Agenda 3/27/2017. An overview Communicable Diseases/ Outbreaks. Sonya E. Frontin, MPH NJDOH Regional Epidemiology Program. Welcome & Overview

Transcription

1 Agenda An overview Communicable Diseases/ Outbreaks Ma isah K. Burks, MBA, MPH Sonya E. Frontin, MPH NJDOH Regional Epidemiology Program Welcome & Overview Disease Prevention and Control Reporting Regulations and Protocols Conducting an Outbreak Investigation Common Types of Outbreaks in Long term Care and Residential Settings Welcome & Overview Nurses Housekeeping Continuing Education Credits Approved for 2.75 PH credits and nursing contact hours Must sign in Complete evaluations at the end Certificates provided at the end of workshop Public Health Credits will appear on NJLMN transcript Questions after each segment and at the end Presentation slides posted on NJLMN under Practice Exchange 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 the signature on the registration form and completion of the evaluation Participants cannot miss more than 5 minutes from a 30 minute segment; 10 minutes from a 60 minute segment 1

2 Nurses Upcoming Conferences No commercial support has influenced the planning of the education objectives and content of this event No influential relationships have been discovered 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 2017 NJDOH Spring Communicable Disease Forum o April 6 th Northeast: 8:30a to Verona Community Center, 880 Bloomfield Ave, Verona, NJ o April 20 th Northwest: 8.30a to Frelinghuysen Arboretum, 353 East Hanover Avenue, Morris Township, NJ May 10 th Healthcare Associated Infections Conference o Conference Center at Mercer, Princeton Junction o $15/pp includes light breakfast, lunch, and credits June 1 st Annual Drug Diversion Conference o Rutgers: Busch Campus Center, Piscataway o $50/pp includes lite breakfast, lunch, and credits Objectives Define a communicable disease outbreak Review of NJDOH outbreak reporting mandates for long term care and other institutional settings Identify specific reporting responsibilities and protocols for the facility, LHD and NJDOH Reinforce the steps of an outbreak investigation Promote public health partner collaboration Topics for Review Disease Prevention and Control Reporting Regulations and Protocols 4 Outbreak Common Types Investigation of Outbreaks in Long Term Care Role of Local Health 2

3 What is a communicable disease? Disease Prevention and Control Definition, mechanism, terminology, and precautions Any disease that can be spread from person to person. It may be spread by: Direct contact with others Contact with contaminated surfaces Improper hand washing practices Sneezing or coughing on one another Why is this important? How are diseases spread? Cause serious health problems Are easily spread Particularly among residents & staff in residential facilities Can be prevented easily Handwashing & cough etiquette 3

4 Example of Disease Spread through Contaminated Food Basic Terms Portal of entry Hosts Germ Source where germ lives Incubation period Infectious period Shedding Mode of transmission Place of exit from source Incubation Period Infectious Period The time period between when an individual comes in contact with the germ and the onset of symptoms Varies by disease The time period when an infected individual is able to transmit the germ to others (infectious) Usually coincide with symptom onset but not always Can persist after symptoms are gone 4

5 Shedding Latent Period & Period of Communicability The process that occurs when a germ is present in bodily fluids or open wounds and can thereby be transmitted to another person May occur after symptoms are resolved Ways to Prevent Spread Standard Precautions Measures Standard Precautions Any body fluid may contain germs Reduce the risk of disease from recognized and unrecognized sources of infection Implement Control Measures Hand washing After using the restroom After handling any body fluids Before and after giving first aid After cleaning up spills or objects contaminated with body fluids After taking off your gloves 5

6 Standard Precautions Measures Control Measures Gloves should be worn During contact with blood or body fluid Cleaning Routine cleaning and disinfection of high touch surfaces with appropriate solution. Proper disposal of items Cohorting Isolate those with symptoms Have a designated place Cohort staff working with respective groups Control Measures Control Measures Hand washing is both a prevention and control measure Encourage frequent hand washing with soap and water Respiratory etiquette Coughing and sneezing into a tissue or elbow Links for information about hand washing Cleaning and Disinfection Increase frequency of cleaning Use an EPA approved disinfectant or a freshly prepared bleach solution Educate residents & staff on prevention & proper hygiene Link to EPA approved disinfectants 6

