Disaster and Emergency Management

SUMMER 2018 • VOLUME 11 NUMBER 2

Disaster and Emergency Management

Certification: The defining difference Relative risks and odds ratios

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Contents

FEATURES

SUMMER 2018

44

#NapaStrong: Infection prevention and emergency preparedness during the 2017 northern California wildfires By Gianna Peralta

48

Tools for the trade: Weathering hurricanes By Aleya Byrd, Ted Jones, Lauren Holloway, Karena von Doehren, Robyn Kay, Christine Bailey

52

Preventing secondary cases of measles in an acute care hospital By Mary Ellen Scales

4 | SUMMER 2018 | Prevention

54

Lessons learned from a hospital scabies outbreak By Stacy Demoss

67

Bioterrorism preparedness: A critical role for the infection preventionist

58

By Amesh Adalja

By Marcia Patrick

San Diego County hepatitis A outbreak: The need for a collaborative approach to infection control

Holiday flood—What a turkey!

62

Elizabethkingia anophelis outbreak in southern Wisconsin: A first-person account By Jennifer Rettman

70

By Melanie Padgett Powers COVER IMAGE: OLLIE THE DESIGNER/SHUTTERSTOCK.COM

VOICE “Suit up” for emergencies

6

Future of the infection preventionist’s role

8

By Janet Haas, 2018 APIC President By Katrina Crist, APIC CEO

Practice is the mainstay of mastery

By Joann Andrews, 2018 CBIC President

10

28

DEPARTMENTS Briefs to keep you in-the-know • Congratulations to the 2018 APIC Award Winners! • PGC Practice Corner • APIC awards travel grants to international attendees • Get involved with APIC • Consumer Alert: Hepatitis A • APIC, SHEA, and SIDP update position paper highlighting synergy of IPC and AS

12

Infection Prevention Leadership: Three Rivers Pittsburgh chapter past president

21

APIC Consultant Corner: Outbreak investigation

23

Capitol Comments: Certification—The defining difference

25

A conversation with Juliet Ferrelli Q&A with Gwen Borlaug

By Rich Capparell, Nancy Hailpern and Lisa Tomlinson

40

PREVENTION IN ACTION My Bugaboo: A microbiological overview of brucellosis

28

From data to decisions: Strength of association— Relative risks and odds ratios

33

Focus on long-term care and behavioral health outbreaks: Identify the pathogen!

40

By Irena Kenneley

By Daniel Bronson-Lowe and Christina Bronson-Lowe

By Steven Schweon

44 w w w.apic.org | 5

PRESIDENT’S MESSAGE

“Suit up” for emergencies

BY JANET HAAS, PhD, RN, CIC, FSHEA, FAPIC, 2018 APIC PRESIDENT

“When the unexpected happens, our colleagues and patients are counting on us to get into gear and lead the way to safety.”

HELLO AND HAPPY SUMMER! I hope to see many of you at the APIC annual

conference in beautiful Minneapolis. There you can join thousands of your peers to learn the latest information on preventing infections, enjoy networking opportunities, refresh yourself, and continue your professional development in the service of your patients, your facility, and your career. Now that the rough flu season of 2017-18 is behind us, you may be tempted to take a break from emergency preparedness and public health. However, I hope this issue of Prevention Strategist, which is focused on emergency preparedness, will convince you that preparedness requires steady and ongoing commitment. We never know when the next emergency will present itself, or exactly what it will be. Whether it’s a natural epidemic, an emerging pathogen, bioterrorism, or another type of disaster, such as a hurricane or fire, an emergency will always have infection prevention and control implications; our communities are counting on us to be ready. In my mind, emergency preparedness has something in common with being ready for bathing suit weather. How is that? Well, many of us tend to focus on eating sensibly and exercising only when we know that we’ll soon be dressing up for an event or putting on a swimsuit. You know, crunch time to be ready for that special occasion…drastic efforts when an event is impending, like crash diets and vigorous workouts. Then, if we’re lucky, we squeeze into that outfit and let out a sigh of relief…only to revert to our usual behaviors as soon as the event is over. Of course, we know we could fit into our bathing suits without all the drama if we just kept our health goals in mind as part of our routine. Our efforts would be more effective if we made healthy behaviors a habit and stuck with them throughout the year. The same is true for emergencies; we can scramble to react as events are unfolding, or we can make emergency preparedness a habit that allows us to calmly serve our patients and colleagues during times of crisis. Being prepared requires team effort, repetition, learning from our practice, and sustained attention. When the unexpected happens, our colleagues and patients are counting on us to get into gear and lead the way to safety. It’s the time to show up and shine, to lead with the confidence that only ongoing planning and practice can give. We must fit in the suit without fail, not by chance or strenuous last-minute exertion, but by diligent attention over the long term. Best wishes for a safe and enjoyable summer. When we meet in Minneapolis, let’s be sure to share ideas about how we can best “suit up” for any challenge.

Janet Haas, PhD, RN, CIC, FSHEA, FAPIC


Prevention SU P RMI M N EGR22017 018• •VO VOLLUUMMEE10 11, I S S U E 12

BOARD OF DIRECTORS President Janet Haas, PhD, RN, CIC, FSHEA, FAPIC President-Elect Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC Secretary Ann Marie Pettis, RN, BSN, CIC, FAPIC Treasurer Sharon Williamson, MT(ASCP)SM, CIC, FAPIC Immediate Past President Linda Greene, RN, MPS, CIC, FAPIC

DIRECTORS Dale Bratzler, DO, MPH, MACOI, FIDSA Tania Bubb, PhD, RN, CIC, FAPIC Thomas Button, RN, BSN, NE-BC, CIC, FAPIC Linda Dickey, RN, MPH, CIC, FAPIC Beth Duffy, MBA Annemarie Flood, RN, BSN, MPH, CIC, FAPIC Pat Metcalf Jackson, RN, MA, CIC, FAPIC Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Lela Luper, RN, BS, CIC, FAPIC Carol McLay, DrPH, MPH, RN, CIC, FAPIC Barbara Smith, RN, BSN, MPA, CIC, FAPIC

EX OFFICIO Katrina Crist, MBA, CAE

DISCLAIMER Prevention Strategist is published by the Association for Professionals in Infection Control and Epidemiology, Inc. (“APIC”). All rights reserved. Reproduction, transmission, distribution, or copying in whole or in part of the contents without express written permission of APIC is prohibited. For reprint and other requests, please email [email protected]. APIC makes no representations about the accuracy, reliability, completeness, or timeliness of the material or about the results to be obtained from using this publication. You use the material at your own risk. APIC assumes no responsibility for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer.

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CEO’S MESSAGE

Future of the infection preventionist’s role

BY KATRINA CRIST, MBA, CAE, APIC CEO

“This consensus conference is a special project. The future-oriented recommendations that emerge from this meeting will be published in the AJIC and disseminated in a variety of other ways in early 2019.”

THIS FALL, APIC is convening a consensus conference on the “Future

of the IP Role” to help establish key strategies that will ensure the ongoing success of infection preventionists (IPs). At this conference, both internal and external stakeholders will consider the future evolution of healthcare as it relates to infection prevention and control (IPC) and the value of IPs. The APIC Board of Directors has appointed a four-member steering committee to lead the program development for the conference and facilitate workgroup discussion and the creation of consensus recommendations. The committee members are all leaders in the IPC profession, and for APIC. Furthermore, they represent diversity of thought through their varied backgrounds and positions: Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP, FAPIC, is a professor of nursing at Thomas Jefferson University, College of Nursing; Denise Murphy, RN, BSN, MPH, CIC, CPPS, FAAN, FAPIC, is vice president of Patient Care Systems, and senior nurse executive at BJC HealthCare–Center for Clinical Excellence; Marc-Oliver Wright, MT(ASCP), MS, CIC, FAPIC, is a clinical infection control practitioner at University of Wisconsin Hospitals and Clinics; and Beth Wallace, MPH, CIC, FAPIC, is senior director, System Infection Prevention and Epidemiology, for Beaumont Health. At the conference, we will focus on four primary topics organized around key questions. For each topic, a workgroup of 10-12 stakeholders will be formed to consider the questions and develop consensus recommendations. External stakeholders representing areas such as population health, insurance/reimbursement, regulatory agencies, medical or healthcare futurism, and biotechnology will play an important role in these discussions. Their perspectives will show us how IPs are viewed by others and help us clearly envision a future in which IPs have increased value and greater influence. This consensus conference is a special project. The future-oriented recommendations that emerge from this meeting will be published in the American Journal of Infection Control and disseminated in a variety of other ways in early 2019. I look forward to seeing those of you attending APIC 2018 in Minneapolis. The Annual Conference Committee and staff have put together another great program. When you see me in sessions or walking through the convention center, I hope you will stop me to say “Hi” or chat for a while. I welcome your feedback on what we are doing or what you would like to see APIC do. I enjoy opportunities to interact with members, the heart and soul of APIC! It is a privilege to serve as your CEO—thank you!

Prevention S U M M E R 2 018 • VO L U M E 11 I S S U E 2

PUBLISHER Katrina Crist, MBA, CAE [email protected] MANAGING EDITOR Rickey Dana [email protected] CONTRIBUTING EDITORS Julie Blechman, MPH, CHES Elizabeth Garman Elizabeth Nishiura PROJECT MANAGER Russell Underwood [email protected] ADVERTISING Brian Agnes [email protected] GRAPHIC DESIGN Dan Proudley

EDITORIAL PANEL Timothy Bowers, MS, CIC, CPHQ, FAPIC Gary Carter, MPH, CIC, CIH, REHS, DAAS Kristine Chafin, MBA, RN, CIC Edina Fredell, MPH, CIC, MT(ASCP) Ruth Freshman, MSN, RN, CIC Kathryn Galvin, MS, MLS(ASCP)CM, CIC Meagan Garibay, RN, BSN, CIC Jessica Hayashi, MS, RN, CIC, CPHQ, FACHE Adrienne Pinto, MSN, RN, CIC Alexander Sundermann, MPH, CIC Christine Young-Ruckriegel, RN, MSN, MPA, CIC

CONTRIBUTING WRITERS Julie Blechman, MPH, CHES Elizabeth Garman Meredith Hotchkiss, MN, RN Kirk Huslage, MSPH, BSN, RN, CIC, FAPIC Silvia Quevedo, CAE

MISSION APIC’s mission is to create a safer world through prevention of infection. The association’s more than 15,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities. APIC advances its mission through patient safety, implementation science, competencies and certification, advocacy, and data standardization. Visit APIC online at www.apic.org. PUBLISHED MAY 2018 • API-Q0218 • 8606

Katrina Crist, MBA, CAE


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CELEBRATING EXCELLENCE

Practice is the mainstay of mastery RECENTLY, OUR HOSPITAL, in partnership with 22 other agencies, participated in a statewide infectious disease exercise that used simulation and a scripted scenario to prepare for the interstate transport of an infectious patient. Among many other things, this exercise made me reflect on the power of practice.

Practice is perhaps most commonly thought of in the context of sports, but it is also a core requisite to become proficient in many other areas of human endeavor. Small children learn all sorts of new skills through long hours of practice. In healthcare facilities, we have monthly fire drills, periodic generator shutdowns, and frequent mock cardiac arrest codes to practice cardiopulmonary resuscitation. Whether we gravitate toward athletics, music, art, dance, or healthcare, practice is the mainstay of mastery. BY JOANN ANDREWS, DNP, RN, CIC, 2018 CBIC PRESIDENT

“Practice is perhaps most commonly thought of in the context of sports, but it is also a core requisite to become proficient in many other areas of human endeavor.”

The psychologist Anders Ericsson has demonstrated that a person may need up to 10,000 hours of deliberate practice to attain expert status in any field. This finding was popularized in Malcolm Gladwell’s book Outliers. But why does “practice make perfect”? Repetition builds the muscle memory, mental acuity, and confidence that one needs to smoothly negotiate even the most arduous of tasks. The repetitive work of practice is what allows infection preventionists to be better prepared and confidently manage rare events, such as an Ebola or Zika virus infection. You may be asking, “What does this have to do with certification?” I propose that the same diligent training and practice that you rely on to accomplish your professional duties will help you prepare for certification. If one of your self-development goals is to attain certification in 2018, you might consider the power of practice as you begin your studies. There are many ways that CBIC and APIC can help you to prepare for certification. For example, you could attend APIC’s Annual Conference, participate in local chapter meetings, form your own study group, follow CBIC’s Micro Mondays and Testing Tuesdays on Facebook, purchase the CBIC Practice Exam, or take the APIC Competency Review online course. I am looking forward to seeing many of you at the APIC Annual Conference in Minneapolis in June. Please join us at the CBIC booth (#332) to participate in our 35th anniversary celebration!

Joann Andrews, DNP, RN, CIC


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BRIEFS TO KEEP YOU IN-THE-KNOW

Congratulations to the 2018 APIC Award Winners! Carole DeMille Achievement Award Terrie Lee, RN, MS, MPH, CIC, FAPIC Charleston Area Medical Center Charleston, WV

TERRIE LEE, RN, MS, MPH, CIC, FAPIC, direc-

tor of infection prevention and employee health at Charleston Area Medical Center, in Charleston, West Virginia, will receive the prestigious Carole DeMille Achievement Award for her innovative contributions and exceptional leadership in infection prevention and control (IPC). The award, which will be presented during the opening session at APIC’s 45th Annual Conference in Minneapolis, is given annually to an infection preventionist who best exemplifies the ideals of Carole DeMille, a pioneer in the field of IPC.

Lee’s career in IPC has spanned more than 30 years, with her leadership in APIC being nearly as long. Beginning as a founding member of the APIC West Virginia chapter, she served as chapter president in 1985-86. Nationally, she served on a number of task forces and committees, culminating in her service as the 1995 APIC president. She has served as a consultant for APIC Consulting Services since 2009 and led the development team for the APIC Program of Distinction, as well as the creation of the Standards of Excellence for Infection Prevention and Control—the first set of standards that APIC published in its 40-year history. Lee is also very dedicated to serving the international infection prevention community, serving as the chair of the International Federation of Infection Control. Lee is a nationally recognized leader on surveillance and risk assessments, and has authored numerous articles on the topic, including the hallmark “Recommended

Practices in Surveillance,” published in the American Journal of Infection Control in 2007. She has been at the forefront of organizational infection prevention risk assessments, and her leadership in teaching the risk assessment process at local, state, national, and international meetings has led to her program’s inclusion in the APIC EPI® 101 course curriculum. Lee also she serves as a member of the West Virginia State Healthcare-Associated Infection Control Advisory Panel on public reporting of infections. Lee’s contributions to the field have been extensively recognized. She was the recipient of the Quality Award for outstanding performance and commitment to reducing healthcare-associated infection rates from the West Virginia Medical Institute in 2014, and winner of the “Hot Shot” Award from the West Virginia Immunization Network for special achievement in achieving healthcare worker immunization in 2010.

President’s Distinguished Service Award, in honor of Pat Lynch Connie Steed, MSN, RN, CIC, FAPIC Greenville Health System Greenville, SC

CONNIE STEED, MSN, RN, CIC, FAPIC, corpo-

rate director of the Infection Prevention Department at Greenville Health System in Greenville, South Carolina, will receive the President’s Distinguished Service Award, in honor of Pat Lynch, at the APIC Annual Conference.


The award is given to an individual who has made major contributions to the profession of infection prevention and control (IPC) through service within APIC. Steed is being recognized by her peers as a champion within the IPC field and as an expert in education tied implementation science. She was one of the first infection preventionists (IPs) to recognize the important of education in reducing needlestick injuries and infection risks to patients and staff. Steed has been a member of APIC since 1979. On the state level, she has served as president of both the Chattahoochee and Palmetto chapters. Nationally, she served on the APIC Board of Directors,

the Membership Committee, and the Governmental Affairs Committee. She was also chairperson of the National Extended Care Facility Recruitment Subcommittee and has been influential in the development of the future path of APIC and the field by assisting in the creation of APIC’s Strategic Plan 2020, the IP Competency Model, and revision of APIC’s national policy manual. Furthermore, Steed has served in every elected position at her local chapter. She has energized and motivated new IPs, teaching basic IPC courses as well as certification review courses. She has mentored nearly 200 IPs, many of whom have gone on to become leaders in the field.

