10/29/2015. Communicable Disease Outbreaks: Methods of Control. Objectives. Review of the Basics

Transcription

1 Communicable Disease Outbreaks: Methods of Control Brian Hartl, MPH Epidemiology Supervisor Kent County Health Department Objectives Contact Tracing Pharmaceutical Interventions Non-Pharmaceutical Interventions Review of the Basics Period of Communicability Transmission High Risk Contacts Post-Exposure Prophylaxis Measles Hepatitis A Pertussis Meningococcal Disease Rabies West Nile Virus Pandemic Flu Ebola 1

2 Measles Period of Communicability 4 days before rash onset to 4 days after rash appearance Transmission Direct contact with infectious droplets Airborne spread when an infected person breathes, coughs, or sneezes Virus can remain infectious in the air for up to two hours after an infected person leaves an area Measles High Risk Contacts Susceptible individuals are those who cannot show evidence of immunity Contact Tracing Household, daycare, classroom contacts Healthcare providers Waiting room contacts Time of patient arrival and up to 2 hours after patient departure Measles Post Exposure Prophylaxis Measles Vaccine Administered within 72 hours of exposure Except in healthcare, those who receive their first dose within 72 hours can return to childcare, school or work Should be monitored for symptoms for one incubation period (7-21 days) Vaccination of infants as young as 6 months may be used as control measure 2

3 Measles Post-Exposure Prophylaxis Immune Globulin Administered within 6 days of exposure Infants <12 months (IM), pregnant women and immunocompromised(iv) Used to reduce risk of infection and complications 0.5 ml/kg (max dose 15 ml) Factors to consider prior to permitting return to work, school, childcare Immune status Prolonged exposure Presence of populations at risk Exclusions Exclude HCPs receiving PEP from day 5 after first exposure to day 21 after last exposure Exclude from school/childcare any susceptible children who do not receive PEP Hepatitis A Period of Communicability Latter half of incubation period and continues for a few days after onset of jaundice Transmission Person to person via the fecal-oral route Hepatitis A High Risk Contacts Susceptible individuals are those who are previously unimmunized Household, sexual, drug using and other close personal contacts Day care attendees Food handlers Restaurant patrons Contact Tracing Identify all high risk contacts during period that begins 7 days prior to onset of jaundice 3

4 Hepatitis A Post Exposure Prophylaxis Hepatitis A Vaccine Administered within 14 days of exposure IG can also be given, but vaccine is commonly preferred Exclusions Exclude food handlers and daycare/school attendees until at least 7 days after the onset of jaundice or are medically cleared Pertussis Period of Communicability Highly communicable in the first two weeks and becomes negligible by about 3 weeks Patients no longer contagious after 5 days of antibiotic treatment Transmission Direct contact with respiratory discharge by airborne route via large droplets Indirect spread through air or contaminated objects may occur rarely Infants often exposed by parents, older siblings or other caregiver Pertussis High Risk Contacts Household contacts Infants and women in their third trimester of pregnancy Persons with pre-existing health conditions that may be exacerbated by a pertussis infection Contacts who themselves have close contact with either infants under 12 months, pregnant women or individuals with pre-existing health conditions at risk of severe illness or complications All contacts in high risk settings that include infants aged <12 months or women in the third trimester of pregnancy 4

5 Pertussis Post Exposure Prophylaxis 5-day course of azithromycin 7-day course of erythromycin or clarithromycin Trimethoprim sulfamethoxazole (TMP SMZ) can be used as an alternative agent to macrolides in patients aged >2 months who are allergic to macrolides, who cannot tolerate macrolides, or who are infected with a rare macrolide-resistant strain of Bordetella pertussis. Exclusions Inadequately immunized household contacts <7 years may be excluded from schools, daycare centers and public gatherings for 21 days after last exposure or until patients and contacts have received 5 days of antibiotics Meningococcal Disease Period of Communicability Until live meningococci are no longer present in respiratory discharge Usually disappear from the nasopharynx within 24 hours of antibiotic therapy Transmission Direct contact with respiratory droplets from the nose and throat 5

6 Meningococcal Disease High Risk Contacts Household contacts Roommates Boyfriends/girlfriends Young children in daycare centers HCPs with intimate exposure to nasopharyngeal secretions Those sharing eating or drinking utensils Those with extended contact in an enclosed space Traveling in a car for 4+ hours Sleeping overnight in the same room Contact Tracing Identify all high risk contacts during period that begins 7 days prior to onset of symptoms Meningococcal Post Exposure Prophylaxis Infants < 1 month old Rifampin 5 mg/kg PO BID for 2 days. Total of 4 doses in 2 days spaced 12 hours apart. Infants > 1 month to children <18 years old Rifampin 10 mg/kg (maximum dose 600 mg) PO BID for 2 days. Total of 4 doses in 2 days spaced 12 hours apart. Adults Ciprofloxacin 500 mg PO in a single dose for adults ( 18 years old) as chemoprophylaxis after potential exposure to meningococcemia or meningococcal meningitis. If Ciprofloxacin is contraindicated, use Rifampin 10 mg/kg (maximum dose 600 mg) PO BID for 2 days. Total of 4 doses in 2 days spaced 12 hours apart. Pregnancy Ceftriaxone (125 mg IM for age 15 and younger, 250 mg for those older than 15) Meningococcal Outbreak March 2013-March cases of serogroup B meningococcal disease were associated with Princeton University In December 2013, CDC allowed importation of a serogroup B vaccine In October 2014, FDA approved Trumemba*, a 3-dose serogroup B vaccine made by Pfizer In January 2015, FDA approved Bexsero*, a 2-dose serogroup B vaccine made by Novartis *Approved for individuals years of age 6