7 Reporting New Jersey Administrative Code (NJAC) 8:57 Reporting Regulations and Protocols New Jersey Administrative Code (NJAC) 8:57 Regulations require reporting and investigation of certain communicable diseases and outbreaks for the purpose of surveillance and public health intervention. Cases should be reported to the local health department with jurisdiction over the facility. Must be reported via telephone! Regulations, responsibilities, and procedures If the local health department cannot be reached, report directly to NJDOH! (609) {M F 8am 5pm} (609) {After 5pm and Holidays} Goals of Reporting When to Report Control the spread of disease Identify and eliminate source of infection Contaminated products Learn about emerging problems Identify and mitigate a carriers role in disease transmission Implement new strategies for prevention As soon as an outbreak is suspected A significant increase of illness above what is expected in a given period of time Current infection control practices are not working to control expected illness levels among residents 7

8 New Jersey Administrative Code (NJAC) 8:52 Local Health Responsibilities At a minimum Health officer must investigate each case of communicable disease to: Determine whether a single case or an outbreak of disease exists. Ascertain the source and spread of the infection. Determine and implement appropriate control measures. Health Officer Powers May prohibit a person infected with a communicable disease which may be transmitted through food from working with food. May prohibit a household contact of an infected person from working with food. May require a person who is employed in a food establishment who is suspected of being infected with a communicable disease that may be transmitted through food, to submit specimens to ascertain whether or not the person is infected. May prohibit sale or distribution of food prepared by a person who is ill or infected with a communicable disease which may be transmitted through food. Responsibility for Investigation»Local Health Departments» Local point source outbreak»njdoh (CDS and FDSP)» Coordinate multi jurisdictional efforts within NJ» NJ Lead in multi state investigations» May be lead agency in multi state outbreak»cdc (FDA or USDA)» May be the lead in multi state investigation GOAL: Determine source of an outbreak and implement control measures to STOP SPREAD! Facility Reporting Protocol The facility shall: Notify NJDOH, Long Term Care licensing at Notify LHD by telephone contact Voic or fax notification is not sufficient If LHD not available, notifies NJDOH directly at and after hours NJDOH contacts the LHD Directory of Local Health Departments An online searchable Directory of Local Health departments in New Jersey provides important information about how to contact local health departments is available at 8

9 Facility Reporting Responsibilities Public Health Response Report to the local health department Initial outbreak report Daily updates of: case numbers (staff and residents) staff includes all facility employees, contracted employees and volunteers control measures implemented other pertinent information Local Health Department (LHD) Legal authority to enforce public health rules Leads investigation & response LINCS Agency Local Information Network and Communications System State Health Department Regional Epidemiologist Oversight, consultation and guidance Issue E number State wide perspective NJDOH Outbreak Prevention and Control Guidelines Gastrointestinal Infections Respiratory Infections Scabies Collaboration is KEY Local, regional, and state health departments are here to help with communicable disease issues. Assistance may be provided in the form of: Fact sheets Sample line lists Technical guidance 9

10 State Facilities Reporting Protocol Notify Long Term Care licensing Immediately report directly to NJDOH at during business hours and after hours DHSS leads the investigation of state facilities DHSS notifies LHD and regional epidemiologist of the incidence of communicable disease for community surveillance Outbreak Investigation Steps for investigation, source, control, and prevention Definition of an outbreak What is an Outbreak? 10