Distinguished Scientist Award Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP, FAPIC Thomas Jefferson University, College of Nursing Philadelphia, PA

MARY LOU MANNING, PhD, CRNP, CIC, FAAN, FNAP, FAPIC, professor at the Thomas Jefferson

University College of Nursing in Philadelphia, will receive the Distinguished Scientist Award at the APIC Annual Conference in Minneapolis. The Distinguished Scientist Award is given to individuals who have made outstanding contributions to the science of infection prevention and control (IPC) as determined by the APIC Research Committee.

Over the past three decades, Manning has extensively contributed to clinical practice, research, and education in IPC. A member of APIC since 1991, she served as the 2015 APIC president, and president of the Delaware Valley and Philadelphia chapter in Pennsylvania. Manning is a member of the editorial board of the American Journal of Infection Control, and has authored and published more than 35 publications dealing with critical IPC topics ranging from antibiotic stewardship to program evaluation and leadership. Prior to Manning’s current position at Thomas Jefferson University, she held leadership positions at the Children’s Hospital of Philadelphia, serving as the director of infection prevention and occupational health for more than 12 years. In this role, she launched a Center for Process Innovation.

Manning has been an ambassador for global infection prevention, providing consultation and education in numerous countries, including Indonesia, where she was a member of a post-tsunami Indonesia Disaster Recovery Program team in 2007. During the recent Ebola crisis, she served as a faculty member of the Centers for Disease Control and Prevention (CDC) safety training course for healthcare workers going to West Africa, and she was a member of the American Nurses Association Expert Advisory Panel on Ebola. Manning also represented APIC on a CDC rapid Ebola preparedness assessment team in Philadelphia. Manning will speak on the “State of the Science in Infection Prevention” at APIC’s 45th Annual Conference.

Healthcare Administrator Award Cindy Barnard, PhD, MBA, MSJS Northwestern Memorial HealthCare Chicago, IL

CINDY BARNARD, PhD, MBA, MSJS, vice president of quality at Northwestern Memorial HealthCare in Chicago has been named as the recipient of the Healthcare Administrator Award.

The award, which will be presented at APIC’s 45th Annual Conference in Minneapolis, recognizes the pivotal role that healthcare leaders play in establishing an organizational culture that enables and supports infection prevention and control (IPC) efforts. Through Barnard’s leadership, Northwestern Memorial HealthCare has developed a culture of safe patient care, ensuring quality infection prevention, and healthcare-associated infection reduction is a top priority. Her thoughtful and ongoing reviews of the IPC department have supported efforts for increased staffing and additional resources.

2017 JUDENE BARTLEY ADVOCACY IN ACTION SCHOLARSHIP Jessica Hayashi, MS, RN, CIC, CPHQ, FACHE Stratton Albany VA Medical Center 2018 JUDENE BARTLEY ADVOCACY IN ACTION SCHOLARSHIP Winner to be announced at the APIC 2018 Annual Conference APIC GRADUATE STUDENT AWARD Tara Millson, MSN, RN, CIC Mohawk Valley Health System Infection prevention in dialysis: The culture of safety and adherence to infection control standards

As Northwestern Memorial HealthCare has continued to grow, Barnard has ensured that the IPC program has remained robust and sustainable. Recently, she has advocated and implemented a standardized electronic surveillance system that ensures the growing health system has the technology for timely rounding and documentation. Her work has helped reduce central line-associated bloodstream infections (CLABSIs) by 25 percent, catheter-associated urinary tract infections (CAUTIs) by 40 percent, and vancomycin-resistant enterococci (VRE) transmission by 75 percent.

BLUE RIBBON ABSTRACT AWARDS Jeanette Harris, MS, MSM, BS, MT(ASCP), CIC, FAPIC MultiCare Health System Moving the science forward: A writers/research forum at the chapter level Kazumi Kawakami, PhD, MSN, RN, CNIC Juntendo University Factors influencing the competency of certified nurses in infection control (CNIC) in Japan Amy Priddy, DNP, RN, CIC Park Nicollet Health Services Measles! Responding to a community outbreak as part of an integrated health system

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BRIEFS TO KEEP YOU IN-THE-KNOW IMPLEMENTATION SCIENCE ABSTRACT AWARD Ayat Abuihmoud, MS, CIC Loyola University Medical Center Unit-based just-in-time coaching significantly improves hand hygiene compliance NEW INVESTIGATOR ABSTRACT AWARD Nancy Hogle, RN, BSN, MPH, MS New York Presbyterian Hospital Incidence of midline catheter-associated bloodstream infections in five acute care hospitals

BEST INTERNATIONAL ABSTRACT AWARD Shahana Parveen, MSS icddr,b Identifying acceptable and feasible infection control interventions for Nipah encephalitis outbreaks in Bangladesh WILLIAM A. RUTALA ABSTRACT AWARD Eman Chami, MHA, CIC Henry Ford Hospital Use of an electronic tool that drives quality improvement in endoscope reprocessing

HEROES OF INFECTION PREVENTION AWARDS Cindy Hou, DO, MA, MBA, FACOI Jefferson Health New Jersey Category: Patient Safety Marc Meyer, RPH, BPharm, CIC, FAPIC Southwest Health System Category: Advocacy and Influence Children’s Hospitals and Clinics of Minnesota Category: Process and System Improvement

Excela Health CDI Lean Team Category: Patient Safety Mountain View Hospital Category: Process and System Improvement University of Louisville Hospital Infection Control Team Category: Advocacy and Influence

APIC/AJIC AWARD FOR PUBLICATION EXCELLENCE Effectiveness of ultraviolet devices and hydrogen peroxide systems for terminal room decontamination: Focus on clinical trials Lead author: David Weber, MD, MPH University of North Carolina School of Medicine Coauthors: • William Rutala, PhD, MPH, MS, CIC • Deverick Anderson, MD, MPH • Luke Chen, MBBS, MPH • Emily Sickbert-Bennett, PhD, MS • John Boyce, MD CHAPTER EXCELLENCE AWARDS Education, Communications, and Information Resources Dallas-Fort Worth (Large Chapter) Heart of New York (Small Chapter) Clinical and Professional Practice Eastern Iowa (Small Chapter) Member Support Greater New York (Large Chapter) Intermountain Region (Small Chapter)

The Heroes program is supported by a grant from BD, an APIC Strategic Partner.

Synergistic Alliances Virginia (Large Chapter)

CHAPTER LEADERSHIP AWARDS Christine Blackmore, RN, MPH, CIC Greater New York Chapter

John Maynard, RN, MSN, CIC Mile High Chapter

Wilma Salkin, RN, BSN, CIC New England Chapter

Valyne Pochop, MS, RN, CIC Greater Kansas City Chapter

Kathleen Steinmann, MT(ASCP), CIC Minnesota Chapter

DeAnn Richards, RN, BSN, CIC Badger Chapter

Marie Hale Wilson, BSN, BS, RN, CIC Dallas-Fort Worth Chapter

Kissa Robinson, RN, BSN, MHA, MBA Washington, DC Metro Chapter

2018 FILM FESTIVAL GRAND PRIZE WINNER KP SRO Surgical Attire The Permanente Medical Group, Santa Rosa Directed by Meghann Brock

Angella Browne, MT(ASCP), MBA, CIC Washington, DC Metro Chapter Susan Engel, BSN Southern New Jersey Chapter Craig Gilliam, BSMT, CIC, FAPIC Memphis Chapter Crystal Heishman, MSN, RN, CIC, ONC, FAPIC Ketuckiana Chapter


Brenda Roup, PhD, RN, CIC, FAPIC, FSHEA Greater Baltimore Chapter


PGC Practice Corner THE APIC PRACTICE GUIDANCE COMMITTEE (PGC), as part of its charge, routinely reviews and comments on guidelines, standards, and draft documents that relate to infection prevention. The PGC Practice Corner is intended to update members on relevant issues. Hand hygiene—The Joint Commission says no more excuses Every infection preventionist knows that hand hygiene is the most effective horizontal infection prevention tool to reduce healthcareassociated infections in our arsenal. The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services certainly agree, as they have placed significant emphasis on compliance with hand hygiene. Since 2004, TJC has had a National Patient Safety Goal (NPSG) standard (NPSG.07.01.01) requiring healthcare organizations to demonstrate improvement in compliance with either the Centers for Disease Control and Prevention or World Health Organization hand hygiene guidelines. The original TJC goal was for organizations seeking accreditation to achieve and sustain 90 percent compliance. However, 90 percent hand hygiene compliance days are over. In December 2017, TJC released a memo stating that, beginning January 1, 2018, any observation by surveyors of a single failure of an individual to perform hand hygiene in the process of providing direct patient care would be cited as a deficiency that would result in a Requirement for Improvement (RFI) under the Infection Prevention and Control (IC) chapter for all accreditation programs (IC.02.01.01, element of performance 2).1 Let that sink in a bit … a single finding will result in an RFI. In its update, TJC stated, “While there are various causes for healthcare-associated infections, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of the patient should no longer be one of them.” Reference 1. The Joint Commission. Accreditation and standards: Effective Jan. 1, 2018: Individual hand hygiene failures to be cited under IC, NPSG standards. December 17, 2017. https://www.jointcommission. org/issues/article.aspx?Article=IlZJaLJCiRBZC2IRvnKkJTqEEU2n1Rxv3fqmsKqKPb0%3D. Accessed March 2018. Additional resources APIC. APIC guide to hand hygiene programs for infection prevention. 2015. https://apic.org/Resources/ Topic-specific-infection-prevention/hand-hygiene. Accessed March 2018.

To achieve the required level of improvement, healthcare organizations must do the following: 1. Have leadership commitment. 2. Create a multidisciplinary design-and-response team led by a senior administrator to emphasize that the organization is committed to hand hygiene compliance. 3. Develop an ongoing monitoring program that includes providing robust, near real-time compliance data to operational leaders throughout the organization. 4. Provide ongoing education and training for staff, patients, families, and visitors. 5. Reinforce hand hygiene behavior and accountability by removing barriers that prevent staff from holding each other accountable for lapses. 6. Ensure that hand hygiene resources are accessible throughout the organization, including in patient care corridors and at the entrances and exits of patient rooms. 7. Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug-resistant pathogens.

Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control Hosp Epidemiol 2014;35(s2):S155-S178.

APIC awards travel grants to international attendees IN A CONTINUING effort to offer international colleagues easier access to APIC education, APIC provided international travel grants

to 10 individuals to facilitate attendance at APIC’s Annual Conference in Minneapolis, MN. Congratulations and we hope you enjoy the conference! Jacinto Chipir, Guatemala Isaac Dolo, Liberia

Komi Habada, Chad Wail Hayajneh, Jordan

Loyce Kihungi, Kenya Jean Paul Mvukiyehe, Rwanda

Shahana Parveen, Bangladesh Sailesh Kumar Shrestha, Nepal

Yunfa Sovelo, Tanzania Ritha Tesha, Tanzania

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Get involved with APIC ACCORDING TO BARBARA LONG, CAE, senior

director of governance and executive affairs, “Volunteers are the lifeblood of APIC. They are actively and enthusiastically involved in every aspect of APIC educational programs, products, services, and advocacy, as well as the governance of APIC.” Simply put, APIC would not function without its volunteers. With more than 15,000 members, APIC relies on the expertise of its members to create a safer world through the prevention of infection. Volunteers help develop valuable products and services, and they advocate on behalf of the profession. APIC’s nurses, epidemiologists, public health professionals, microbiologists, doctors, and other health professionals work around the clock at their facilities and still find time to volunteer on committees and panels. Volunteering gives you an opportunity to use your expertise to help develop products and services that not only aid in your own professional development but also help you

“With more than 15,000 members, APIC relies on the expertise of its members to create a safer world through the prevention of infection.”


add value to your workplace and to patient care at the bedside. Contributing to APIC also helps you develop your leadership skills. APIC has nine committees and four panels to choose from. Each committee or panel has its own initiatives and projects. To learn more about specific committees, visit apic. org/About-APIC/Committees. Some committees are more visible than others. Notably, the Annual Conference Committee is responsible for planning and presenting the annual educational program. Additionally, the Professional Development Committee is responsible for promoting professional development of APIC members and diffusion of the APIC Competency Model. Did you know that the Communications Committee is the driving force behind those amazing consumer and healthcare resources on the Infection Prevention and You website? The Communications Committee has developed countless consumer alerts (apic.org/ For-Consumers/Monthly-alerts-for-consumers),

infographics ( professionals.site.apic.org/ infographic), and resources for International Infection Prevention Week (professionals.site. apic.org/iipw). These resources are free to print and share! On the next page of this magazine, you will find APIC’s most recent infographic (The ABCs of Prescribing Antibiotics for Healthcare Professionals) translated into Spanish. Tear it out and share it in your facility! APIC welcomes you to become involved in a leadership capacity on a committee or panel. If you are interested in volunteering on a committee or panel, please download and submit the application found on the “Volunteering with APIC” page (apic.org/ About-APIC/Volunteering). If you have questions, contact the membership department at [email protected]. If you are attending APIC 2018 Annual Conference, stop by APIC Central to speak directly with APIC’s membership department. We would love to meet you in person!

w w w.apic.org | 17


Consumer Alert: Hepatitis A APIC HAS PUBLISHED a consumer alert to

use as a resource for infection prevention and control education. Hepatitis A is a vaccine-preventable viral infection that causes inflammation of the liver. It is usually a mild illness, but in some instances, it can cause severe liver damage. To read and download this alert, and many others, visit our webpage: apic.org/For-Consumers/ Monthly-alerts-for-consumers. Read about how infection preventionists and the public health department managed the hepatitis A outbreak in California on page 70!

APIC, SHEA, and SIDP update position paper highlighting synergy of IPC and AS Infection prevention and control (IPC) and antibiotic stewardship (AS) programs are inextricably linked, according to a joint position paper published by APIC, the Society for Healthcare Epidemiology of America (SHEA), and the Society of Infectious Disease Pharmacists (SIDP) in the American Journal of Infection Control and Infection Control and Hospital Epidemiology. This paper is an important update to a 2012 paper that affirmed the key roles of infection preventionists and healthcare epidemiologists in promoting the effective use of antimicrobials in collaboration with other healthcare professionals. The new paper highlights the connections between IPC and AS programs, including the importance of a well-functioning IPC program as a central component to a successful AS strategy. To read this paper, visit http://www.ajicjournal.org/article/S01966553(18)30001-4/fulltext.

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INFECTION PREVENTION LEADERSHIP

Three Rivers Pittsburgh chapter past president A Conversation with Juliet Ferrelli, MS, MT(ASCP), CIC, FAPIC

JULIET FERRELLI has worked in infection pre-

vention for more than 15 years at several Pittsburgh hospitals; she is currently the network director at Allegheny Health Network. Juliet holds a master’s in clinical laboratory science and bachelor’s in medical technology. She has been an APIC member since 2002 and received her APIC Fellow designation in 2016. Prior to working in infection prevention, Juliet was an associate professor of hematology at Bismarck State College. She served as president of the Three Rivers Pittsburgh APIC chapter in 2012 and 2016, and is currently serving as the Three Rivers Pittsburgh APIC fall conference cochair for the third year.

How did you get involved in your local APIC chapter? I was introduced to my local APIC chapter when I first started out as an infection

preventionist. Years later, I was approached at one of our meetings to see if I would be interested in being a board member.

What are some challenges you faced as a chapter leader? One of the biggest challenges was getting active participation on the board of directors and committees. We are a smaller chapter, and, being in Pennsylvania with our increased demands for surveillance, it can be difficult to find members with the willingness to try and find the extra time.

What does leadership mean to you? To me, leadership means helping to guide and elevate others though teaching and mentorship. As a leader in infection prevention, I think it’s important that we are supportive of all who choose to go into this field and work hard to educate them in any way we can.

