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

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


Outlines

Application of Epidemiology in real life in clinical settings – an example

Personal Experience

Application of Epidemiology

– When

– How

– Where

– Why

– What next


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)


43 Lung

Transplant


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


43 Lung

Transplant

34 Tumor


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.


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


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.


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


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.


The Victims

Doctors try several combinations of antibiotics

even an experimental drug still in development.

Nothing works.

And some patients die.


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.


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.


Looking for a link

Throughout the outbreak, the hospital used epidemiological and genetic

analysis to help understand the transmission sequence.


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.


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


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


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


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.


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


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


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.


Thank You

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