1710 dr leong hoe nam infection at the workplace - we can prevent it!
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Transcript of 1710 dr leong hoe nam infection at the workplace - we can prevent it!
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Expert Doctor’s Showcase Infection at the work place – we can
prevent it!
Dr Leong Hoe Nam Infectious Diseases Physician
Raffles Hospital, Singapore [email protected]
Unrestricted Educational Grant from
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Financial Declaration
• Advisory Board
– Pfizer
– GlaxoSmithKline
– Sanofi-Pasteur
– MSD
• Site Principal Investigator
– Sanofi-Pasteur – Dengue Vaccine Trial
Unrestricted Educational Grant from
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Infection in the Workplace is PREVENTABLE
Begins with
PERSONAL RESPONSIBILITY
Stephen Covey’s 7 Habits of Highly Effective People
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SILVER WORKFORCE
• Co-morbidities
– Diabetes Mellitus, Chronic Obstructive Airway Disease, Asthma, Heart Disease, etc
• Reduced Immunity
• Same medical condition – HIGHER MORTALITY
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INFECTIONS
GERMS
Listeriosis Contaminated Cantaloupes
E Coli Haemolytic Uraemic Syndrome
BACTERIA
FUNGI
HIV / AIDS
Viruses
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RECENT EPIDEMICS / PANDEMICS
• Spread Fast
• Made use of Airport Routes
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www.airliners.net
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RECENT EPIDEMICS / PANDEMICS
• Humans were the carrier
• SINGAPORE – major airport hub
• Spread Fast
• Made use of Airport Routes
RESPIRATORY ROUTE!
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Germany E Coli O104, Beansprout
FAECAL ORAL TRANSMISSION
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INFECTIONS
• Risk of infection higher in the immunocompromised host. Cancer patients
• Diabetes mellitus type 2. Good control helps
“sugar to the white cells is like brandy to an alcoholic”
The pleasure of it all makes them not want to work.
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Two main modes of transmission of Illness
• FAECAL ORAL
• RESPIRATORY
balkris.blogspot.com
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Faecal Oral Transmission
粪便口头传输 Viral infection (Rotavirus, Enteroviruses) Salmonella (Typhoid fever), Shigellosis Hepatitis A - diarrhoea.
Chong Kneas — a floating village over Tonle Sap Great lake in Cambodia. A child refills lake water into her drinking bottle.
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Faecal Oral Transmission
粪便口头传输
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Spot the Difference
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Straits Times Nov 3, 2011
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What do I do?
• Keeping the environment clean
– Clearing / wiping down table.
– Eating at the office table
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• Cover for keyboard.
• Who used the keyboard previously?
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What do I do?
• Keeping the environment clean
– Clearing / wiping down table.
– Eating at the office table
• Nothing in the mouth except FOOD!
• Washing Hands
• Good toileting habits
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• Ovaries of Hens
• Bacteria enters egg prior to
egg shell formation
Salmonella enteritidis
Source: salmonellablog.com Topnews.in
• Faecal contamination
Fresh eggs go through the same vent as faeces
PATIENTS with CANCER /
IMMUNOCOMPROMISED – TAKE
NOTE!
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Faecal Oral Transmission 粪便口头传输
It’s all about….. 1. Personal hygiene 2. Personal responsibility 3. Using some common sense….
Unwell 1. Seek treatment 2. Rest at home 3. Strict handwashing
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Respiratory (呼吸)
Influenza / Tuberculosis / Pertussis
Biggest burden – Influenza (流行性感冒) Spread by Droplet (通过飞沫传播) Other respiratory viruses Respiratory syncytial virus (RSV), parainfluenza, enteroviruses, adenovirus, coronaviruses, bocavirus, metapeumovirus Other bacterial infections Streptococcus pneumoniae, Haemophilus influenzae, Moxarella catarrhalis
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Respiratory
Spread by droplets - minimise exposure - cover cough - dispose of dirty tissue - no spitting - hand hygiene - surgical mask SEE A DOCTOR! Stay at home. Influenza Vaccinations for those with chronic Illnesses Option of antiviral therapy <48hrs for influenza
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Surgical Masks – THEY WORK!
THEY PROTECT THE WEARER!
THEY PROTECT OTHERS!
PREVENTION OF INFECTION
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Johnson et al. Clin Infect Dis. (2009) 49 (2): 275-277.
INFLUENZA
COUGH!