What is your leadership style?

“To me, leadership means helping to guide and elevate others though teaching and mentorship. As a leader in infection prevention, I think it’s important that we are supportive of all who choose to go into this field and work hard to educate them in any way we can.”

I like to think that I have a supportive leadership style that is built on trust. I try to be a good listener so that I’m able to relate better to the person’s style of learning. That way, I am able to mentor and teach in a more meaningful way.

How has your experience within APIC translated to your work as an infection preventionist? Being an active member in my local APIC chapter has continued to help me push and challenge myself through networking and tackling of new projects. I’ve led CIC® study groups, helped plan educational conferences, and worked on the development

of our website. I even had the opportunity to record an educational spot for the radio on Clostridium difficile prevention in the community. These opportunities have really helped me broaden my overall experiences and grow as a leader in my career.

What have you learned during your APIC volunteer experience that you have been able to apply to your career? I’ve learned that you need to be flexible and well organized. Things don’t always go as planned, so you need to be as prepared as you can be when they don’t. Staying organized has been critical in many of my duties as a chapter board member, and these skills have translated to my everyday work. In infection prevention, you never know what the day will bring when the phone rings—it’s one of the most challenging parts of our job, but also what makes it exciting.

What are some leadership lessons/ or advice you can share from your work and management experiences in infection prevention? Having had a lot of leadership and management experience in infection prevention, I think others need to understand that our work is about relationship-building. By taking a positive approach to our work, we can help educate colleagues on what is important and develop processes that can improve care for our patients. I have always said that we spend more time with the people we work with than we spend with our own families, so it’s important that we make each day meaningful and enjoy the work that we do. w w w.apic.org | 21

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APIC CONSULTANT CORNER

Outbreak investigation Q&A WITH GWEN BORLAUG, MPH, CIC, FAPIC

GWEN BORLAUG, MPH, CIC, FAPIC, recently retired from the Wisconsin Division of Public Health, where she served as the infection pre-

vention epidemiologist and manager of the HAI Prevention Program. She was involved in numerous outbreak investigations, including several incidents of carbapenem-resistant Enterobacteriaceae (CRE) transmission in healthcare settings, and was a member of the team that investigated the largest recorded Elizabethkingia outbreak. Prior to joining the Division of Public Health, Gwen was an infection preventionist (IP) in an acute care setting.

Q:

an you tell us about an C outbreak investigation you have conducted?

A:

A case of New Delhi metallo-betalactamase carbapenem-resistant Enterobacteriaceae (NDM CRE) occurred in a hospitalized patient from India. Approximately six weeks later, the same hospital reported a case of NDM CRE infection in a second patient who had no risk factors for NDM CRE infection. A molecular analysis determined that the isolates were genetically related, and a medical records review revealed the only epidemiological link was that both patients underwent endoscopic retrograde cholangiopancreatography with the same duodenoscope. The scope was removed from service, and exposed patients were tested, which led to the identification of four more patients with the same NDM CRE organism. Although no breaches in scope reprocessing procedures were identified, similar incidents occurred elsewhere at unrelated facilities, which underscored the need to address current scope design and reprocessing procedures.

Q:

hat are your thoughts on W the chief roles of a facility IP when conducting an outbreak investigation?

A:

Two key points come to mind. First, the IP is skilled in what is known as descriptive epidemiology—collecting the clinical and epidemiologic data critically necessary to describe the outbreak, or cluster

of events, in terms of person, place, and time. With these skills, the IP can collect, organize, and summarize data to share with the facility epidemiologist and others supporting the outbreak investigation. He or she ensures accurate and complete data collection and produces a useful summary and analysis to present to the outbreak investigation team. Second, the IP plays a crucial role in assessing the facility’s infection prevention practices, to identify gaps or breaches that may have led to the outbreak, and in developing the corrective action plan to control the outbreak.

Q:

hat are the primary elements W of an effective outbreak investigation?

A:

First, confirm the diagnosis and that an outbreak exists, and then formulate a case definition. Next, find additional cases and create a line list. Review the data to generate a hypothesis regarding outbreak sources and modes of transmission, and design studies to test the hypothesis. Finally, implement control measures, communicate findings to the outbreak team, and continue surveillance to ensure event incidence has returned to baseline.

Q:

hat are some of the best W ways that an IP consultant can support outbreak investigations?

A:

The IP consultant can support and coordinate the often-overwhelming task of data collection, surveillance, and

frequent updating of line lists and epi curves. The consultant can also serve as an objective observer for assessing infection prevention practices and exploring potential sources and modes of transmission.

Q:

hat tools and resources can W IPs use to develop effective outbreak investigation plans?

A:

Developing line listings, an epi curve, and patient notification templates will help facilities prepare for outbreaks. Data management systems should accommodate accurate, real-time collection and analysis of large data sets. Surge capacity of ancillary departments, such as the clinical laboratory, and increased supply needs, such as personal protective equipment, should be assessed. Outbreak management plans should have effective internal and external communication methods that include staff, patients, and visitors, as well as state and local department of health contacts. Resources Centers for Disease Control and Prevention. Line list template. January 2008. https://www.cdc.gov/urdo/downloads/linelisttemplate. pdf. Accessed February 2018. Centers for Disease Control and Prevention. n.d. Quick learn lesson: Create an epi curve. https://www.cdc.gov/training/QuickLearns/ CreateEpi. Accessed February 2018. Centers for Disease Control and Prevention. Patient notification toolkit. December 2013. https://www.cdc.gov/injectionsafety/pntoolkit/ index.html. Accessed February 2018.

To read more about the largest recorded Elizabethkingia outbreak, see page 62. w w w.apic.org | 23

Join us at the APIC 2018 Annual Conference for a Symposium on Prevention of HAIs The Importance of Decolonization Methods to Prevent Healthcare-associated Infections (HAIs) When: Wednesday, June 13, 2018 | 6:00 am-7:45 am Where: Minneapolis Convention Center, Room 205 A-D VISIT US AT BOOTH 721 Breakfast will be served. Register at www.medline.com/go/APIC2018 © 2018 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT1898464 / 15

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CAPITOL COMMENTS

BY RICH CAPPARELL, NANCY HAILPERN, AND LISA TOMLINSON

IN AN EFFORT to meet the goal put forward

in the APIC Strategic Plan 2020 to “support board certification in infection prevention and control (CIC®) to promote widespread adoption,” APIC launched its Certification: The Defining Difference campaign earlier this year. This initiative is a state-based effort to encourage infection preventionists (IPs) to become certified in infection control. The campaign kicked off with APIC staff heading to New York chapters to discuss the idea of legislation related to certification and was followed by the introduction of bills in the New York legislature.

APIC hits the road As part of this program, APIC staff provided a 20-minute presentation on key aspects of the legislation and took questions from New York chapter members regarding the potential legislation and certification. Focus groups were also held with volunteers to hear their thoughts about the bill and any of their outstanding concerns. Despite the efforts of Mother Nature (both Washington, D.C., and upstate New York received more than two feet of snow), APIC staff successfully visited five chapters during monthly chapter meetings

“This initiative is a state-based effort to encourage infection preventionists to become certified in infection control.”

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New York State Capitol Building

w w w.apic.org | 25

CAPITOL COMMENTS “The presentation focused on two key aspects of the bill: It would primarily affect incoming IPs, and it would involve only those working in acute care settings.”

throughout the spring. Members were gracious hosts and provided an open atmosphere for a give-and-take conversation about certification. The staff presentation reviewed the evidence supporting certification, the current number of certified IPs in the United States, and the criteria for what provisions are included in the legislation. The presentation focused on two key aspects of the bill: It would primarily affect incoming IPs, and it would involve only those working in acute care settings. After some in-depth conversations, most members recognized that this legislation would not directly affect IPs in current practice as much as it would set the

Legislative specifics To be employed by an acute care facility, an IP would be required to: – successfully pass an exam from a nationally accredited infection prevention and epidemiology accrediting organization, such as the Certification Board of Infection Control and Epidemiology, Inc.; or – provide evidence that he/she was employed or otherwise contracted as an IP in a healthcare facility for a cumulative period of one year, within the last four years prior to passage of the bill; or – be a student or intern performing the functions of an IP while serving under direct supervision of an IP. An IP not meeting certification requirements: ‒ will have three years from the date of hire to obtain an infection prevention and control credential. An acute care facility may employ or contract with an IP who does not meet the certification requirements if: – the facility is unable to hire a certified infection preventionist after a diligent and thorough search;* or – an IP earns his/her certification within three years of the start of employment. *Note: The facility is expected to keep appropriate records of their hiring efforts.


expectation for new entrants to the profession. Additionally, members practicing in acute care settings were receptive to this new direction for the profession and brought a number of great questions and concerns to the table. APIC public policy staff spoke with more than 100 New York members at these meetings. We cannot thank these chapters enough for making time available for this conversation and for their attention to this matter! Because not all New York APIC members were able to attend their chapter meetings, a conference call was held for members in the state interested in learning more about the proposal. Members who participated on the call were also receptive to the proposal and offered helpful suggestions. To find out more about the campaign, go to www.apic.org/getcertified.

New York legislative proposal The legislation being considered in New York was introduced in April 2018. The bills require acute care facilities to either hire IPs with infection prevention certification or hire IPs with the expectation that they will be certified within three years. IPs with more than one year of experience when the legislation passes will not be required to become certified, as they will be “grandfathered” into the current system. If hospitals are absolutely unable to find an IP meeting the criteria in the legislation, they are provided an avenue to hire an uncertified IP. This measure is still very early in the legislative process and could be amended. However, the legislation crafted in New York will be the starting point for APIC’s legislative efforts in other states.

Moving forward Legislation is not adopted overnight—it can take weeks, months, or even years to pass. The New York measure is this campaign’s first effort to promote state certification legislation. In the coming years, APIC will start the process of looking for other states that may be amenable to such legislation. It is important to emphasize that the goal of this campaign is not to change the criteria for currently practicing IPs, but to prepare future IPs for the challenges they will face in the field and to help clarify the important role they play in healthcare.

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PREVENTION IN ACTION

MY BUGABOO

A microbiological overview of

brucellosis BY IRENA KENNELEY, PhD, RN, CNE, CIC, FAPIC

GREETINGS FELLOW INFECTION PREVENTIONISTS! The science of infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available about microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated. Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the “bug parade”). However, too much information makes it difficult to tease out what is important and directly applicable to practice. This issue’s My Bugaboo column features information about the human pathogen Brucella. The intention is to convey succinct information to busy IPs about this cause of relevant recent outbreaks. Please feel free to contact the author with questions, suggestions, and comments at [email protected].

OVERVIEW

Brucella is an important zoonotic pathogen that occasionally causes human disease. It is a gram-negative coccobacillus that grows slowly in the laboratory (taking about a week or more to grow) and requires complex media.1 The Centers for Disease Control and Prevention (CDC) categorizes brucellosis as a Class B agent of bioterrorism.2 Brucella is named after Sir David Bruce, who first identified the organism as the cause of undulant fever. Currently, four species are known to be associated with brucellosis in humans: • B. abortus: In humans, this species causes a mild disease with pyogenic formation (pus). It is also associated with abortion in humans and animals. • B. melitensis: This species was discovered on the island of Malta, where the first outbreak was recognized by Bruce; 28 | SUMMER 2018 | Prevention

it causes severe, acute disease, often with complications. • B. suis: This pig (swine) pathogen causes chronic, pyogenic, destructive disease. • B. canis: This dog (canine) pathogen is associated with mild disease with pyogenic formation. After initial exposure, the organisms are phagocytosed by macrophages and monocytes and become intracellular parasites of the reticuloendothelial system. Phagocytes carry the bacteria to the spleen, liver, bone marrow, lymph nodes, and kidneys.1 EPIDEMIOLOGY

Brucellosis is a bacterial disease that affects many kinds of animals, including sheep, goats, cattle, deer, elk, pigs, and dogs. In humans, brucellosis can manifest with flu-like symptoms, such as fever, sweating, headaches, back pain, and generalized overall

weakness. Symptoms begin anywhere from 5 to 60 days after exposure.1,3 In serious cases, the central nervous system and the lining of the heart may be affected, and one form of the disease may cause long-lasting symptoms, such as recurrent fevers, joint pain, and fatigue. Brucella can also cause miscarriage and other pregnancy complications. Recent brucellosis outbreaks have occurred in the United States. In November 2017, the CDC reported that people in four states—Connecticut, New Jersey, New York, and Rhode Island—became infected with B. abortus from ingesting raw milk.3 TRANSMISSION/PORTALS OF ENTRY

Brucella may be spread from animals to people in three main ways: • Ingestion: Brucella bacteria in the raw milk of infected animals can spread

KATERYNA KON/SHUTTERSTOCK.COM

3D illustration of Brucella bacteria. These gram-negative pleomorphic bacteria can be transmitted by direct contact with infected animals or by ingesting contaminated milk.

to humans who ingest unpasteurized milk, ice cream, butter, and cheeses. Transmission can also occur by ingesting raw or undercooked meat from infected animals. This is one reason why pregnant women should not consume dairy products made with raw milk or eat undercooked meats. • I nhalation: Brucella bacteria spread quickly and easily in the air. Farmers, laboratory technicians, and slaughterhouse workers can inhale the bacteria. • Direct contact: Brucella in the blood, semen, or placenta of an infected animal can enter a person’s bloodstream through a cut or other wound. Regular interaction with pets and other animals, such as touching, brushing, or playing, does not cause infection, and people rarely get brucellosis from their pets or animals at a petting zoo. However, immunocompromised

individuals should avoid contact with dogs known to have the disease.1 Brucella is not transmitted from person to person except, rarely, via banked spermatozoa or sexual contact.4 INDIVIDUALS AT HIGHER RISK

Individuals who work with animals or come into contact with infected blood without barrier precautions are at higher risk of brucellosis.1,3 People at higher risk include: • Veterinarians • Dairy farmers • Ranchers • Slaughterhouse workers • Hunters • Microbiologists COMPLICATIONS

Brucellosis can affect the reproductive system, liver, heart, and central nervous system.

Chronic brucellosis can cause complications in just one organ, or systemically.1 Potential complications include: • Endocarditis: An infection of the heart’s inner lining, endocarditis is one of the most severe complications of brucellosis. If untreated, the heart valves can be damaged or destroyed, which is the primary cause of brucellosis-related deaths. • A rthritis: Joint infection produces pain, stiffness, and swelling in the joints, especially the knees, hips, ankles, wrists, and spine. Spondylitis, a specific type of inflammation of the joints between the vertebrae of the spine or between the spine and pelvis, can be particularly hard to treat and may cause lasting damage. • Inflammation and infection of the testicles (epididymo-orchitis): If infection of the epididymis occurs, it can spread to the testicles, causing severe swelling and pain. w w w.apic.org | 29


• Inflammation and infection of the liver and spleen (hepatosplenomegaly): Brucellosis causes these organs to enlarge. • C entral nervous system infections: Brucellosis complications can include life-threatening illnesses such as meningitis and encephalitis (inflammation of the brain). DIAGNOSIS

Table 1 summarizes the laboratory criteria for diagnosis. According to the CDC, a case may be considered probable if it is epidemiologically linked to a confirmed human or animal brucellosis case, or there is presumptive, but not definitive, laboratory evidence of infection.5 INFECTION PREVENTION AND TREATMENT

According to the CDC guidelines for isolation in healthcare settings, patients hospitalized with brucellosis need standard precautions. The CDC also recommends provision of antimicrobial prophylaxis to individuals subject to laboratory exposure (inhalation).3,5 If brucellosis is diagnosed, the recommended treatment is generally the antibiotics doxycycline and rifampin in combination for at least 6 to 8 weeks.6 To reduce the risk of getting brucellosis, the following precautions are recommended: • Avoid raw milk and unpasteurized dairy foods. As noted, a few outbreaks of brucellosis in the U.S. have been linked to raw dairy products from domestic farms. Unpasteurized milk, cheese, and ice cream from other countries should also be avoided. • Cook meat thoroughly. Meat should be cooked until it reaches an internal temperature of 145°F to 165°F (63°C to 74°C). When dining out, order beef and pork that is at least medium-well done. • Wear gloves. Standard Precautions are recommended for veterinarians, farmers,

“Recent brucellosis outbreaks have occurred in the United States. In November 2017, the CDC reported that people in four states—Connecticut, New Jersey, New York, and Rhode Island—became infected with B. abortus from ingesting raw milk.” hunters, and slaughterhouse workers, especially when handling sick or dead animals or animal tissue or when assisting an animal giving birth. • Take safety precautions in high-risk workplaces. Laboratory workers should handle all specimens under appropriate biosafety conditions. Lab personnel who have been exposed must be treated promptly. • Vaccinate domestic animals. In the U.S., brucellosis has nearly been eliminated due to aggressive vaccination programs of livestock. The brucellosis vaccine is a live vaccine; anyone who has a needle stick while vaccinating an animal should be treated.

