Airbornepathogens nov202015
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Rounds for Dept.Anesthesia Nov 2015 Occupational Risks of Airborne Pathogens for Anesthesiologists Royal Victoria Hospital, Barrie, Ontario
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Airbornepathogens nov202015
- 1. Airborne Pathogens and the Anesthesiologist Just Hold your Breath? Dr. Amy Thiele-Kuntz November 20, 2015
- 2. Outline Why this talk? Airborne pathogens and Occupational Risk Review the history, mechanics, efficacy and future of the N95 mask TB or not TB? Epidemiology, screening, and treatment
- 4. The CDC has come out in saying that globally there are 1.7 million health care worker related infections a year which account for 99,000 deaths http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0070174/
- 5. Case Study- ATK 2009 Mycoplasma Pneumonia Induced Steven’s Johnson Syndrome- in ICU 10 days, off work 2.5 months 2011 Rigors and high fever at work- Influenza A- off work for a week! 2015- Sedation for Bronchoscopy- Active TB! so far so good. Touch wood. Skin test Dec8. ATK= attracts tons of klap (community or work, who knows?)
- 6. Airborne Pathogens Modes of Transmission Droplet mucosa to mucosa, 3-6feet, meningococcus, SARS, Rubella, Pertussis, Strep, colds, Influenza Airborne smaller particles that can be aerosolized and carried in the air for longer periods of time, inhaled deeply into lungs TB, Measles, Varicella, smallpox, avian flu Indirect- fomite RSV, SARS
- 7. LIST OF AIRBORNE PATHOGENS, INCLUDING ALLERGENIC , TOXIGENIC, AND SUSPECTED RESPIRATORY AND NON-RESPIRATORY PATHOGENS AIRBORNE PATHOGEN GROUP DISEASE STATUS Primarily Nosocomial Source SHAPE TYPE CDC Class MOTILE Annual Cases Annual Fatal ID50 LD50 DIA. Logmean Francisella tularensis Bacteria tularemia Non wild animals pleo. rod gram- Reportable 0.2 0.19 Bordetella pertussis Bacteria whooping cough Contagious Yes Humans ovoid gram- bacilli Reportable Non 2000 15 0.25 0.24 Mycoplasma pneumoniae Bacteria pneumonia Contagious Humans pleomorphic no wall Reportable Motile rare 100 0.25 0.24 Chlamydia pneumoniae Bacteria pneumonia, bronchitis Contagious Humans spherical gram- Reportable 0.3 0.28 Chlamydia psittaci Bacteria psittacosis Non Birds spherical gram- Reportable 120 rare 0.3 0.28 Klebsiella pneumoniae Bacteria opportunistic infections Endogenous Yes Environmental ovoid gram- bacilli Reportable Non 1488 0.4 0.39 Haemophilus influenzae Bacteria meningitis Contagious Yes Humans rods gram- bacilli Reportable 0.43 0.24 Coxiella burnetii Bacteria Q Fever Non Cattle, sheep gram- 0.5 0.5 Pseudomonas aeruginosa Bacteria opportunistic infections Contagious Yes Environmental rods gram- bacilli Motile 2626 0.57 0.49 Pseudomonas pseudomallei Bacteria opportunistic infections Non Yes Environmental rods gram- bacilli Motile rare 0.57 0.49 Actinomyces israelii Bacteria actinomycosis Endogenous Humans rods gram+ Reportable 0.6 0.45 Legionella parisiensis Bacteria pneumonia(?) Non Environmental rods gram- bacilli Reportable 0.6 0.52 Legionella pneumophila Bacteria LD, Pontiac fever Non Environmental rods gram- bacilli Reportable 40 10 0.6 0.52 Saccharomonospora viridis ACTINOMYCETES Farmer's Lung Non Agricultural spores 0.6 0.52 Thermomonospora viridis ACTINOMYCETES Farmer's Lung, HP Non Agricultural spores 0.6 0.52 Cardiobacterium Bacteria opportunistic infections Endogenous Yes Humans rods gram- 0.63 0.61 Micropolyspora faeni ACTINOMYCETES Farmer's Lung Non Agricultural spores 0.69 0.7 Thermoactinomyces sacchari ACTINOMYCETES bagassosis, HP Non Agricultural spores 0.7 0.69 Alcaligenes Bacteria opportunistic infections Endogenous Yes Humans rods gram- rare rare 0.75 0.71 Yersinia pestis Bacteria pneumonic plague Contagious Rodents rods gram- bacilli Reportable Non 40 0.75 0.71 Pseudomonas cepacia Bacteria nonrespiratory airborne(?) Non Yes Environmental rods gram- 