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Policy Implications of Healthcare Associated Infections
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Intro to Infectious Diseases and Epidemiology of Nosocomial Infection

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by Dr. Arthur Dessie E. Roman

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Intro to Infectious Diseases and Epidemiology of Nosocomial Infection

  1. 1. Arthur Dessi Roman, MD, MTM, FPCP, FPSMID Internal Medicine – Infectious Diseases Infectious Diseases at the Forefront @gonnabedess @gonnabedess Outline I. Why are infectious diseases unique II. Introduction and Epidemiology of healthcare- associated infections
  2. 2. Most of them are communicable. Case of The Black Death  Caused by Yersinia pestis carried by black rats  one of the most devastating pandemics in human history  estimated to have killed 30–60% of Europe's population reducing the world's population from an ~450M to between 350 and 375M in the 14th century  it took 150 years for Europe's population to recover Why are infectious disease unique? How infectious is MERS?
  3. 3. Reproduction Number MERS: Reproduction number
  4. 4. There is sometimes a need for urgency for control. Why are infectious disease unique? MERS South Korean South Korean outbreak: May - July 2015 • Index case: 68/M, (+) travel to Bahrain, UAE, Saudi Arabia, and Qatar; diagnosed with MERS 9 days after initial medical consult • Total of 186 cases with 36 deaths Korean Centers for Disease Control and Prevention. Available from www.mers.go.kr. Accessed on 11 August 2015. MERS Economic toll on South Korea • Department store sales: down by 17% (June 2016) • No. of people going to the movies, amusement parks, baseball games and museums also recorded large slumps, ranging from 38% to 82% • No. of trips cancelled: 100,000 foreign travelers • Tourist arrivals in the first 11 days of the month have fallen by 25% http://www.businessinsider.com/mers-outbreak-hurting-korean-retail-and-tourism-2015-6
  5. 5. MERS: What went wrong in Korea? • MERS unexpected and unfamiliar to most physicians • Sub-optimal prevention and control measures in some hospitals • Overcrowding at the ER an in ward rooms • Patient habits and customs • “Doctor-shopping” - patients seek care at a number of medical facilities • Visits to hospitalized patients by many friends and family members. • “Superspreader” Training on Hospital Preparedness and Management of MERS WHO Press release. WHO recommends continuation of strong disease control measures to bring MERS-CoV outbreak in Republic of Korea to an end. 13 June 2015. Why are infectious diseases unique? Microbes adapt and evolve. Clatworthy AE, Pierson E and Hung DT. Targeting virulence: a new paradigm for antimicrobial therapy. Nature Chemical Biology 3, 541 - 548 (2007) Published online: 20 August 2007 doi:10.1038/nchembio.2007.24 Timeline of antibiotic deployment and the evolution of antibiotic resistance.
  6. 6. They are sometimes occur with environmental, ecological and even behavioral events. • Ondoy left Metro Manila flooded in September 26, 2009 • DOH: 2,272 leptospirosis cases, 174 deaths between October 1 and November 3, 2009 in 15 hospitals in Metro Manila. • peak incidence reached 2-3 weeks after Why are infectious diseases unique? Factors Leading to the Emergence of Infectious Diseases in the 21st Century
  7. 7. Factors Leading to the Emergence of Infectious Diseases in the 21st Century They know NO boundaries. Why are infectious diseases unique? Before: 9 countries affected (1970) Now: ~50 million dengue infections worldwide every year (WHO) and 2/5 of the world's population at risk in over 100 countries attributed to expanding geographic distribution of the mosquito vectors, predominantly Aedes aegypti Average annual number of dengue cases reported to the WHO, and of countries reporting dengue, 1955–2007.
  8. 8. Why are infectious diseases unique? • Started in Mexico, with its greatest burden of critical illness and death occurring between March 18- June 1, 2009 • In 6 weeks, it has spread as far as previous pandemic influenza viruses have spread within six months. • continues to be the dominant influenza virus in circulation in the world comprising more than 60% of all influenza positive specimens reported to WHOInfluenza A(H1N1) They know NO boundaries. Why is PH concerned about the threat of EIDs? • • •
  9. 9. Why is PH concerned about the threat of EIDs? 3,983,627 tourists (Jan-Sep 2015) 10.76% higher than 2014 46.7 % are foreigner Why is PH concerned about the threat of EIDs?