References 1. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology, 8th ed. Philadelphia, PA: Elsevier, Mosby; 2016. 2. Centers for Disease Control and Prevention. Bioterrorism agents/ diseases by category. 2017. https://emergency.cdc.gov/ agent/agentlist-category.asp. Accessed March 2018. 3. Centers for Disease Control and Prevention. People in four states may be drinking contaminated raw milk: CDC and partners urge families at risk to see their doctor for antibiotics. November 2017. https://www.cdc.gov/media/releases/2017/ p1121-contaminated-raw-milk.html. Accessed March 2018. 4. Centers for Disease Control and Prevention. Guideline for Isolation Precautions: Preventing transmission of infectious agents in healthcare settings. 2007. https://www.cdc.gov/ infectioncontrol/pdf/guidelines/isolation-guidelines.pdf. Accessed March 2018. 5. Centers for Disease Control and Prevention. Brucellosis case definition. 2010. https://wwwn.cdc.gov/nndss/conditions/ brucellosis/case-definition/2010. Accessed March 2018. 6. Centers for Disease Control and Prevention. Brucellosis treatment. 2012. https://www.cdc.gov/brucellosis/treatment/index. html. Accessed April 2018. Additional resource

WHAT IPs NEED TO KNOW

Brucellosis has been a nationally notifiable disease since 1944. It is a Class B reportable disease, which means it must be reported to the local public health department where the patient resides by the close of the next business day after the case or suspected case presents and/or a positive laboratory result occurs. If the patient’s residence is unknown, report the confirmed or suspected case to the local public health department in which the reporting healthcare provider or laboratory is located.5 Irena Kenneley, PhD, RN, CNE, CIC, FAPIC, is a professor at Case Western Reserve University, Frances Payne Bolton School of Nursing in Cleveland, Ohio. She serves on the APIC Board of Directors and is a past member of the Prevention Strategist editorial panel.

Centers for Disease Control and Prevention. Brucellosis case report form. https://www.cdc.gov/brucellosis/pdf/case-report-form. pdf. Accessed March 2018.

READ MORE ABOUT BRUCELLOSIS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Temporal study of human brucellosis in china from 1978 to 2015. Ting Zhou, Tao Zhang, Yuanyuan Liu, et al. American Journal of Infection Control, Vol. 45, Issue 6, S151–S152. Dynamic relationship between human brucellosis and economic growth in China. Tao Zhang, Ting Zhou, Xingyu Zhang, et al. American Journal of Infection Control, Vol. 45, Issue 6, S148.

Table 1. Laboratory criteria for diagnosis5

Definitive • Culture and identification of Brucella spp. from clinical specimens • Evidence of a fourfold or greater rise in Brucella antibody titer between acute- and convalescent-phase serum specimens obtained greater than or equal to two weeks apart


Presumptive • Brucella total antibody titer of greater than or equal to 160 by standard tube agglutination test (SAT) or Brucella microagglutination test (BMAT) in one or more serum specimens obtained after onset of symptoms • Detection of Brucella DNA in a clinical specimen by PCR assay

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FROM DATA TO DECISIONS

Strength of association—

Relative risks and odds ratios

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BY DANIEL BRONSON-LOWE, PhD, CIC, FAPIC, AND CHRISTINA BRONSON-LOWE, PhD, CCC-SLP, CLD

WELCOME TO THE NINTH installment in a series examining statistical concepts relevant to the field of infection prevention. This article continues the discussion from the last three issues around the roles that ratios can play in making data more useful.

A

n infection preventionist (IP) meandering through the posters at a conference spots one with an intriguing title: “Clostridium difficile outbreak traced to radiology chair.” In this fictitious study, the

authors discovered that most of the cases in a C. difficile outbreak at their facility were patients who had been working with the speech-language pathologist (SLP). The SLP identified these patients as a subset of her caseload; all were referred for a modified barium swallow study (MBSS), were unable to stand for that procedure, and therefore used the dedicated MBSS chair. Further investigation determined that cleaning procedures for the chair had not been w w w.apic.org | 33


FROM DATA TO DECISIONS reviewed in several years and were not consistent with best practices used elsewhere in the facility. The research question posed by the authors was whether the chair had served as a means of transmitting C. difficile. Based on the poster title, the IP knows the conclusion they reached, but she wonders how strong the evidence was. She finds the following information on the poster:

“Epidemiological analysis is based on making comparisons. Measures of association compare two groups of people based on who within those groups got a particular disease and who had a specific exposure. This analysis gives us a better understanding of the exposure-disease connection.”

A case-control study was conducted. Cases were inpatients with healthcare facility-onset Clostridium difficile infections (CDIs). Controls were inpatients without CDI, randomly selected and matched on hospital length of stay. Use of the MBSS chair was associated with a statistically significantly increased risk of later acquiring CDI (OR, 13.5; 95% CI, 3.1-42.2; P 1: Risk of disease was higher in the group with exposure to the risk factor. There is a positive association between the risk factor and the disease. For both negative and positive associations, the distance from 1 shows the strength of the association; a greater distance implies a stronger association (Figure 2). RR allows the researchers to answer the question, “If someone is exposed to a specific risk factor, what is the risk they will get the disease of interest?” For example: • If RR = 0.5, individuals exposed to the risk factor were half as likely to get the disease as those who were not exposed. • If RR = 3, individuals exposed to the risk factor were three times more likely to

get the disease than those who were not exposed. RR speaks clearly to the connection between risk factor and disease, but it’s not always appropriate to use. To calculate RR, we need incidence proportions for both exposed and unexposed groups that accurately reflect how common or rare the disease is in the real world. If the incidence proportions in the study aren’t realistic, we have to use a different measure of association: OR. For instance, the CDI poster mentioned earlier described a case-control study. Unlike cohort studies, case-control studies are retrospective, and the two groups compared are those with disease and those without disease. The researchers decide how many people with and without disease are included in the study; therefore, any incidence proportion calculated will be representative of this artificial population, not the real world. For example, if a disease occurs in 1 person out of every 100, the real-world incidence proportion is 1%. If researchers compare 10 cases with that disease and 10 controls without it, the incidence proportion for their study population is 50%. That incidence proportion doesn’t represent reality, and so it can’t be used to calculate an accurate RR. ORs avoid this problem by comparing the two groups based on the likelihood—the odds—of the variable that the

“The researchers decide how many people with and without disease are included in the [case control] study; therefore, any incidence proportion calculated will be representative of this artificial population, not the real world.”

Figure 2. Interpretation of risk ratio

w w w.apic.org | 35


FROM DATA TO DECISIONS Figure 3. Case-control study and odds ratio

“With the OR, researchers can answer the question, ‘If someone has the disease of interest, what is the likelihood that they had been exposed to the risk factor?’”


researchers are not manipulating: exposure to the risk factor (Figure 3). OR is calculated as follows: OR =

Odds of exposure in group with disease (Cases) Odds of exposure in the group without disease (Controls)

Just like RR, OR values range from zero to infinity. ORs are interpreted as: • OR < 1: The odds of exposure are higher among the controls; individuals with disease are less likely to have been exposed to the risk factor. • OR = 1: The odds of exposure are the same for both groups; there does not seem to be an association between getting the disease and having been exposed to the risk factor. • OR > 1: The odds of exposure are higher among the cases; individuals with disease are more likely to have been exposed to the risk factor. Again, for both negative and positive associations, the greater the distance from 1, the stronger the association. With the OR, researchers can answer the question, “If someone has the disease of interest, what is the likelihood that they had been exposed to the risk factor?” Here are some examples: • If OR = 0.5, individuals with the disease were half as likely as individuals without the disease to have been exposed to the risk factor. • If OR = 3, individuals with the disease were three times more likely than individuals

without the disease to have been exposed to the risk factor. The IP reading the CDI poster can tell a casecontrol study design was used, so it makes sense that the authors calculated an OR. She can interpret the OR value to mean that patients with CDI were 13.5 times more likely to have been exposed to the MBSS chair before becoming ill than were patients who did not end up with CDI. That suggests there was a very strong association between the disease and the exposure. If you have any questions or comments, please feel free to contact us at [email protected]. Daniel Bronson-Lowe, PhD, CIC, FAPIC, has been an infection preventionist, an infectious disease epidemiologist, and a statistics lecturer. He has been an instructor for APIC’s “Basic Statistics for Infection Preventionists” Virtual Learning Lab and is a senior clinical manager with Baxter Healthcare Corporation. Christina Bronson-Lowe, PhD, CCC-SLP, CLD, is a speech-language pathologist who has worked in hospitals, inpatient and outpatient rehabilitation, skilled nursing facilities, and home healthcare. Additional resources Potts A. Chapter 13: Use of statistics in infection prevention. In: Grota P, et al., eds. APIC Text Online. APIC; 2014. Potts A. Chapter 2: Use of statistics in infection prevention. In: PogorzelskaMaziarz M, ed. Fundamental Statistics & Epidemiology in Infection Prevention. APIC; 2016. Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics, 3rd ed. 2012. http://www.cdc.gov/ophss/csels/dsepd/ SS1978/SS1978.pdf.

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Focus on long-term care and behavioral health outbreaks:

Identify the pathogen! BY STEVEN SCHWEON, RN, MPH, MSN, CIC, FSHEA, FAPIC

Hospital outbreaks are reported more often in the medical literature than occurrences in the long-term care (LTC) or behavioral health setting. By studying and learning from outbreaks in the LTC/behavioral health setting, infection preventionists (IPs) will glean additional knowledge and apply this information to hopefully prevent future infections, and infection clusters, in their facility. This quarterly column will assist the IP with heightening awareness of appropriate interventions for preventing an outbreak.

P

iednoir and colleagues reported that 29 LTC patients and 12 staff members developed keratoconjunctivitis (inflammation of the cornea and the conjunctiva) during an eight-week period.1 The outbreak occurred at a 57-bed facility, with 47 private and five semiprivate rooms. The facility is associated with a 2,500-bed university hospital in France. The resident attack rate was 51 percent. The staff attack rate was not known. All infected individuals recovered without sequelae. Based on your knowledge and experience, would you suspect the following pathogen to be: • Pneumococcus type 8, • Meningococcus type 8, • Adenovirus type 8, or • Varicella type 8?

Epidemiological and microbiological analysis determined that adenovirus type 8 was the pathogen responsible for the outbreak. The authors believed that the infection was transmitted from contact with the conjunctival discharge of infected patients through contaminated fingers, clothing, or environmental surfaces.1 Numerous interventions were implemented to prevent additional transmission. Standard precautions were emphasized, and the use of personal protective equipment, consisting of a gown, gloves, and protective eyewear for the healthcare worker, was promoted along with handwashing with a virucidal solution. Separation of infected patients from others was encouraged. All staff and visitors were educated about the disease, including transmission, symptoms, and the necessary

“According to the Centers for Disease Control and Prevention, there are more than 50 distinct types of adenoviruses that can cause infection in humans. Adenoviruses are the most common cause of epidemic keratoconjunctivitis.” 40 | SUMMER 2018 | Prevention

control measures. The dining rooms were closed, patients were isolated to the unit, and community activities and nonurgent visits were suspended. According to the Centers for Disease Control and Prevention (CDC), there are more than 50 distinct types of adenoviruses that can cause infection in humans.2 Adenoviruses are the most common cause of epidemic keratoconjunctivitis (EKC).3 Adenoviruses can be identified using antigen detection, polymerase chain reaction, virus isolation, and serology; typing is performed by molecular methods.4 Adenoviruses most commonly cause respiratory illnesses, including the common cold, pneumonia, croup, and bronchitis. Other types of adenoviral illnesses include gastroenteritis, conjunctivitis, cystitis, and neurological disease. Large adenoviral EKC outbreaks have been reported in eye clinics, hospitals, nursing homes, camps, military bases, and child care centers.5 Ophthalmic instruments, such as tonometers and slit lamps, and contaminated ophthalmic solutions can also contribute to

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infection transmission. Infected healthcare workers may be both a reservoir for infection and a means of transmission to other patients. Additionally, Rutala and colleagues found that 50 percent of infected patients had adenovirus type 8 on their hands.5 EKC symptoms usually appear within 14 days after exposure and commonly include a gritty feeling in the eyes, watery discharge, photophobia, and redness.6 Eye pain, fever, and preauricular lymphadenopathy may also occur.3 A person can be infectious from a few days before developing symptoms to approximately 14 days after symptom onset.6 Viral shedding can occur for several days to weeks after symptom resolution.6 The CDC notes that “adenoviruses are resistant to many common disinfectants and can remain infectious for long periods on environmental surfaces and medical instruments.” 7 Adenovirus has been recovered from plastic and metal surfaces for more than 30 days,5 and it can remain viable for prolonged periods on sinks and towels.3

TAKE-HOME MESSAGES • To prevent adenovirus infection outbreaks, the CDC recommends strictly following infection control practices and, depending on the infection location, initiating contact and/or droplet precautions. The CDC also recommends promptly responding to and reporting any increased number of cases to the appropriate department of health.7 • The authors who described the outbreak estimated the outbreak to have cost $29,527, and staff absenteeism was the costliest aspect. The estimate was based on the costs of direct medical, investigative, and prevention measures, as well as lost productivity.1 (Note that the article was published in 2002.) • Viral conjunctivitis can occur through droplet exposure when an individual with an upper respiratory tract infection coughs or sneezes. Infection can also result as the virus spreads from the body’s own mucous membranes, affecting the lungs, throat, nose, tear ducts, and conjunctiva.10 • To prevent and control outbreaks, eyedrop vials should be dedicated to single patients. Also, the frequency of environmental surface disinfection should be increased in outbreak situations.6

w w w.apic.org | 41


“The CDC recommends standard and contact precautions for acute viral (acute hemorrhagic) conjunctivitis for the duration of illness.”

Ophthalmology equipment must be cleaned and disinfected, per manufacturer’s instructions, between uses.8 Room surfaces and other high-touch areas should be cleaned and disinfected between patient encounters using an EPA-registered disinfectant with proven efficacy against adenovirus; a bleach solution is an effective disinfectant, but it may not be compatible with all medical equipment.8 The CDC recommends standard and contact precautions for acute viral (acute hemorrhagic) conjunctivitis for the duration of illness.9 Healthcare providers must perform proper hand hygiene before and after patient contact.8 There is no specific treatment for adenoviral conjunctivitis. Supportive management of symptoms and complications is recommended.7 Cool compresses and artificial tear solutions may provide relief. An adenovirus vaccine is not available for the general public. A live, oral vaccine against adenovirus types 4 and 7 is approved for U.S. military recruits entering basic training to prevent acute respiratory disease. Steven Schweon, RN, MPH, MSN, CIC, FSHEA, FAPIC, is an infection prevention consultant with a specialized interest in acute care/long-term care/behavioral health/ambulatory care infection challenges, including outbreaks.