0.77 0.49 Pseudomonas mallei Bacteria opportunistic infections Non Yes Environmental rods gram- 0.77 0.49 Enterobacter cloacae Bacteria nonrespiratory airborne(?) Contagious Yes Humans spherical gram+ Reportable Non 213964 0.8 0.77 Enterococcus Bacteria airborne(?) Contagious Yes Humans spherical gram+ Reportable Non 213963 0.8 0.77 Neisseria meningitidis Bacteria meningitisp y Endogenous Humans spherical gram- Reportable 510 0 0.8 0.77 Streptococcus faecalis Bacteria airborne(?) Contagious Yes Humans spherical gram+ Reportable Non 213962 0.8 0.77 Streptococcus pyogenes Bacteria scarlet fever, pharyngitis Contagious Yes Humans spherical gram+ Reportable Non 213962 0.8 0.77 Mycobacterium kansasii Bacteria cavitary pulmonary Non Unknown rods gram+ bacilli Reportable rare rare 0.86 0.35 Mycobacterium tuberculosis Bacteria TB Contagious Yes Humans rods gram+ bacilli Reportable 21000 10 0.86 0.35 Streptococcus pneumoniae Bacteria pneumonia, otitis media Contagious Yes Humans spherical gram+ Reportable Non 500000 50000 0.9 0.89 Staphylococcus aureus Bacteria opportunistic infections Endogenous Yes Humans spherical gram+ Reportable Non 2750 0.95 0.92 Staphylococcus epidermis Bacteria nonrespiratory airborne(?) Endogenous Yes Humans spherical gram+ Reportable Non 2751 0.95 0.92 CoryneBacteria diphtheria Bacteria diptheria Contagious Yes Humans rods gram- bacilli Reportable 490000 1 0.49
- 8. Clostridium tetani Bacteria nonrespiratory airborne(?) Non Yes Environmental spores 1 0.98 Haemophilus parainfluenzae Bacteria opportunistic infections Endogenous Yes Humans rods gram- bacilli 1 0.98 Micromonospora faeni ACTINOMYCETES Farmer's Lung Non Agricultural spores 1 0.87 Moraxella lacunata Bacteria opportunistic infections Endogenous Yes Humans rods gram- rare 0 1 0.98 Thermoactinomyces vulgaris ACTINOMYCETES Farmer's Lung, HP Non Agricultural spores 1 0.87 Bacillus anthracis Bacteria anthrax Non Cattle, sheep spores gram+ Reportable Non rare rare 1.13 1.12 Nocardia asteroides ACTINOMYCETES nocardiosis Non Yes Environmental spores Reportable rare 1.14 1.12 Mycobacterium avium Bacteria cavitary pulmonary Non Environmental rods gram+ bacilli Reportable rare rare 1.2 1.19 Mycobacterium intracellulare Bacteria cavitary pulmonary Non Environmental rods gram+ bacilli Reportable rare rare 1.2 1.2 Acinetobacter Bacteria opportunistic infections Endogenous Yes Environmental rods gram- 147 1.25 1.22 Moraxella catarrhalis Bacteria opportunistic infections Endogenous Yes Humans rods gram- rare 0 1.25 1.22 Serratia marcescens Bacteria opportunistic infections Endogenous Yes Environmental rods gram- 479 1.25 1.22 Nocardia brasiliensis ACTINOMYCETES pulmonary mycetoma Non Yes Environmental spores Reportable Non 1.5 1.41 Nocardia caviae ACTINOMYCETES nocardiosis Non Yes Environmental spores Reportable Non 1.5 1.41 Thermoactinomyces dichotomicus ACTINOMYCETES Farmer's Lung Non Environmental Phialaphora repens Fungi allergic alveolitis Non Environmental spores Hyphomycetes 1.5 1.5 Exophiala jeanselmei Fungi humidifier water Non Environmental spores Hyphomycetes Non 1.95 1.9 Phialaphora hoffmannii Fungi allergic alveolitis Non Environmental spores Hyphomycetes 2 1.9 Phialaphora richardsiae Fungi allergic alveolitis Non Environmental spores Hyphomycetes 2 1.9 Phialaphora mutabilis Fungi allergic alveolitis Non Environmental spores Hyphomycetes 2.15 2.1 Acremonium spp. Fungi allergic alveolitis Non Environmental spores Hyphomycetes 2.5 2.4 Trichoderma harzianum Fungi allergic alveolitis Non Environmental spores 2.65 2.6 Oidiodendron tenuissimum Fungi allergic alveolitis Non Environmental spores 2.75 1 Geomyces pannorum Fungi allergic alveolitis Non Environmental spores 3 2.8 Histoplasma capsulatum Fungi histoplasmosis Non Yes Environmental spores Hyphomycetes Reportable Non common 3 2.2 Paecilomyces variotii Fungi allergic alveolitis Non Environmental spores Hyphomycetes 3 2.8 Wallemia sebi Fungi allergic alveolitis Non Environmental spores Hyphomycetes 3 3 Emericella nidulans Fungi allergic alveolitis Non Environmental spores Ascomycetes 3.25 3.2 Phoma spp. Fungi allergic alveolitis Non Environmental spores Coelomycetes 3.25 3.2 Penicillium brevicompactum Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium chrysogenum Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium citreonigrum Fungi allergen(?) Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium commune Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium corylophilum Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium cyclopium Fungi allergen(?) Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium expansum Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium freii Fungi allergen(?) Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium glabrum Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium hordei Fungi allergen(?) Non Environmental spores Hyphomycetes Non 3.3 3.3 Penicillium olsonii Fungi allergic alveolitis Non Environmental spores Hyphomycetes Non 3.3 3.3
- 11. Occupational Infection Control Source control (see next slide) Surg Mask, Resp Etiquette Vaccinate workers, have Personal Protective education/cart and fitting program, proper fit-donning-doffing, early detection and diagnoses of suspect cases Universal Precautions- hand washing, gloves, eye protection Droplet Protection- isolation, maintain 6ft distance surg mask, gloves, eye shield Airborne Pathogen Protection- Droplet plus- negative pressure room, , eye shield, gowns Post Exposure Prophylaxis
- 13. Aerosol Generating Procedures INTUBATION- elective/emergent, extubations Bronchoscopy , sputum inductions open suctioning of airways, trach’s NIPPV, aerosol treatments, HFO ventilation CPR insertion NG tubes autopsy chest physio
- 14. Personal Protection Handwashing Gowns, cap, gloves, goggles/eye shields from blood/droplet Surgical masks protect others from YOU ( or-source control for droplet) Can block larger particles Respirators protect YOU from others in smaller particles/airborne pathogens/chemicals FFR (filtering face piece respirators) N95 and other masks PAPR hoods (powered air purifiers)
- 15. History of Respirators animal bladder skins from Roman mines iron ore dust AD 25 1848 inventors race to get devices patented for miners and soldiers chemical warfare protection for ww1 Germans used Chlorine gas Ypres allies used urine soaked cloth to neutralize refined for health care use in 1990s due to emergence of MDR-TB SARS scare 2000 H1N1 scare 2009 and pandemic flu preparation
- 16. Mechanism Definition of N95 95 % of 0.3micron stopped N= not resistant to oil R= some resistance to oil P= oil proof
- 17. Efficacy In summary- YES!! The N95 is effective in our clinical scenarios however Compliance can be poor due to discomfort from heat, humidity Fit- an ill fitting mask is like NO MASK at all, consider PAPR (powered air purifier respirator) Head motion, bending over- can derail fit Communication difficult Cost of stocking right sizes and supplies in a pandemic- the respirator is considered 3rd line protection after Admin/Engineering controls- hand washing, isolation and ventilated rooms. In a crisis, AGP to be triaged as priority for N95’s or PAPR’s
- 25. On Compliance
- 29. N95 masks Although the benefits seem remote- they are REAL success by having your Fit test –especially simulate your Activities at work Get trained on use, donning and doffing Refresh fit and training every year –they are hot and uncomfortable, pain spots develop if straps not done right, they interfere with communication and performance, they are not easily accessible when you need them(esp your size), hard to look sexy in them, perception of resistance is high, your HR increases, can produce anxiety and claustrophobia, can impair vision of things.