7 Rabies angry-hissing-cat.jpg Mosquito-Borne Disease West Nile Virus Cases Pandemic Influenza 7

8 Non-Pharmaceutical Interventions Voluntary Isolation of Ill at Home Voluntary Quarantine of household members in homes with ill persons Social Distancing (School) Dismissal of school and school-based activities, closure of child care Reduce out-of-school social contacts and community mixing Social Distancing (Workplace/Community) Decrease social contacts (teleconference, reduce face-to-face meetings) Increase distance between persons (public transit, workplace) Cancel public gatherings (stadium events, festivals, performances) Modify work schedules (telework, staggered schedules) Ebola Virus Disease Period of Communicability Highest during the late stages of illness when patient has vomiting, diarrhea and hemorrhages During funerals with unprotected body preparation Transmission Direct contact with infected blood, urine, vomit, diarrhea, secretions, organs or semen 8

9 Ebola Virus Disease High Risk Contacts Anyone with unprotected direct contact with bodily secretions of an infected patient. Anyone participating in burial rights without appropriate protective equipment HCPs caring for a patient without using appropriate protective equipment 9

10 High Risk Exposures Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids from a person with Ebola who has symptoms Direct contact with a person with Ebola who has symptoms, or the person s body fluids, while not wearing appropriate personal protective equipment (PPE) Laboratory processing of blood or body fluids from a person with Ebola who has symptoms while not wearing appropriate PPE or without using standard biosafety precautions Providing direct care to a person showing symptoms of Ebola in a household setting Direct contact with a dead body while not wearing appropriate PPE Public Health Actions for High Risk Travelers Direct Active Monitoring Controlled Movement Exclusion from Congregate Gatherings Exclusion from Workplaces for the duration of the public health order Non-congregate public activities may be permitted Federal Travel Restrictions (Do Not Board) if allowed, must be by conveyance separate from general public Some Risk Exposures In any country Being in close contact (within 3 feet for prolonged period) with a person with Ebola who has symptoms while not wearing appropriate PPE (for example, in households, healthcare facilities, or community settings) In countries with widespread transmission Direct contact with a person with Ebola who has symptoms, or the person s body fluids, while wearing appropriate PPE Being in the patient-care area of an Ebola treatment unit Providing any direct patient care in non-ebola healthcare settings 10

11 Public Health Actions for Some Risk Travelers Direct Active Monitoring For people who have had close contact with a person with Ebola while the person was symptomatic: Controlled movement consisting, at a minimum, of restrictions on long-distance travel on commercial or public transportation in the same conveyance as members of the general public If long-distance travel is allowed, the conditions of travel should include: Restriction to a conveyance separate from the general public in which close contact with other people can be appropriately limited Coordination with public health authorities at both origin and destination Uninterrupted direct active monitoring Federal public health travel restrictions (Do Not Board) may be implemented to enforce controlled movement. Additional restrictions as deemed appropriate by public health agency Low Risk Exposures In any country Brief direct contact (such as shaking hands) with a person in the early stages of Ebola, while not wearing appropriate PPE. Early signs can include fever, fatigue, or headache. Brief proximity with a person with Ebola who has symptoms (such as being in the same room, but not in close contact) while not wearing appropriate PPE Laboratory processing of blood or body fluids from a person with Ebola who has symptoms while wearing appropriate PPE and using standard biosafety precautions Traveling on an airplane with a person with Ebola who has symptoms and having had no identified some or high risk exposures In countries with widespread transmission, cases in urban settings with uncertain control measures, or former widespread transmission and current, established control measures Having been in one of these countries and having had no known exposures In any country other than those with widespread transmission Direct contact with a person with Ebola who has symptoms, or the person s body fluids, while wearing appropriate PPE Being in the patient-care area of an Ebola treatment unit Public Health Actions for Low Risk Travelers For anyone in this category other than travelers from countries with former widespread transmission and current, established control measures: Direct active monitoring for healthcare workers providing direct care to patients with Ebola while wearing appropriate PPE Self-monitoring for certain travelers who were on an aircraft with a person with symptomatic Ebola Active monitoring for all others in this category No restrictions on travel, work, congregate gatherings, or commercial or public transportation (although cruise ship travel is not recommended) 11

12 Traveler Health Monitoring Michigan Summary as of September 30, 2015 (n=378) Number of Travelers by Risk Group Monitored Risk Group Travelers Some Risk 13 Low Risk 343 Zero Risk (Ruled Out) 22 Traveler Health Monitoring Michigan Summary as of September 30, 2015 (n=378) Thank You Questions?