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Epidemics and Epidemic Investigation

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by Dominga C. Gomez, RN

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Epidemics and Epidemic Investigation

  1. 1. DOMINGA C. GOMEZ, R.N.
  2. 2.  Surveillance and the work-up of epidemics are the two inseparable responsibilities of IPCN.  Surveillance provides the baseline data to define the presence or absence of an epidemic or problem  Epidemics of infection and diseases occur when an agent and an adequate number of susceptible individuals have sufficient contact for continuing transmission
  3. 3.  An epidemic continues until the susceptible hosts in the population falls below the number at which the probability of contact, transmission and infection becomes too low for the process to continue
  4. 4.  Epidemic is defined as an excess of cases over the expected or usual number of occurrences  “ The occurrence of more cases of disease than expected in a given area or among the specific group of people over a particular period of time”- CDC
  5. 5.  Outbreak is a sudden occurrence of a disease in a community, which has never experienced the disease before or when cases of that disease occurs in numbers greater than expected in a given area.  Outbreaks carries the same definition of epidemic, but is often used for more limited geographic area.
  6. 6. • Common source epidemics appear when susceptible individual have mutual exposure to the same agent. Example- exposure to contaminated water with enteric organisms. Sometimes infections and associated cases may appear sequentially. If the exposure happens as a single time and place, it is called “ point source epidemic”
  7. 7.  Propagated epidemics take place when serial direct or indirect transmission takes place from susceptible host to susceptible host. This may occur in the form of person to person spread with a rapid sequence as in airborne transmission with short incubation period or slow pace in transmission with agent with longer incubation period as in hepatitis B
  8. 8.  1. Assure the presence of an epidemic. Confirm the diagnosis or define the entity. -know the endemic rate of occurrence -Know the etiology or disease -Verification of the diagnosis may come from the laboratory or sometimes purely from clinical grounds - with identified agent or clinical features, the approach is simplified with knowledge of incubation periods, sources and routes of transmission.
  9. 9.  Last April 20, 2017, the Office of the Hospital Director forwarded to the ICC the report of the Dept of Pediatric regarding the two cases of varicella at the ER.  TH- 8, year old was first seen April 16, 2017. Vesicular lesion appeared April 18, 2017. He was admitted to the Pediatric ward, placed in the isolation room  GB- 3 year old was seen April 18, 2017. He was sent home
  10. 10.  2.Case definition- must be fulfilled for each event that is counted as associated with epidemic. This may include a medical sign or symptoms or laboratory test or isolation of etiologic agent. It may include classification of the ill as a) definite case or confirmed b)probable and c) suspected cases
  11. 11. • Varicella Zoster Virus (VZV)Agent •Pre-school, young school-aged children •Highly communicable Epidemiology • Fever • Malaise • Generalized vesicular rash Symptoms
  12. 12. High Risk Patients Newborns of mothers with Varicella before delivery Infants 28 weeks gestation, less 1000 gms birth weight Immuno – compromised adults Pregnant women
  13. 13.  On April 25, another probable case of varicella was reported. JO 8 year old was admitted at the Pedia ward for hematologic problem as primary diagnosis  At about the same time, a Medical Intern reported at the Employees Clinic as a probable varicella. He said, he was the one on duty when the two varicella cases were managed at the ER.
  14. 14.  He said, he was with his Resident-trainor and and Pedia IDS Fellow. They were not feeling well but they continued their rounds at the Pedia Neuro ward and Pedia ICU  The following day, a physical therapist reported to have clinical symptoms of varicella  On April 28, Baby RH, 35 year old, admitted at the NICU was confirmed to have varicella
  15. 15. NEONATAL – ICU Name (+) exposure to Varicella Zoster (+) Vaccine BASINAG FE A. (+) BARBARAN, MA. MAGDALENA D. (+) BALDAGO, BERNADETTE T. (+) BERAYA, CHRISTOPHER R. ? ? DE LEON, SHEEN ANN (-) (-) DENOLAN, GWENDOLINE G. (-) (-) DOCE, JOANNE (+) (-) DURAN, APRILYN (-) (-) FELICES, DARWIN O. (+) (+) FELIPE, PATRICIA (+) (-) GARCIA, MA. MACRINA MERICI S. (+) (-) GUZMAN, ARLENE B (+) (-) GUZMAN, ARLENE JOY M. (+) (-) LABORDO, GENEVIEVE A. (+) (+) LACUNA, RIZALYN A. - NIII (-) (-) LANDICHO, GENAR T. – NIII (+) (-) LIM, MABIN (+) (+) MACABABBAD , KATHRINA BIANCA (+) (-)
