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Expert Doctor’s Showcase Infection at the work place – we can
prevent it!
Dr Leong Hoe Nam Infectious Diseases Physician
Raffles Hospital, Singapore [email protected]
Unrestricted Educational Grant from
Financial Declaration
• Advisory Board
– Pfizer
– GlaxoSmithKline
– Sanofi-Pasteur
– MSD
• Site Principal Investigator
– Sanofi-Pasteur – Dengue Vaccine Trial
Unrestricted Educational Grant from
Infection in the Workplace is PREVENTABLE
Begins with
PERSONAL RESPONSIBILITY
Stephen Covey’s 7 Habits of Highly Effective People
SILVER WORKFORCE
• Co-morbidities
– Diabetes Mellitus, Chronic Obstructive Airway Disease, Asthma, Heart Disease, etc
• Reduced Immunity
• Same medical condition – HIGHER MORTALITY
INFECTIONS
GERMS
Listeriosis Contaminated Cantaloupes
E Coli Haemolytic Uraemic Syndrome
BACTERIA
FUNGI
HIV / AIDS
Viruses
RECENT EPIDEMICS / PANDEMICS
• Spread Fast
• Made use of Airport Routes
www.airliners.net
RECENT EPIDEMICS / PANDEMICS
• Humans were the carrier
• SINGAPORE – major airport hub
• Spread Fast
• Made use of Airport Routes
RESPIRATORY ROUTE!
Germany E Coli O104, Beansprout
FAECAL ORAL TRANSMISSION
INFECTIONS
• Risk of infection higher in the immunocompromised host. Cancer patients
• Diabetes mellitus type 2. Good control helps
“sugar to the white cells is like brandy to an alcoholic”
The pleasure of it all makes them not want to work.
Two main modes of transmission of Illness
• FAECAL ORAL
• RESPIRATORY
balkris.blogspot.com
Faecal Oral Transmission
粪便口头传输 Viral infection (Rotavirus, Enteroviruses) Salmonella (Typhoid fever), Shigellosis Hepatitis A - diarrhoea.
Chong Kneas — a floating village over Tonle Sap Great lake in Cambodia. A child refills lake water into her drinking bottle.
Faecal Oral Transmission
粪便口头传输
Spot the Difference
Straits Times Nov 3, 2011
What do I do?
• Keeping the environment clean
– Clearing / wiping down table.
– Eating at the office table
• Cover for keyboard.
• Who used the keyboard previously?
What do I do?
• Keeping the environment clean
– Clearing / wiping down table.
– Eating at the office table
• Nothing in the mouth except FOOD!
• Washing Hands
• Good toileting habits
• Ovaries of Hens
• Bacteria enters egg prior to
egg shell formation
Salmonella enteritidis
Source: salmonellablog.com Topnews.in
• Faecal contamination
Fresh eggs go through the same vent as faeces
PATIENTS with CANCER /
IMMUNOCOMPROMISED – TAKE
NOTE!
Faecal Oral Transmission 粪便口头传输
It’s all about….. 1. Personal hygiene 2. Personal responsibility 3. Using some common sense….
Unwell 1. Seek treatment 2. Rest at home 3. Strict handwashing
Respiratory (呼吸)
Influenza / Tuberculosis / Pertussis
Biggest burden – Influenza (流行性感冒) Spread by Droplet (通过飞沫传播) Other respiratory viruses Respiratory syncytial virus (RSV), parainfluenza, enteroviruses, adenovirus, coronaviruses, bocavirus, metapeumovirus Other bacterial infections Streptococcus pneumoniae, Haemophilus influenzae, Moxarella catarrhalis
Respiratory
Spread by droplets - minimise exposure - cover cough - dispose of dirty tissue - no spitting - hand hygiene - surgical mask SEE A DOCTOR! Stay at home. Influenza Vaccinations for those with chronic Illnesses Option of antiviral therapy <48hrs for influenza
Surgical Masks – THEY WORK!
THEY PROTECT THE WEARER!
THEY PROTECT OTHERS!
PREVENTION OF INFECTION
Johnson et al. Clin Infect Dis. (2009) 49 (2): 275-277.
INFLUENZA
COUGH!
