SIX TOP CONCERNS FROM A PUBLIC HEALTH STANDPOINT THAT ADULT LIVING FACILITIES MAY ENCOUNTER: WAYS TO PROTECT OUR SENIORS OCTOBER 26,2016

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1 Source: CDC, Mumps Source: CDC, Measles Source: CDC, MERS SIX TOP CONCERNS FROM A PUBLIC HEALTH STANDPOINT THAT ADULT LIVING FACILITIES MAY ENCOUNTER: WAYS TO PROTECT OUR SENIORS OCTOBER 26,2016 Alana Sulka, MPH, RN, CPH Director, Epidemiology and Infectious Diseases Gwinnett, Newton, and Rockdale County Health Departments Lori Koyuncu, RN VP of Clinical Operations CaraVita Home Care

2 TODAY S DISCUSSION WILL HELP YOU TO: Understand basics of pathogens that impact the Adult Living Facility community State what actions to take when a pathogen is identified or suspected Understand disease reporting laws and responsibilities Recognize appropriate disease prevention and infection control measures Develop a relationship with local Public Health Know what is reportable Single cases of all of the pathogens we will discuss today are not reportable to Public Health, but outbreaks are reportable.

3 INFLUENZA Spread through large particle respiratory droplets expelled when sick people cough, sneeze, blow their nose, sing, or talk Requires close contact because droplets only travel a short distance People become ill when they inhale the droplets or when they touch a contaminated object (telephone, doorknob, handrail, etc) and then touch their eyes, nose, or mouth Influenza can survive on surfaces for 2 to 8 hours Incubation period: 1-4 days (average 2 days) Symptoms include: fever, cough, sore throat, runny/stuffy nose, body aches, fatigue, headache Some people have GI symptoms including vomiting and diarrhea Infectious 1 day before to 5-7 days after onset of symptoms Risk from complications highest persons 65 years of age and older 98.3 deaths per 100,000

4 INFLUENZA PREVENTION Fundamental elements of influenza prevention Administration of influenza vaccine Vaccination policies Systematic strategies for improving vaccination rates Implementation of respiratory hygiene and cough etiquette Education Screening and triage of patients Monitoring patients, staff and visitors (limit access to ill individuals) Appropriate management of ill HCP Employee illness policies (including exclusion) Use of antiviral treatment to shorten course of illness Adherence to infection control precautions for all patient-care activities and aerosolgenerating procedures CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines Hand washing, hand washing, hand washing Implementing environmental and engineering infection control measures Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer Standard cleaning and disinfecting agents are generally sufficient for influenza. Follow labeled instructions for contact times and specific instructions. Ensure all common touch surfaces are cleaned and disinfected frequently

5 INFLUENZA PREVENTION (CONT.) Manage visitor access and movement within facility Limit visitors for patients in isolation for influenza to persons who are necessary for the patient s emotional well-being and care For persons with acute respiratory symptoms, facilities should develop visitor restriction policies that consider location of patient being visited (e.g., oncology units) and circumstances, such as end-of-life situations, where exemptions to the restriction may be considered at the discretion of the facility Visits to patients in isolation for influenza should be scheduled and controlled to allow for: Screening visitors for symptoms of acute respiratory illness before entering the hospital. Facilities should provide instruction, before visitors enter patients rooms, on hand hygiene, limiting surfaces touched, and use of personal protective equipment (PPE) according to current facility policy while in the patient's room. Visitors should not be present during aerosol-generating procedures. Visitors should be instructed to limit their movement within the facility. If consistent with facility policy, visitors can be advised to contact their healthcare provider for information about influenza vaccination.

6 NOROVIRUS A.K.A. Winter Vomiting Disease or Stomach Flu Most common cause of acute gastroenteritis outbreaks Symptoms Nausea, vomiting, abdominal cramping, diarrhea, less often fever Incubation: hours Duration: hours Highly contagious and incredibly environmentally hardy Alcohol based hand sanitizers ineffective Requires use of labeled cleaning agents Primary cause of outbreaks in GNR and US Norovirus was the confirmed pathogen in 47.6% of outbreaks investigated in Gwinnett, Newton and Rockdale Counties in 2015.