  10. 10. Why are infectious diseases unique? Disease Associated Etiologic Agent CAD and stroke Chlamydia pneumoniae, atypical microorganisms, Mycoplasma Deafness, hearing loss Lassa fever virus Gastric & duodenal ulcer Helicobacter pylori Infertility Chlamydia trachomatis Cervical carcinoma Human papillomavirus Hepatocellular Ca Hepatitis B and C viruses Kaposi’s sarcoma HHV-8 Non-Hodgkin’s lymphoma Hepatitis C virus Lyme arthritis Borrelia burgdorferi Reactive arthritis Campylobacter jejuni, Salmonella Guillain-barre syndrome Campylobacter jejuni They may be associated with malignancies and other chronic diseases. Why are infectious diseases unique? Host immunity is involved.  Intergrity of the immune system (innate immune system, humoral and cell-mediated immunity)  Extremes of age  State of immunity (vaccination status, presence of co- morbidities)  Presence of immunocompromised state
  11. 11. The Smallpox Threat • Eradicated in 1979 (WHO) • Routine vaccination stopped in 1974 (US) • Last documented case 1949 (US) • More the 3/4 of the world’s population is now susceptible Why are infectious disease unique? They deal with more than one population. With complex interactions among them Reservoir (animals)Dogs and sheep/goats – Echinococcus; mice and ticks – Borrelia Host (e.g. humans)Infectious agents (helminths, bacteria, fungi, protozoa, viruses, prions) Vectors Mosquito (malaria), snails (schistosomiasi s), blackfly (onchocerciasis )
  12. 12. Measures of Disease Frequency Case  Measuring disease frequency in populations requires the stipulation of diagnostic criteria.  In clinical practice the definition of "a case" generally assumes that, for any disease, people are divided into two discrete classes - the affected and the non- affected.  For most acquired diseases the real question in population studies is not "Has the person got it?" but "How much of it has he or she got?" BMJ. Epidemiology for the uninitiated. Accessed from http://www.bmj.com/about- bmj/resources-readers/publications/epidemiology-uninitiated/2-quantifying-disease- populations Measures of Disease Frequency “Case Definition”  A set of uniform criteria used to define a disease for public health surveillance.  Enable public health to classify and count cases consistently across reporting jurisdictions, and should not be used by healthcare providers to determine how to meet an individual patient’s health needs. http://wwwn.cdc.gov/nndss/case-definitions.html
  13. 13. Measures of Disease Frequency “Case Definition”  Should be precise and unambiguous  Essential to define and standardize the methods of measuring the chosen criteria. BMJ. Epidemiology for the uninitiated. Accessed from http://www.bmj.com/about- bmj/resources-readers/publications/epidemiology-uninitiated/2-quantifying-disease- populations Measures of Disease Frequency Prevalence  no. of cases of disease at a particular point in time  includes old and new cases  better in detecting burden of disease in a particular population
  14. 14. In the Philippines, what is the prevalence of HIV among MSM? A. <1% B. 12% C. 30% D. 51% Question  ~12 positivity rate at the RITM Satellite Clinic.  ~12 incidence in the MSM Cohort study MSM and HIV in PH Personal communication with Dr. Rossana Ditangco, Head, HIV/AIDS Research Group
  15. 15. What city in Metro Manila has the greatest prevalence of HIV among MSM? A. Manila B. Quezon City C. Mandaluyong D. Caloocan Question • NCR • Region 4A (Batangas, Cavite, Laguna, Rizal, Quezon, Tagaytay) • Region 7 (Bohol, Cebu, Negros Oriental, Siquijor) • Region 3 (Aurora, Bataan, Bulacan, Nueva Ecija, Pampanga, Tarlac) • Region 11 (Compostela Valley, Davao del Norte, Davao del Sur and Davao) MAY 2015
  16. 16. Prevalence rate of HIV among MSM (DOH 2015) – Quezon City - 6.6% – Manila - 6.7% – Caloocan - 5.3% – Cebu - 7.7% – Davao - 5.0% – Cagayan de Oro - 4.7% http://www.rappler.com/move-ph/93344-700-hiv-cases-philippines-highest-1984 MAY 2015 Measures of Disease Frequency Incidence  no. of new cases of disease in a defined time period  better in detecting outbreaks BMJ. Epidemiology for the uninitiated. Accessed from http://www.bmj.com/about- bmj/resources-readers/publications/epidemiology-uninitiated/2-quantifying-disease- populations
