 2009 / Vol. 58 RR8 R. Ball, MD MPH FACP
Zanamivir “Relenza” & Oseltamivir “Tamiflu”Zanamivir “Relenza” & Oseltamivir “Tamiflu”treat & prevent most Influenza A & B infectionstreat & prevent most Influenza A & B infections(& cover most strains of A(& cover most strains of A--H1N1 “swine flu”H1N1 “swine flu”
Influenza Antivirals:Influenza Antivirals:For Treatment AND PreventionFor Treatment AND Prevention
deJong et al.NEJM 12-22-05
Influenza Antivirals: Tx EffectsInfluenza Antivirals: Tx Effects
• Children with influenza: 53% less likely to develop pneumonia,
• Adults ill with influenza: 71% less likely to die.
if given oseltamivir early (~ 1
∴∴∴∴∴∴∴∴ Tx with Tx with “TIMELY TAMIFLU”*“TIMELY TAMIFLU”*
*Source: ICAAC abstracts*Source: ICAAC abstracts
“…treat patients ASAP…” (duration 5 days) CDC
7.09
Influenza Antivirals: Tx EffectsInfluenza Antivirals: Tx Effects
Children with influenza: 53% less likely to develop pneumonia,
Adults ill with influenza: 71% less likely
if given oseltamivir early (~ 1st 2+ days)
“TIMELY TAMIFLU”*“TIMELY TAMIFLU”*
R. Ball, MD MPH*Source: ICAAC abstracts*Source: ICAAC abstracts-- 9/29/069/29/06
“…treat patients ASAP…” (duration 5 days) CDC
R. Ball, MD MPH FACP
Slide courtesy: F. Hayden MD Feb.2010
SC Pandemic Influenza Ethics
Taskforce: New Guidelines
Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant & Epidemiologist, SC DHEC
Phil Schneider, PhD, Emeritus Professor of BioethicsPhil Schneider, PhD, Emeritus Professor of BioethicsCoastal Carolina University
CoCo--Chairs, SC Pan Flu Ethics TaskforceChairs, SC Pan Flu Ethics Taskforce
with thanks to Covia Stanley, MD M.Div., Tom Fabian, MD MPH, Covia Stanley, MD M.Div., Tom Fabian, MD MPH, Pan Flu Consultant, SC DHEC, Pan Flu Consultant, SC DHEC, and
New Standards of Care for
Medical Professionals re: Pan Fluspring 2010
SC Pandemic Influenza Ethics
Taskforce: New Guidelines
Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant & Epidemiologist, SC DHEC
Phil Schneider, PhD, Emeritus Professor of BioethicsPhil Schneider, PhD, Emeritus Professor of BioethicsCoastal Carolina University
Chairs, SC Pan Flu Ethics TaskforceChairs, SC Pan Flu Ethics Taskforce
Covia Stanley, MD M.Div., Tom Fabian, MD MPH, Covia Stanley, MD M.Div., Tom Fabian, MD MPH, and Rick Foster, MD, VRick Foster, MD, V--P, SCHAP, SCHA
R. Ball, MD MPH
New Standards of Care for
Medical Professionals re: Pan Fluspring 2010
CURRENT MODEL OF MEDICINE:
Sickest Patients get first claim on
medical resources.
PANDEMIC MODEL OF MEDICINE:
Patients with best chance of recovery get
first claim on medical resources.
South Carolina Prepares for Pandemic Influenza:South Carolina Prepares for Pandemic Influenza:
An Ethical PerspectiveAn Ethical PerspectiveSouth Carolina Pandemic Influenza Ethics Task ForceSouth Carolina Pandemic Influenza Ethics Task Force
R. Ball, MD MPH FACP
CURRENT MODEL OF MEDICINE:
Sickest Patients get first claim on
PANDEMIC MODEL OF MEDICINE:
Patients with best chance of recovery get
first claim on medical resources.
South Carolina Prepares for Pandemic Influenza:South Carolina Prepares for Pandemic Influenza:
An Ethical PerspectiveAn Ethical PerspectiveSouth Carolina Pandemic Influenza Ethics Task ForceSouth Carolina Pandemic Influenza Ethics Task Force
What events prompt ‘altered’ standards of care?What events prompt ‘altered’ standards of care?