20cm
PREVENTS Transmission
Myths on Influenza
• It is a whimpy virus
• It doesn’t kill
• There is no influenza in Singapore
• The influenza vaccination doesn’t work
Two FLU SEASONS in SINGAPORE
• BIMODAL APRIL – JULY
NOVEMBER – JANUARY
Follows the Southern and Northen hemispheres
Greater PEAK – APRIL – JULY
Angela Chow et al. EID. Vol 12. No.1 Jan 2006
A
Angela Chow et al. EID. Vol 12. No.1 Jan 2006
All Cause Death
Underlying Pneumonia and Influenza
Underlying Circulatory and Respiratory Deaths
Influenza – excess death
INFLUENZA is responsible for DEATH in TROPICS
Angela Chow et al. EID. Vol 12. No.1 Jan 2006
Every peak of excess death paralleled Influenza peaks (except 1)
An experiment in TTSH
• ALL patients admitted over 48 hour period tested for influenza
• 10% were positive for influenza by PCR
• 60% had “Influenza-like illness”
• “underrecognition and underdiagnosis of influenza in hospitals. “
Leo YS et al. Lancet Inf Dis. August 2009
An experiment in TTSH
• ALL patients admitted over 48 hour period tested for influenza
• 10% were positive for influenza by PCR
• 60% had “Influenza-like illness”
• “underrecognition and underdiagnosis of influenza in hospitals. “
Leo YS et al. Lancet Inf Dis. August 2009
INFLUENZA in the AT-RISK POPULATIONS
RR Hospitalisation
• Non-epidemic years 1.1 (1977) 1.0 (1979)
• Epidemic years 5.7 (1976) 6.2 (1978)
• 5 X Increase risk of HOSPITALISATION • Pneumonia RR 25.6
• Death RR 30.9 (1977) 91.8 (1978)
• .
The adjusted rates of excess influenza-associated hospital admissions for the three diagnoses combined amounted to 58.5, 20.0, 29.2, and 13.4 per 10,000 populations aged 65 years in 1998, 1999, 2000, and 2001, respectively.
Pneumonia / Diabetes Mellitus / Heart + INFLUENZA
= BAD NEWS
What about children…..?
www.colourtown.com
• The risk of INFLUENZA on HOSPITALISATIONs
<6 mo 103.8 1-3y 18.6 5-15y – 4.1
6 – 12 mo 49.6 3-5y 8.6 Excess/10K chn/yr
Relationship within the family
Children
Grandparents Parents
Children gives “multiple doses” (exposures) to grandparents
• 1 child can give
multiple doses
The Good News…..
We have a vaccine…….
In Singapore A vaccine is just dead vaccine lightly salted….
Effectiveness of the Vaccine
• COPD
• Decrease in ARI / Hospitalisation / Mechnical Ventilation
MILD
MODERATE
SEVERE
ALL
• Part of PRISMA Study (Prevention of Influenza, surveillance and management Study). 75,000
• 1999-2000 Influenza A
• Vaccine : Control 1:4
Reduction in Death / Hospitalisation
BURDEN OF INFLUENZA…. BEYOND THE PATIENT…..
The burden of respiratory illness…
• All respiratory illnesses can result in visits, prescriptions, lost school and work days…
• BUT – INFLUENZA – had more of them…..
Burden of Influenza vs Others
• More transmissibility in family
• More prescriptions
• More medical visits
• More lost work / school days
Vaccinating the YOUNG to save the OLD
• Mandatory Flu vaccination in Children – 1962-87
• Laws relaxed 1987
• Repealed in 1994
• VACCINATION of CHILDREN PROTECTS ELDERLY
COMPULSORY
Vaccine Effectiveness
Adults / Children with Asthma
>65 yo
713, 872 person-years observation. VACCINATION
27% reduction HOSPITALISATION (for pneumonia / influenza (OR 0.73, CI 0.68-0.77)
48% reduction in Risk of Death. (OR 0.52 CI 0.5 – 0.55)
• Vaccine effectiveness repeated in Taiwan…..
Cost EXcluding Operating Income
PRODUCTIVITY RATE 70 50 30
Cost INcluding Operating Income
PRODUCTIVITY RATE 70 50 30
Vaccine Safety
Generally safe…
Pain / Ache site of infection
Limited fever post vaccination
MOH guidelines on Influenza Vaccination • Persons aged 65 years and older; • Residents of nursing homes and other chronic care facilities; • Adults and children who have chronic disorders of the lungs
or heart, including asthma; • Adults and children who have required regular medical
follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), kidney or blood disorders, or lowered immunity caused by medications or by the Human Immunodeficiency Virus (HIV);
• Children and teenagers aged 6 months to 18 years who are receiving long-term aspirin therapy;
• Women who are in the second or third trimester of pregnancy.
INDIVIDUALs in contact with patient
INDIVIDUAL To Protect!
INFECTIONS are transmitted by those around the patient
Vaccinations must include the OUTER PERIMETER – the patients’ contacts!