  17. 17. What is the current rate of HIV diagnosis in PH? A. 100 new cases per month B. 10 new cases per week C. 10 new cases per day D. 1 new case per hour Question What is the current rate of HIV diagnosis in PH? A. 100 new cases per month B. 10 new cases per week C. 10 new cases per day D. 1 new case per hour Question
  18. 18. INTRODUCTION TO HEALTHCARE-ASSOCIATED INFECTIONS (HAIs) Arthur Dessi E. Roman MD MTM FPCP FPSMID 9 February 2016 gonabedess @gonnabedess Question Of the total SARS infections (n-=8,422), what percentage are HCWs? A. <10% B. 21% C. 48% D. 80% WHO/CDS/CSR/GAR/2003.11. Consensus document on the epidemiology of severe acute respiratory syndrome (SARS)
  19. 19. Question Of the total SARS infections (n-=8,422), what percentage are HCWs? A. <10% B. 21% C. 48% D. 80% WHO/CDS/CSR/GAR/2003.11. Consensus document on the epidemiology of severe acute respiratory syndrome (SARS) OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III. Chain of HAIs
  20. 20. Epidemiology the study of the distribution or occurrence of a disease or event in a given population or geographical area including the factors that contributed to these Hospital Epidemiology the identification, understanding and development of strategies to eliminate or minimize the risk of acquiring healthcare- associated infections by applying techniques of epidemiology
  21. 21. Hospital Epidemiology “in the current era…,hospital epidemiology has expanded and become relevant beyond the acute care hospital to all settings where healthcare is delivered…” Healthcare settings •Hospitals: acute care facilities, critical access hospitals •Long term care facilities (LTCF)
  22. 22. Healthcare settings •Outpatient settings dialysis centers ambulatory surgical centers Healthcare settings •Outpatient settings Physician’s offices Ambulatory chemotherapy centers
  23. 23. Infection the state or condition in which the body or part of the body is invaded by a pathogenic agent (bacteria, virus, parasites etc.) which under favorable conditions multiplies and produces injurious effects Question The Latin term nosocomium means: A. Reverse or ironic B. Hospital C. Hands D. Doctor
  24. 24. Question The Latin term nosocomium means: A. Reverse or ironic B. Hospital C. Hands D. Doctor Healthcare-associated Infections (HAIs) •Previously termed hospital-acquired infection or nosocomial infection ‒“nosocomium” (latin) – hospital ‒ reflects their original association with hospitalized patients ‒ concern to separate the terminology of events from fear of liability that might have interfered with identification and control efforts [of the hospital]
  25. 25. Healthcare-associated Infections • A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). • There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting. Am J Infect Control 2008;36:309-32. Healthcare-associated Infections • Presently the preferred term • Infection acquired 48 hours after admission to hospital - not present or incubating at the time of admission • Infection acquired while in the hospital and developed during admission or after discharge [up to 6 weeks]
  26. 26. OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III.Chain of HAIs 52 Fundamental roles of hospital epidemiology 1. Identify risks (what) 2. Understand risks (how, why) 3. Eliminate or minimize risks
  27. 27. 53 Areas of interest to a hospital epidemiologist • Surveillance for nosocomial infection • bloodstream infections • pneumonia • urinary tract infections • surgical wound infections • Patterns of transmission of nosocomial infections • Outbreak investigation • Isolation and other transmission- based precautions • Evaluation of exposures • Employee health • Disinfection and sterilization • Hospital engineering and environment • water supply • air filtration • Reviewing policies and procedures for patient care 54 Areas of interest to a hospital epidemiologist • Antibiotic use • Antibiotic resistant pathogens • Microbiology support • National regulations on infection control • Infection control committee • Quantitative methods in epidemiology • Education • CQI strategies
  28. 28. OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III.Chain of HAIs Common Sites of HAIs Urinary tract Respiratory tract Gastrointestinal Blood stream Skin, Wound, Burn Surgical wound infection
