Guidelines for Management of Outbreak in Healthcare Organization

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Guidelines for Management of Outbreak in Healthcare Organization
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.

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  • Epidemic curve plots the number of cases on the y axis and time (in days or weeks or months) on the x axis
    What time interval you use on the x axis depends on the incubation period and the time period over which cases are distributed.
    For example, S aureus should be hours, while hepatitis B or TB should be days or weeks.
    Failure to use the right time interval mqy obscure the temporal distribution.
    As a rule of thumb, select aunit that is one-eighth to one-third as long as the incubation period.
    If you don’t know the incubation period, draw several epidemic curves with different time intervals on the x axis.
    Show the pre-epidemic period in the graph also to show the baseline.
    Can suggest whether its person to person or common source outbreak
    A common source outbreak id defined as an outbreak due to transmission from a single environmental or human source.
    Propagated (continuing) outbreaks are person to person spread.
    Outbreaks may begin as a commn source and then become person to person spread (e.g., viral gastroenteritis from shrimp consumption that is then spread person to person); most common with food or water borne outbreaks.
    Provide info regarding when the cases were likely exposed to the source
    The course of the exposure (limited or ongoing)
    Can also provide info on seasonal trends
  • Reservior of an agent is the habitat in which an infectious agent normally lives ,grows , and multiplies .it could be human ,animals,and invironment.
  • The infectious process, commonly referred to as the "chain of infection", requires the presence of four elements which, like the links of a chain, are all essential and interrelated. These elements consist of: an agent (infecting microorganism), a source of infecting microorganisms, a susceptible host, and a mode of transmission of the infectious agent. The four elements must be present for an infection to occur.
     1. THE AGENT
     The agent may be a bacteria, a virus, a fungus or a parasite. It must be pathogenic, that is, capable of causing disease (infection) and must be present in sufficient numbers (infective dose) to transmit infection.
     2. THE SOURCE
     Sources of pathogenic agents in the hospital include patients, personnel and to a much lesser extent visitors, and may comprise any of the following:
                            · Persons with acute infections
                            · Persons in the incubation phase of an infection
                            · Persons colonized with an infectious agent
                            · Persons who are chronic carriers of an infectious agent 
    Other sources of infectious microorganisms include inanimate environmental objects which have become contaminated, for example:  
                            · Patient care equipment
                            · Instruments
                            · Needles and sharps
                            · Surfaces
                            · Medications, etc.
    The patient's own microbial flora (microorganisms normally present in and on the human body) may also be the source of an infection in a susceptible or
    compromised host.
    3. THE HOST
    The host is a person who becomes infected after exposure to an infectious agent. Factors which influence the development of an infection include the resistance of the host, the portal of entry, the size of the inoculum (infective dose), and the type and duration of the contact with the pathogen.
    Resistance to pathogenic microorganisms varies widely from person to person. Some individuals may be immune to, or able to resist, infection by a particular infectious agent. Others, exposed to the same pathogen, may develop clinical or subclinical infection. Still others may become either colonized with the organism, or asymptomatic carriers of the disease.
    The following host factors may increase an individual's susceptibility (decrease his/her resistance) to infection:
                            · Extremes in age (the very young and the very old).
                            · Presence of chronic diseases/conditions (Diabetes Mellitus, Neoplasia, Leukemia, Anemia, etc.).
                            · Malnutrition, chronic alcoholism, drug abuse. ,
    Other factors which contribute to lowered resistance include:
       · Antimicrobial, immunosuppressive, steroid and irradiation therapies.
    · Breaks in the "first line of defense" (skin, mucous membranes), as a result of: trauma; surgery; anaesthesia; invasive procedures; pressure ulcers; etc..
    To prevent the transmission of infection within a hospital, it is clear that one of the links in the chain of infection has to be "broken". Of the four links which make up the chain of infection, we have the least control over the agent, the source and the host. On the other hand, we do have a great deal of control over the mode of transmission, the weakest link in the chain, and the easiest to break. By implementing measures that interrupt transmission, we can prevent pathogenic microorganisms from reaching or entering a susceptible host.
