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Role of-epidemiology-for-clinical-services nirmal-kandel

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Role of-epidemiology-for-clinical-services nirmal-kandel

  1. 1. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 1 | 3rd Epidemiology National Scientific Meeting Role of Epidemiology in Clinical Services Dr Nirmal Kandel , MBBS, MA (Anthropology), MPH, EMBA Public Health Specialist
  2. 2. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 2 | Outlines  Application of Epidemiology in real life in clinical settings – an example  Personal Experience  Application of Epidemiology – When – How – Where – Why – What next
  3. 3. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 3 | Background In 2011, KPC came to one of the nation’s flagship research hospitals, the Clinical Center at the National Institutes of Health in Bethesda, Maryland, known as the NIH. Klebsiella pneumoniae carbapenemase (KPC)
  4. 4. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 4 | 43 Lung Transplant
  5. 5. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 5 | Patient Zero  A 43-year-old woman with complications from a lung transplant is transferred from a New York City hospital with a highly resistant superbug known as KPC – June 13, 2011  The NIH is one of the most prestigious research hospitals in the country, but it has never had a case of KPC before.  Immediately went on high alert, implemented IPC measures. – The woman went into strict isolation: – Everyone entering her room donned a protective gown and gloves and rigorously washed their hands. – Her medical equipment got special decontamination. – All other patients in the ICU had their throats and groins tested regularly to see if the bug was spreading.  The patient was later discharged – July 15, 2011
  6. 6. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 6 | 43 Lung Transplant 34 Tumor
  7. 7. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 7 | Second Infection  Several weeks later,  a 34-year-old man hospitalized with a tumor tests positive for KPC.  The two patients have no known link:  They spent no time in the ICU together, and  they had different caregivers and equipment.
  8. 8. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 8 | 43 Lung Transplant 65 Lymphoma 27 Transplant 54 Solid Tumor 34 Tumor 45 Solid Tumor 39 Solid Tumor 29 Lymphoma 71 Lymphoma 59 bronchiec tasis 50 Lymphom a 72 Solid Tumor 19 Immuno- deficiency 29 Aplastic Anemia
  9. 9. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 9 | Outbreak  Over the next few months, several more patients test positive for KPC.  As the NIH attempts to deal with the outbreak, no combination of antibiotics seems to be able to stop it.
  10. 10. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 10 | 43 Lung Transplant 65 Lymphoma 27 Transplant 54 Solid Tumor 34 Tumor 45 Solid Tumor 39 Solid Tumor 37 Sickle Cell Anemia 29 Lymphoma 71 Lymphoma 59 bronchiec tasis 50 Lymphom a 72 Solid Tumor 34 Aplastic Anemia 19 Immuno- deficiency 29 Aplastic Anemia 60 bronchiec tasis 59 Immuno- deficiency
  11. 11. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 11 | Beyond ICU  The hospital creates a separate ICU for KPC patients.  The old ICU is cleaned out and disinfected by robots before patients are moved back in.  But somehow, it spreads beyond the ICU.
  12. 12. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 12 | The Victims  Doctors try several combinations of antibiotics  even an experimental drug still in development.  Nothing works.  And some patients die.
  13. 13. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 13 | Underlying Conditions  Five other patients die, but the hospital believes their deaths are due to their underlying health problems, not the KPC infection.  Ultimately, 11 infected patients die.
  14. 14. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 14 | Hospital Measures  New ICU was constructed for KPC infection  To stop the bug, entire sinks have been disassembled and vents cleaned with bleach.  The hospital has tested and retested patients and health professionals looking for carriers of the superbug (using rectal swabs too).  Test after test never found the bug on hospital workers' hands. Tainted objects like the ventilator couldn't be ruled out  It went on an aggressive campaign to demand more stringent hand washing.  NIH adopted more complex and expensive decontamination, using robot-like machines to spray germ-killing hydrogen peroxide into the tiniest of crevices in all affected rooms and equipment.