11 Outbreak Investigation CONDUCTING AN OUTBREAK INVESTIGATION Steps to an Investigation 1. Confirm outbreak 2. Verify diagnosis 3. Develop case definition 4. Perform active surveillance 5. Document cases in a line list 6. Identify and eliminate transmission sources 7. Institute control measures 8. Evaluate effectiveness of control measures 9. Submit a written final report Notification STEP 1: Confirm that an Outbreak Exists Notify NJDOH, Communicable Disease Service. During business hours at , after hours at Obtain an E number for tracking samples and reports associated with the outbreak Outbreaks at other locations may be happening at same time Compare the number of current cases to expected norms Suspect an outbreak when number of cases exceeds what would typically occur within a unit/wing/facility during a defined timeframe Never use a precise number or percentage of ill to identify an outbreak 11

12 STEP 2: Verify the Diagnosis NJ Public Health Laboratory (PHEL) Testing Determine the cause of illness based on the patients history, clinical presentation and /or laboratory findings At least two laboratory confirmed cases are needed to confirm an outbreak s etiology. Probable outbreak status denotes only one laboratory confirmed case NJDOH Communicable Disease Service may approve PHEL testing in certain outbreak situations (norovirus, influenza) Collect specimen during acute illness Label each specimen and lab slip with patient name, DOB, collection date & E number Facilitate transport of specimen to PHEL through the local health department STEP 3: Develop a Case Definition Define the criteria that an individual must meet to be counted as an outbreak case, including: o clinical signs and symptoms o duration of illness o physical location and o specific time period Case definition is developed based on the current situation and thru collaboration of: o facility staff o local health department o regional epidemiologist Example #1 Case Definition for Acute Gastroenteritis Fever, nausea, and abdominal discomfort on or after mm/dd/yy Plus 2 or more episodes of vomiting and /or loose or watery stools above the expected norm for the unit resident or staff within a 24 hour period 12

13 Example #2 Case Definition for Acute Gastroenteritis Laboratory evidence of gastrointestinal pathogen such as norovirus, Shigella, Escherichia coli etc. in unit resident or staff on or after mm/dd/yy Plus at least one symptom or sign compatible with a gastrointestinal infection (e.g. nausea, vomiting, abdominal pain etc.) Example #3 Case Definition for Acute Gastroenteritis Fever, nausea, and abdominal discomfort Plus 2 or more episodes of vomiting and /or loose or watery stools In individuals (staff, volunteers and visitors) with an exposure to the facility within 24 hours of symptom onset Creating a Case Definition Case Definition» Cast a wide net at first» Begin general become increasingly specific as information is gathered» Person, place and time association» Clinical criteria case definitions» Objective criteria» Outbreak associated vs. normal background» Value of routine surveillance data» Primary vs. secondary cases» Ongoing throughout investigation» Precise definitions reduce potential for misclassification» Incorrectly classifying individuals can bias results» Makes it harder to detect true associations Residents or staff on XYZ Unit experiencing an illness that is characterized by fever and at least two of the following, on or after mm/dd/yy: Rhinorrhea (runny nose) Nasal congestion Sore throat Cough (productive or non productive) Change in appetite Change in mental status Headache Lethargy Myalgia Respiratory distress, dyspnea, shortness of breath Pleuritic chest pain Radiographic evidence of a pulmonary infiltrate Laboratory evidence of a respiratory pathogen such as influenza in a resident or staff member of Unit XYZ on or after mm/dd/yy AND at least one symptom or sign compatible with respiratory infection (e.g. rhinitis, pharyngitis, laryngitis, cough or pneumonia). 13

14 STEP 4: Perform Active Surveillance STEP5: Document and Count Cases Seek out additional cases among residents, staff; including volunteers and visitors Be alert for new onset illness among exposed person Review resident and staff histories to identify previous onsets of illness that could have been part of the outbreak. Facility shall develop a line list. DOH sample line list is available at: Line List A case tracking tool Ensures consistent data collection Summarize descriptive epidemiology (gender, age, onsets, symptoms, locations, role status... ) Make recommendations for additional control measures, as needed New Jersey Department of Health and Senior Services Infectious and Zoonotic Diseases Program PATIENT SYMPTOMS LINE LISTING (Gastrointestinal Infection) E - Patient Symptoms (GI) Name, Address and Telephone Number Case Age Sex Abdominal Pain Bloody Stool Chills Diarrhea Fever Headache Muscle Ache Nausea Vomiting Other Date of Onset Time of Onset Incubation Duration Saw Doctor Medication Hospitalization Specimen Comments Break Time 9 10 CDS-12 MAR 03 -KEEP PATIENT NAMES IN IDENTICAL ORDER ON BOTH PAGES- Page 1 of 2 Pages. 14