5- to 19-year-olds are expected to suffer the
highest incidence during the initial epidemic phase of an emerging infection
Mossong et al. PLoS Med. 2008 Mar 25;5(3):e74.
Lessons on influenza
• Children transmit the viruses
• Children pass the infection to others
(YOUR EMPLOYEE / YOURSELF)
Manhours, medical leave.
• Vaccinating the children of your employee helps
Impact of Annual Influenza Epidemics
• No. of workdays lost
1.5 – 4.9 days / person
lab-confirmed influenza.
Keech and Beardsworth. Pharmacoeconomics. 2008;26(11):911-24
• Lost of productivity
“reduced capacity to work”
5 - 6.2 days
Kavet. Am J Public Health. 1977;67:1063-1070
Economics of Workplace Vaccination
• Cost savings….($15 to $995) per vaccinated employee)
(20% attack rates)
Bruce lee at al. Vaccine. 2010 August 23; 28(37): 5952–5959
TWO LARGE RANDOMISED CONTROL TRIALS TWO WELL RECOGNISED JOURNALS
But there are detractors….
• “vaccines are undoubtedly the best preventive means for clinical influenza in healthy adults.”
• “low effectiveness and high incidence of trivial local adverse effects that the trade-of is unfavourable”
• “most cost-effective option is not to take any action”
Demicheli V et al. Vaccine. 2000 Jan 6;18(11-12):957-1030. Review
How much vaccination is enough?
• In an epidemic of influenza
• Computer Modelling
• 20% compliance – MAXIMUM GAIN!
Vaccine Cover Attack Rates
100% 0.5%
50% 0.6%
20% 0.7%
0% 2.8%
60 Days to complete vaccination
Vaccine Cover Attack Rates
100% 1.5
50% 1.5%
20% 1.8%
0% 3.8%
120 Days to complete vaccination
Lee et al. Am J Prev Med. 2010 March ; 38(3): 247–257
Physical Barriers Help
Respiratory Infections
• Influenza biggest burden
• Vaccination helps! $23-25
– Hospitalisation / Deaths
• Influenza has two peaks in Singapore
• Surgical masks can help prevent infections.
Barriers to Vaccination
1. Doctor’s Recommendations
2. Perceived benefits
3. Previous vaccinations
4. Convenience to vaccinations eg. Vaccination programme at workplace, at GP consultation
Some parting words
• “If there is any conceivable way a germ can travel from one species to another, some microbe will find it,”
William McNeill
Plagues and Peoples
The END
Infection in the Workplace is PREVENTABLE
Begins with
PERSONAL RESPONSIBILITY (CORPORATE RESPONSIBILITY)
Annual Impact of Seasonal Influenza - USA
• 2003 US population 294 million
• 610,660 life years lost
• 3.1 million hospitalised days
• 31.4 million outpatient visits
• Direct medical costs $10.4 billion
• Lost earnings $16.3 billion
• Total Economic Burden $87.1 billion
INDIVIDUALs in contact with patient
INDIVIDUAL To Protect!
INFECTIONS are transmitted by those around the patient
Vaccinations must include the OUTER PERIMETER – the patients’ contacts!
How much vaccination is enough?
• In an epidemic of influenza
• Computer Modelling
• 20% compliance – MAXIMUM GAIN!
Vaccine Cover Attack Rates
100% 0.5%
50% 0.6%
20% 0.7%
0% 2.8%
60 Days to complete vaccination
Vaccine Cover Attack Rates
100% 1.5
50% 1.5%
20% 1.8%
0% 3.8%
120 Days to complete vaccination
Lee et al. Am J Prev Med. 2010 March ; 38(3): 247–257
Difficulty in Studying Influenza
INFLUENZA INFLUENZA-LIKE ILLNESSES
Lab-confirmed Clinically suspected
low sensitivity Other viruses responsible.
Characteristic features (50%)
URTI only (30%)
No Symptoms (20%)
Costly!
INFLUENZA A, B
Parainfluenza 1,2,3 Respiratory Syncytial Virus, Adenovirus, Enterovirus, Coronaviruses, Mycoplasma
Risk of Guillain Barre Syndrome
• Incidence GBS – 4-10/ 1,000,000
• Flu – 15-20% of the cases.
• “the attributable rate of GBS would be 0.71 per 100,000 person-years, corresponding to an attributable risk of 0.8 excess cases of GBS per 1 million vaccinations.“
Impact of Annual Influenza Epidemics
• No. of workdays lost
1.5 – 4.9 days / person
lab-confirmed influenza.
• Lost of productivity
“reduced capacity to work” Keech and Beardsworth. Pharmacoeconomics. 2008;26(11):911-24