- 32. Future of Respirators Reduced resistance and better effectiveness! nanotechnology or PAPRs digital headform tracking software to assist size and fit expiratory valves- not in sterile field, may be better in ICU/ER/Bronch suite/isolation unit UV light at upper part of room
- 35. A bit about TB Fast Facts TB infects 1/3 of the world population 2014- 9.6 million new cases, 1.5 million died, 480000 new cases of MDR-TB, second biggest cause of infectious death in the world after HIV, HIV+ 30x more likely to die from TB MDR and XDR emerging from EUROPE 0.8% of TB isolates in Ontario
- 37. lists, there are 49 countries that are in at least one list. There are 13 countries (see central diamond in the figure and the countries highlighted in bold below) that are in all three lists. Figure1: ThethreeHBC listsof 30 countrieseach that will beused by WHO 2016 2020 The 30 TB HBCs (those in all 3 lists in bold) are: Angola, Bangladesh, Brazil, Cambodia, China, Congo, Central African Republic, DPR Korea, DR Congo, Ethiopia, India, Indonesia, Kenya, Lesotho, Liberia, Mozambique, Myanmar, Namibia, Nigeria, Pakistan, Papua New Guinea, Philippines, Russian Federation, Sierra Leone, South Africa, Thailand, the United Republic of Tanzania, Viet Nam, Zambia and Zimbabwe. Changes compared with the lists in use in 2015 can be summarized as follows: TB HBC list. Two countries are no longer in the list: Afghanistan and Uganda. Ten new countries are included: Angola, Central African Republic, Congo, DPR Korea, Lesotho, Liberia, Namibia, Papua New Guinea, Sierra Leone and Zambia.
- 44. TB or not TB Surveillance in HCW yearly TST. If no previous, 2 step. If previous +TST and previous N CXR, watch for clinical Sx . If new +TST but BCG vaccination less than a year old- treat like new case do CXR new +TST and exposure to Tb case- CXR and clinical assessment. LTBI- converted but not active- lifetime risk of active TB 10- 20% is halved with treatment. Higher risk of active TB depends on your age and comorbidities. Treatment- 9 months of INH- hepatotoxic in 2%. (rash, nausea, neuropathy) they may add in rifampin for 2 months. If MDR or XDR you will be on MANY antibiotics for MANY months
- 45. Summary Reminder- we are in a high risk profession Get your immunizations up to date Source control effective, so is Administrative and Environmental controls as first lines get proper fit and wear the N95- cap/gloves/gown/goggles for bronch (you never know what the …it is) Treatment for TB is not fun, missing work and your family is not fun. may the force be with you
Editor's Notes
- Administrative, Engineering/Environmental and Personal Protection as third line.
- We’re getting better but Resp Protection Practice Plan should be refreshed more often, proper indications and technique, supplies adequate, etc
- the more we use them, the better we tolerate and get used to them, more effective
- Despite CDC and WHO guidelines many underdeveloped places not instituting measures uniformly
- see internet slide- heart rate, VO2 and RR increase over an hour