15 Complete a line list Document and Count Cases (cont ) Exercise LHD investigator shall review the line list with the facility and regional epidemiologist to: assess the status of the outbreak make recommendations for control measures create an epidemic curve of the outbreak What is an Epidemic Curve? An epidemic curve (epi curve) is a graphical representation of the number of cases of illness by the date of illness onset. Document and Count Cases (cont ) Epidemic Curve Created from line list data Date of onset on X axis Number of cases on Y axis 15

16 How can Epi Curves help in outbreaks? Point Source Outbreak An epi curve can provide information on: Magnitude of the outbreak Pattern of transmission Exposure and/or incubation period Effectiveness of control measures Propagated Outbreak 16

17 STEP 6: Identify and Eliminate Possible Transmission Sources Study the line list and epi curve for patterns What factors do the cases share? Medical and/or therapy equipment Eating facilities Environmental exposures Care provider Modify factors that can be controlled 17

18 STEP 6: Identify and Eliminate Possible Transmission Sources Use a floor plan in conjunction with a line list Document location of ill residents and staff Look for commonalities Identify possible routes of transmission STEP 6: Identify and Eliminate Possible Transmission Sources STEP 6: Identify and Eliminate Possible Transmission Sources Exclude sick staff Restrict sick visitors Encourage other visitors to limit the length of visits and limit direct contact with residents Remind visitors (through posted signs and other informational handouts) of importance of proper hand hygiene before and after patient contact Inform receiving facilities of the outbreak when transferring residents; Those who are ill and Exposed well residents When possible, limit transfers to medically necessary The facility, LHD and regional epidemiologist collaborate to determine the outbreak source. 18

19 Incubation Period Average time from exposure to development of illness signs and symptoms. When the infecting organism is known, the incubation period can be found in texts. Norovirus hours Influenza 1 4 days Scabies 4 6 weeks STEP 7: Institute Control Measures Control measures are the tools that can end an outbreak by halting transmission. Maintain control measures for 2 incubation periods of causative agent. The LHD in consultation with the regional epidemiologist shall provide recommendations and guidance to the facility regarding control measures. Effective Control Measures Control measures affect quality of life and staffing. Nevertheless, facilities should make every effort to maintain adequate control measures until the outbreak is over. If new cases persist, evaluate and enforce adherence to infection control precautions. Institute Control Measures Basic control measures include: A. Cohorting B. Contact precautions C. Universal Respiratory Etiquette (URP) D. Droplet precautions E. Hand hygiene F. Post exposure prophylaxis (PEP) G. Mandatory In Service education H. Restrict visitors 19

20 Cohorting Who and what? Residents, staff, equipment and supplies according to their living/working area How? Separate into three groups ILL Exposed (not ill, but potentially incubating) Not ILL/not exposed Close the facility to new admissions unless cohorting of these new residents can be maintained Cohorting Residents and Staff How? Do not allow residents/staff from one cohort to mix with other cohorts Community dining, activities, adjunct therapies Symptomatic residents remain in room for at least 24 hours after symptom resolution Assign staff to one cohort and DO NOT ROTATE Cohorting Equipment and Supplies Institute Transmission Precautions Restrict equipment use to one specific area within a unit Restrict exchange of resident supplies between cohorts Bed linens, wound dressings, water pitchers Medical or therapy equipment Disposable Segregate to cohort Clean and disinfect common use equipment There are 3 categories of transmission based precautions: Contact precautions Droplet precautions Airborne precautions 20