  15. 15. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 15 | Looking for a link  Throughout the outbreak, the hospital used epidemiological and genetic analysis to help understand the transmission sequence.
  16. 16. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 16 | Looking for a link  They compared samples from each patient, along with information such as whether patients overlapped in the same ward, to track the most plausible transmission sequence: – Black lines mean the infected patient was in the same ward, which likely provided an opportunity for the KPC to spread to the next patient. – Red lines indicate the two patients had no overlap, but genetic analysis makes clear the bacteria in the two patients were closely related and likely spread in a more complicated path. – Dotted black lines mean the patients shared a ward, but there’s at least one other way they might have been infected. – Dotted red line mean the patients didn’t overlap in a ward, but there’s more than one way they might have been infected.
  17. 17. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 17 | 43 Lung Transplant 65 Lymphoma 27 Transplant 54 Solid Tumor 34 Tumor 45 Solid Tumor 39 Solid Tumor 37 Sickle Cell Anemia 29 Lymphoma 71 Lymphoma 59 bronchiec tasis 50 Lymphom a 72 Solid Tumor 34 Aplastic Anemia 19 Immuno- deficiency 29 Aplastic Anemia 60 bronchiec tasis 59 Immuno- deficiency
  18. 18. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 18 | 43 Lung Transplant 65 Lymphoma 27 Transplant 54 Solid Tumor 34 Tumor 45 Solid Tumor 39 Solid Tumor 37 Sickle Cell Anemia 29 Lymphoma 71 Lymphoma 59 bronchiec tasis 50 Lymphom a 72 Solid Tumor 34 Aplastic Anemia 19 Immuno- deficiency 29 Aplastic Anemia 60 bronchiec tasis Young Man ID 59 Immuno- deficiency
  19. 19. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 19 | Last Case  Then, a year after the outbreak, a young man arrives at NIH due to complications from a bone marrow transplant. He becomes infected with KPC and dies.  Finally, the outbreak – contained – December 2012
  20. 20. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 20 | Links  27 years old female (transplant) had been in the ICU at the same time as the New York woman and really was the next infected, silently carrying the bug longer before becoming sick.  that was enough time for 34 year old man’s (tumor) infection to spread to 27 year old female, who just got sick faster.
  21. 21. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 21 | Personal Experience  Was Medical Officer for Surgery - noticed post surgical wound infection  Observed and triangulate all the causes of wound infection with those cases  Simple experimental study carried out – All the cases of my unit is asked to shave a 2 hours before surgery – Controls – other unit who were practicing exiting mechanism (shaving a day before – After one month – there was significant decrease of wound infection in our unit than others – we didn’t do any statistical analysis and I just presented and hospital adopted since then to apply pre-operative shaving before 2 hours of surgery
  22. 22. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 22 | Application of Epidemiology – When • any abnormal events, aberration from normal phenomena – How • Abreast with disease endemicity in your area, • basic with epidemiology techniques – Where • OPDs, IPDs, ICUs, Post Ops – Why • The first contact of patient or any suspected case is Physician/Clinicians – What to do • If you find any abnormalities then inform authorities accordingly
  23. 23. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 23 | References and Acknowledgement 1. Evan S. Snitkin, Adrian M. Zelazny, Pamela J. Thomas, Frida Stock, David K. Henderson, Tara N. Palmore, Julia A. Segre. Tracking a Hospital Outbreak of Carbapenem-Resistant Klebsiella pneumoniae with Whole-Genome Sequencing . Sci Transl Med. 2012 August 22; 4(148): 148ra116. doi:10.1126/scitranslmed.3004129 2. Authors of this article and the investigation team and all people directly or indirectly related to control of this outbreak investigation. Disclaimer: This reference and its content is only used for teaching purpose.
  24. 24. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 24 | Thank You Email kandeln@gmail.com

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