References 1. Piednoir E, Bureau-Chalot F, Merle C, et al. Direct costs associated with a nosocomial outbreak of adenoviral conjunctivitis infection in a longer-term care institution. Am J Infect Control 2002;30:407-410. 2. Centers for Disease Control and Prevention. Adenoviruses. Clinical overview. May 2017. https://www.cdc.gov/adenovirus/hcp/clinical-overview.html. Accessed February 2018. 3. Munoz FM, Flomenberg P. Diagnosis, treatment, and prevention of adenovirus infection. UpToDate. https://www.uptodate.com/contents/diagnosis-treatment-andprevention-of-adenovirus-infection. Accessed February 2018. 4. Centers for Disease Control and Prevention. Adenoviruses. Diagnosis. May 2017. https:// www.cdc.gov/adenovirus/hcp/diagnosis.html. Accessed February 2018. 5. Rutala WA, Peacock JE, Gergen MF, et al. Efficacy of hospital germicides against adenovirus 8, a common cause of epidemic keratoconjunctivitis in health care facilities. Antimicrob Agents Chemother 2006;50(4):1419–1424. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC1426955. Accessed February 2018. 6. Centers for Disease Control and Prevention. Adenovirus-associated epidemic keratoconjunctivitis outbreaks—four states, 2008-2010. MMWR 2013;62(32):637-641. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6232a1.htm. Accessed February 2018. 7. Centers for Disease Control and Prevention. Adenoviruses.Prevention and treatment. May 2017. https://www.cdc.gov/adenovirus/hcp/prevention-treatment.html. Accessed February 2018. 8. West Virginia Department of Health and Human Services. Health advisory: Outbreak of epidemic keratoconjunctivitis due to adenovirus Kanawha County area. September 2015. http://dhhr.wv.gov/oeps/disease/documents/hans/wv%20hans/ wv104-outbreak-keratoconjunctivitis-from-adenovirus.pdf. Accessed February 2018. 9. Siegel JD, Rhinehart E, Jackson M, et al. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www. cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf. Accessed February 2018. 10. American Optometric Association. Conjunctivitis. n.d. https://www.aoa.org/ patients-and-public/eye-and-vision-problems/glossary-of-eye-and-visionconditions/conjunctivitis. Accessed February 2018.

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INFECTION PREVENTION AND EMERGENCY PREPAREDNESS DURING THE 2017 NORTHERN CALIFORNIA WILDFIRES BY GIANNA PERALTA, MPH

W

VINCENT PIOMBO

hen you work as an infection preventionist (IP), you are always on the alert for unusual events that may affect patient safety or disrupt the delivery of healthcare. But some events are more unusual than others. On Sunday, October 8, 2017, the strong smell of smoke awakened me in the early hours of the morning. I sensed immediately that something was wrong, but I could never have imagined the extent of what was to come. I checked social media and learned that a fire had started in north Napa County, California, and was growing quickly. Soon, concerned and confused friends and family were texting me. Knowing that the authorities were alert and working on containment, I eventually fell back to sleep, but with a lingering feeling of unease.

Smoke from the fires creeps over a Napa vineyard. 44 | SUMMER 2018 | Prevention

Later that morning, when I arrived at St. Joseph Health Queen of the Valley, where I work as an infection prevention specialist, our facility’s incident command center was already up and running. To everyone’s great dismay, the fire was still spreading rapidly, fueled by the drought-stricken environment. Even indoors, there was no relief from the smoke, which permeated every nook and cranny of the hospital. The view from my office window was apocalyptic—a thick layer of smoke made the city look monochrome, and the mountains surrounding our beautiful Napa Valley had vanished from sight. Hospital operations became increasingly more complicated when the cellular network went down. Ensuring adequate staffing became an immediate concern. Without cell service, our facility struggled to reach out to providers and other staff. We issued a call to action on the hospital’s Facebook page, which fortunately went viral, and we quickly received an overwhelming response.

Photo of a Napa house that burned to the ground.

VINCENT PIOMBO

Staff showed up, even though the fires were uncontained and their friends and family were at risk. Some came to work knowing their homes might be destroyed by the fire before the end of their shifts. I will never forget my own panic upon hearing that the houses of my mother and grandparents were in an advisory zone, and that we would need to be packed and ready to leave in case of a mandatory evacuation. It becomes almost impossible to fathom what possessions you would take, and what you could bear to leave behind. In Sonoma and Napa counties, 97 St. Joseph Health caregivers and 51 physicians lost their homes. During the first few days of the fires, the air quality was extremely hazardous and residents of Napa Valley were warned to avoid going outside unless absolutely necessary. I started wearing an N95 mask when walking to and from my car, and sometimes even when indoors. As you might imagine, workflow at this time was anything but normal. As an IP, I assumed a supportive role

VINCENT PIOMBO

Smoke rising over the mountains to the east of Napa. w w w.apic.org | 45

VINCENT PIOMBO


to address the concerns of staff and support the incident command center. Some of the major actions taken included the following: • Patient monitoring: We reminded staff to notify physicians if their patients experienced any respiratory distress or discomfort. • Masking: We made a point to visit every department to ensure that they had an adequate supply of N95 masks, and to verify that they were being worn appropriately. This experience was an important reminder to staff regarding the importance of fit-testing. • A ir scrubbers: Despite our best efforts, smoke was seeping into the building, causing respiratory difficulty for staff and patients. We worked with engineering to bring in as many air scrubbers as we could buy or borrow. At the peak of this crisis, our facility had more than 120 scrubbers throughout the hospital. The results were almost immediate. Reports of respiratory distress declined, and staff were pleased to have clean air in their work environment once more. 46 | SUMMER 2018 | Prevention

• Closed doors: Keeping doors closed may seem like an obvious way to slow the spread of smoke, but this strategy was complicated by the fact that many doors are automatic and stay open for a predefined period of time. We kept the doors closed whenever possible and asked engineering to block off some entrances with plastic barriers to limit traffic. • Instrument sterility: In addition to the smoke, ashes from the fires also infiltrated the hospital, including sterile processing. Infection prevention instructed that department to make sure all bags of processed instruments were wiped down before being stored in surgery, where they were then wiped down a second time before use. This experience provided a strong case for later purchasing shelf covers for the sterile processing department. Several weeks passed before the fires were fully contained. During this time, I was humbled and amazed by the dedication and selflessness of our staff, who put the care of our patients first. And, of course, we owed a huge thank you to the first responders

ANGELA GRAF

View from across the Napa River of smoke coming off the nearby mountains.

View from Queen of the Valley staff parking lot during mid-day.

who put their lives on the line. In a time of great tragedy, the Napa community pulled together in a display of unity and strength, and I was reminded why I am so proud to call this place my home. It is a privilege to serve at Queen of the Valley, where I can continue to help the Napa community through my practice as an IP. We are, and will forever be, #NapaStrong. Gianna Peralta, MPH, is the infection prevention specialist at Queen of the Valley Medical Center in Napa, California. She previously served as a CDC/ CSTE Applied Epidemiology Fellow in infectious diseases in Atlanta, Georgia.

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TOOLS FOR THE TRADE:

Weathering hurricanes

BY ALEYA BYRD, RN, BSH, CHES, CIC; TED JONES, RN, CIC; LAUREN HOLLOWAY, MSN, RN, CIC; KARENA VON DOEHREN, RN, BSN, CPN; ROBYN KAY, MPH, CIC, FAPIC; AND CHRISTINE BAILEY, RN, BSN, MSH, CIC, FAPIC

L

ike other healthcare facilities located near coastlines or in flood zones, the hospitals of the Baptist Health System of Jacksonville, Florida, are in vulnerable locations, especially during hurricane season. Because a hospital evacuation significantly affects the entire health system, as well as the community in which we operate, we plan ahead to ensure safety before, during, and after a storm. The effectiveness of this planning was tested in September 2017, as Hurricane Irma passed through the Caribbean and targeted northeast Florida.

BEFORE THE STORM

Advances in weather forecasting mean that we can now anticipate when a hurricane might strike, but the history of hurricanes demonstrates how unpredictable such storms can be. When preparing for and enduring a hurricane, healthcare organizations must be cognizant of the needs of team members and their families, acquire the proper resources, manage the financial impact, and keep patients safe. Appropriate planning ensures that critical infection control variables are addressed. However, if planning is inadequate, the risk for infection increases, the financial costs for the health system are harder to control, and the community may be left without necessary healthcare resources after the storm. As the Baptist Health System began its preparations for Hurricane Irma, two of the five hospitals in the health system received special consideration: Baptist Medical Center Nassau (BMCN) and Baptist Medical Center Beaches (BMCB). 48 | SUMMER 2018 | Prevention

A 62-bed hospital with 430 employees, BMCN has more than 41,000 outpatient visits and more than 28,000 emergency visits annually. BMCB is a 146-bed hospital with 756 employees that provides inpatient and outpatient services and has more than 35,000 emergency department visits a year. Both facilities are located within one mile of the Atlantic Ocean, and we anticipated that they were likely to be subject to extreme flood and wind damage during the hurricane. Therefore, both hospitals, which serve as the largest healthcare facilities for their respective communities, had to be ready to evacuate and then reopen as quickly as possible. The infection prevention teams for BMCN and BMCB began preparing for this specific storm four days before the anticipated arrival of tropical force winds and evacuation orders. Based on lessons learned during previous storms, such as Hurricane Matthew in 2016, a team of our clinical and nurse epidemiologists had already created a facility

evacuation and re-entry action plan to use during hurricanes. This working document contains a list of the key personnel from various departments (surgical services, food services, public health, and so on). The tool for re-entry also lists key actions that might need to be addressed, depending on what happens during the hurricane. For example, if water is shut off, the tool would guide the team through the actions to be taken prior to occupancy. Steps are also included to evaluate the use of sterile items, food safety, and other critical safety matters. In preparation for Hurricane Irma, the hospitals updated the existing evacuation and re-entry tool to reflect current contact information for employees in key departments, as well as county and state agencies that would need to be notified before the hospitals could reopen after the storm. Accurate contact information for employees is crucial whenever the healthcare system activates its emergency plan. Some employees may be required to remain onsite, and

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BAPTIST HEALTH SYSTEM STAFF

w w w.apic.org | 49



others will be expected to report to the hospital to relieve the emergency team. Employees who do not remain onsite during the storm could be far from their homes and workplaces, or they could be hindered from returning to work by blocked roadways or power outages. To ensure that the hospital can be operational in an emergency, we need to know where these employees are and how to reach them. As BMCN and BMCB readied themselves for the possibility of evacuation, Wolfson Children’s Hospital (a 213-bed pediatric hospital), BMC-Jacksonville (a 477-bed hospital located in downtown Jacksonville), and BMC-South (a 245-bed hospital) prepared to remain operational during the hurricane. During this time, the infection prevention teams for all five campuses were sharing resources and pre- and post-storm strategies. Reportable conditions in the state of Florida, such as carbon monoxide poisoning due to improper generator and food poisoning due to inadequate temperature control, were topics of concern. The infection prevention team rounded with staff in patient care areas to address infection control issues, and an infection preventionist was designated to remain at the largest campus to oversee the systemwide infection prevention response to the hurricane. The team collaborated to anticipate issues that could arise during the storm and developed a hurricane resource manual. This manual was prepared in the four days prior to the storm to complement the re-entry 50 | SUMMER 2018 | Prevention

checklist that had been created earlier. Because we already knew where to find many of the resources that were included in the manual, team members could work swiftly to obtain and share evidence-based resources and create guided scenarios based on different projections about the severity of the storm’s impact. Aware that engineering controls could fail, the team gave priority to environmental controls (such as masking, spatial separation, HEPA filters in high-risk locations, and boil-water notices) in an effort to reduce the risk of disease transmission. Critical discussions with surgical services and the supply chain department focused on maintenance of medical devices and supplies, as well as staging of these items in locations that would be at lower risk for storm damage. Planning for limited computer access, we distributed a hard-copy compilation of resources related to reopening after a hurricane, as well as how to function and reduce the risk to patients during the storm. The resources we compiled included an APIC report on the role of the infection preventionist in emergency management,1 a list of reportable diseases,2 and several advisories from the Centers for Disease Control and Prevention (CDC).3 Emergency guidance was also included for triage, public isolation signs, water disruption and decontamination methods, tanker water use for dialysis, and well water disinfection. We also provided hand hygiene recommendations, based on previously published guidelines

from both the CDC and the World Health Organization (WHO), that encourage the use of alternate resources such as waterless surgical scrub. Copies of these documents were provided to nursing leadership and the incident command center. As we prepared, we sought to understand how our healthcare facilities might be vulnerable to the effects of water intrusion. A strong relationship with the leaders of the facilities department is critical to the success of this part of the emergency preparedness plan. The team met with those leaders to discuss scoring of potential infection control risk assessments for water intrusion and kept a log of historical leaks from a prior storm to help map our higher-risk areas. DURING THE STORM

When Irma neared, the two coastal hospitals, BMCN and BMCB, were evacuated with 87 patients relocated to other hospitals within the health system. The location of one of the generators for the downtown campus, BMC-Jacksonville, forced the relocation of 40 babies from the neonatal intensive care unit to a different location in the pediatric hospital. In addition to the patient movement that took place within our health system, we also received patient transfers from other coastal hospitals. The downtown campus is located along the St. Johns River, and water breeched the basement of one of the buildings. Prior to the hurricane’s landfall, the hospital pharmacy, located in the basement, was relocated. The infection prevention team’s planning prior to the storm helped to guide the implementation of barriers for the water intrusion that occurred. From this experience, we have learned to pay special attention to our preplanning for certain outpatient facilities, based on their locations and building designs. In these locations, the storage of items that require temperature and humidity control, such as surgical medical devices or supplies, should be relocated to safeguard their integrity. AFTER THE STORM

We used our facility evacuation and reentry tool to assess and address infection control–related elements prior to reopening the two hospitals that were evacuated. The plant facility departments were contacted first

to determine whether water, sewer, or HVAC systems had been disrupted during the storm. Fortunately, no disruptions occurred. The day after the hurricane passed, both of the hospitals that were evacuated received authorization from the state to reopen their emergency departments. Coordination between the health system and the emergency medical services allowed for patients to be transferred back to the original health facility as ambulances became available. Several outpatient centers experienced flooding. One of our surgical centers just reopened in March 2018. REFLECTIONS ON OUR PLANNING AND PREPAREDNESS


The assessment tool that we prepared with contact information for the Florida Department of Health, the Environmental Protection Agency, and municipal agencies for recommendations for remediation after a disruption was instrumental in the days prior to and following Hurricane Irma. The tool was also helpful because it clearly outlined for the incident command team specific criteria for water temperatures, chlorine levels, and water pressure for water or sewer service disruption. Our original tool was created prior to Hurricane Matthew in 2016. Since then, we have added additional criteria, including air temperature and humidity levels for the operating rooms as well as parameters for when food items must be discarded. Readily

accessible information leads to improved workflow. The checklist in the tool addresses the need to service mechanical systems such as cooling towers, ice machines, air filters, freezers, and refrigerators. Environmental issues such as water leaks, standing water, and building damage are also addressed. Elements within the tool can be modified as standards and other criteria change. For example, during re-entry after Hurricane Matthew, we learned that endoscopes should be assessed to ensure that no scope exceeds the recommended reprocessing time in accordance with the hospital policy. Initial tasks after a disaster include assessing the damage, with critical departments and patient care areas being the first priority. Verification to ensure sterile items are safe for use is paramount. Being prepared for evacuations and reentry takes advance planning. During Irma, BMCN and BMCB used lessons from past hurricane experiences to create and deploy their facility evacuation and re-entry tool. The use of this tool ensures that critical infection control elements are addressed during an emergency, which increases staff and patient safety while allowing the infection prevention team to perform in an efficient and effective manner. Many elements of the document are standard, but they can be customized for individual facilities based on the scope of services provided. Understanding your hospital’s vulnerabilities and risks is important to guide planning efforts. When preparing for an emergency, we recommend that you gather resources from the CDC and APIC; develop a relationship with the county health department; and modify existing checklists for your facility. With proper planning, infection control risks during and after a hurricane can be minimized. Aleya Byrd, RN, BSH, CHES, CIC, is a nurse epidemiologist in the infection control department for Baptist Health System. Her primary area of focus is Wolfson Children’s Hospital. She is the treasurer for APIC Chapter 50 and serves on the National APIC Education Committee. Lauren Holloway, MSN, RN, CIC, is a nurse epidemiologist in the infection control department for Baptist Health System. Her primary area of focus is neurosciences and oncology.