21 Institute Contact Precautions Institute Control Measures Contact Precautions include: Resident placement such as single patient room and balancing infection risks with possible adverse psychological impact Use of gloves and standard precautions Use of gowns and proper disposal Wearing of face protection Limit resident transfer and use personal protection equipment (PPE) Institute environmental measures prioritize rooms for frequent cleaning and disinfection Reemphasize hand hygiene among residents, staff and visitors Provide in service education to ALL staff All shifts this includes volunteers, private duty, contracted personal etc. Provide information on the infecting organism and its transmission, contact precautions and movement restrictions Institute Contact Precautions Universal Respiratory Etiquette Restrict visits from family, friends and volunteers as necessary Utilize the line list and epidemic curve to evaluate the effectiveness of control measures and modify as needed. Use signage to discourage visitors with respiratory infection. Provide tissues and/or surgical masks to residents and visitors who are coughing or sneezing so that they can cover their mouth and nose. Encourage persons who are coughing to sit at least 3 to 6 feet from others when feasible, or limit their visitation time. Reinforce meticulous hand hygiene 21

22 Droplet Precautions Hand Hygiene Resident placement Acute care settings placed in a single room Longterm care and residential settings Case by case basis Balance the infection risk of roommates with psychological impact of relocation on the ill resident Masks Wear surgical mask when entering the room, remove and dispose of it prior to leaving the residents room Resident Transport Limit transportation and relocation to medically necessary Ensure proper personal protection equipment is used The CDC has identified hand washing as the single most important means of preventing the spread of infection at all times. Hand Hygiene Pre and Post Exposure Prophylaxis (PEP) Reemphasize hand hygiene among residents, staff and visitors Provide hand washing supplies at sinks alcohol based hand rubs in other locations. Provide hands free trash cans when possible Alcohol based hand rubs are ineffective against norovirus and spore forming organisms like C. difficile Prophylaxis means disease prevention Pre exposure prophylaxis is a treatment administered before exposure to a disease producing pathogen Post exposure prophylaxis is a treatment administered immediately after exposure to a disease producing pathogen 22

23 Mandatory In service Education Restrict Visitors Provide in service education to ALL staff All shifts this includes volunteers, private duty, contracted personal etc. Provide information on the infecting organism and its transmission, contact precautions and movement restrictions Reemphasize hand hygiene Provide information on how staff can protect family and friends from secondary transmission of illness Restrict sick family, friends and volunteers from visiting as possible Family who insist on visiting cannot be excluded Post signs to reinforce control measures Educate all visitors (e.g., family, friends and volunteers) of the importance of hand hygiene, pre exposure (vaccination) and/or post exposure prophylaxis to prevent infection STEP 8: Evaluate Effectiveness of Control Measures When is the outbreak over? Outbreak is over after 2 incubation periods have passed without a new case ---- Implementation of Effective Control Measures 23

24 STEP 9: Outbreak Summary Report LHD summarizes the investigation in a written report utilizing the NJDOH Outbreak Summary Form available at: 30.dot Instructions for completion of the outbreak summary form is available at: 30_instr.doc Break Time Common Types of Outbreaks in Long term Care Gastrointestinal Illness Etiology, outbreak definition, and prevention 24