  29. 29. Most common HAIs Central Line Associated Bloodstream Infection (CLABSI) Surgical-site Infection (SSI) Most common HAIs Ventilator Associated Pneumonia (VAP) Catheter-associated Urinary Tract Infection (CAUTI)
  30. 30. OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III.Chain of HAIs Factors Promoting HAIs • Prolonged and inappropriate use of medical devices • Extremes of age • Duration of hospitalization • Insufficient application of standard, isolation and transmission-based precautions • Surgery (type of operation) and other medical procedures http://www.who.int/gpsc/country_work/burden_hcai/en/
  31. 31. Factors Promoting HAIs • Immune status: chemotherapy, radiation therapy, malignancy • Understaffing • Overcrowding • Poor knowledge and application of basic IC measures • Inadequate environmental hygienic conditions and waste disposal • Poor infrastructure • Lack of knowledge of injection and blood transfusion safety http://www.who.int/gpsc/country_work/burden_hcai/en/ OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III. Chain of HAIs
  32. 32. Healthcare-Associated Infections Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. Healthcare-Associated Infections http://www3.gehealthcare.com.co/~/media/images/product/product-categories/healthcare- it/it%20department/hai-data-visualization.png
  33. 33. Healthcare-Associated Infections 1-day survey • 183 hospitals • 11,282 patients • 504 infections identified in 452 (4%) patients • 25.6% device- associated infections Multi-state Point Prevalence Survey of Healthcare-Associated Infections in the U.S. N Engl J Med 2014;370:1198-208. Healthcare-Associated Infections 0 2 4 6 8 10 12 14 16 SHIP NHSN INICC CA-Urinary Tract Infection CL-Associated Bloodstream Infection Ventilator Associated Pneumonia Comparison of Device-Associated Infections (per 1000 device days) SHIP 2013 / NHSN 2006-2008 / INICC 2004-2009 SHIP – Surveillance of Hospital Acquired Infections in the Philippines NHSN – National Healthcare Safety Network INICC – International Nosocomial Infection Control Consortium American Journal of Infection Control 2012; 40(5):396-407.
  34. 34. OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III. Chain of HAIs The “C ST” of HAIs Personnel • Need for hospitalization • Income loss • Pain and suffering • Disfigurement/Disability • Death Institutions • Loss of revenue • Extra duty • Liability insurance • Malpractice • Reputation Increased resistance of microorganisms
  35. 35. Extra C STS by type of HAI JAMA Intern Med. 2013;173(22):2039-2046 Extra C STS by type of HAI
  36. 36. 17 Extra Costs and Length of Stay of HAIs Increased Mortality (excess crude mortality) CLABSI 14.7% CAUTI 7.3% VAP 15.3% BURDEN OF DEVICE-ASSOCIATED INFECTIONS Longer Hospital Stay (extra LOS in days) CLABSI 10.9 CAUTI 12.2 VAP 11.7 American Journal of Infection Control 2012; 40(5):396-407.
  37. 37. OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III. Chain of HAIs How do infections occur in hospital setting ? AGENT SUSCEPTIBLE HOST MEANS OF TRANSMISSION Epidemiologic Triangle DISEASE
  38. 38. How do infections occur in hospital setting ? AGENT SUSCEPTIBLE HOST MEANS OF TRANSMISSION Epidemiologic Triangle DISEASE AGENTS GRAM NEGATIVE RODS GRAM POSITIVE COCCI OTHERS Escherichia coli Staphylococcus aureus Fungi - Candida sp.; Aspergillus sp. Klebsiella sp. Staphylococcus epidermidis Protozoans Pseudomonas aeruginosa Enterococci Mycobacterium tuberculosis Acinetobacter sp. Pneumocystis carinii Enterobacter sp. Anaerobes
  39. 39. Sources of Agents of Nosocomial Infections EXOGENOUS • Hands • Instruments • Catheters • Respiratory equipments • Transfusions • IV system • Linen • Air ENDOGENOUS • Oropharynx • Respiratory • Gastrointestinal • Skin How do infections occur in hospital setting ? AGENT SUSCEPTIBLE HOST Epidemiologic Triangle DISEASE MEANS OF TRANSMISSION
  40. 40. Means of Transmission of HAIs CONTACT AIRBORNE DROPLET VECTOR VEHICLE - direct or indirect - measles, varicella, TB - meningococcemia - insects or animals - food, water, blood, medication Means of Transmission of HAIs CONTACT - most common means of transmitting microorganisms from one person to another
  41. 41. CONTACT A. Direct Contact - occurs when one person touches another - direct contact is an ongoing process in the hospital - best vehicle : Hands Means of Transmission of HAIs CONTACT B. Indirect Contact - occurs when a person touches an inanimate object contaminated by an infected patient Means of Transmission of HAIs
