WHAT S INFECTIOUS and HOT: 2014

Transcription

1 WHAT S INFECTIOUS and HOT: 2014 Gary Garber MD FRCPC FACP FIDSA CCPE Medical Director-Infection Prevention and Control Professor-Division of Infectious Diseases Ottawa Hospital/U Ottawa

2 OUTBREAK ALERT: How to prepare for the inevitable. The inevitabilities of life: Death Taxes Novel pathogens 2

3 Conflicts of Interest No financial COI related to this presentation 3

4 April 23, 2014: New Emerging and High Profile Issues: MOHLTC-Ontario & PHO Mers-CoV Influenza H7N9 (Avian influenza A) Ebola Measles Influenza H10N8 Polio 4

5 Other Pathogens Carbapenemase Producing Enterobacteraceae (CPE/CRE) VRE- to isolate or not HCW vaccination: pertussis, influenza, measles 5

6 MERS-CoV Middle East Respiratory Syndrome Caused by a coronavirus Same Genus as SARS First reported in Saudi Arabia in 2012 Multiple cases seemingly unrelated and seen in a number of regional and local hospitals Nosocomial spread in dialysis units Several HCW infections but no deaths 6

7 MERS-CoV Mortality rate seems to go down over time Close contact associated with spread in dialysis unit at least 2 hrs of contact in the next bed Coronavirus: is a large virus and is droplet/contact spread Pattern of the disease was interesting as after initial cases, disease petered and then re-emerged Real concern of worldwide spread during the Hajj Didn t happen Where was the reservoir? 7

8 MERS-CoV: the culprit? 8

9 MERS-CoV: (April 23rd 2014) 250 cases world wide with 93 deaths Saudi-183, UAE-41, Qatar-8, Kuwait-3, Oman-2, Jordan other countries Latest cases include Greece (1) and Malaysia (1) All with contact Middle East Multiple studies show camels have coronavirus in their upper resp. tract. But contact with camels is not consistent Coronavirus is commonly carried by bats 9

10 Presentation Severe resp. illness, progressing to bilateral pneumonia Treatment is symptomatic and supportive Steroids will increase viral shedding Ribavirin shows no evidence of impact Some discussion of the role of interferon HCW protection: droplet and contact precautions In Ontario that will include airborne N95 respirators 10

11 Bird flu : Influenza A H7N9 (coming soon H10N8) H7N9 is known as bird influenza A, also H5N1 and others Usually do not cause disease in humans Usually associated with close contact with birds and especially the markets where birds are sold Human to human spread is extremely uncommon Culling of the bird flocks ends outbreaks China/Taiwan: 397 cases, 60 deaths (14 months) 11

12 Human Contact with Birds 12

13 Bird Flu-Why the concern? Human influenza: the new subspecies often pass through birds and/or pigs Antigenic shift vs drift: H3N2 H1N1 is a shift If the bird influenza acquires a gene that makes it compatible with human to human spread, the lack of background immunity among humans would lead to a pandemic and high morbidity and mortality Bird influenza A circulating at the same time as human H1N1: if birds are co-infected this could cause genetic rearrangement Is this inevitable? Or theoretical? 13

14 Bird Influenza; Treatment and Prevention In most cases oseltamivir is effective, some resistance has been reported Prophylaxis?? Likely minimally effective and may induce resistance if widespread Vaccination: bird flu doesn t grow well in eggs so novel vaccine techniques are required Droplet and contact precautions Influenza is airborne for less than 1 metre (3 feet) Ontario recommends N95 respirators 14

15 Ebola 15

16 Ebola-Viral Hemorrhagic Fever Source of infection unclear but presumed to be associated with hunting and eating of bush meat Presentation is severe DIC, renal/pulmonary hemorrhage Historically high rate of transmission to HCWs and close family members who take care of the person or body Masking and gloving has virtually eliminated spread to HCW Latest outbreak is in Gabon/Democratic Republic of Congo Guinea/Zaire different clade. First fatality Dec 2013 Why there are waves of disease is unknown 16

17 Measles 17

18 Measles Severe viral illness eradicated in the Americas Most people born before 1969 have had natural infection and are protected lifelong Complications of the disease include pneumonia, encephalitis, deafness and death Extremely contagious: airborne and contact Vaccine programs in the 70 s essentially eradicated the disease with single injection at 1 yr of age In the 90 s several outbreaks in N America changed policy to 2 vaccine dosages 18

19 Why do we continue to have Measles Outbreaks Vaccine not 100% effective Reliance on herd immunity to protect those who do not respond or are immune suppressed 2 dosages improves herd immunity Pockets of vaccine refusers increases the pool of those who may get ill if an active case presents Religious objectors travel to countries with active measles return to Canada infected and spread within their and outside communities Sources for active measles: Netherlands, Philippines, China 19

20 Measles protection Natural or vaccine immunity Serologic proof, 2 doses of vaccine, age + definite prior infection Airborne precautions plus contact due to active cases having significant infectious discharge If exposed and not immune, HCW must stay home from day 5-14 post-exposure 20

21 Resistant Bacteria-CPE These bacteria have resistance against our most potent antimicrobials, the Carbapenems, and usually also resistant to the B-lactams and Quinolones Patients die of serious infections with CPE due to lack of effective therapy Rates of CPE are rising in many settings NDM-1, outbreaks in NYC and Israel, and more recently across Canada Ontario cases have stabilized over past 18 months 21

22 CPE Most isolates are from patients screened for colonization Most infections have been urinary track infections Majority of patients have either visited SE Asia or India subcontinent Associated with medical care overseas Some cases source is unknown Possible nosocomial spread 22

23 Protection against CPE The bacteria colonize the GI track so appropriate isolation and screening, proper hand hygiene and environmental cleaning should prevent spread Screening policies are not routinely followed so at risk patients are not identified Unfortunately our hand hygiene compliance and environmental cleaning are not rigorous enough to do the job 23

24 Vancomycin Resistant Enterococcus-VRE What happens if a hospital stops their VRE screening and isolation? PHO is studying this question in Ontario VRE bacteremia rates do go up Our goal now is to determine who is most at risk to acquire VRE bacteremia and see if we can modify screening and isolation recommendation to target those most at risk 24

25 ER Nurses at the Front line: Protection! Hand hygiene Clean your hands When in doubt, clean them again PPE- masking, gloves, and gowns Vaccination: as adults we are not good in maintaining our own immunity 25

26 The Front Line: Dynamic and Uncertain Routine IPAC precautions are the best way to protect ourselves Almost all novel pathogens are transmitted in the same way Severity of illness does not equate with mode of transmission Hand hygiene is far and away the best protection for us in direct patient care Adopting a habitual routine of PPE and hand hygiene will be the best protection against the pathogens we know and those that are HOT 26