25 Gastrointestinal Illness Gastrointestinal Illness Outbreak in LTC Settings Facts: Several outbreaks of GI illness occur in LTC and rehabilitation centers annually Communal living makes transmission easier Norovirus is the most common cause Outbreaks in this setting may be prolonged, sometimes lasting months Outbreak Definition: One laboratory confirmed positive case of norovirus along with other cases of gastrointestinal illness in the facility; OR Two or more laboratory confirmed positive cases of an enteric pathogen (e.g., Campylobacter, E. coli, Salmonella, Shigella, etc.) in the facility; OR A sudden increase over the normal background rate of acute gastrointestinal illness, with or without lab confirmation (above the established baseline for that facility). Facts: Genus Norovirus, family Caliciviridae Human NoVs are divided into 3 genogroups (GI,GII,GIV) 25 genetic clusters CDC estimates 23 million cases/year in U.S. Responsible for ~58% foodborne illness in U.S. and ~50% local foodborne outbreaks Vigorous replication inside human host (humans only reservoir) Norovirus Transmission: Fecal oral o Person to person o Foodborne Contaminated RTE foods by infected foodhandlers or contamination of food products with human sewage o Waterborne o Mixed Airborne o Vomitus Fomites Norovirus Clinical Features: Average incubation hrs. (median in outbreaks is hrs.) Average duration hrs. Acute onset Nausea Vomiting Diarrhea (non bloody) Abdominal cramps Constitutional symptoms Headache Low grade fever (<100.3) Chills Myalgia Outbreaks common in long term care facilities/institutional settings 25

26 General Preventive Measures GI Illnesses 1. Cohort residents, staff equipment and supplies according to the living/work area 2. Institute contact precautions 3. Reemphasize hand hygiene among residents, staff, and visitors Respiratory Illness 4. Provide in service educations to ALL staff on ALL Shifts Emphasize on good hand washing practices Wash hands carefully after using the bathroom, changing diapers and after handling pets (i.e reptiles, chicks) Contact precautions Movement restrictions Reinforce staff illness reporting procedures and not to provide care if ill 5. Restrict visits from family, friends, and volunteers as necessary Respiratory Illness Facts: Several outbreaks of respiratory illness occur in LTC and rehabilitation centers annually Underlying health issues make this population more susceptible for serious complications or death when acutely ill Emphasis usually placed on influenza Respiratory Illness Outbreak in LTC Settings Outbreak Definition: One laboratory confirmed positive case (e.g., influenza, RSV, adenovirus) in a resident along with other cases of respiratory illnesses on the unit; OR A sudden increase over the normal background rate of acute respiratory illness (ARI)* cases, with or without documented fever (temperature 100 F OR 2 above the established baseline for that resident). *ARI includes any two of the following symptoms: fever, sore throat, cough, rhinorrhea, and nasal congestion in the absence of a known cause (e.g., seasonal allergies, COPD). 26

27 Influenza Facts: Infection caused by Influenza viruses 5 20% of US population get flu each year Estimated 310,000 hospitalizations with flurelated illness during season (CDC, 2016) CDC estimates that 12,000 deaths from pneumonia and influenza occurred during the season (CDC, 2016) Transmission: Direct contact Person to person Droplets: inhaled Indirect contact Contaminated surfaces Clinical Features: Average incubation 1 4 days Average duration 3 7 days Acute onset of Fever Cough Sore Throat Runny or stuffy nose Muscle of body aches Headache Fatigue Influenza General Preventive Measures Respiratory Illnesses 1. Cohort residents, staff equipment and supplies according to the living/work area 2. Maintain standard precautions 3. Institute droplet precautions 4. Reemphasize hand hygiene among residents, staff, and visitors 5. Administer antiviral treatments as indicated (Influenza ONLY) 6. Provide in service educations to ALL staff on ALL Shifts Emphasize on good hand washing practices Wash hands carefully after using the bathroom, changing diapers and after handling pets (i.e reptiles, chicks) Standard and droplet precautions Movement restrictions Reinforce staff illness reporting procedures and not to provide care if ill 7. Restrict visits from family, friends, and volunteers as necessary 8. Environmental measures TREATMENT Antiviral treatment (oseltamivir and zanamivir) is recommended as soon as possible for all residents with confirmed or suspected influenza (ILI). Treatment should not wait for laboratory confirmation of illness. Antivirals Influenza Illness CHEMOPROPHYLAXIS All eligible residents in the entire long term care facility (not just currently impacted ward) should receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined. Additionally, the guidance says, the facility should promptly initiate antiviral chemoprophylaxis to all non ill residents, regardless of whether they received influenza vaccination during the previous season. Antiviral chemoprophylaxis can be considered or offered to unvaccinated personnel who provide care to persons at high risk of complications. Antiviral chemoprophylaxis should continue for 14 days, or 7 days after the last onset of illness, whichever is longer Early action with chemoprophylaxis for all non ill residents can strongly impact morbidity and length of the outbreak. 27

