(and what you can do about them)

What’s an outbreak? In general, more cases than expected (baseline) More cases clustered in a specific unit or facility than

you’d expect at a particular time of year

Some disease-specific definitions: One confirmed case of influenza in an LTC 2 or more cases (staff or residents) with vomiting,

diarrhea or both clustered by time and place

Outbreak investigation Start a line list to track ill residents and staff

Include: name, symptoms, onset of illness, resolution of illness and any lab testing/results

Notify Epidemiology (907-269-8000) of suspected outbreak Review cases and symptoms from line list Coordinate specimen (NP swab or stool) collection for lab testing

Implement infection control measures

Includes education of staff and visitors

Line list follow-up Monitor daily, confirm your cases Check each one with your case definition

What’s a line list?

https://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/Outbreaks/Gastroenteritis/Pages/gastro.aspx#control

http://dhss.alaska.gov/dph/Epi/id/Pages/dod/norovirus.aspx

https://www.cdc.gov/longtermcare/prevention/index.html

Norovirus-general The most common cause of cases of acute gastroenteritis

and gastroenteritis outbreaks

Can affect nearly everyone in the population (from children to the elderly and everyone in between!) particularly because there is no long term immunity to the virus

Causes acute but self-limited diarrhea, often with vomiting,

abdominal cramping, fever, and fatigue Most individuals recover from acute symptoms with 2-3 days , but can be more severe in vulnerable populations

Burden of Norovirus Infection

#1 cause of acute gastroenteritis in U.S. 21 million cases annually 21 million cases annually 1 in 14 Americans become ill each year

71,000 hospitalized annually in U.S.

91,000 emergency room visits overall in the U.S. 80 deaths annually in UK (global disease)

Occurs year round with peak activity during the winter months Scallan et al. 2011. EID. 17(1): 7-15.; Patel et al. 2008. EID. 14(8); 1224-31.; Harris et al. 2008. EID. 14(10); 1546-52.

Norovirus Infectious dose: 18-1000 viral particles

Viral shedding is mostly in stool (can be in vomit) Shedding peaks in 4 days after exposure

Incubation period: 12-48 hours

Acute-onset vomiting and/or diarrhea

Watery, non-bloody stools Abdominal cramps, nausea, low-grade fever 30% infections asymptomatic

Most recover after 12-72 hours

More severe illness and death possible in elderly

Norovirus Transmission Highly contagious (as low as 18 virus particles)

Survives freezing and heat (140 F)

Direct person to person Fecal-oral Vomitus Indirect via fomites or contaminated environment

Food or water

Infected by food handlers Point source (e.g. food-raw, served multiple days) Well contamination or chlorination insufficient

In healthcare, the most likely and common modes of transmission are through direct contact with infected persons or contaminated equipment

What should I do for suspected cases of norovirus? Rapid identification and isolation of suspected cases Communicate and coordinate efforts with your

infection prevention team Call SOE (907-269-8000) Review norovirus guidelines (CDC, Alaska, Oregon)

Implement control measures as soon as possible;

don’t wait for lab results!

Summary Detect and confirm suspected norovirus cases rapidly During outbreaks, implement Contact Precautions,

enhanced hand hygiene, environmental infection control measures, exclusion of ill staff from work for a minimum of 48 hrs

after symptom resolution surveillance for new and resolving cases,

Develop a communication plan during outbreaks to include key departments and services

Consult with and report outbreak to state health department (907-269-8000)

Influenza Be aware of influenza activity in your area http://dhss.alaska.gov/dph/Epi/id/Pages/influenza/fluinfo.aspx

Outbreaks of flu in long-term care facilities are

COMMON have a plan! One confirmed case of influenza in an LTC is an outbreak Give antivirals and chemoprophylaxis to residents

Influenza in the Elderly Adults > 65 years higher risk for developing complications

Pneumonia, bronchitis, sinus infections and ear infections are flu-related complications that can result in hospitalization or death

Annual influenza vaccination is recommended, no preference from CDC on which type of vaccine

A few studies that have shown improved immune response to the “high-dose” versus standard dose influenza vaccine

DiazGranados, CA et.al Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults NEJM 2014; 371:635-645

Presenter

Presentation Notes

For the 2015-2016 influenza season, CDC estimates that influenza vaccination prevented approximately 5.1 million influenza illnesses, 2.5 million influenza-associated medical visits, and 71,000 influenza-associated hospitalizations (see Table 1). CDC estimates that influenza vaccination prevented 3,000 Pneumonia & Influenza deaths.

How Flu Spreads People with flu can spread to others-about 6 ft away

Spread by droplets made when people with flu cough,

sneeze or talk

Less often, a person might get flu by touching a surface or object that has flu virus on it and then touching their own mouth or nose

Most adults may infect others 1 day before symptoms develop and 5 to 7 days after becoming sick

Influenza Vaccinations for Health Care Providers (HCP) HCP can acquire flu and

transmit flu to patients or other workers

Vaccination is still the most

effective intervention

People infected with flu can spread it one day before they feel sick through five to seven days after

*Higher vaccination rates among staff are associated with lower rates of flu in

residents (LTC) and patients (hospital)

Fundamentals to Prevent Flu Have a facility plan (include your pharmacist)!

Promote and give influenza vaccine Minimize exposure-use respiratory hygiene and cough

etiquette Management of ill HCP Adhere to infection control precautions for all patient-

care activities and aerosol-generating procedures Implement environmental infection control measures

Outbreak Prevention and Prep Vaccinate residents, patients and staff!

Influenza (annual) Don’t forget other VPDs: Chickenpox/varicella, MMR

Shingles (residents in LTC)

Have records of vaccination/immunity status for everyone

Have standing orders for antivirals/antibiotics in case of an outbreak (especially for Long Term Care)

Summary Detect and confirm suspected influenza cases rapidly During outbreaks, implement Droplet Precautions,

enhanced hand hygiene, environmental infection control measures, exclusion of ill staff from work for a minimum of 24 hrs after

they no longer have a fever surveillance for new and resolving cases,

Develop a communication plan during outbreaks to include key departments and services

Consult with and report outbreak to state health department (907-269-8000)

Presenter

Presentation Notes

Includes: fact sheet, planning stuff, line list template, antiviral and prophy recommendations, isolation precaution recommendations and signage, and employee vaccination materials.

Resources • Centers for Disease Control and Prevention https://www.cdc.gov/flu/ Alaska DHSS, Epidemiology http://dhss.alaska.gov/dph/Epi/id/Pages/influenza/fluinfo.aspx

Infectious Diseases Society of America (IDSA) http://www.idsociety.org/Influenza/

Alaska Conditions Reportable to Public Health http://dhss.alaska.gov/dph/Epi/Pages/default.aspx

Condition Timeframe Acceptable report methods

Public Health Emergencies Immediate Phone* Infectious diseases • Sexually transmitted diseases or HIV • All other infectious diseases

Within 5 days Phone*, Fax, Mail

Firearm injuries Within 5 days Phone*, Fax Occupational disease and injury Within 5 days Phone, Fax Blood lead levels (link p14) • >5 ug/dl in persons < 18 years old • >10 ug/dl in persons >18 years old

Within 1 week Phone*, Fax, Mail

Toxic or hazardous exposures Within 1 day Phone*, Fax Healthcare associated infections required to be reported to federal authorities

Follow NHSN practice

NHSN

http://dhss.alaska.gov/dph/Epi/Documents/pubs/conditions/ConditionsReportable.pdf#page=8

http://dhss.alaska.gov/dph/Epi/Documents/pubs/conditions/ConditionsReportable_LABS.pdf