Outbreak Management
Wisconsin Department of Health Services
Heather Kloth RN, BSN
Infection Preventionist, HAI Prevention Program
Wisconsin Division of Public Health (DPH)
August 10, 2017
After the presentation, attendees will be able to:
Identify an outbreak and be prepared to manage the outbreak
List the necessary steps to contain and manage an outbreak
Name resources available to assist with outbreak management and investigation
Identify common outbreak management errors
Objectives
2
Is This REALLY an outbreak?
3
Respiratory Outbreak:
Three or more residents AND/OR employees from the same unit
With similar illness onset within 72 hours of each other
Who have an Acute Respiratory Illness (ARI), such as pneumonia, or lab-confirmed viral or bacterial infection, including influenza
Is this really an outbreak?
4
Gastrointestinal (GI) Outbreak:
Three or more residents AND/OR employees
Who develop new onset of vomiting and/or diarrhea
Onset dates are within 1-2 days
5
Is this really an outbreak?
Scabies Outbreak:
Two or more positive scrapings
One positive scraping and two clinically suspect cases
At least two clinically suspect cases in anyone (employees, visitors, or residents)
During a two-week period
Is this really an outbreak?
6
Two or more of the following symptoms:
Fever
Cough
Rhinorrhea or nasal congestion
Sore throat
Myalgia
Common ARIs include pneumonia, influenza, Respiratory Syncytial Virus (RSV), and many others
Clinical Signs and Symptoms (S/Sx)
of Acute Respiratory Illness (ARI)
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Sudden onset of vomiting and/or diarrhea, which may also include:
Headache
Fever
Chills
Abdominal cramps
Common viral GI illnesses include norovirus, rotavirus, and sapovirus
Clinical S/Sx of Viral GI Illness
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Norovirus
Acute-onset watery, non-bloody diarrhea
Acute-onset vomiting
Stomach cramps
Chills
Fatigue
Short incubation period and highly infectious
Common “outbreak” organism
C. Difficile
Frequent, foul-smelling watery stool
Stomach cramps
Stool usually contains blood and/or mucous
Commonly associated with antibiotic usage
Not a typical “outbreak” organism
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Norovirus Versus C. Difficile
An illness of the skin characterized by a papular, extremely pruritic rash and:
Is often burrow-like
Itching is predominantly worse at night
Typical locations?
Clinical S/Sx of Scabies
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Encourage and educate
Staff call-ins
Walking rounds
Working line list
Recognition and Confirmation
11
Swift, effective management of the outbreak will be the key to your success.
Where appropriate, a prophylactic plan should already be in place with MD approval.
12
Recognition and Confirmation
Confirm presence of outbreak
Alert key partners about investigation
Literature review
http://text.apic.org/toc/epidemiology-surveillance-performance-and-patient-safety-measures/outbreak-investigations#book_section_17256
Fundamental Components of
Preliminary Investigation
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Establish a preliminary case definition
Develop a methodology for case finding
Fundamental Components of
Preliminary Investigation
14
Prepare line list and mapping
Observe and review potentially implicated patient care activities
Consider environmental sampling when appropriate
Implement control measures
Fundamental Components of
Preliminary Investigation
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https://docs.legis.wisconsin.gov/code/admin_code/dhs/110/145/III/15
17
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Category I
Disease: must
be reported
immediately
https://www.dhs.wisconsin.gov/disease/diseasereporting.htm
Current guidance for outbreak management:
Annual reporting, prevention, and control of acute respiratory illness outbreaks in long-term care facilities https://www.dhs.wisconsin.gov/influenza/ltc-respiratory-
memo.pdf
Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities https://www.dhs.wisconsin.gov/publications/p0/p00653.pdf
Healthcare Infection Control Practices Advisory Committee https://www.cdc.gov/hicpac/pubs.html
Outbreak Management
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Droplet Precautions Contact Precautions
Influenza X
RSV X
Parainfluenza X
Rhino/Enterovirus X
Coronavirus X
Human Metapneumovirus
X
Adenovirus X X
Unknown Etiology X X
CDC Recommendations for
Common ARIs
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F441 – §483.80 (a) states that “Written standards…must
include…When and how isolation should be used for a resident;
including, but not limited to: Type and duration of isolation and requirement
that isolation be least restrictive possible…under the circumstances”.
Isolation: Is it necessary?
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Evaluation
Observation
Being Prepared in an Outbreak
Situation
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Lack of situational awareness
Failure to recognize outbreak
Sick staff
Failure to initiate appropriate precautions
Improper use or lack of use of personal protective equipment (PPE)
Common Outbreak Management Errors
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Policies and procedures
Hand hygiene related to the “Five Moments”
Lack of appropriate environmental cleaning https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants
Failure to notify your local health department https://www.dhs.wisconsin.gov/disease/diseasereporting.htm
Lack of knowledge of line lists and why/how they are used
Common Outbreak Management Errors
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Initials Rm # Age Sex Date
of
Onset
Resolution
Date
Type of
Precaution
Date
Precaution
Ended
N V D A Lab spec Result ABX
MM 102 70 M 12/1 12/3 Contact 12/5 X X X Stool + Noro N
DD 104 81 M 12/2 12/5 Contact 12/7 X X X X Stool +Noro N
PB 101 67 F 12/2 12/4 Contact 12/6 X X X Stool +Noro N
EF 107 90 M 12/3 12/6 Contact 12/8 X X Stool +Noro N
JJ 106 85 F 12/3 12/4 Contact 12/6 X Stool (-) N
RP 100 68 M 12/4 12/7 Contact 12/9 X X X Stool +Noro N
GY 103 78 F 12/4 12/6 Contact 12/8 X X Stool +Noro N
Example of Line List for GI
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*N = Nausea ; V = Vomiting ; D = Diarrhea ; A = Abdominal cramping Notes: Unit “quarantined” on 12/2. DPH notified on 12/2 of outbreak of Norovirus. Staff education provided regarding outbreak, hand hygiene, PPE use, and environmental cleaning. Signs posted re: outbreak and precautions. MD notified and blanket order obtained to test symptomatic residents for Norovirus. No floating of staff allowed as of 12/2.
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Norovirus
Outbreak in a
Nursing Home
Foodborne
Best practices for identification and management of an outbreak
Resources
Staying ahead of the game!
Questions?
Conclusion
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