  • At the end of the descriptive analysis it should be possible to:
    formulate a hypothesis on the type
    Of infection
    Exogenous,
    Endogenous)
    Identify the
    source and route of infection
    suggest and implement initial control measures
  • Cohort studiesA cohort study is the best technique for analyzing an outbreak in a small, well-defined population. For example, you would use a cohort study if an outbreak of gastroenteritis occurred among people who attended a social function, such as a wedding,
  • Guidelines for Management of Outbreak in Healthcare Organization

    1. 1. Kingdom of Saudi Arabia Ministry of Health General Directorate for Health Affairs – Najran King Khalid Hospital 1
    2. 2. Introduction 2 An Outbreaks of HAIS infection should be identified and promptly investigated because of their importance in terms of morbidity, costs and institutional image. Early identification of an outbreak is important to limit transmission among patients by health care workers or through contaminated materials.
    3. 3. An outbreak is defined AS 3 Occurrence of more cases of disease than expected HAIs outbreak-any group of illnesses of common etiology occurring in patients of a medical care facility acquired by exposure of those patients to the disease agent while confined in such a facility.
    4. 4. Definition- (cont.) 4 Occurrence of more cases of disease more than expected  over a particular period of ( TIME )  in a given area (PLACE )  among a specific group of people (PERSONS)
    5. 5. Aim of this Guideline 5 1.Provide a management protocol of an outbreak in health care facilities. 2.Early detection of an outbreak and institute immediate control measures. 3.Assign roles and responsibilities of persons involved in management of an outbreak.
    6. 6. Aim of Outbreak Investigation 6 1.Prevent further disease transmission 2. Provide information that can be used to control the outbreak 3.Prevent similar occurrences in the future 4.Identify populations at risk of a disease 5.Identify modes of disease transmission
    7. 7. Aim of Outbreak Investigation, cont7 6. Evaluate the effectiveness of infection control measures. 7. Learn more about a disease, including the impact of control measures. 8. Share knowledge and findings with other health professionals by documenting the outbreak investigations in reports or journal article
    8. 8. Steps Of An Outbreak Investigation 8 1.Verify the diagnosis; identify the agent 2.Confirm that an outbreak exists 3.Search for additional cases. 4.Characterize the cases by person, place, time. 5. Form a tentative hypothesis (best guess at the time). 6. Institute preliminary control measures. 7. Test the hypothesis. 8. Refine the control measures. 9. Monitor and evaluate the control measures. 10. Prepare and disseminate a final report.
    9. 9. Planning of Outbreak Investigation 9 Notify the appropriate individuals and departments in the institution of the problem; Establish terms of reference for the investigation. This must include  development of an outbreak team.  Infection control must be part of the outbreak team.
    10. 10. 1. Preparation 10 Investigation  Scientific knowledge  Review literature  Consult experts  Sample questionnaires  Supplies  Consult with laboratory  Equipment  Laptop, camera etc.
    11. 11. 1-Verify the Diagnosis; Identify the agent 11 Describe the initial magnitude of the problem and what symptoms got the facility's attention . What diagnosis has been established? What agent (bacterial, viral, other) has been identified?
    12. 12. Establish a Case Definition. 12  Standard set of criteria for deciding whether an individual should be classified as (case ) or non (cases ) based on whether or not they meet the criteria identified for outbreak  Includes clinical criteria and restrictions by time, place and person.  Must be applied consistently and without bias to all persons under investigation
    13. 13. Case Definition cont.. 13 Classification  Definite (confirmed)   Probable   Laboratory confirmed Typical clinical features without lab confirmation Possible (suspected)  Fewer of the typical clinical features
    14. 14. 2. Confirm that an Outbreak Exists 14 Use your case definition to find all cases Based on your knowledge in #1, are the numbers of cases above what is endemic (usually seen) in the facility? If yes, consider that an outbreak exists Total number of cases .? Do you have an outbreak? If yes, proceed If no, reasons why report will made with justification why this case is not considered an outbreak.
    15. 15. 3.Search for Additional Cases 15 Encourage immediate reporting of cases (laboratory, physicians, and personnel). Search for other cases by retrospective record review, ADM , REFERAL ,lab reports, etc. Total number of cases: Date
    16. 16. 4.Characterize the Cases 16 by Person - Place- Time. Prepare Line Listing Draw Epidemic Curve
    17. 17. The Line List 17 It is an important tool in effective outbreak management. collecting data that are. CONSISTS -of Rows and columns.  Each Row represents a case  Each column represents descriptive factors or clinical details (i.e. date of birth, onset date, symptoms
    18. 18. Epidemic Curves 18 •Epidemic curve plots the number of cases on the –y- axis • and time (in days or weeks or months) on the -x- axis •What time interval you use on the x axis depends on the incubation period and the time period over which cases are distributed.