28 Legionellosis (Legionella) Facts: Infection caused by Legionella bacteria Two distinct forms: Legionnaires disease (severe pneumonia) Pontiac fever (milder no pneumonia) Named after 1976 Outbreak held at American Legion in Philadelphia Estimated 8,000 18,000 hospitalizations with legionnaires disease annually (CDC, 2013) 2012: 173 cases in NJ Reservoir: Naturally in environment, typically in warm water Transmission: Airborne Droplets: inhaled NO person to person transmission Legionellosis (Legionella) Clinical Features: Symptom onset: 2 14 days following exposure Cough Shortness of breath High fever Muscle aches Headaches Lung failure Death (5 30%) People at risk for infection and resulting complications: Elderly (55+) Current or former smokers Persons with chronic lung disease immunocompromised persons Legionellosis (Legionella) Key Points Look for HAI links 1 confirmed case in LTC Resident = OUTBREAK!!! Assess travel outside of the facility within incubation period Report to the Local Health Department General Preventive Measures Legionella Facilities should maintain hot water at highest temperatures allowable by state regulations or codes Treatment of municipal water supplies Routine maintenance and sampling of water systems Portable water systems, water features etc. Use of sterile water for filling and terminal rinsing of nebulization devices Decontamination of portable water supplies hyper chlorination Recommend hiring a water consultant in outbreak situations 28

29 Scabies Scabies Facts: Infection caused by the Sarcoptes scabiei mite Outbreaks usually occur in crowded living conditions Individual community cases are not reported to public health, but outbreaks should be reported Do not transmit disease, but can cause irritation and allergic responses to infestation Transmission: Direct contact Skin to skin Indirect contact May infest host through inanimate objects i.e. shared clothing, bedding, carpets, and furniture There are an estimated 1 million cases of scabies that occur annually Scabies Illness Outbreak in LTC Settings Outbreak Definition: One or more laboratory confirmed (via positive skin scraping) cases of scabies OR At least two clinically suspected cases (which includes clinically diagnosed and treated individuals) in residents, health care providers, visitors, and/or volunteers within a four week period of time Clinical Features: Scabies Symptom onset: May take 4 6 weeks to begin for first time hosts 1 4 days for previously infested Symptoms: Intense itching (pruritis) Pimple like (papular) itchy rash Rash may have tiny blisters (vesicles) and scales Tiny burrows visible on skin People at risk for infestation: ANYONE Healthcare workers Elderly and immunocompromised persons are at risk of developing crusted scabies 29

30 Negative Skin Scrapings DO NOT rule out the presence of scabies May occur in actual cases during a confirmed outbreak Consider clinical presentation and exposure history in diagnosis Alternate diagnosis: Negative scrapings in multiple people AND Response to treatment is minimal after two weeks Scabies: Managing Symptomatic Cases Symptomatic Residents Contact isolation for suspected infestations Until treatment completed AND/OR Determined to be non infectious by physician or other experienced professional Prepare a line listing that includes: Name Age Gender Unit Room number Symptoms Onset Date Scabies evaluation results Any prior treatment Sample Line List for Residents CDS 34: 34.dot Treat with scabicide according to physician s recommendations Environmental cleaning of case resident s room Scabies: Managing Symptomatic Cases Symptomatic Healthcare Workers (HCW) Worker = ANY employee, staff, students, religious workers, volunteers, etc. Immediately remove any HCW with signs and symptoms consistent with scabies AND refer for evaluation Prepare a line listing that includes: Name Age Gender Symptoms Onset date Scabies evaluation results Any prior treatment Usual work and float assignments from SIX weeks before onset until current date Symptoms in household or other close contacts Treat with scabicide according to physician s recommendations Re evaluate cases after treatment on days 14 and 28 to monitor response Can return to work once treatment completed, BUT should use gowns and gloves for direct resident care Recommend scabicide prophylaxis for all household or other close contacts Scabies: Managing Contacts Identify Exposure Period What is the exposure period? Six weeks prior to the onset of symptoms Sample Line List for Staff CDS 35: 35.dot 30