R. Ball, MD MPH FACP
New EnglandJournal of Medicine358:1
What events prompt ‘altered’ standards of care?What events prompt ‘altered’ standards of care?
R. Ball, MD MPH FACP
R. Ball, MD MPH FACP
Of the manygood articles…
SC Pandemic Influenza Ethics Task ForceSC Pandemic Influenza Ethics Task ForceStandards of Care paper & Summit 2009Standards of Care paper & Summit 2009
Clinical Practices
Public Health Practices
Public Risk Communication
Ethics Workgroup: Co-Coordinators
Legal Workgroup: Co-Coordinators
SC Pandemic Influenza Ethics Task Force
Co-Chairs (DHEC & non-DHEC)
Steering Committee
SC Pandemic Influenza Coordinating Council
South Carolina Prepares for Pandemic Influenza:
An Ethical Perspective
many thanks to:Tom Fabian,Max Learner,Phyllis Beasleyet al.
R. Ball, MD MPH FACP
SC Pandemic Influenza Ethics Task ForceSC Pandemic Influenza Ethics Task ForceStandards of Care paper & Summit 2009Standards of Care paper & Summit 2009
Clinical Practices Workgroup: Co-Coordinators
Public Health Practices Workgroup: Co-Coordinators
Public Risk Communication Workgroup: Co-Coordinators
Workgroup: Co-Coordinators
Workgroup: Co-Coordinators
SC Pandemic Influenza Ethics Task Force
Co-Chairs (DHEC & non-DHEC)
Steering Committee
SC Pandemic Influenza Coordinating Council
*
South Carolina Prepares for Pandemic Influenza:
An Ethical Perspective
These Clinical Practice and Public Health Practice Guidelinesbecome SC’s Standard of Care in Pandemic Influenza mainlyby consensus via adoption by many/ most major health careorganizations, providers, DHEC, etc (ie, new laws unnecessary)
R. Ball, MD MPH FACP
These Clinical Practice and Public Health Practice Guidelinesbecome SC’s Standard of Care in Pandemic Influenza mainlyby consensus via adoption by many/ most major health careorganizations, providers, DHEC, etc (ie, new laws unnecessary)
Pan Flu rationing scenario 1Pan Flu rationing scenario 1
An elderly lady with Pan Flu is admitted with An elderly lady with Pan Flu is admitted with ARDS and other complications and put on the last ARDS and other complications and put on the last ventilator in the ICU. Additional patients, some ventilator in the ICU. Additional patients, some less severely ill & younger w/ more of a chance less severely ill & younger w/ more of a chance of survival come to the ED also needing ventilator of survival come to the ED also needing ventilator support. Their physicians appeal to the lady’s support. Their physicians appeal to the lady’s
physician/ the hospital triage team to remove her physician/ the hospital triage team to remove her from the ventilator into palliative care so that from the ventilator into palliative care so that one of their patients can have a better chance.one of their patients can have a better chance.
What does each participant do, and why?What does each participant do, and why?
Pan Flu rationing scenario 1Pan Flu rationing scenario 1
An elderly lady with Pan Flu is admitted with An elderly lady with Pan Flu is admitted with ARDS and other complications and put on the last ARDS and other complications and put on the last ventilator in the ICU. Additional patients, some ventilator in the ICU. Additional patients, some less severely ill & younger w/ more of a chance less severely ill & younger w/ more of a chance of survival come to the ED also needing ventilator of survival come to the ED also needing ventilator support. Their physicians appeal to the lady’s support. Their physicians appeal to the lady’s
physician/ the hospital triage team to remove her physician/ the hospital triage team to remove her from the ventilator into palliative care so that from the ventilator into palliative care so that one of their patients can have a better chance.one of their patients can have a better chance.