    19. 19. Epidemic Curves 19 What it tells you  Mode    of transmission  Propagated  Common source Timing of exposure Course of exposure Incubation Period
    20. 20. Epidemic Curves )Common source: point exposure (e.g., salmonella 8 7 Cases 6 5 4 3 2 1 0 1 2 3 4 5 6 7 Days 8 9 10 11 20 12
    21. 21. Epidemic Curves Propagated source: secondary and tertiary cases (e.g., hepatitis A) 10 9 8 Cases 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 Week 21
    22. 22. Estimating date of exposure Maximum incubation days 21 9 8 7 Cases Probable time of exposure 10 6 5 4 3 Minimum incubation 2 days 14 1 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Days 22
    23. 23. Develop Hypotheses(best guess at the time) 23 Hypotheses should address Reservoir Source of the agent Mode of transmission (Vector or vehicle )  Exposure that caused disease Review data to determine common host factors and exposures.
    24. 24. Implement Control /Prevention Measures 25 Implement control measures as soon as possible if you know the source of an outbreak. Aim control measures at the specific agent, source, or reservoir. Aim control measures at the weak link in the chain of infection. (mod of transmission )
    25. 25. Infection Chain 26
    26. 26. bacteria PATIENT virus EQUPEMEN TS parasite MEDICATIO NS fungus SURFACES CONTACT (DIRECT,INDIRECT) DROPLETS AIRBORNE     The host is a  person who  becomes  infected after  exposure to an  infectious agent
    27. 27. Control Measure 28 Chain broken
    28. 28. Monitor and evaluate the control measures.. 29  The control measures will vary depending on the agent and mode of transmission  but may include isolation procedures or improvements in patient care Hand hygiene Cohorting or environmental cleaning.  In some outbreaks, you would direct control measures at reducing the susceptibility of the host. Examples  Immunization against rubella  Malaria chemoprophylaxis for travelers.
    29. 29. Refine the control measures 30  additional control measures may be added if needed  example  Destroying contaminated foods . fluids  An infectious staff or food handler could be removed from the work and treated.  Close the unit
    30. 30. The Descriptive Analysis 31 This includes identifying a potential exposure type ,source and route of infection for the outbreak . and testing this hypothesis using statistical methods. Special epidemiologic studies may be needed
    31. 31. Analytic Epidemiology 32  which allows you to test your hypotheses.  Use rates to identify high-risk groups Numerator = number of case  Denominator = number of people at risk  The nature of the outbreak determines which of these studies you will use.  Cohort studies .  Case-control studies
    32. 32. Cohort Studies 33 Small, well defined population  Contact each attendee and ask a series of questions  Ill Vs not ill Look for source exposure.      Attack rate is high among those exposed Attack rate is low among those not exposed Most of the cases were exposed. Relative risk = mathematical measure of association between exposure and disease .
    33. 33. Case-Control Studies 34 Case-control    Population not well defined Case patients and comparison group (controls) questioned about exposure(s) Compute measure of association = Odds Ratio IS a mathematical measure of association OR relationship between exposure and disease A case-control study is the most common approach To test hypothesis .
    34. 34. Communication and Conclusion 35 During the investigation of an outbreak, timely, up to date information must be communicated to the hospital administration, public health authorities, and, in some cases, to the public. Based on all evidence and the results of an outbreak investigation A final report describing all aspects of the investigation should be prepared.
    35. 35. Prepare and disseminate a final report 36  A final report on the outbreak investigation should: describe the outbreak interventions, and effectiveness,  summarize the contribution of each team member participating in the investigation.  should also make recommendations to prevent future occurrence.  Make the final report. as detailed as possible.
    36. 36. Final Report 37  should also be a written report that follows the usual scientific format of introduction  background  methods results, discussion  and recommendations. By formally presenting recommendations, the report provides a blueprint for action.
    37. 37. 38

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