  16. 16. Name (+) exposure to Varicella Zoster (+) Vaccine BUHAT, NENITA A. (+) (-) CANALEZA, ELISA MILBA A. (+) (-) CLEOFE, AURELIA E. (+) (-) CORPUZ, THELMA C. DELOS SANTOS, ROSALINDA T. (-) (-) EUSEBIO, CATHERINE E. (+) (+) GAMENG, MYRNA V. IBANEZ, LANIE A. NAI (+) (-) ILAO, MA. CRISTINA (+) (-) MANIO, LUCILA ? ? METRAN, MARIA THERESA (+) (-) NAVARRO, RACHELLEMAR (+) (+) OPULENCIA, JULNETTE A. (+) (-) NURSING ATTENDANTS
  17. 17. • 2 days before onset of rash until lesions have crusted. Period of Communicability •10-21 days after exposure • Post Exposure VZIG: 28 days Incubation Period • Contact with vesicles • 3-6 feet close proximity in a room for >/ 1 hour Exposure Definition
  18. 18. Hospital Acquired Sharing of 2-4 bed hospital room Prolonged direct face to face contact
  19. 19. IMMUNE  Varicella by history Serologic immunity (97-99%)  Negative or Uncertain Serologic immunity (71-93%) NON - IMMUNE  No reliable history of Varicella - Seronegative
  20. 20.  4.Formulate a working hypothesis-based on the preliminary analysis, a hypothesis is prepared. One may attempt to identify the risk population and find the level of exposure and to contrast the exposed and not exposed.  With additional findings , analysis all cases will be done and prepare an interpretation of the event. If the hypothesis is supported, it is confirmed in the report.
  21. 21.  5. Test the hypothesis  6. Add data on all additional cases  7. As soon as etiology is established. Any pertinent control measures should now be activated
  22. 22. VARICELLA (CHICKEN POX) AND VARICELLA ZOSTER (SHINGLES) Source Case VZV Infection (Chicken Pox) Exclude from work until lesions have crusted Exclude from work: 10-28 days post-exposure Post exposure Prophylaxis 1. ACYCLOVIR: 20-40 mg/kg q day x 7 days 2. VARICELLA VACCINE: (0.5 mL 5Q x 2 doses, last dose after 4 weeks No Further Intervention No Further Intervention Patient HCW Confirm Diagnosis History and PE Immunity Status 1. Early Discharge 2. Source Isolation Airborne and Contact Precautions 3. Immune Personnel Immune Negative Non-Immune Prior History of Chicken Pox PositiveSerologic Test
  23. 23. Immunization 99% seropositive after 2nd dose Routine testing not necessary Serologic Test: ELISA IgG
  24. 24. VARICELLA (CHICKEN POX) AND VARICELLA ZOSTER (SHINGLES) Source Case VZV Infection (Chicken Pox) Exclude from work until lesions have crusted Exclude from work: 10-28 days post-exposure Post exposure Prophylaxis 1. ACYCLOVIR: 20-40 mg/kg q day x 7 days 2. VARICELLA VACCINE: (0.5 mL 5Q x 2 doses, last dose after 4 weeks No Further Intervention No Further Intervention Patient HCW Confirm Diagnosis History and PE Immunity Status 1. Early Discharge 2. Source Isolation Airborne and Contact Precautions 3. Immune Personnel Immune Negative Non-Immune Prior History of Chicken Pox PositiveSerologic Test
  25. 25. Source Isolation Airborne precautions Contact precautions
  26. 26. Vaccination Two 0.5 ml doses SQ 4-8 weeks apart Within 3-5 days of exposure
  27. 27. Work Restrictions Post Exposure: exclude from duty a. 10-21 days after exposure b. 10-28 days of VZIG given Vaccinated Exposed: serotest for antibody If negative; exclude form duty or monitor for symptoms Infected Exclude unti lesions have crusted
  28. 28. VARICELLA (CHICKEN POX) AND VARICELLA ZOSTER (SHINGLES) Source Case VZV Infection (Chicken Pox) Exclude from work until lesions have crusted Exclude from work: 10-28 days post-exposure Post exposure Prophylaxis 1. ACYCLOVIR: 20-40 mg/kg q day x 7 days 2. VARICELLA VACCINE: (0.5 mL 5Q x 2 doses, last dose after 4 weeks No Further Intervention No Further Intervention Patient HCW Confirm Diagnosis History and PE Immunity Status 1. Early Discharge 2. Source Isolation Airborne and Contact Precautions 3. Immune Personnel Immune Negative Non-Immune Prior History of Chicken Pox PositiveSerologic Test
  29. 29.  8. Recommend control programs- directed at three links in the chain of infection. ◦ * modifying the environmental reservoirs- active surveillance can be done for proper management and work restriction. Inanimate environment can be altered by following IPC protocols ◦ *Interrupting transmission-should include behavioral changes… hand hygiene, personal hygiene, use of PPE ◦ * Protecting the host-active immunization ◦ * Antibiotic Prophylaxis
  30. 30. * Other action taken- contact tracing of all who are possibly exposed , other patients and watchers, and possibly the community 9.Announce result and prepare written report 10. Continue surveillance and documentation
  31. 31.  Investigation of an epidemic requires a prioritized and systematic approach to gathering and analysis of data with careful attention to detail at each step of the way  It must be recognized that “cook book” approach is not always to all epidemics  Investigative steps may be carried out concurrently instead of sequence.  Epidemic investigation is being conducted with the ultimate aim of solving the problem
  32. 32.  Thank you
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by Dominga C. Gomez, RN

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