Karena von Doehren, RN, BSN, CPN, is a nurse epidemiologist in the infection control department for Baptist Health System. Her primary area of focus is Wolfson Children’s Hospital. She is the bylaws representative for APIC Chapter 50. Robyn Kay, MPH, CIC, FAPIC, is a clinical epidemiologist at Baptist Medical Center Jacksonville. She served as the 2017 Chapter 50 APIC president. Christine Bailey, RN, BSN, MSH, CIC, FAPIC, is a Baptist Health nurse epidemiologist and has provided care at Wolfson Children’s Hospital since 2005. Her focus areas include pediatric intensive care, neurology, gastroenterology, cardiology, and surgery. An active member of APIC Chapter 50, she served as the 2016 chapter president.

Acknowledgments: The authors wish to acknowledge the assistance of Shelia Crews, Michelle Maynard, Kathy Murray, Linda Pearce, Ginger Marti Phelps, Becky Saltford, Jeffrey Shanholtzer, Dawn Smith, Patricia Starling, and Karla Walsh. References 1. Rebmann, T, et al. APIC state-of-the-art report: The role of the infection preventionist in emergency management. Am J Infect Control 2009;37:271-281. 2. Florida Department of Health. Reportable Diseases/Conditions in Florida Practitioner List. http://duval.floridahealth.gov/ programs-and-services/infectious-disease-services/ epidemiology/_documents/disease-reporting-listpractitioners-duval-county.pdf. Accessed March 2018. 3. Centers for Disease Control and Prevention. Natural Disasters and Severe Weather. https://www.cdc.gov/disasters/index. html. Accessed March 2018.

READ MORE ABOUT HURRICANES IN AMERICAN JOURNAL OF INFECTION CONTROL Infection prevention at a medical needs shelter for hurricane evacuees. Robin Haag, Renee B. HembreeBey, Marian Mondiello, et al. American Journal of Infection Control, Vol. 41, Issue 6, S3. A needs assessment of infection control training for American Red Cross personnel working in shelters. Jocelyn J. Herstein, Janice Springer, Jono Anzalone, et al. American Journal of Infection Control, Vol. 46, Issue 4, p471-473.

w w w.apic.org | 51


PREVENTING SECONDARY CASES OF

measles in an acute care hospital BY MARY ELLEN SCALES, RN, MSN, CIC, FAPIC

R

ubeola (measles) is a highly contagious infectious disease. Although it is preventable with the measlesmumps-rubella (MMR) vaccine, our Massachusetts healthcare community includes areas where immunization rates are the lowest in the state. Therefore, when we were presented with a confirmed case of measles a few years ago, it placed underimmunized persons of all ages at risk for infection, and a coordinated effort to prevent secondary cases was needed.

IDENTIFYING THE RISK

Measles occurs most frequently in the late winter and spring in temperate climates. In early April of 2017, a middle-aged woman wearing a surgical mask presented to our urban, 759-bed hospital emergency department (ED) with classic signs and symptoms of measles. She had recently traveled internationally and had not previously received MMR immunization. Many residents of the valley where this person lived and worked are underimmunized by choice, relying on neighboring immunized communities to offer some protection from vaccine-preventable illnesses. During the initial consult, an adult infectious disease physician identified the risk for measles and recommended testing and airborne and contact isolation. Because the patient was wearing a surgical mask, the care providers in the ED decided that the current, regular-airflow room would be adequate. However, when the patient removed her mask, supportive care, including passive and active immunization for those exposed and susceptible to infection, was needed. Measles is transmitted via infectious droplets and airborne as droplet nuclei for up to two hours after a contagious person passes through an area, which makes contact investigation tracing and containment 52 | SUMMER 2018 | Prevention

challenging. In this case, there was risk for exposure in the ED as well as the inpatient location where the patient was transferred. Using guidance from the state department of public health, we determined that 389 patients, 460 employees, and numerous visitors, family, friends, and volunteers were considered to be at risk. PREVENTION EFFORTS

Coordinated prevention efforts included various multifactorial tactics. Our initial contact was with the state department of public health. For the week that followed, we were in daily contact with department officials and requested their guidance as specific patient and population issues arose. They recommended regional vaccine clinics, which were held during the two days after our infection control program was notified (on a Saturday and Sunday). The public health department provided vaccine for the clinics and directions for patient screening and management. We faced many unique issues during the clinics. For example, we needed medical taxis to transport community-discharged patients to and from the clinic. Some patients and their families

did not have phones, and, in those cases, representatives of the local board of health had to go to their homes to notify them and provide instructions on next steps for those exposed. Some families had generations of underimmunized individuals living in the same house, all needing follow-up. Additionally, some of our clinic patients had never been patients in our system, and record-keeping became a challenge for the clinic. We also identified immunocompromised ED visitors who needed immunoglobulin infusion and were advised to go to

KEY LESSONS LEARNED ➔ S urrounding healthcare facilities should be notified when a measles case is identified. ➔ Ensuring adequate supplies of the vaccine and intravenous immunoglobin was challenging. ➔ T riage for signs and symptoms was difficult because few healthcare providers in this generation have seen a case of measles.

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our infusion suite for access and infusion. Furthermore, we had to ensure that we had adequate supplies for the clinics. At this facility, the pharmacy coordinates immunoglobulin ordering, delivery, and storage, and we also needed vitamin A supplies to decrease risks associated with severe reactions to the measles. To expand our capacity to accomplish the required tasks, we activated our emergency management system, including engaging the administrator on call. A call room was established, and approximately 45 healthcare leaders responded on this Saturday in early April. Our established call center staff and infection preventionists made telephone contact with exposed patients and notified community physicians via fax and telephone. Employee health services (EHS) followed up with exposed employees once their health records were reviewed for immune status. Our reference lab did not have the capacity for the quick turnaround we needed, so we had to send tests to a nearby commercial lab. Measles IgG testing was done for 140 employees, 14 inpatients, and 60 outpatients (visitors and family members). Thorough chart review of the ED where the patient first reported helped us to identify the exposed population. The flagging functionality in our electronic health record system was used to identify 158 exposed ED patients for readmission, isolation, immunity testing, and immunization. Medical documentation for inpatients was reviewed for immunosuppression,

immunization status, and exposure risk. At-risk patients were isolated and treated as warranted with intravenous or intramuscular immunoglobulin. Immunoglobulin was also administered, when appropriate, to other susceptible persons, including one employee as well as visitors and family members. Internal and external communication supported the community notification processes as well as internal triage and screening. Our outreach included press releases, news articles, healthcare facility leaflets and posters, and email alerts to providers and healthcare workers. Screening tools and educational materials were developed and circulated to ambulatory clinics to support knowledge and triage of individuals worried about measles exposure or with signs and symptoms of measles. Faxes to primary care providers included public health fact sheets on measles, patient-specific information on exposure, and how patients could get reimbursed for routine charges incurred for assessment and treatment. Healthcare workers in the health system are required to receive two doses of the MMR vaccine. However, we found that many long-term employees had received only one MMR. We had more hard-copy employee medical records than electronic ones, so checking the immunization status of workers was burdensome. Once nonimmune healthcare workers were identified, employee immunization followed. Employee personal information was handled confidentially, and, if an employee could not take a second dose

of MMR, next steps were discussed with EHS and the hospital epidemiologist. A week later, our aggressive response was tapered. No secondary cases were identified. Mary Ellen Scales, RN, MSN, CIC, FAPIC, is the chief infection control officer for a four-hospital system. She has 42 years of nursing experience, including 26 years of progressive infection control roles and responsibilities. Additional resource Centers for Disease Control and Prevention. Measles (rubeola). February 2018. https://www.cdc.gov/measles/index.html. Accessed March 2018.

READ MORE ABOUT MEASLES IN THE AMERICAN JOURNAL OF INFECTION CONTROL Increased reports of measles in a low endemic region during a rubella outbreak in adult populations. Takako Kurata, Daiki Kanbayashi, Hiroshi Nishimura, et al. American Journal of Infection Control, Vol. 43, Issue 6, p653-655. Immunity of nursing students to measles, mumps, rubella, and varicella in Yozgat, Turkey. Çigdem Kader, Ayse Erbay, Nazan Kılıç Akça, et al. American Journal of Infection Control, Vol. 44, Issue 1, e5-e7. In-flight transmission of measles: Time to update the guidelines? Lyn-li Lim, Su Ann Ho, Mary O’Reilly, American Journal of Infection Control, Vol. 44, Issue 8, p958-959.

w w w.apic.org | 53


LESSONS LEARNED FROM A

hospital scabies outbreak BY STACY DEMOSS, RN, MSN, CIC

O

n the afternoon of September 14, 2009 (a Tuesday), the infection prevention office at Mercy Medical Center, a 445-bed acute care facility in Cedar Rapids, Iowa, received a phone call from a skilled nursing unit about several staff members with complaints of a rash. This call started a chain of events that would, in the end, affect almost 1,500 people (patients, hospital staff, and family members). Four symptomatic staff members were not immediately available for interview, but three others were interviewed that afternoon. One of the interviewees had classic signs of scabies. The infectious disease physician was notified of the rash cluster, and human resources gave permission to send one of the symptomatic employees to the emergency department for physician diagnosis. That employee was diagnosed with scabies and sent home, and the infection preventionist (IP) was given the names of three possible source patients. IDENTIFYING AND TREATING THE SOURCE PATIENT

Two of the potential source patients were ruled out on examination. The third was a patient currently on the oncology unit of the hospital in palliative care. Upon entry to the patient room, the IP was immediately concerned that the patient might have Norwegian (crusted) scabies, a relatively rare infection. The IP had never seen a patient with Norwegian scabies, but she recognized the classic scaly, crusted sores on the patient’s hands from pictures that were presented during an APIC conference seminar she had attended. The patient was placed on contact isolation, and then a fingernail scraping was collected and taken to the microbiology lab, where scabies mites were identified under a microscope. The source patient had been seen in the wound center in July and August 2009 and was admitted on August 18 to a general medical floor. The patient had been 54 | SUMMER 2018 | Prevention

diagnosed with psoriasis a few years earlier by a dermatologist, and the nursing staff, although uncomfortable with her skin condition, were not highly concerned. Exfoliating skin treatments were started on September 3, and the patient was transferred to a skilled nursing unit. On September 9, the patient was transferred to the oncology floor for palliative care after a change in condition. Thus, the patient had been in the hospital for almost a month before infection prevention was notified and contact isolation precautions were put into place. Once Norwegian scabies was identified, we initiated our incident command system because of the length of time that this patient was not in isolation, as well as the number of floors and hospital departments that we knew were going to be affected. The concept of an incident command system was fairly new to our organization, but we knew the system had worked well the year before, when our hospital campus was affected by

flooding. We immediately brought representatives from marketing, human resources, pharmacy, nursing leadership, and administration to the table and started to work through the logistics of treating our staff and patients as well as communicating what was unfolding. The patient was transferred back to a medical floor, and treatment was started. The patient was losing large amounts of the “crusting” that had developed, so we dedicated two rooms for care and transferred the patient back and forth. Using two rooms allowed for us to keep isolation precautions in place while thoroughly cleaning the rooms. We initially took for granted that our environmental services staff would be comfortable being in these rooms; however, the staff expressed some hesitation and anxiety. In response, we provided additional education to them about precautions in place and their risks of becoming infested.

CDC/SUSAN LINDSLEY

IMPLEMENTING INCIDENT COMMAND

By using our incident command system, we effectively addressed the multiple challenges that arose from this outbreak. We knew we were going to be dealing with an overwhelming number of staff members and patients, and we concluded we did not have the resources to conduct physical examinations of all the staff involved to determine who might be infected. Instead, we would treat all who reported symptoms or exposure, without confirming infestation. One of our earliest decisions was to allow all nursing staff to continue working while wearing isolation gowns and gloves during all patient care. Because so many members of the nursing staff were reporting symptoms consistent with scabies, we could not furlough them all and still provide safe care for our patients. The incident command system helped us mobilize a hospital-wide response. Marketing and the public information officer worked on education and communication for staff and patient notifications. Letters were sent to all the patients who were housed in the three affected inpatient

units and their providers. Marketing and the public information officer also prepared for media outreach. Because the local health department was made aware of the outbreak, we anticipated that media would soon find out about it. Pharmacy procured permethrin to treat exposed staff and patients, and labor pool staff helped us administer permethrin treatment, in one evening, to all the patients on the floor from which the source patient had been transferred. Information services worked with the infection prevention staff to develop a SharePoint database to track employee and patients who were exposed and treated. A similar SharePoint database was used for the H1N1 vaccination and seasonal influenza clinics later that year. An employee exposure clinic was set up to treat all exposed or symptomatic staff. Any staff members who were experiencing any symptoms were also offered treatment for their immediate family members. We soon found out that we had secondary transmission (asymptomatic staff members with symptomatic family members). Following guidance from the California Department of

Health,1 our incident command team, with the approval of our incident commander and administration, agreed to offer treatment to all household family members of any exposed staff to stop transmission. Because of this decision, we did not have any ongoing transmission and quickly stopped the outbreak. The incident command center remained open to support the employee clinic from September 15 until September 22. Of the 418 Mercy Medical Center staff and family members who were treated, 139 reported symptoms. In total, 1,236 employees and family members received medication through the employee health scabies clinic, and 37 received medication through another outpatient pharmacy. Employees from 57 hospital departments were affected by this outbreak. Of the 241 patients who had potential exposure during this time, 70 received treatment and four were known to be symptomatic. LESSONS LEARNED

• The organization needs to continually reinforce to all staff a clear and formal process for reporting any unusual, potentially infectious conditions to the IP. w w w.apic.org | 55


• Broad treatment and prophylaxis are critical to prevent ongoing transmission of Norwegian scabies. Prophylactic treatment should not be limited to staff and family members with symptoms. Our infectious disease physician approved the mass prophylaxis order for our employees. Patients currently on the affected unit could be examined by providers and have their treatment ordered by their provider, whereas patients who had been discharged were asked to see their personal care providers. We faxed an order form to every staff member’s family physician to get orders for their family members. • Staff members need instruction on cleaning their homes to prevent transmission of the infection. Although we had worked closely with our marketing department during this outbreak to provide information to employees about the infestation and how to prevent its spread, employees followed up with questions about cleaning their homes. We then sent that information, which should have been included in the initial communications.

• IPs should reinforce to healthcare providers that they can routinely use personal protective equipment, even when contact precautions are not implemented, if they have concerns about infection transmission. Before the scabies diagnosis, multiple staff members felt uncomfortable about the patient’s skin condition, but they did not use gowns or gloves because they knew of the patient’s history of psoriasis. • Events that involve overwhelming staff exposure can adversely affect the hospital’s ability to care for patients. In this case, we could not follow up with the patients as well as we would have liked because so many employees were exposed. This outbreak was one factor that drove our institution to develop an employee health role.

Reference 1. California Department of Health Division of Communicable Disease Control. Management of scabies outbreaks in California health care facilities. 2008. https://www.cdph.ca.gov/ Programs/CID/DCDC/CDPH%20Document%20Library/ MgmntofScabiesOutbreaksinHCFacilities.pdf. Accessed March 2018. Additional resource Centers for Disease Control and Prevention. Parasites: Scabies. 2010. https://www.cdc.gov/parasites/scabies/index.html. Accessed March 2018.

Stacy DeMoss, RN, MSN, CIC, is the infection prevention supervisor at Mercy Medical Center in Cedar Rapids, Iowa, and is the president-elect and a board member for the Eastern Iowa APIC Chapter. She has more than 20 years of nursing experience, including 13 years as an infection preventionist.