What does each participant do, and why?What does each participant do, and why?R. Ball, MD MPH
SOFA Scoring: a scientificallySOFA Scoring: a scientifically
method of predicting mortalitymethod of predicting mortality
R. Ball, MD MPH FACP
SOFA Scoring: a scientificallySOFA Scoring: a scientifically--validated validated
method of predicting mortalitymethod of predicting mortality
JAMA. 2001;286:1754-1758
Critical Care Triage Tool
R. Ball, MD MPH FACP
Critical Care Triage Tool
Critical Care Triage Tool
R. Ball, MD MPH FACP
Critical Care Triage Tool
1.20.09
R. Ball, MD MPH FACP
1.20.09
SC laws addressing health SC laws addressing health provider limited liability, 2008provider limited liability, 2008
� Emergency Health Powers Act � “Any HCP appointed by [DHEC]… civil damages as a result of medical care or Tx… unless the damages result from Tx… under circumstances demonstrating a reckless disregard for the consequences…”
� Medical Malpractice Act� “Volunteer {non-compensated} health care provider… not liable for any civil damage for any act or omission resulting from the rendering of the (medical) services unless… act or omission was the result of…gross negligence or willful misconduct. The agreement to provide voluntary noncompensated service must be made before…”
SC laws addressing health SC laws addressing health provider limited liability, 2008provider limited liability, 2008
Emergency Health Powers Act 44-4-570, (C)(1)“Any HCP appointed by [DHEC]… MUST not be held liable for any
civil damages as a result of medical care or Tx… unless the damages result from Tx… under circumstances demonstrating a reckless disregard for the consequences…” (not automatic/ billing OK)
Medical Malpractice Act 38-79-30compensated} health care provider… not liable
for any civil damage for any act or omission resulting from the rendering of the (medical) services unless… act or omission was the result of…gross negligence or willful misconduct. The agreement to provide voluntary noncompensated service must be made before…”
R. Ball, MD MPH
SC laws addressing health SC laws addressing health provider limited liability, 2008provider limited liability, 2008
� Medical Practice Act 40� “The Board may publish advisory opinions and position statements relating to practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of practice.”
� Nurse Practice Act 40-33� “The Board may publish advisory opinions and position statements relating to nursing practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of nursing
practice.”
SC laws addressing health SC laws addressing health provider limited liability, 2008provider limited liability, 2008
40-47-10, (I)(1)“The Board may publish advisory opinions and position statements
relating to practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of practice.”
33-10, (I)(1)“The Board may publish advisory opinions and position statements
relating to nursing practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of nursing
R. Ball, MD MPH
R. Ball, MD MPH FACP
SCHASCHASCHASCHA
GI illnessesGI illnesses--? contaminated food? contaminated food
10 Question: HOW did the food become contaminated, and with what bug?
A: During the months of April-May, in the upper hills of Guatemala,
the local village populations experience “Mal de Mayo”
(diarrheal illness of May), caused predominantly by Cyclospora.
Most village people use outhouses which runoff directly into
the local streams (or use the streams directly).
Many raspberry farmers, in order to harvest the raspberries at their
“juiciest” in April-May, usually drench the plants x 3 days with
pumped directly from the local stream, often contaminated with Cyclospora.
Raspberries are then picked & packed directly (not rinsed) into clamshells
and quickly shipped (refrigerated) directly to the USA (R. Ball, MD MPH FACPR. Ball, MD, MPH
? contaminated food? contaminated food
food become contaminated, and with what bug?
May, in the upper hills of Guatemala,
the local village populations experience “Mal de Mayo”
(diarrheal illness of May), caused predominantly by Cyclospora.
Most village people use outhouses which runoff directly into
the local streams (or use the streams directly).
Many raspberry farmers, in order to harvest the raspberries at their
May, usually drench the plants x 3 days with waterwater, often
pumped directly from the local stream, often contaminated with Cyclospora.
Raspberries are then picked & packed directly (not rinsed) into clamshells
and quickly shipped (refrigerated) directly to the USA (ie, Miami)…
R. Ball, MD MPH FACP
1st US report
NEJM. Vol. 336: 1548NEJM. Vol. 336: 1548
R. Ball, MD MPH FACP
NEJM. Vol. 336: 1548NEJM. Vol. 336: 1548--56, 556, 5--2929--9797
“Those who carry on great public schemes
must be proof against the most fatiguing delays,
the most mortifying disappointments,
the most shocking insults,
and what is worst of all,
the presumptuous judgments
of the ignorant.
- Edmund Burke (1729
The mind can absorb only
as much as the fanny can endure.
Thank you for your interest. Questions?
R. Ball, MD MPH FACP
Those who carry on great public schemes
must be proof against the most fatiguing delays,
the most mortifying disappointments,
the most shocking insults,
and what is worst of all,
the presumptuous judgments
of the ignorant.”
Edmund Burke (1729 - 1797)
The mind can absorb only
as much as the fanny can endure.
Thank you for your interest. Questions?