  42. 42. Question According to WHO, what percentage of HAIs are caused by poor hand hygiene? A. <1% B. 20% C. 40% D. 75% Question According to WHO, what percentage of HAIs are caused by poor hand hygiene? A. <1% B. 20% C. 40% D. 75%
  43. 43. How do infections occur in hospital setting ? AGENT Epidemiologic Triangle DISEASE MEANS OF TRANSMISSION SUSCEPTIBLE HOST Factors that Increase Host Susceptibility to HAIs •Chronic underlying diseases •Immune deficiency states • Malignancies • Therapeutic measures • Immunosuppression • Antibiotic therapy •Invasive devices •Surgery •Age
  44. 44. AGENT Means of Transmission Susceptible Host Bacteria Virus Fungi CONTACT AIRBORNE DROPLET VEHICLE VECTOR Disease AGENT Susceptible HOST Means of Transmission The CHAIN of INFECTION Break the chain of Infection
  45. 45. Susceptible HOST Breaking the Chain of Infection AGENT Breaking the Chain of Infection: AGENT The hands should be washed after handling infectious materials (e.g. bed linen, dressings, secretion and excretions). The skin of the patient should be disinfected before invasive procedures
  46. 46. Emphasize HAND WASHING for personal hygiene Breaking the Chain of Infection: AGENT Rational Use of Devices -avoiding or removing factors that impair host defenses. -invasive devices should be avoided or should be removed as soon as possible. Breaking the Chain of Infection: AGENT
  47. 47. Susceptible HOST Breaking the Chain of Infection Means of Transmission AGENT Isolation techniques based on method of spread Breaking the Chain of Infection
  48. 48. Protective or Reverse Isolation Rationale: decreasing the contact of the immunocompromised host to potential pathogens Breaking the Chain of Infection Breaking the Chain of Infection The environment should be HOSTILE to the multiplication of pathogens i.e. clean, dry, exposed to light and well ventilated
  49. 49. Breaking the Chain of Infection All infectious materials (e.g. linen, clinical waste, sharps) should be safely contained, decontaminated or destroyed Breaking the Chain of Infection Use of disposable supplies and equipment in an attempt to limit the spread of infection by this means
  50. 50. Breaking the Chain of Infection All instruments and equipments should be clean and dry. Invasive items should be sterilized and items in contact with mucous membranes, body fluids and potentially infectious materials should be disinfected Breaking the Chain of Infection Food should be hygienically prepared, properly cooked and stored at low temperatures until used
  51. 51. Breaking the Chain of Infection Control of insect and rodents that serve as vectors in the spread of microorganisms AGENT Susceptible HOST Breaking the Chain of Infection Means of Transmission
  52. 52. Breaking the Chain of Infection Susceptible patients or sites should be protected from pathogenic microorganisms: i.e. aseptic technique practice during wound dressing, or procedures Immunotherapy, immunizations and other methods of reconstituting patients’ immune response maybe attempted Breaking the Chain of Infection
  53. 53. Susceptible HOST Means of Transmission Hand Hygiene Environmental Care Waste management Disinfection and Sterilization Hand Hygiene Rational use of Devices Isolation Breaking the Chain of Infection Hand Hygiene Vaccination Environmental Care Prophylaxis AGENT OUTLINE I. Definition of Terms II. Overview of HAIs A. Hospital epidemiology B. Common Sites of HAIs C. Factors Promoting HAIs D. HAI Rates : Local and Global E. Cost and Burden of HAIs III.Chain of HAIs
  54. 54.  The Health Care Worker (HCW) should be aware of how infection is transmitted and the factors involved in the process  The HCW should be able to implement the MOST effective and applicable measures to prevent and control infection in his place of work  The HCW should have the proper attitude towards infection prevention and control. INFECTION CONTROL is…
  55. 55. BUT… is not too common. Infection Control should be ..... a WAY of LIFE
  56. 56. Thank you!
  • filchibuff

    Jul. 24, 2020
  • MichaelPrades

    Nov. 28, 2018

by Dr. Arthur Dessie E. Roman

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