20cm
PREVENTS Transmission
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Myths on Influenza
• It is a whimpy virus
• It doesn’t kill
• There is no influenza in Singapore
• The influenza vaccination doesn’t work
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Two FLU SEASONS in SINGAPORE
• BIMODAL APRIL – JULY
NOVEMBER – JANUARY
Follows the Southern and Northen hemispheres
Greater PEAK – APRIL – JULY
Angela Chow et al. EID. Vol 12. No.1 Jan 2006
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A
Angela Chow et al. EID. Vol 12. No.1 Jan 2006
All Cause Death
Underlying Pneumonia and Influenza
Underlying Circulatory and Respiratory Deaths
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Influenza – excess death
INFLUENZA is responsible for DEATH in TROPICS
Angela Chow et al. EID. Vol 12. No.1 Jan 2006
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Every peak of excess death paralleled Influenza peaks (except 1)
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An experiment in TTSH
• ALL patients admitted over 48 hour period tested for influenza
• 10% were positive for influenza by PCR
• 60% had “Influenza-like illness”
• “underrecognition and underdiagnosis of influenza in hospitals. “
Leo YS et al. Lancet Inf Dis. August 2009
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An experiment in TTSH
• ALL patients admitted over 48 hour period tested for influenza
• 10% were positive for influenza by PCR
• 60% had “Influenza-like illness”
• “underrecognition and underdiagnosis of influenza in hospitals. “
Leo YS et al. Lancet Inf Dis. August 2009
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INFLUENZA in the AT-RISK POPULATIONS
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RR Hospitalisation
• Non-epidemic years 1.1 (1977) 1.0 (1979)
• Epidemic years 5.7 (1976) 6.2 (1978)
• 5 X Increase risk of HOSPITALISATION • Pneumonia RR 25.6
• Death RR 30.9 (1977) 91.8 (1978)
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• .
The adjusted rates of excess influenza-associated hospital admissions for the three diagnoses combined amounted to 58.5, 20.0, 29.2, and 13.4 per 10,000 populations aged 65 years in 1998, 1999, 2000, and 2001, respectively.
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Pneumonia / Diabetes Mellitus / Heart + INFLUENZA
= BAD NEWS
What about children…..?
www.colourtown.com
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• The risk of INFLUENZA on HOSPITALISATIONs
<6 mo 103.8 1-3y 18.6 5-15y – 4.1
6 – 12 mo 49.6 3-5y 8.6 Excess/10K chn/yr
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Relationship within the family
Children
Grandparents Parents
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Children gives “multiple doses” (exposures) to grandparents
• 1 child can give
multiple doses
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The Good News…..
We have a vaccine…….
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In Singapore A vaccine is just dead vaccine lightly salted….
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Effectiveness of the Vaccine
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• COPD
• Decrease in ARI / Hospitalisation / Mechnical Ventilation
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MILD
MODERATE
SEVERE
ALL
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• Part of PRISMA Study (Prevention of Influenza, surveillance and management Study). 75,000
• 1999-2000 Influenza A
• Vaccine : Control 1:4
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Reduction in Death / Hospitalisation
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BURDEN OF INFLUENZA…. BEYOND THE PATIENT…..
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The burden of respiratory illness…
• All respiratory illnesses can result in visits, prescriptions, lost school and work days…
• BUT – INFLUENZA – had more of them…..
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Burden of Influenza vs Others
• More transmissibility in family
• More prescriptions
• More medical visits
• More lost work / school days
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Vaccinating the YOUNG to save the OLD
• Mandatory Flu vaccination in Children – 1962-87
• Laws relaxed 1987
• Repealed in 1994
• VACCINATION of CHILDREN PROTECTS ELDERLY
COMPULSORY
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Vaccine Effectiveness
Adults / Children with Asthma
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>65 yo
713, 872 person-years observation. VACCINATION
27% reduction HOSPITALISATION (for pneumonia / influenza (OR 0.73, CI 0.68-0.77)
48% reduction in Risk of Death. (OR 0.52 CI 0.5 – 0.55)
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• Vaccine effectiveness repeated in Taiwan…..
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Cost EXcluding Operating Income
PRODUCTIVITY RATE 70 50 30
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Cost INcluding Operating Income
PRODUCTIVITY RATE 70 50 30
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Vaccine Safety
Generally safe…
Pain / Ache site of infection
Limited fever post vaccination
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MOH guidelines on Influenza Vaccination • Persons aged 65 years and older; • Residents of nursing homes and other chronic care facilities; • Adults and children who have chronic disorders of the lungs
or heart, including asthma; • Adults and children who have required regular medical
follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), kidney or blood disorders, or lowered immunity caused by medications or by the Human Immunodeficiency Virus (HIV);
• Children and teenagers aged 6 months to 18 years who are receiving long-term aspirin therapy;
• Women who are in the second or third trimester of pregnancy.
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INDIVIDUALs in contact with patient
INDIVIDUAL To Protect!
INFECTIONS are transmitted by those around the patient
Vaccinations must include the OUTER PERIMETER – the patients’ contacts!
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5- to 19-year-olds are expected to suffer the
highest incidence during the initial epidemic phase of an emerging infection
Mossong et al. PLoS Med. 2008 Mar 25;5(3):e74.
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Lessons on influenza
• Children transmit the viruses
• Children pass the infection to others
(YOUR EMPLOYEE / YOURSELF)
Manhours, medical leave.
• Vaccinating the children of your employee helps
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Impact of Annual Influenza Epidemics
• No. of workdays lost
1.5 – 4.9 days / person
lab-confirmed influenza.
Keech and Beardsworth. Pharmacoeconomics. 2008;26(11):911-24
• Lost of productivity
“reduced capacity to work”
5 - 6.2 days
Kavet. Am J Public Health. 1977;67:1063-1070
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Economics of Workplace Vaccination
• Cost savings….($15 to $995) per vaccinated employee)
(20% attack rates)
Bruce lee at al. Vaccine. 2010 August 23; 28(37): 5952–5959
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TWO LARGE RANDOMISED CONTROL TRIALS TWO WELL RECOGNISED JOURNALS
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But there are detractors….
• “vaccines are undoubtedly the best preventive means for clinical influenza in healthy adults.”
• “low effectiveness and high incidence of trivial local adverse effects that the trade-of is unfavourable”
• “most cost-effective option is not to take any action”
Demicheli V et al. Vaccine. 2000 Jan 6;18(11-12):957-1030. Review
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How much vaccination is enough?
• In an epidemic of influenza
• Computer Modelling
• 20% compliance – MAXIMUM GAIN!
Vaccine Cover Attack Rates
100% 0.5%
50% 0.6%
20% 0.7%
0% 2.8%
60 Days to complete vaccination
Vaccine Cover Attack Rates
100% 1.5
50% 1.5%
20% 1.8%
0% 3.8%
120 Days to complete vaccination
Lee et al. Am J Prev Med. 2010 March ; 38(3): 247–257
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Physical Barriers Help
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Respiratory Infections
• Influenza biggest burden
• Vaccination helps! $23-25
– Hospitalisation / Deaths
• Influenza has two peaks in Singapore
• Surgical masks can help prevent infections.
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Barriers to Vaccination
1. Doctor’s Recommendations
2. Perceived benefits
3. Previous vaccinations
4. Convenience to vaccinations eg. Vaccination programme at workplace, at GP consultation
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Some parting words
• “If there is any conceivable way a germ can travel from one species to another, some microbe will find it,”
William McNeill
Plagues and Peoples
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The END
Infection in the Workplace is PREVENTABLE
Begins with
PERSONAL RESPONSIBILITY (CORPORATE RESPONSIBILITY)
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Annual Impact of Seasonal Influenza - USA
• 2003 US population 294 million
• 610,660 life years lost
• 3.1 million hospitalised days
• 31.4 million outpatient visits
• Direct medical costs $10.4 billion
• Lost earnings $16.3 billion
• Total Economic Burden $87.1 billion
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INDIVIDUALs in contact with patient
INDIVIDUAL To Protect!
INFECTIONS are transmitted by those around the patient
Vaccinations must include the OUTER PERIMETER – the patients’ contacts!
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How much vaccination is enough?
• In an epidemic of influenza
• Computer Modelling
• 20% compliance – MAXIMUM GAIN!
Vaccine Cover Attack Rates
100% 0.5%
50% 0.6%
20% 0.7%
0% 2.8%
60 Days to complete vaccination
Vaccine Cover Attack Rates
100% 1.5
50% 1.5%
20% 1.8%
0% 3.8%
120 Days to complete vaccination
Lee et al. Am J Prev Med. 2010 March ; 38(3): 247–257
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Difficulty in Studying Influenza
INFLUENZA INFLUENZA-LIKE ILLNESSES
Lab-confirmed Clinically suspected
low sensitivity Other viruses responsible.
Characteristic features (50%)
URTI only (30%)
No Symptoms (20%)
Costly!
INFLUENZA A, B
Parainfluenza 1,2,3 Respiratory Syncytial Virus, Adenovirus, Enterovirus, Coronaviruses, Mycoplasma
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Risk of Guillain Barre Syndrome
• Incidence GBS – 4-10/ 1,000,000
• Flu – 15-20% of the cases.
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• “the attributable rate of GBS would be 0.71 per 100,000 person-years, corresponding to an attributable risk of 0.8 excess cases of GBS per 1 million vaccinations.“
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Impact of Annual Influenza Epidemics
• No. of workdays lost
1.5 – 4.9 days / person
lab-confirmed influenza.
• Lost of productivity
“reduced capacity to work” Keech and Beardsworth. Pharmacoeconomics. 2008;26(11):911-24