READ MORE ABOUT SCABIES IN THE AMERICAN JOURNAL OF INFECTION CONTROL Implementing systems thinking for infection prevention: The cessation of repeated scabies outbreaks in a respiratory care ward. Sheuwen Chuang, Peter Howley, Shih-Hua Lin, American Journal of Infection Control, Vol. 43, Issue 5, p499-505. Collaborative public health response during a scabies outbreak. Jessica Vakili, Stephanie Etter, Debbie Hoy, et al. American Journal of Infection Control, Vol. 43, Issue 6, S66. Utilizing a hospital point of dispensing (hpod) architecture for control of a scabies outbreak at an acute care hospital. Casey Calabria, Michelle Vignari, Alexandra Yamshchikov, American Journal of Infection Control, Vol. 42, Issue 6, S156.

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HOLIDAY FLOOD—

What a turkey! BY MARCIA PATRICK, MSN, RN, CIC, FAPIC

“The outpatient building was old, built in 1955, and the ventilation system was the original one, kept running by our excellent engineering department. Unfortunately, that system had lots of thin, copper pipes, which were vulnerable to cold, and we’d had a string of several cold days, with the temperature dropping well below freezing the night before Thanksgiving.”

T

hanksgiving morning. I slept in, planning to go out to dinner with friends at about 1 p.m. I just didn’t want to cook! As usual, as a manager, I was on call, so my infection prevention staff could enjoy the day with their families. Around 10 a.m., the phone rang, it was the system safety officer. He said there was significant flooding in our pediatric outpatient center, across the street from the main hospital. The outpatient building was old, built in 1955, and the ventilation system was the original one, kept running by our excellent engineering department. Unfortunately, that system had lots of thin, copper pipes, which were vulnerable to cold, and we’d had a string of several cold days, with the temperature dropping well below freezing the night before Thanksgiving. Fortunately, one of the engineers made rounds in the closed building early in the morning and discovered that some of the copper tubes had burst when the water in them froze and expanded. The water pressure pushed the ice out, and water poured from the top of the building all the way to the basement, four floors below. The engineer shut off the water to the facility to stop the flooding, but there was already a lot of water in the building. (In a previous flood in the main hospital, the night engineer did not know how to turn off the water when a high-pressure pipe burst, leading to significantly more water damage than would have occurred if the water had been shut off promptly.) THE INITIAL DAMAGE ASSESSMENT

I met the safety officer soon after he called me, and we, along with engineering, clinic staff, and members of the administration, started at the third floor to assess the damage. 58 | SUMMER 2018 | Prevention

That floor housed the outpatient pediatric therapy center as well as staff offices. The main gym ceiling was soaked, two of the walls were very wet, the flooring was saturated, and most of the big therapy toys and several computer CPUs were wet. At that point, we notified information technology (IT), and the on-call IT person came in and joined us. On the second floor, the walls, ceilings, and floors of the exam and treatment rooms and clinic offices were also wet. Some of these areas were carpeted, and the carpet was very squishy. The first floor contained the pediatric outpatient operating rooms, preoperative care, the postanesthesia care unit, offices, and clinics. The operating rooms were only minimally involved, but the pre- and postoperative areas were wet. The basement held storage and some offices. These were wet as well. THE RAPID RESPONSE

After the rapid assessment and adding IT to the team, we called a water remediation company that we used for this type of disaster. Our goal was to reopen most of the facility on the Monday morning after the Thanksgiving weekend. The water remediation company came and assessed the damage and then immediately began to work on the problem. First, our engineers replaced the burst copper tubing. There

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was no sense in doing repairs to other parts of the building until the leaks were all fixed. Second, the remediation people began to open ceilings and walls, putting in dehumidifiers and fans, wet-vacuuming, and removing wet carpeting and other damaged, wet materials. Our policy was that any wallboard that was not dry (as measured by a meter, not merely by touching the surface) within 48 hours had to be removed. Mold can form in a short time, and it loves wallboard! The wet debris was securely bagged and removed from the building. It was critical to get this process started as soon as possible to try to save as much building material as we could from needing replacement. Wet ceiling tiles were removed and discarded from the grids that formed the drop ceilings in most areas. Wall insulation was removed and discarded because it tends to retain water and would slow the drying of the walls. There were hot lights, dehumidifiers, and fans everywhere. Having an expert company that knows how to dry a building is critical—the drying

would not have been done quickly enough without their expertise and equipment. They had a full team there and worked on all floors simultaneously. Once water remediation was started, we had to just wait and see how quickly the building would dry out. I did get to go out for dinner for a couple of hours, and then I was back to continue coordinating the infection prevention part of the plan. IT removed the damaged computers and, where possible, replaced them. I believe they were able to recapture data from some of the hard drives. Since this flood, all CPUs are now placed on desks, not the floor. Because so many therapy items were wet with unclean (gray) water, we had to plan to wipe everything with bleach wipes—kids will put things in their mouths. We couldn’t do this until Sunday, when the pipes were fixed and the water could be turned back on. We hired a cleaning company for this task, rather than bringing in our janitorial staff; it was quicker and easier to use the vendor’s

services. I met with its director, and we reviewed exactly what we needed done on each floor. After items were wiped with bleach wipes, they had to be rinsed with potable water to remove bleach residue. Some items, such as cloth dolls, books, and crayons, had to be discarded and replaced. Fabric items that could be laundered were sent to our in-house laundry. All wet papers were discarded after the employees working in those areas sorted through them. The staff knew best what was replaceable and what needed to be copied before disposal. They also knew what supplies needed to be reordered for their departments to function on Monday. By Friday, we saw good progress in the drying process; the remediators were encouraged and encouraging. By Saturday, some areas were dry enough to begin repairs, and insulation and wallboard were either replaced or removed. Everyone worked hard to get everything accomplished. w w w.apic.org | 59


By Sunday afternoon, only a few areas in the basement, which is not a patient care area, were still being dried. The wet wallboard had been replaced, and some ceiling tiles were replaced. Areas where there were still openings because we lacked materials, such as ceiling tiles, were covered with plastic until supplies could be obtained. The cleaning and disinfecting of the affected areas and items had been done, and enough computers were functional, so the decision was made to open on Monday morning. The flood response and repair process required close coordination among many people and departments. Fortunately, we were used to working together and were generally all on the same page during the crisis. Expert remediators were critical, as was the cooperation of the staff affected by the flood. Our policies and procedures were followed. While this was a very expensive experience, being able to open the facility on Monday ensured that we did not lose revenue from cancelled appointments, inconvenience patients and families, or need to furlough staff.

RR-Microbes_PS_Hpg_Summer'18_1.indd 60 | SUMMER 2018 | Prevention 913533_Editorial.indd 1

1

LESSONS LEARNED

Of course, we did an after-action meeting and report, emphasizing the following key items: o Use of an experienced remediation company familiar with hospital work was essential to our rapid, effective response. o Engineers must know how to shut off water, power, and other utilities in an emergency. o A ll-hazards risk assessments and plans are essential to a good outcome. o By involving the affected staff, we could resume operations faster. o Working together on teams for projects helped us to function well as a team for this disaster. Marcia Patrick, MSN, RN, CIC, FAPIC, has worked in infection prevention and control for more than 35 years. She helped develop and implement APIC’s ASC course and currently serves as faculty for ASC 101 and 102. Marcia has served in numerous volunteer positions with APIC throughout her career.

READ MORE ABOUT FLOODS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Effectiveness of infection prevention measures featuring advanced source control and environmental cleaning to limit transmission of extremely-drug resistant Acinetobacter baumannii in a Thai intensive care unit: An analysis before and after extensive flooding. Anucha Apisarnthanarak, Uayporn Pinitchai, Boonyasit Warachan, et al. American Journal of Infection Control, Vol. 42, Issue 2, p116-121. Infection prevention response to a medical office building flood. Les Chock, American Journal of Infection Control, Vol. 44, Issue 6, S78. Behind the red line: Surface and supply disinfection following a flood in sterile supply. Jared Sutton, American Journal of Infection Control, Vol. 42, Issue 6, S33-S34.

4/10/2018 4:42:40 PM 4/13/18 4:01 PM


Elizabethkingia anophelis outbreak in southern Wisconsin: A FIRST-PERSON ACCOUNT BY JENNIFER RETTMANN, RN, BSN, CIC

I

n late fall 2015, I was the infection preventionist at a rural Wisconsin hospital, a position I had held for almost a year. Influenza was the most pressing issue confronting us in this small community (approximately 88,000 residents), and, although I was still learning something new almost every day, I was beginning to worry that I might get bored in infection prevention. Then, I received the first notice of a blood culture identifying a bacterium I had never seen before, Stenotrophomonas maltophilia, an opportunistic, aquatic organism that can cause serious complications in hospitalized and immunocompromised patients.1 I needed practice to pronounce all the syllables in its name. The doctor suspected the culprit was a contaminant in the culture. FIRST SIGNS OF AN OUTBREAK

A few weeks later, a second blood culture from our hospital tested positive for S. maltophilia. What initially seemed like an interesting fluke was now more concerning. I checked with the lab director, Marydon McCreery, to see whether she spotted anything unusual in the two samples. Looking back, one thing I appreciate was how knowledgeable and supportive Marydon was. She checked for commonalities on her end but found that a different phlebotomist had drawn the two cultures, from two different people, in different departments. On New Year’s Eve, a Thursday and the last day before the infection prevention department closed for four days, we had a third blood culture test positive for S. maltophilia. My own facility was on a skeleton crew, as was the lab. We attempted to call a few people at the Wisconsin Department of Health Services, but they were gone, too. 62 | SUMMER 2018 | Prevention

There was always the emergency hotline, and we discussed calling it before deciding to wait until Monday. We spent our final hours of the year checking to see whether any blood collection kits or agar plates had been recalled, suspecting a possible contamination, and reading up on S. maltophilia. Over the weekend, I felt puzzled but remained unaware of what challenging times were just around the corner. THE INVESTIGATION

On Monday morning, Marydon and I were both in early, checking and doublechecking everything we knew about the situation. When my director came in, I advised her of the situation. It just so happened we had a new director of patient services starting that day. I’ll never forget the terrible sinking feeling I had as I introduced myself to her by saying, “Hi, I’m Jenni Rettmann, the infection preventionist. I know you’ve only been

here a few hours, but I thought you should know I’m going to be calling the department of public health soon to alert them to a potential outbreak.” She took the news like a trooper. Then we made the phone call. On the other end of the line was Gwen Borlaug, infection control epidemiologist at the Wisconsin Division of Public Health Bureau of Communicable Diseases (see “APIC Consultant Corner,” p. 23). She listened carefully as I told her of the three cultures, the things we had done to try to rule out the possibility of contamination, and the results of our chart review. A careful reading of the charts showed that the only thing all three cases had in common was that a 10 mL saline flush had been used at some recent point prior to the blood culture. Now we had cause to worry. Gwen instructed us to start sending samples of saline flush products to the state lab of hygiene. However, as we worked to comply

CDC/ CYNTHIA GOLDSMITH AND MELISSA BELL

with this request, we quickly learned that we had a decentralized ordering process for IV flushes, and, consequently, there were at one point 17 different lot numbers of flushes being used throughout the facility. Soon, the department of health requested other types of products as well, including nebulizers and IV mini-bags. A few days later, Gwen and Dr. Lina Elbadawi from the Centers for Disease Control and Prevention (CDC) came to inspect our facility. The plan was to do environmental swabbing in high-risk areas. I was very nervous, as this was the first time in my nursing career that I had participated in anything like this. A cadre of staff members accompanied the inspectors throughout the hospital, taking notes. Later that day, we huddled to compare our observations. Looking back, I realize how gracious, kind,

and helpful Gwen and Lina were. I think they sensed how concerned we were. Dr. Elbadawi had been attached to the Wisconsin Department of Health Services from CDC, and this outbreak soon became a main area of focus for her. She conducted interviews with each staff member who had cared for the first three patients; these staff involved worked in the emergency department, medical/surgery department, and intensive care unit. This was a new experience for our staff, and we were all on edge. But, again, Dr. Elbadawi did her best to put us at ease. The purpose of her investigation wasn’t to cast blame, but to try to untangle what was going on with these cases. While investigators were swabbing sinks and interviewing staff members at our hospital, the Wisconsin Department of Health Services put out a call for cases. Soon, other

local facilities were reporting similar findings. In a way, I was relieved because it appeared that whatever was happening wasn’t just confined to our facility. But I was also concerned. My family and my friends all lived in the area affected. Were we all at risk too? When the available blood tests were retested, first at the State Lab of Hygiene, and then by CDC, we found out our organism wasn’t Stenotrophomonas after all. It was Elizabethkingia.2,3 At first, the organism was identified as Elizabethkingia meningoseptica, but even more sensitive testing by the CDC determined it to be Elizabethkingia anopheles. Periodically during the investigation, Gwen would call to ask us to send another product to the state lab. We received the environmental swab results back, but they shed no light on the source of the outbreak. The Wisconsin public health and the CDC teams began visiting patients in their homes, testing things like their toothpaste and deodorant. The investigators would eventually test natural spring water and soil samples, as well. The story was picked up on national news. I even have a clipping of a story about Elizabethkingia from the German newspaper Der Speigel. Seeing the media coverage, my friends and family asked me questions about the cause of the infection and the risk to people in the community. Answering them was challenging. I wanted to reassure everyone, but the information I could share was limited because I had to protect patient privacy and the confidentiality of the investigation. Also, because we did not know the source of the infection, we didn’t know for certain what its impact on the community would be. Above all, we were deeply concerned for the well-being of our patients. The Department of Health Services recommended “the use of contact precautions in addition to standard precautions for managing patients with Elizabethkingia infections,”3 as well as combination antibiotic therapy. About three months after making the first phone call to the Wisconsin Department of Health Services, two representatives of the CDC came to the hospital to review a 17-page questionnaire for each infected patient. Another nurse, Joann Lemmenes, w w w.apic.org | 63


and I sat with them in the computer lab, going through the details of each chart. I was pleased that we were able to get through all their questions in about four hours, and I was grateful that Joann was willing to offer so much of her time that day to assist. OUTCOMES AND LESSONS LEARNED

The cause of the outbreak is still unknown.3 We were relieved when we were told that the cause was not a healthcareassociated infection. During the outbreak, 63 cases were confirmed in Wisconsin,3 almost all of which were confined to the southern part of the state. Most of the patients who became infected were elderly and had a history of serious illness.3 Most patients recovered; however, 18 deaths in the Wisconsin outbreak were associated with Elizabethkingia.3 Gwen Borlaug presented the findings at the APIC 2016 Annual Conference, including details about how the organisms in the outbreak were genetically related. Dr. Elbadawi decided to stay in Wisconsin. They both

contributed to a paper describing their findings.4 I moved to Illinois a year ago, where I am still working in infection prevention. The outbreak was certainly a learning experience. Here are my biggest takeaways: • Always be on the lookout for an outbreak. • Don’t be afraid of public health officials— they are here to support you in a crisis. • Be grateful for your team. In addition to the people mentioned previously, I had help from just about every department in the facility. I hope anyone who was not mentioned by name knows that their time, energy, and effort were meaningful and appreciated. • Some mysteries may never be solved, but our experiences in infection prevention are nevertheless a part of a larger history. During the outbreak, I learned that Elizabeth King, a microbiologist who worked for the CDC from the 1940s through the 1960s, discovered this genus of bacteria. Knowing the story of how the organism got its name gave me a sense of continuity. In our investigation, we were carrying on King’s work. I was also grateful

when Gwen said that the early identification of E. anophelis probably saved lives. We don’t always know what good our work in infection prevention does. Sometimes, though, we get a glimpse. Jennifer Rettmann, RN, BSN, CIC, graduated from University of Wisconsin-Milwaukee College of Nursing in 2008. She has worked in two rural hospitals and the employee health department of a large manufacturing facility. She currently is the director of infection prevention and employee health at RML Specialty Hospital, a long-term acute care facility in the greater Chicago area. References 1. National Institutes of Health Genetic and Rare Diseases Center. Stenotrophomonas maltophilia infection. November 2016. https://rarediseases.info.nih.gov/diseases/9772/ stenotrophomonas-maltophilia-infection. Accessed March 2018. 2. Centers for Disease Control and Prevention. Elizabethkingia. June 2016. https://www.cdc.gov/elizabethkingia/index. htm. Accessed March 2018. 3. Wisconsin Department of Health Services. Elizabethkingia. May 2017. https://www.dhs.wisconsin.gov/disease/ elizabethkingia.htm. Accessed March 2018. 4. Elbadawi L, Borlaug G, Gundlach K, et al. A large and primarily community associated outbreak of Elizabethkingia anopheles infections, Wisconsin, 2015–2016. Open Forum Infect Dis 2016;3(suppl 1). doi: 10.1093/ofid/ofw195.09.