31 Scabies: Managing Contacts Prophylaxis of Contacts Healthcare Workers Single course of scabicide for all who had direct contact with case Avoid skin to skin contact with case residents for at least 8 hours after treatment HCWs refusing treatment: Monitor weekly for six weeks from last potential exposure Required to wear gown and gloves for contact with residents or employees for six weeks from last potential exposure date If two or more HCWs assigned to the same unit are symptomatic, then prophylaxis is recommended for ALL unit contacts Residents Scabies: Managing Contacts Prophylaxis of Contacts Single course of scabicide to any resident who are direct contacts to a case Daily monitoring for six weeks of those residing on same unit at a case of Norwegian scabies with no direct contact Discharged resident contacts: Should be notified of their potential exposure If symptomatic: should be treated and household contacts receive prophylaxis If asymptomatic: should be directed to follow up with healthcare provider Notify facilities of to which resident contacts have been transferred of potential exposure Scabies: Managing Contacts Prophylaxis of Contacts Extending Recommendations for Prophylaxis Mass Prophylaxis: Facility wide (mass) prophylaxis of all residents and staff recommended if confirmed of suspect cases are found in patients or employees assigned to two or more areas of the facility where no direct link with an infested case resident or HCW can be established. All should be treated within the same 24 hour period. Scabies: Managing Contacts Notifications and Advisories Who to notify? HCWs, volunteers, family members, sexual partners, and anyone having close contact with a scabies case should be notified immediately of the facility outbreak and assessed for symptoms How to Notify? Distribute a notification letter and fact sheet which includes information about the scope of the outbreak and strategies implemented for the control and prevention of outbreaks 31

32 Scabies: Additional Control Measures Surveillance Long term surveillance Screening of new residents Notify the LHD of any outbreaks Education Staff training on scabies Provide general information to residents, volunteers, families, and visitors Evaluation If new cases are identified after control measures have been implemented for ONE incubation period, then one should evaluate and enforce adherence to infection control precautions by all staff, residents, and visitors Scabies Prevention and Control Plan Recommended for ALL healthcare and residential facilities Plans should include: 1. Written policies and procedures for prevention and control Include a plan for mass prophylaxis 2. Policy to screen new admissions during initial assessment Implement contact isolation for suspected cases 3. Policy to screen ALL new employees as part of pre employment screening 4. Employee training to conduct monitoring for self and residents Monitor for unexplained rashes or pruritus Report such occurrences to supervisory staff 5. Access to and usage of a healthcare provider experienced in scabies diagnosis Should be skilled in the evaluation of difficult and unusual cases and response to treatment 6. Assurance of administrative and staff support for the appropriate evaluation and treatment of employees, residents, and discharged residents in the event of an outbreak 7. Regular staff in service training on scabies prevention and control measures Forms Resources Guidance documents Web sites Resources CDC Infection Control Measures for Preventing and Controlling Influenza Transmission in Long Term Care Facilities, care.htm CDC Disinfection & Sterilization Guideline: Authors HICPAC g.htm Association Professionals in Infection Control (APIC) 32

33 Questions??? THANK YOU! M.K. Burks, MBA, MPH, CPH, PMP Career Epidemiology Field Officer Regional Epidemiology Program Office: Fax: Sonya E. Frontin, MPH Communicable Disease Epidemiologist Regional Epidemiology Program Office: Fax: