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Emerging and re-emerging infectious diseases: a key issue of governance for heealth
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Emerging and Re-emerging Infectious Diseases

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by Dr. Mark Kristoffer U. Pasayan

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Emerging and Re-emerging Infectious Diseases

  1. 1. INFECTION PREVENTION AND CONTROL IN EMERGING INFECTIOUS DISEASES Mark Kristoffer U. Pasayan, MD, FPCP, DPSMID Internal Medicine – Infectious Diseases
  2. 2. SOUTHEAST ASIA IS AN EID HOTSPOT
  3. 3. EMERGING INFECTIONS IN THE PHILIPPINES Ebola Reston in monkeys (Reston, Virginia) 2006 ▼ 1998 ▼▼ 2002 ▼ 2003 2005 ▼ Serological Surveillance ABLV West Nile Virus Pseudo outbreak (RITM as Referral Laboratory) SARS Outbreak Pandemic A H1N1 1989 ▼ Bioterrorism threat using Bacillus anthracis as biological weapon ▼ Meningococcemia outbreak in CAR2004 2001 2008 2009 ▼ Ebola Reston in pigs and humans/ Leptospirosis/ Salmonella typhi 2007 ▼ Resistant Shigella flexneri 2a in Cavite, Bohol and Cotabato 2010 ▼ Dengue2011 ▼ Chikungunya 2012 Leptospirosis ▼ No H5N1, H7N9, Ebola in PH2013 Pertussis, Measles ▼ 2014 ▼ Measles, MERS CoV, Henipah ▼ 1992 ▼ 1996 Ebola Reston in monkeys (Sienna, Italy) Ebola Reston in monkeys (US) 2015 MERS CoV, Ebola Reston ▼
  4. 4. EMERGING AND RE-EMERGING INFECTIOUS DISEASES
  5. 5. Middle East respiratory syndrome coronavirus (MERS-CoV)
  6. 6. 1,638 laboratory confirmed cases of MERS- CoV infection, globally 587 MERS-CoV – related deaths since September 2012 26 countries have reported cases of MERS- CoV since September 2012 WHO, as of February 16, 2016
  7. 7. A 35-year-old male was tested positive for MERS- CoV on October 12 in South Korea. WHO, as of February 14, 2015 Between January 22 and 27 2016, KSA notified WHO of 5 additional cases of MERS-CoV infection One laboratory-confirmed case from the Philippines, reported on July 6, 2015 On 24 January 2016, Thailand notified WHO of 1 laboratory case of MERS-CoV infection
  8. 8. What is the mode of human-to-human transmission of MERS - Coronavirus?  AIRBORNE  DROPLET  CONTACT  VECTOR-BORNE MERS-CoV, like other coronaviruses, is thought to spread from an infected person’s respiratory secretions, such as through coughing. However, the precise ways the virus spreads are not currently well understood.
  9. 9. Ebola Virus Disease
  10. 10. 28, 639 cases of Ebola virus disease and 11,316 deaths as of 31 January 2016 WHO, as of January 31, 2016 On 7 November 2015 , WHO declared that Ebola virus transmission had been stopped in Sierra Leone; on 90-day period of enhance surveillance On 14 January 2016, a new confirmed case was reported in Sierra Leone
  11. 11. 28, 639 cases of Ebola virus disease and 11,316 deaths as of January 31, 2016 WHO, as of January 31, 2016 Human-to-human transmission linked to the most recent cluster of cases in Liberia was declared to have ended on 14 January 2016 Guinea was declared free of Ebola transmission on 29 December 2015
  12. 12. What is the mode of human-to-human transmission of Ebola virus?  AIRBORNE  DROPLET  CONTACT  VECTOR-BORNE Ebola among healthcare personnel and other people is associated with DIRECT CONTACT with symptomatic people with Ebola (or the bodies of people who have died from Ebola) and DIRECT CONTACT with body fluids from Ebola patients. Airborne transmission of Ebola virus among humans has never been demonstrated in investigations that have described human-to-human transmission, although hypothetical concerns about aerosol transmission of Ebola virus have been raised
  13. 13. Best Defense Strategy: GOOD BASIC INFECTION CONTROL PRACTICE Yes No Yes, with reservation
  14. 14. IPC and EID Emerging infections associated with healthcare depends on the full implementation of the core components of IPC programs. Healthcare institutions are advised to consider reinforcing a service for the oversight of HCW’s health to ensure a safe environment for patients and HCW’s HCWs are provided with the best locally available protection for caring for patients infected with an EID, and are followed up if exposure has occurred.
  15. 15. Core component for IPC programs  Organization of IPC programs  Technical guidelines  Human resources (training, staffing, occupational health)  Surveillance of diseases and of compliance with IPC practices  Microbiology laboratory support  Clean and safe environment  Monitoring and evaluation of IPC program  Links with public health and other services
  16. 16. Principles of Infection Prevention and Control Strategies Associated with Health Care CONTROLS Administrative Environmental and EngineeringPPE
  17. 17. Administrative Controls ■ Clinical triage ■ IPC infrastructures and activities ■ Education of HCWs ■ Prevention of overcrowding in waiting areas ■ Providing dedicated waiting areas for the ill and placement of hospital patients ■ Organization of health-care services for adequate provision and use of supplies ■ Policies and procedures for all facets of occupational health ■ Monitoring of HCW compliance
  18. 18. Administrative Controls Infrastructure of Policies and Procedures ■ Prevent, detect, and control infections – from first point of patient encounter at triage through discharge ■ Implement occupational health policies and procedures – e.g. Exclude ill health care personnel from facility ■ Implement source control measures – e.g. change ventilator circuits between patients – One-time use of oxygen delivery devices – Sufficient PPE available at all times ■ Organize health care service delivery – e.g. Postponement of elective procedures if necessary – Restrict visitors
  19. 19. Administrative Controls Management of PUIs/Confirmed Cases ■ Timely and Effective Patient Triage – Prevent overcrowding in (dedicated) waiting areas – Avoid admitting patients with no risk factors ■ Admitted patients – Place in one ward, when possible – Minimum of 1 meter distance between patients with ARI – Cohorting policies ■ Drafting and access to specific case and clinical management protocols ■ Safe transport or discharge home
  20. 20. Principles of Infection Prevention and Control Strategies Associated with Health Care CONTROLS Administrative Environmental and EngineeringPPE
  21. 21. Engineering Controls: Objective Reduce exposures at the source and reduce the spread of pathogens during health care delivery using basic health-care facility infrastructure
  22. 22. Engineering Controls: Examples ■ Physical barriers or partitions to guide patients through triage areas ■ Appropriate environmental ventilation – At least 12 air changes per hour – Keep doors and windows open onto well ventilated corridors – If available, ensure air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) are properly maintained
  23. 23. Engineering Controls: Examples ■ Curtains between shared areas ■ Regular and proper technique for environmental cleaning ■ Closed systems for airway suctioning in intubated patients
  24. 24. Principles of Infection Prevention and Control Strategies Associated with Health Care CONTROLS Administrative Environmental and EngineeringPPE
  25. 25. Personal Protective Equipment ■ Rational and consistent use of available PPE and appropriate hand hygiene PPE is the strongest in the hierarchy of IPC measures to prevent transmission of EIDs? Yes No Yes, with reservation
  26. 26. Personal Protective Equipment ■ Rational and consistent use of available PPE and appropriate hand hygiene ■ PPE is the last and weakest in the hierarchy of IPC measures AND should not be relied upon as a primary prevention strategy. ■ In the absence of effective administrative and engineering controls, PPE HAS LIMITED BENEFIT
  27. 27. Personal Protective Equipment ■ Workers must receive training on and demonstrate an understanding of: – When to use PPE – What PPE is necessary – How to properly don and doff PPE – How to properly dispose of or disinfect and maintain PPE – Limitations of PPE ■ Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses.
  28. 28. Personal Protective Equipment PPE use is based on risk assessment of potential exposure and non-intact skin and should be applied during all potential exposure times, removed correctly and does not eliminate need for hand hygiene
  29. 29. Recommended Personal Protective Equipment ■ Goggles or face shield ■ Fit-tested N95 mask (or P100) ■ Impermeable gown ■ Gloves ■ Shoe cover ■ Additional: cap
  30. 30. Personal Protective Equipment ■ General sequence to donning for respiratory pathogens: gown, respirator, goggles or face shield, gloves. ■ General sequence to doffing: gloves, goggles or face shield, gown, then respirator.
  31. 31. Personal Protective Equipment  Except for respirator, remove PPE at doorway or in anteroom. Remove respirator after leaving patient room and closing door.  Careful attention should be given to prevent contamination of clothing and skin during the process of removing PPE.  Perform hand hygiene as described above immediately before putting on and after removing all PPE.
  32. 32. Infection prevention and control (IPC) precautions ■ Standard precautions – cornerstone for providing safe healthcare, reducing the risks of further infection and protecting HCWs, should always be applied in all health care settings for all patients.
  33. 33. Hand Hygiene PPE Prevention Needle- stick Injury Safe Waste CDS Environment Respiratory Hygiene
  34. 34. ■ The use of PPE does not eliminate the need for hand hygiene. Hand hygiene is also necessary while putting on and especially when taking off PPE.
  35. 35. ■ Ensure that cleaning and disinfection procedures are followed consistently and correctly ■ Cleaning environmental surfaces with water and detergent and applying commonly used disinfectants is an effective and sufficient procedure.
  36. 36. What is the most common mode of transmission of infection in the healthcare settings? Contact Transmission Droplet Transmission Airborne Transmission Inoculation
  37. 37. Additional IPC precautions… ■ In addition to Standard Precautions… – Use a medical mask when in close contact and upon entering the room or cubicle of the patient – Perform hand hygiene before and after touching the patient and his or her surroundings and immediately after removal of a medical mask
  38. 38. IPC precautions for aerosol-generating procedures ■ There is a consistent association between pathogen transmission and tracheal intubation ■ There is an increased risk of infection associated with tracheostomy, non-invasive ventilation and manual ventilation before intubation
  39. 39. When caring for patients with probable or confirmed EID… ■ Place patients in adequately ventilated single rooms or ‘Airborne Precaution’ rooms ■ When single rooms are not available, place confirmed patients together and separate them from probable patients ■ If this is not possible, place patient beds at least 1m apart ■ Limit the number of HCWs, family members and visitors in contact with a patient
  40. 40. When caring for patients with probable or confirmed EID… ■ If possible, use either disposable equipment or dedicated equipment ■ If equipment needs to be shared among patients, clean and disinfect it after each patient use ■ Avoid the movement and transport of patients out of barrier nursing room or area unless medically necessary. If transport is required, use routes of transport that minimize exposures of staff, other patients and visitors.
  41. 41. Duration of barrier nursing precautions ■ Fact: duration of infectivity of (some) EIDs is unknown ■ While Standard Precautions should always be applied, additional barrier nursing precautions should be used for the duration of symptomatic illness, and continued for 24 hours after the resolution of symptoms ■ Testing for viral shedding should assist decision-making when readily available.
  42. 42. Collection and handling of laboratory specimens from patients EIDs of potential concern ■ Ensure that HCWs who collect specimens use appropriate PPE ■ Ensure that personnel who transport specimens are trained in safe handling practices and spill decontamination procedures ■ Ensure that healthcare facility laboratories adhere to appropriate biosafety practices and transport requirements
  43. 43. ■ Need for comprehensive strategy to enhance IPC – Efforts directed to EIDs must be aggregated and efficient to build IPC capacity in the country ■ Need for integrated approach – WHO: improved liaison/collaboration among IPC-related initiatives – DOH: vertical programs ■ Creation of national resources centers that can foster country capacity building ■ Political will + combination of efforts = WORKS!
  44. 44. EBOLA VIRUS DISEASE MERS-CoV
  45. 45. Emerging Threats ■ A new variant of a fatal neurologic illness, Creutzfeldt-Jakob disease, appeared in the United Kingdom and was possibly transmitted by ingestion of beef from animals afflicted with bovine spongiform encephalopathy, also known as "mad cow disease." ■ A new and virulent strain of influenza in Hong Kong raised fears of a global pandemic ■ The United States had several multistate foodborne outbreaks, including outbreaks caused by Cyclospora parasites; hepatitis A virus; and Escherichia coli O157:H7 ■ Staphylococcus aureus with reduced susceptibility to vancomycin was reported for the first time in the United States and Japan ■ A new strain of tuberculosis (strain W), which is multidrug-resistant and appears more frequently in persons with HIV infection, has become endemic in New York
  46. 46. In recent years, we have seen the emergence and re-emergence of many infectious diseases. EID outbreaks highlight the shortcomings in our understanding of the complexities of infectious diseases. The reasons for emergence and re-emergence are multiple and complex. Clearly, human activities are a key factor for driving disease emergence and current knowledge of the various emerging viruses is far from complete. 50
  47. 47. It could be said that the current global situation favors disease emergence, and we may be faced with MORE outbreaks or pandemics of EIDs in the FUTURE 51
  48. 48. Thank you for listening
  • lavanyabaskaran8

    Sep. 14, 2021
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    Oct. 15, 2019
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    Jul. 11, 2017
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    Feb. 4, 2017

by Dr. Mark Kristoffer U. Pasayan

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