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A CRITICAL ROLE FOR THE INFECTION PREVENTIONIST

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BY AMESH ADALJA, MD, FIDSA, FACEP, FACP

T

he infection preventionist (IP) plays a crucial role in a healthcare facility’s response to bioterrorism emergencies. Not all biological weapons are contagious from person to person; however, in the midst of a biological attack, misinformation, calamity, and widespread panic are to be expected. At such times, IPs will be called upon to develop protocols, maintain situational awareness, and brief hospital administrative and clinical leaders. In this article, I will highlight some important aspects of this challenge. w w w.apic.org | 67


“The role of an IP in bioterrorism preparedness is not limited to implementing the relevant infection control protocols. Because IPs routinely peruse medical records and microbiology reports and field questions about infections, they may be among the first individuals to notice a potentially unusual circumstance of infection.” INFECTION CONTROL PROTOCOLS FOR CATEGORY A AGENTS

In the event of a bioterrorism event, the IP will be expected to implement appropriate infection control protocols. The Centers for Disease Control and Prevention divide bioterrorism agents into three main groups (categories A, B, and C), with category A agents given the highest priority. The category A agents are anthrax, plague, tularemia, smallpox, botulism, and viral hemorrhagic fevers. Of these agents, only plague, smallpox, and viral hemorrhagic fevers are contagious from person to person and require special infection control considerations.1 Plague, the agent of the Black Death, is contagious in its pneumonic form, which is the presentation to be expected during a biological attack. It is transmitted via droplets, and infected persons would merit droplet isolation for 48 hours of antimicrobial treatment.2 Smallpox, the only human infectious disease eradicated from the planet, can spread via respiratory droplets or through airborne particles. Therefore, strict airborne and contact isolation with negative pressure room use and N95 masks or respirators of higher level of protection (e.g., PAPRs) would be merited. Because smallpox vaccination is no longer routinely done, a single case of smallpox anywhere in the world would constitute a national security emergency of a grave nature, and there would likely be a call for augmentation of infection control above and beyond airborne precautions (e.g., use of biocontainment units) to delimit the spread of the disease and reassure the public.1,3 Viral hemorrhagic fevers are a diverse class of viruses that have various geographical niches and are spread primarily through blood and body fluids. Infection control measures would be aimed at limiting exposure to body fluids and would include contact and droplet precautions. Also, following the experience of Ebola in U.S. healthcare settings in 2014, airborne and contact isolation with swift transfer to a biocontainment unit would occur.3 68 | SUMMER 2018 | Prevention

IPs AS EMERGENCY PREPAREDNESS LEADERS AND EXPERTS

The role of an IP in bioterrorism preparedness is not limited to implementing the relevant infection control protocols. Because IPs routinely peruse medical records and microbiology reports and field questions about infections, they may be among the first individuals to notice a potentially unusual circumstance of infection. Their sentinel role can help mitigate the cascading effects (e.g., nosocomial spread) of any event. Additionally, the IP can serve as an expert moderating voice during a bioterrorism emergency. Any event involving biological agents will place many extraneous and external pressures on hospital operations. For example, hospital public relations and quality management personnel can be expected to attempt to integrate their own priorities into operational planning. Municipal authorities may also have extraneous considerations regarding such matters as hospital sewage.4 In such scenarios, IPs can continually reinforce the scientific basis of recommendations, draw from historical experiences, and ward against the danger of overreactions. Reflecting this key role, IPs should advocate strongly that infection prevention personnel have prominent, empowered positions in hospital emergency preparedness committees and regional healthcare coalition emergency preparedness activies.5 Infectious disease physicians should also insist on the robust inclusion of IPs in these activities, as the presence of both infectious disease and infection control experts would be synergistic. The defense against a biological weapon is a complex process, and a bioterrorism attack will require a tremendous amount of a healthcare facility’s assets, as well as guidance from local, state, and federal public health authorities. IPs can serve as an essential lynchpin in emergency preparedness planning and during actual bioterrorism events.

Dr. Amesh A. Adalja, MD, FIDSA, FACEP, FACP, is board-certified in infectious disease, critical care medicine, emergency medicine, and internal medicine, and a senior scholar at the Johns Hopkins Center for Health Security. He blogs about infectious disease issues at www. trackingzebra.com and can be followed on Twitter @AmeshAA. References 1. Adalja AA, Toner E, Inglesby TV. Clinical management of potential bioterrorism-related conditions. N Engl J Med 2015;372:954-962. 2. Siegel JD, Rhinehart E, Jackson M, et al. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/ isolation/index.html. Accessed February 2018. 3. Koonin LM, Jamieson DJ, Jernigan JA, et al. Systems for rapidly detecting and treating persons with Ebola virus disease—United States. MMWR 2015;64:222-225. 4. Centers for Disease Control and Prevention. Interim guidance for managers and workers handling untreated sewage from individuals with Ebola in the United States. https://www.cdc.gov/ vhf/ebola/prevention/handling-sewage.html. Accessed February 2018. 5. Courtney B, Toner E, Waldhorn R, et al. Healthcare coalitions: The new foundation for national healthcare preparedness and response for catastrophic health emergencies. Biosecur Bioterror 2009;7:153-163. Additional resources Centers for Disease Control and Prevention. Emergency preparedness and response: Bioterrorism. March 30, 2017. https://emergency. cdc.gov/bioterrorism/index.asp. Accessed March 2018. U.S. Department of Homeland Security. Bioterrorism. https://www. ready.gov/Bioterrorism. Accessed March 2018.

READ MORE ABOUT BIOTERRORISM IN THE AMERICAN JOURNAL OF INFECTION CONTROL The association between self-perceived proficiency of personal protective equipment and objective performance: An observational study during a bioterrorism simulation drill. Itay Fogel, Osant David, Chaya Balik, et al. American Journal of Infection Control, Vol. 45, Issue 11, p1238–1242. The effectiveness of computer based educational program regarding bioterrorism for infection control practitioners in Japan. Takahito Miyake, Yoko Tsukamoto, MIchiko Saito, American Journal of Infection Control, Vol. 42, Issue 6, S163–S164.


San Diego County hepatitis A outbreak: THE NEED FOR A COLLABORATIVE APPROACH TO INFECTION CONTROL BY MELANIE PADGETT POWERS

I

n November 2016, health workers in San Diego County, California, noticed that the number of reported hepatitis A cases had increased. Over the next four months, 19 cases were reported in the county, as compared with the normal infection rate of two or three infections per month. The San Diego County Health and Human Services Agency issued its first health alert about the outbreak on March 10, 2017.1 DISTINCTIVE ASPECTS OF THE OUTBREAK

According to Eric McDonald, MD, MPH, deputy public health officer for the County of San Diego, the hepatitis A strain in the county is a genotype 1B strain that had not previously been identified in North America. It’s not the same 1B strain causing outbreaks in other places, such as Michigan. Also, while the strain found in San Diego spread unexpectedly, public health experts don’t believe it is more virulent than others, Dr. McDonald said. San Diego officials haven’t been able to uncover where the disease originated locally. Typically, hepatitis A is linked to international travel or food poisoning at a restaurant or potluck. In San Diego County, however, it has been spreading primarily among people who are homeless and/or illicit drug users. As of March 2018, 584 cases of hepatitis A had been confirmed in the county, including 197 people who were both homeless and illicit drug users, 89 who were homeless only, and 74 who were illicit drug users only.2 In most of the other 224 cases, the patients had some sort of relationship with individuals from one of 70 | SUMMER 2018 | Prevention

those groups, such as living with a person who used illicit drugs or working in services for homeless or illicit drug use populations. Several healthcare workers became infected during the outbreak, although it’s unclear exactly how. Dr. McDonald suspects improper handwashing and eating in patient care areas to be the culprits. A couple of the healthcare workers worked in clinical settings where many of the outbreak cases were treated, but it’s not known how they became infected. Other healthcare workers didn’t have clear connections to the outbreak cases but did work with the at-risk populations, homeless people, and illicit drug users. In one case, two physicians worked in the same urgent care facility and shared a bathroom and clinical space. However, there were no outbreak cases diagnosed at that urgent care facility, and, according to Dr. McDonald, that was the only known secondary case in the outbreak of any of the healthcare workers. INFECTION PREVENTION AND CONTROL LESSONS

While the spread of hepatitis A in an unexpected population has presented challenges,

it has also led to changes and improvements in infection prevention and control. Thus, the San Diego outbreak can provide lessons for all infection preventionists (IPs). Reporting of suspected cases The mainstay of hepatitis A control is to interview people to discover who their contacts are, where they’ve been, and what they’ve been eating, but it can be difficult to gather this information from homeless people and those who use illicit drugs. To help address this challenge during the outbreak, notification requirements were changed. Before the outbreak, California required labs and providers to report confirmed cases of hepatitis A. However, “by the time the lab test comes back, the patient sometimes has been admitted to the hospital and been discharged, or they may not have been admitted to the hospital at all,” Dr. McDonald noted. Therefore, beginning with the first health alert, the county has asked that providers report all suspected cases immediately, while the patient is still in the hospital or provider’s office.1 That way, public health workers can conduct phone interviews before the patient leaves the healthcare facility. The

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department has an off-hours phone number and a duty officer available 24/7. Vaccination policies Vaccination policies also changed. There is no cure for hepatitis A, and, once a person is infected, the vaccine doesn’t help. However, if someone exposed to the virus receives the hepatitis A vaccine or immune globulin within two weeks of exposure, this measure could prevent disease, Dr. McDonald said. The San Diego County Health and Human Services Agency recommended vaccination of homeless people who show signs of hepatitis A infection before infection is confirmed. UC San Diego Health facilities offered the vaccine to all patients presenting with symptoms such as diarrhea, as well as to outpatients who were not already vaccinated. The hospital also changed its employee vaccination program after a new employee who was not vaccinated became infected. Previously, hepatitis A vaccine was recommended for all new employees. Since April 2017, the

hospital has required vaccination for all new hires and opened the hepatitis A vaccination program to all current employees. Hospital infection control and prevention procedures After a healthcare worker in the county became infected, a county health alert was issued on May 31, 2017.3 This alert included hospital infection control recommendations, including handwashing reminders, standard precautions, and the recommendation to not eat food in any patient care areas. At the time the alert was issued, UC San Diego Health already prohibited food in patient care areas. To reduce the risk for infection, the hospital went a step further and banned sharing of food—such as potlucks and birthday celebrations—in all areas. The hospital implemented the ban “because we saw that this was happening, and our hand hygiene rates weren’t where we wanted them to be,” said Kim Delahanty, RN, BSN, PHN, MBA/HCM, CIC, FAPIC,

administrative director of infection prevention-clinical epidemiology at UC San Diego Health. “Everyone pretty much complied because nobody wants to get sick.” The hospital infection prevention and control (IPC) team also stepped up its IPC monitoring and roamed the hospital—particularly in the emergency department and other outpatient settings—to educate personnel about hepatitis A infection. “We were just out on the floors doing shoe-leather surveillance, watching hand hygiene, reminding people what was happening in the community and that this could be a risk,” Delahanty said. Delahanty’s department created one-page information fliers to post in the emergency department, ambulatory care areas, and the hospital’s outpatient cancer center, reminding personnel to consider hepatitis A when patients presented with symptoms such as diarrhea, abdominal pain, or vomiting. However, for Delahanty, one of the biggest takeaways is to not simply send out a w w w.apic.org | 71


“‘We meet even in times of noncrisis, so when you do have a crisis, you already have relationships,’ she explained. ‘You have the contact information. We can mobilize quickly.’”

memo, but also to talk to people face to face. “Get down there in the trenches with them and help them understand the seriousness of the transmission and what they need to do to mitigate that,” she said. Data collected by the hospital’s IPC staff showed that proper handwashing and use of personal protective equipment increased during the outbreak. Such data can be used to illustrate to staff that compliance is doable and to advocate for compliance in areas where hospitals have found it to be lacking, Delahanty said. “Take that data, really use it next time,” she advised. When educating healthcare personnel, IPs can tell them, “We know we can have really good compliance, so let’s work on that going forward because there are other things we’re transmitting that we might not even know yet,” she said. The importance of ongoing collaboration An existing commission called the Group to Eradicate Resistant Microorganisms (GERM), which is a part of the San Diego County Medical Society (SDCMS), helped San Diego County mobilize and coordinate its actions during the hepatitis A outbreak. Created to advise the SDCMS board of directors on antibioticresistant microorganisms and provide expert input on infectious disease and bioterrorism, GERM was the first group to be alerted about the hepatitis A outbreak because its quarterly meeting happened to be scheduled two days before Dr. McDonald issued the first health alert. “We were able to get commission members on board to help us do things like implementing hepatitis A vaccination programs in the emergency departments in their hospitals,” Dr. McDonald said. With representatives from hospitals, county public health agencies, and physician groups, GERM has created a way for local health workers to establish trusting relationships and collaborate before a health emergency occurs. The commission meets quarterly and communicates via email throughout the year. Its objective has “morphed into all areas of sharing best practices of infection control,” Dr. McDonald said. When an outbreak occurs, “We all come together as a community to address those issues. That’s certainly what we do with hepatitis A, and it’s what we’ve done over the years with many different infection control issues.”


Delahanty shared this perspective: “We meet even in times of noncrisis, so when you do have a crisis, you already have relationships,” she explained. “You have the contact information. We can mobilize quickly.” For example, when H1N1 influenza spread to the county from Mexico, the team, including a border physician, was able to gather quickly at SDCMS offices. The response operations were coordinated and streamlined, allowing for prompt infection control actions and the efficient distribution of information on prevention. CONCLUSION

While the declared emergency was lifted in San Diego County on January 23, 2018,the outbreak continues.4 Since it began, 20 deaths and more than 400 hospitalizations in the county have been associated with hepatitis A infection.2 The county reports about one confirmed case per week and remains ever vigilant. Melanie Padgett Powers is a medical writer based in the Washington, D.C., metropolitan area. References 1. California Health Alert Network San Diego. Hepatitis A virus outbreak associated with homelessness, drug use in San Diego County. March 10, 2017. https://www.sandiegocounty.gov/content/ dam/sdc/hhsa/programs/phs/cahan/communications_ documents/03-10-17.pdf. Accessed March 2018. 2. San Diego County Health and Human Services Department. Hepatitis A: San Diego hepatitis A outbreak. https://www.sandiegocounty.gov/ content/sdc/hhsa/programs/phs/community_epidemiology/ dc/Hepatitis_A.html. Accessed March 2018. 3. California Health Alert Network San Diego. Update #3: Hepatitis A virus outbreak in San Diego County. May 31, 2017. https://www. sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/ cahan/communications_documents/05-31-2017-Hep-A.pdf. Accessed March 2018. 4. California Health Alert Network San Diego. Update #8: Hepatitis A virus outbreak in San Diego County. February 15, 2018. https://www. sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/ cahan/communications_documents/02-15-2018.pdf. Accessed March 2018.

READ MORE ABOUT HEPATITIS A IN THE AMERICAN JOURNAL OF INFECTION CONTROL Low level of immunity against hepatitis A among Korean adolescents: Vaccination rate and related factors. Jung Yeon Heo, Joon Young Song, Ji Yun Noh, et al. American Journal of Infection Control, Vol. 41, Issue 10, e97-e100.

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