Summer Communicable Disease Forum. July 30, 2015

Transcription

1 Summer Communicable Disease Forum July 30, 2015

2 Overview Communicable Disease Forum format Continuing education credits group signin sheet needed for persons not logged in to webinar Questions Recording Slides posted on NJLMN under Practice Exchange

3 CDS Training Resources Website

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5 Quarterly Reports Quarterly regional highlight report feedback CD reports by LHD Discuss other data needs with regional epi

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7 Nurses Participants must attend the entire session in order to earn contact hour credits Attendees must participate in all learning activities Verification of participation will be noted by webinar attendance reports or group sign-in sheet and completion of online evaluation Participants cannot miss more than 5 minutes from a 30 minute session; 10 minutes from a 60 minute session Participants must complete the online program evaluation and include your name and address to receive nursing certificate

8 Nurses No commercial support has influenced the planning of the educational objectives and content of this event No influential relationships have been disclosed by planners or presenters which would influence the planning of this activity. If any arise, an announcement will be made at the beginning of the session There is no endorsement of any product by the NJSNA or the ANCC associated with this session

9 STEPS TO INVESTIGATING LEGIONELLA ASSOCIATED WITH A HOSPITAL/LONG- TERM CARE FACILITY Rebecca Greeley, MPH, Infectious Disease Team Coordinator Eric Weren, MSIH, Research Scientist, Environmental & Occupational Health Assessment

10 Legionella Organisms Legionella are ubiquitous in natural and artificial fresh water environments Hot tubs Cooling towers Hot water tanks Large plumbing systems Decorative fountains Grows best in warm temperatures, F Dormant under 77 F and killed above 124 F Legionella pneumonophila serogroup 1 causes majority of human illness, but other serogroups do cause disease

11 Amplification Aerosolization Asolization Protozoa Biofilms Pathogen Proliferation Aerosol Exposure Droplet Size Size Distance Risk of Contracting Legionnaires Disease Susceptible Population Immunosuppressed Elderly

12 Legionellosis Legionnaires' Disease Low attack rate: 5% High mortality: 15% Incubation: 2-14 days Fever: F Breathing difficulty Cough (dry/phlegm) Chills Chest pain Pontiac Fever High attack rate: 90% No mortality Incubation: 1-3 days Muscle aches Flu-like symptoms Self-limiting

13 Who is at risk for legionellosis? Most healthy individuals do not become infected with Legionella bacteria after exposure. People at higher risk of getting sick are: Older people (usually 50 years of age or older) Current or former smokers Those with a chronic lung disease (like COPD or emphysema) Those with a weak immune system from diseases like cancer, diabetes, or kidney failure People who take drugs that suppress (weaken) the immune system (like after a transplant operation or chemotherapy) Aspiration risk or swallowing problems

14 Who to test for legionellosis? Patients who have failed outpatient antibiotic therapy Patients with severe pneumonia, in particular those requiring intensive care Immunocompromised host with pneumonia Patients with pneumonia in the setting of a legionellosis outbreak Patients with a travel history (Patients that have traveled away from their home within two weeks before the onset of illness.) Patients suspected of healthcare-associated pneumonia NO Person-to-Person Spread!

15 Public Health Investigations Surveillance Rationale Monitor and describe incidence and trends of cases Rapidly recognize cases that occur in similar locations or with similar exposures Identify opportunities for control and prevention

16 Reporting of Cases Cases are reported into NJ s Communicable Disease Reporting and Surveillance System (CDRSS) Local Health Departments are responsible for performing a disease investigation into each case reported for their residents Information needed includes illness onset, incubation period, potential exposures that include water, LTC resident, over-night travel, decorative fountains

17 Perfect Partnership Public Health LHD NJDOH Healthcare Stakeholders Acute care Patients being seen who may be cases IPs obtaining pertinent info Long-term care Residents with pneumonia Building investigations

18 Initial Steps in Long-Term Care Investigations One-confirmed case of legionellosis in LTC resident = OUTBREAK LHD to verify the person meets confirmed case definition LHD to establish illness onset date and incubation period LHD needs to confirm patient was only in LTC (or healthcare facility) during incubation period

19 Investigation Continues Once case is linked to the building, NJDOH generates an Outbreak Number (E-number) LHD and NJDOH to set up conference call with facility Facility Administrators Director of Nursing Infection Preventionist Facility Manager and Maintenance Information needed on initial conference call: Clinical information on the case (nebulizer, oxygen, aspiration risk?) Possible water exposures of the case Building information (age, size, number of water outlets)

20 Immediate Actions for Facility Immediate prevention actions: shower filters, bottled water, removing aerators from sinks Hiring water consultant with experience in Legionella control Schedule building walk-through with consultant, LHD and NJDOH represented On-going surveillance for clinical pneumonias Water sampling for Legionella culture Remediation Follow-up testing

21 BUILDING INVESTIGATION

22 Building Investigation Hire experienced water consultant Schedule building walk-through Facility management Consultant LHD and NJDOH Water sampling for Legionella culture and speciation Plan Remediation & Follow-up

23 Conditions for Legionella amplification Water from supplier is not sterile Temperatures: optimum F Grow F Water stagnation Scale and sediment Symbiotic with amoeba, protozoa & algae Rubber, some plastics support growth

24 Building information Age, size & construction, room configurations Renovation History Plumbing system Design Number & type of water outlets Preventive Maintenance Connection to fire sprinkler system Heating/Cooling System Occupancy

25 Building Assessment: Water condition as supplied (Cl & Temp) Whirlpool spas and hot tubs Decorative fountains Cooling towers and evaporative condensers AC drip pan drainage Recent or ongoing construction/renovation Repair or construction of public water system

26 Sources of Exposure Breath mist Cooling tower mist Showers & aerators Nebulizer Spa/whirlpool Decorative fountain Aspiration of water Ice machines Drinking tap water Eating food made with tap water

27 Plumbing System Risk Factors Tanks sediment & temp stratification Biofilm in plumbing Deadlegs stagnant water Pipes inappropriately capped off Unused rooms (sections closed off, rooms unoccupied) Rubber gaskets & expansion tank lining Water temperature & Cl at outlets

28 Pre-Remediation Sampling Recommendations Use a CDC certified ELITE Laboratory ( Sample & process entire1 liter Approximately 10% of outlets Rooms associated with case Rooms distal to the case room Unused & underused outlets All tank(s) Hot water return(s) Supply water

29 Safe Limits in Potable Water No known safe amount Shoot for ALARA OSHA Technical Manual limits do NOT apply Assess preventive maintenance if detected in <30% of samples Remediate if detect in >30% of samples Local remediation at locations with >1 cfu/ml

30 Emergency Remediation Superheat or Hyperchlorination hours Minimum contact level at outlets Heat >160F Chlorine >50 ppm Hourly sampling to assure contact level Significant Patient Safety Issues to address

31 Post-Remediation Sampling Recommendations Same analysis and locations as the preremediation sampling Every 2 weeks for 3 months Monthly for 3 months Quarterly for 1.5 years Review all results to reassess situation Can relocate for repeat negative results LHD to get updates from facility progress

32 Secondary Disinfection Systems Chlorination Chlorine Dioxide Monochloramine Copper-Silver Ion Heat Ozone UV

33 LHD Follow-up Plan? Maintain communication with facility Assure sampling results are distributed LHD NJDOH Schedule conference calls as needed Frequent and regular contact with facility

34 Questions? Rebecca Greeley Eric Weren

35 UPDATE ON VIRAL RESPIRATORY PATHOGENS AVIAN INFLUENZA & MERS Lisa McHugh, Influenza Surveillance Coordinator / Manager, Regional Epidemiology Program

36 Influenza Viruses Three types Type A Can infect humans and a variety of animals (birds, pigs, horses) Wild birds are the natural reservoir Greatest risk for epidemic/pandemic Type B Humans only known reservoir Can cause epidemics but not pandemics Type C Humans and swine known reservoirs Mild illness in humans without seasonality

37 Antigenic Shift and Drift Shift (Type A only) Major changes new subtype Exchange of gene segments May cause pandemic Example: H3N2 replaced H2N2 in 1968 Drift (Types A and B) Minor change, within subtype Gradual accumulation of amino acid changes in HA and/or NA May cause epidemic Example: drifted A/H3N2/Fujian circulated A/H3N2/Panama (vaccine strain 2003/4) Occurs infrequently Occurs continuously Cox NJ, Subbarao K. Lancet 1999;354:

38 Novel Influenza A Virus Human infections with influenza A virus subtypes that are different from the currently circulating human subtypes (A/H1 and A/H3) Human infections with novel influenza A viruses which are transmissible person to person may signal the beginning of an influenza pandemic

39 Pandemics Factors that can favor a pandemic Ability to replicate in humans and cause serious disease with high mortality Have immunologically naïve human population Efficient human-to-human transmission

40 Novel Influenza A In June 2007, Novel Influenza A was added to the nationally notifiable disease list Novel influenza A viruses under surveillance H5N1 Avian Influenza 2009 H1N1 Swine Influenza H3N2 Swine Influenza H7N9 Avian Influenza H10N8 Avian Influenza H1N1 Swine Influenza H5Nx Avian Influenza

41 Avian Influenza (AI) Viruses Type A viruses Natural reservoir is wild waterfowl Birds carry virus in respiratory tract and intestines Does not usually cause illness in wild birds May cause severe disease in domesticated birds Can survive at low temperatures and low humidity for days to weeks Can survive in water

42 LPAI vs. HPAI (Birds) Low Pathogenic Avian Influenza (LPAI) Does not usually cause illness in wild birds May cause mild disease in poultry Cause poultry outbreaks worldwide Can evolve into HPAI Highly Pathogenic Avian Influenza (HPAI) Usually does not cause illness in wild birds Usually causes high mortality in domestic poultry Examples: H5,H7

43 HPAI H5Nx US Detections began December 2014 H5N2, H5N8, H5N1 Detected in 21 states Pacific, Central, and Mississippi Flyways 15 states with outbreak in domestic poultry/captive birds 6 states with detections in wild birds only NJ has not been impacted No human illness to date

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45 Response Animals USDA/NJDA lead agency illness in animals Ongoing AI surveillance Outbreaks in animals Quarantine restrict movement Eradicate - depopulation Monitor region Disinfect affected locations Test to confirm virus-free

46 Response Animals Outbreak identified/confirmed Zones created around area Depopulation of inner rings Foam or CO Gas Surveillance and prevention of outer rings Establishment of control zones to prevent spread On-site composting and burial

47 Public Health Response CDC/NJDOH lead for human illness Reporting and testing of ill individuals Monitoring of exposed individuals 10 days from last exposure Type of monitoring TBD Administration of antiviral post exposure prophylaxis

48 Public Health Guidance Risk to general public LOW Highest risk to impacted farm and outbreak response workers Same reporting and testing as other novel influenza A viruses ILI plus exposure Antivirals are being recommended for workers

49 Middle East Respiratory Syndrome Coronavirus (MERS CoV)

50 Coronavirus (CoV) Common virus Mild to moderate upper-respiratory tract illnesses (common cold) Can be associated with GI illness CoV was the cause of SARS (severe acute respiratory syndrome) Incubation periods longer than common cold Usually circulate in the winter and spring

51 CoV Prevalent in humans and domestic animals (cats, dogs, birds) SARS was a novel coronavirus believed to originate from civet cats Current novel coronavirus is believed to have originated in bats

52 Middle Eastern Respiratory Syndrome (MERS- CoV) Identified in human in April 2012 Initial circulation Arabian peninsula (Jordan, Saudi Arabia, and Qatar) Case count as of 7/17/15 1,368 cases; 490 deaths Travel related cases in other countries Clusters with person to person spread have been documented (not sustained)

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54 MERS CoV Epidemiology Asymptomatic to severe Fever, chills, headache, cough, dyspnea, myalgia are common Mostly adults (median age 50 years) Most with chronic co-morbidities Case fatality ~35%

55 MERS CoV Epidemiology Incubation period 5 days (range 2-14) Infectious period at least while symptomatic may be as long as 3 weeks No shedding prior to symptoms Asymptomatic cases have been identified HCW s and children who had contact with confirmed cases

56 Surveillance Criteria Need to meet both clinical and epidemiologic criteria Fever and pneumonia or acute respiratory distress Travel history to affected country Close contact with confirmed/suspect case History of working in health care facility in impacted country Less symptoms requirement

57 Surveillance Criteria A patient with fever (>100.4 F) AND pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence) AND one of more of the following: History of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset OR Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula OR History of being in a healthcare facility (as a patient, worker, or visitor) in the Republic of Korea within 14 days before symptom onset, OR A member of a cluster of patients with severe acute respiratory illness (e.g., feve and pneumonia requiring hospitalization) of unknown etiology in which MERSCoV is being evaluated by state of local health officials

58 Surveillance Criteria A patient with fever (>100.4 F) AND pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence) AND one of more of the following: History of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset OR Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula OR History of being in a healthcare facility (as a patient, worker, or visitor) in the Republic of Korea within 14 days before symptom onset, OR A member of a cluster of patients with severe acute respiratory illness (e.g., feve and pneumonia requiring hospitalization) of unknown etiology in which MERSCoV is being evaluated by state of local health officials

59 Surveillance Criteria (con t) A patient with fever (>100.4 F) AND symptoms of respiratory illness (not necessarily pneumonia; e.g., cough, shortness of breath) AND history of being in a healthcare facility (as a patient, worker, or visitor) within 14 days before symptom onset in countries in or near the Arabian Peninsula in which recent healthcare associate cases of MERS have been identified, OR Fever OR symptoms of respiratory illness (not necessarily pneumonia; e.g. cough, shortness of breath) AND close contact with a confirmed MERS case while the case was ill.

60 Republic of Korea May 2015 first case Symptomatic traveler from Middle East Seen at 2 clinics and 2 hospitals Extensive contact tracing/monitoring 186 laboratory confirmed cases and 35 deaths (7/21/15) To date, all cases (excluding the index case) have been linked to a single chain of transmission and are associated with health care facilities.

61 Last onset July 2

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64 MERS COMMON ISSUES/CONCERNS

65 MERS CoV Lab Testing PHEL can conduct testing NP/OP, Sputum, Serum Others Priority of testing on a case by case basis Results with 6-8 hours after receipt at PHEL Transportation of specimens can be challenging

66 Clinical Management Mostly supportive care Standard, contact, and airborne precautions should be implemented upon suspicion Hospitalization is not required e-care.html

67 Facility Response/Implications Implement measures to quickly identify suspect cases and prevent additional transmission Monitor staff, patients and visitors that came in contact with case Will be asked to monitor staff for signs/symptoms Asymptomatic workers with unprotected exposures will be excluded from work for 14 days

68 Local Health Department Gather case information Complete or assist with PUI form Assist facility in specimen transport At home patient management Monitoring of exposed contacts

69 Questions? Lisa McHugh, MPH New Jersey Department of Health Communicable Disease Service Phone:

70 COMMUNICABLE DISEASE BRIEFS Kristin Innes, Zoonotic Disease Epidemiologist Shereen Semple, Vectorborne Disease Coordinator Diana Theriault, Regional Epidemiologist

71 Kristin Innes, MPH, CHES RABIES UPDATE

72 Rabies Exposure A bite (penetration of the skin by teeth) from a potentially rabid animal Non-bite - Scratches, abrasions, open wounds (bleeding within 24 hrs.), or mucous membranes (eyes) contaminated with saliva or other potentially infectious material (brain or spinal cord) from a potentially rabid animal

73 Bat Exposures Known bite or non bite exposure Any direct contact with a bat when a bite or other exposure cannot be excluded Rabies prophylaxis should be considered when a bat is in the same room as a person/domestic animal who might be unaware, or cannot communicate that a bite or direct contact occurred Deeply sleeping person who awakens to find a bat in the room An adult witnessing a bat in the room with a previously unattended small child or mentally disabled or intoxicated person or domestic animal

74 Rabies Submission State couriers can transport low risk specimens to Rabies Lab Know where your nearest location is and its scheduled pick up time Test results are generally available the next working day, if received by 2:00pm Submit specimens Monday Wednesday, if possible, for timely results. High risk samples should be delivered directly to the Rabies Lab to prevent delay in prophylaxis

75 Notification of Test Result All test results will be faxed to the Health Officer from the Rabies Lab NJDOH will call the LHD to confirm that results were received and to assist in identification of exposed persons or domestic animals The LHD should notify all parties involved This may include investigating and identifying other exposed individuals and domestic animals Note: The NJ Dept. of Agriculture will handle exposed livestock species.

76 Constituent Outreach Provide after hours contact information to ACOs, vets, EDs, and physicians If you notice an increase in calls from a certain provider or on a specific topic, provide education to the facility

77 Resources NJDOH Rabies website: Bat Guidance: Specimen submission: Guide to Post-exposure Prophylaxis: pdf

78 Shereen Semple, MS, Vectorborne Disease and Ebola Team Lead VIRAL HEMORRHAGIC FEVERS: EBOLA UPDATES AND LASSA CASE INVESTIGATION

79 Diana Theriault, MPH, Regional Epidemiologist IDENTIFYING & MONITORING COMMUNITY CONTACTS IN RESPONSE TO LASSA FEVER CASE

80 Community contact tracing and monitoring Newark HD established a local response team Key responsibilities Identify close community contacts Survey administration Risk assessment Daily symptom monitoring and response Data management Identify community leaders and educators to assist in messaging REP collaborated onsite with Newark HD and was liaison to NJDOH response team

81 Contact Identification Case patient had a close-knit extended family 37 potential contacts identified Standard questionnaire was developed and used to interview contacts and determine risk

82 High Risk Classification & Response Exposure: Direct, unprotected contact (skin/mucosal) with potentially infectious material (vomitus, excreta, blood or body fluids) Including mouth-to-mouth kissing or sexual contact Response: Direct active monitoring for 21 days 2x daily temperature readings, 1 directly observed Exclusions Young children excluded from daycare; no other work/school restrictions No airline travel, no commercial conveyances Out of state travel case-by-case basis

83 Low Risk Classification & Response Exposure: Casual contact (skin to skin, sharing room/vehicle) or protected close contact (healthcare, cleaning/laundry, lab) with PPE (no contact with blood/body fluids) Response: Active monitoring for 21 days 2x daily self-monitored temperature readings, reported 1x daily to LHD with any symptoms Exclusions Young children excluded from daycare; no other work/school restrictions International travel case-by-case basis

84 Risk Classifications Risk assessment questionnaires reviewed by regional epidemiologists and Newark HD and assigned risk category 37 total community contacts 14high risk 13low risk 9no known risk 1refused interview PEP was offered for high risk contacts; all declined

85 Daily Monitoring All contacts monitored temperatures twice daily Low risk contacts were contacted by phone once daily (same as EVD active monitoring) High risk contacts were observed taking temperatures at the family s home or via FaceTime/Skype once daily The LHD made a site visit at the home for any non-complaint community members

86 Data Management All exposed community contacts entered and managed in CDRSS Temperature readings entered by Newark HD; compliance issues documented in case Regional epidemiologists monitored CDRSS data daily and brought compliance issues/ symptoms to DOH lassa response team REP notified LHDs where persons resided if outside Newark, but Newark monitored all community contacts At end of monitoring period, cases closed as not a case

87 When Exposed Persons Become Symptomatic #1: One high risk community contact became symptomatic with a low grade temperature (99ºF), back pain, heavy eyes and swelling. Admitted to Hospital C on day 7 of DAM. Tested negative for lassa and was released home #2: The same contact also became ill on day 20 of DAM with increasingly severe symptoms of fever, headache, and tonsilitis while at work in Morris County. Contact visited Occupational Health and consulted NJDOH NJDOH and CDC decided to have contact evaluated. Morris County EMS transported her to Hospital C Contact was again tested for lassa fever, result negative

88 Challenges Difficult to quickly identify and interview large number of contacts Some contacts hesitant to provide information Cultural practices regarding mourning and burial Direct active monitoring logistics, sensitivity to family concerns

89 Importance of Messaging Community meetings held to educate contacts and build rapport with the community Meetings held with a religious leader to address concerns with the family while respecting customs Discussing the stigma faced with community members helped to address concerns and foster good communication Establishing a point of contact within the extended family for communications addressed both logistics and sensitivity to family concerns

90 Lessons Learned Previously established relationships with community and religious partners provided assistance in communication and education Stigma associated with on going EVD outbreak in Liberia may have contributed to delayed diagnosis and hesitancy with contact interviews Previously established EVD monitoring protocols facilitated implementation for lassa fever response Collaboration between NJDOH and LHD was essential to a coordinated response

91 Acknowledgements Newark Department of Health and Human Services Essex Regional Health Commission Morris County Office of Health Management Livingston Health Department All Local Health Departments involved Community leaders throughout Newark NJDOH Lassa Team CDC CERT Team THANK YOU!!!

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93 Fifth Disease New Education Materials FAQ Exposure Notice for Childcare

94 Upcoming training / meetings 2015 Northeast Epidemiology Conference ($): September 30 October 2, 2015; New Brunswick: e.html Fall 2015 Communicable Disease Forums (in-person) October/November dates TBD

95 Evaluations and Credits Attendees will receive an evaluation link If you are registered with gotowebinar, you have attended If you watched webinar in a group: Send sign-in sheet containing Summer 2015 CD Forum, today s date (July 30, 2015), participant s name/signature, organization, and NJLMN address to Kim Cervantes, at fax or kim.cervantes@doh.state.nj.us Evaluation will be active for 1 week Public health CEs will appear on NJLMN transcript Nursing certificates will be ed following completion of evaluation include name/ *Credits may take up to 2 weeks

96 Questions / Suggestions: Kim Cervantes, kim.cervantes@doh.state.nj.us