7 NOROVIRUS FACTS: (SOURCE: CDC)

8 KEYS FOR PREVENTION Report immediately to Public Health for guidance Disease control measures vary significantly from other GI pathogens Key messages: Hand washing! Alcohol based hand sanitizers are ineffective Asymptomatic infections are common. Can easily aid in spreading illness. Ensure cleaning agents are effective (labeled) against Norovirus Limit/stop movement of patients/staff All residents should be isolated/quarantined in their rooms No social activities

9 NOROVIRUS PREVENTION (CONTINUED) Isolation precautions Norovirus spread through direct contact (fecal-oral) Can also be spread through aerosolized virus in vomitus Recommend exclusion of ill staff members until symptom free for hours (without the aid of medication) Ill food handlers are required to be excluded for 24 hours. Exclusion also required if food handlers have ill individuals at home. All staff who deliver meals or assist in feeding are food service staff and fall under the state food safety regulations Staff education is key! Partner with Public Health to ensure all staff are educated. Schedule an in-service so all staff are appropriately educated. Regular Environmental Services staff can not do the cleaning on their own. They will need help. Consider reassigning activities staff to assist in cleaning

10 KEYS TO CONTROL Pull all key staff together immediately. Everyone has a role! Communicate early! Ensure your staff are educated Ensure you know where to find key control activities Norovirus as a Healthcareassociated infection ( anisms/norovirus.html#a4) Remember, all outbreaks are reportable to Public Health by law PUB-HLTH

11 CLOSTRIDIUM DIFFICILE Clostridium difficile also known as C. diff [See-dif], is a spore forming bacteria. Most cases of C. diff infection occur in patients taking antibiotics. The most common symptoms of a C. diff infection include: watery diarrhea, fever, loss of appetite, nausea, belly pain and tenderness The elderly and people with certain medical problems have the greatest chance of getting C. diff. Difference between colonization and infection? Clostridium difficile colonization patient exhibits NO clinical symptoms patient tests positive for Clostridium difficile organism and/or its toxin more common than Clostridium difficile infection Clostridium difficile infection patient exhibits clinical symptoms patient tests positive for the Clostridium difficile organism and/or its toxin

12 CLOSTRIDIUM DIFFICILE The risk for disease increases in patients with: antibiotic exposure gastrointestinal surgery/manipulation long length of stay in healthcare settings a serious underlying illness immunocompromising conditions advanced age a.k.a. C. diff 1 in 11 people age 65 and older die within a month of C. diff diagnosis

13 C. DIFF TRANSMISSION Spread person to person through poor hand washing and contaminated objects and surfaces Can live on surfaces for as long as 5 months Patients can shed for several days after symptoms end To prevent C. diff. infections, doctors, nurses, and other healthcare providers: Clean their hands with soap and water before and after caring for every patient. This can prevent C. diff and other germs from being passed from one patient to another on their hands Carefully clean hospital rooms and medical equipment that have been used for patients with C. diff. Use Contact Precautions Single room or share a room only with someone else who also has C. diff. PPE including gloves and gown Visitors may also be asked to wear a gown and gloves Hand washing Alcohol does not kill C. diff spores (efficacy of hand sanitizer???) Only give patients antibiotics when it is necessary.

14 TREATMENT AND PREVENTION In 23% of patients, C. diff will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed The infection can usually be treated with an appropriate course (about 10 days) of antibiotics including metronidazole or vancomycin (administered orally) After treatment, repeat C. diff testing is not recommended if the patients symptoms have resolved, as patients may remain colonized. Full facility partnership and support required Guidelines and Recommendations Remember, all outbreaks are reportable to Public Health by law PUB-HLTH

15 MRSA Staphylococcus aureus commonly found on skin & mucous membranes 20-40% of healthy humans are carriers Transmission: self-inoculation or person-toperson Treated with penicillin Methicillin resistant Staphylococcus aureus Staph that is resistant to common antibiotics Most infections are skin infections In a healthcare setting, can cause severe problems including bloodstream infections, pneumonia and surgical site infections. If not treated quickly, MRSA infections can cause sepsis and death 2% of population are MRSA carriers Commonly misdiagnosed as a spider bite

16 MRSA MRSA is identified by a bacterial culture and antibiotic sensitivity of the suspected site of infection or colonization (e.g., blood, sputum, urine, wound, exudate, pressure ulcer material). Two criteria are necessary for the organism to be identified as MRSA The organism is identified as Staphylococcus aureus or coagulase-positive Staphylococcus species. The antibiotic sensitivity test will show that the organism is resistant to oxacillin or methicillin. Community acquired vs. hospital acquired Risk Factors for MRSA Prior prolonged hospitalization Preceding antimicrobial therapy Close proximity to a resident colonized or infected with MRSA Presence of open wounds and/or pressure ulcers Presence of invasive devices, such as gastrostomy tubes, tracheostomy tubes, intravascular lines, indwelling urinary catheters, etc.

17 MRSA PREVENTION Primarily spread through direct and indirect contact with infected or colonized patients Patients should be on contact precautions Poor adherence to standard infection control precautions can lead to transmission between patients and to clusters of infections Hand washing is key! MRSA is hardy in the environment and can survive for extended periods in facilities Daily cleaning of patient rooms by trained staff (including equipment cleaning) If there is shared equipment, establish routine cleaning schedules for shared equipment (i.e. bleach spray on table surfaces between use) Wash soiled linens and clothes with laundry detergent at the highest temperature the items are labeled for (hot water/hot dryer is most effective) Disinfectants effective against S. aureus or staph are most likely also effective against MRSA Read label to determine contact time and application instructions EPA approved list

18 SCABIES Caused by infestation of the skin by the microscopic mite Sarcoptes scabiei Infestations are common and found world wide and spread rapidly in crowded conditions Mite burrows into the upper layer of the skin where it lives and lays its eggs Spread by direct, prolonged, skin-to-skin contact with a person who has scabies Spreads easily under crowded conditions where close body and skin contact is common. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks Infestation is easily spread to sexual partners and household members. Infestation may also occur by sharing clothing, towels, and bedding

19 Source: Georgia Scabies Manual, 2011 Source:

20 SYMPTOMS OF SCABIES Most common symptoms of scabies are Pimple-like irritations, burrows or rash of the skin, especially: the webbing between the fingers the skin folds on the wrist, elbow, or knee the penis, the breast, or shoulder blades Intense itching, especially at night and over most of the body Sores on the body caused by scratching which can sometimes become infected Norwegian crusted scabies More severe form of disease Large areas of the body, like the hands and feet, may be scaly and crusted Crusts hide thousands of live mites and their eggs, making treatment difficult because medications applied directly to the skin may not be able to penetrate the thickened skin This type of scabies is extremely infectious and occurs mostly among the elderly, in some AIDS patients, or in people whose immunity is decreased Itching is caused by a toxin produced when the female mite lays eggs in the skin stanford.edu hardinmd.lib.uiowa.edu dermatlas.med.jhmi.edu

21 SCABIES TREATMENT Anyone who is diagnosed with scabies, as well as his or her sexual partners and persons who have close, prolonged contact to the infested person should be treated. All contacts need to be treated or reinfection is likely to occur Scabies is generally treatable with topical lotions/ointments Permethrin cream 5% (Elimite) Crotamiton lotion/cream 10% (Euran/Crotan) Sulfur ointment 5-10% (multiple brand names) Lindane lotion 1% not recommended as first line therapy Ivermectin (Stromectol) not FDA approved for this use; used after treatment failures with topical treatment or in patients who cannot tolerate topical treatments For crusted scabies, both oral and topical agents should be used May add benzyl benzoate 25% or keratolytic cream

22 SCABIES PREVENTION Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks Undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching) New patients and employees should be screened carefully and evaluated for any skin conditions that could be compatible with scabies The onset of scabies in a staff person who has had scabies before can be an early warning sign of undetected scabies in a patient Skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites Typically, there are fewer than mites on the entire body of the infested person, which makes it easy for an infestation to be missed Notify Public Health immediately Public Health will provide specific infection control measures to limit transmission and help you to control the spread of disease

23 SCABIES: ENVIRONMENTAL CONTROL Onset of symptoms may not occur for up to two months following infestation Can transmit scabies even without symptoms All clothes, bedding, and towels used by the infested person 2-3 days before treatment should be washed in hot water and dried in a hot dryer Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic bag for several days to a week Once away from the human body, mites do not survive more than hours. When living on a person, an adult female mite can live up to a month Rooms used by a patient with crusted scabies should be thoroughly cleaned and vacuumed after use. Pesticide sprays or fogs are generally unnecessary and their use is discouraged Individuals can return to school/work 24 hours after treatment

24 BED BUGS Bedbugs (Cimex lectularius) are nocturnal insects and as such, typically hide out during the time people are awake Will travel 5-20 feet from their hiding pace to feed Bedbugs can hide in mattresses, bedding, clothing, luggage, and furniture When cleaning, changing bedding, or staying away from home, look for: Rusty or reddish stains on bed sheets or mattresses caused by bed bugs being crushed. Dark spots which are bed bug excrement and may bleed on the fabric like a marker would. Eggs and eggshells, which are tiny (about 1mm) and pale yellow skins that nymphs shed as they grow larger. Live bed bugs. While bedbugs are not known to transmit infections, some individuals may have allergic reactions to bedbug bites Secondary infections may develop at the site of the bite Unlike head lice, bed bugs do not live on people; they move from one place to another in backpacks, clothing, luggage, books, and other items Photo credit: CDC/ CDC-DPDx; Blaine Mathison - This image depicts a view from above of an adult, Cimex lectularius bed bug. Adult bed bugs are on average 5 mm long and have an oval-shaped and flattened body.

25 MANAGEMENT OF BED BUGS Aggressive Integrated Pest Management essential in reducing the likelihood of infestations Anything removed from the room should be placed in a sealed plastic bag and treated. Items that cannot be treated should be placed in a sealed plastic bag and left for an extended period of time to ensure any active bugs are dead (research shows variation in the length of time needed, but it can be as long as a year). Empty the vacuum after each use. Seal the bag and throw it out in an outdoor trash container. Life cycle of the bed bug. Photo Courtesy of Stephen Doggett, Department of Medical Entomology, Westmead Hospital, Sydney, Australia Put bedding and clothing in the dryer at high temperatures for 30 minutes to kill bed bugs (just washing will generally not kill bed bugs).

26 BED BUG MANAGEMENT (CONT.) To kill bed bugs with heat, the room must be even hotter to ensure sustained heat reaches the bugs no matter where they are hiding Use mattress, box spring, and pillow encasements to trap bed bugs and help detect infestations. Heat treatments (greater than 113 F) can kill bed bugs F for greater than 90 min will kill live bugs 118 F for greater than 20 min will kill live bugs Eggs must be heated to 118 F form 90 min Steaming works, but you must move slowly enough so that the heat concentration (target temperatures F) is maintained over every inch of surface (the pace should be about 12 inches every 30 seconds) Two adult bed bugs in a petri dish (courtesy of Kim Jung) 1

27 NOTIFIABLE DISEASES GA Department of Public Health determines what diseases are considered reportable in the state Follow CSTE and CDC recommendations Diseases categorized by reporting requirements and timeframes Report immediately Report within 7 days Report within 1 month Report within 6 months

28 NOTIFIABLE DISEASE REPORTING OPTIONS Paper based reporting Snail Mail Fax Integration with EMR ELR data feeds Phone Calls All Immediately Notifiable Diseases MUST be reported within 24 hours of diagnosis (or suspicion) Ask for Epi-on-call After hours or PUB-HLTH

29 WHAT REQUIRES IMMEDIATE REPORTING? Why do some pathogens require immediate reporting? Outbreak/Cluster mitigation Disease prevention Prophylaxis of contacts Bioterrorism response CDC involvement Novel infections Early communication is key! Allows for prompt disease control efforts Botulism treatment requires antitoxin release through Public Health Involve Hospital Infection Control!!

30 Hand washing is the single most important way to prevent the spread of pathogens!!!!

31 PUBLIC HEALTH AS A CAREER CHOICE Public health is a diverse and growing field that offers many career options for people from a variety of educational backgrounds Public health professionals are essential to developing and maintaining safe and healthy communities Positions exist at the local, county/district, state, and federal level

32 RESOURCES: Influenza Norovirus C. diff MRSA Scabies Bed Bugs

33 All data provided from Preliminary GNR 2015 Annual Epidemiology Report THANK YOU! Alana C Sulka, MPH, RN, CPH Director of Epidemiology and Infectious Diseases Alana.Sulka@GNRHealth.com Main: Office: Cell: /7 On Call: or PUB-HLTH