ABCs in EIDs: Preparing for Emerging Infectious Diseases

Your Step by Step Guide in Preparing for Emerging Infectious Diseases

Arthur Dessi E. Roman MD MTM FPCP FPSMIDPHICS 21st Annual Convention

Crowne Plaza Galleria Manila, 28 May 2015

EIDs

@gonnabedess #WhatNow@PHICS2015 @gonnabedess

‘s in

by AD Roman presented during the 21st PHICS Annual Convention, 27-28 May 2015

2RESEARCH INSTITUTE FOR TROPICAL MEDICINE

Why is PH concerned about the threat of EIDs?

According to NSO, as of April 2014:

•

worldwide

• ~53.3 % in Middle East (majority are in KSA)

• China is nearby


With emerging diseases at the forefront, should travel

history be placed in the general data?



Objectives

• To discuss general guidelines in preparing for EIDs in your institution

• To elaborate on the roles of hospitals/frontliners in case detection, reporting, and controlling the spread of EIDs



EIDs are evolving

Interim guidelines change as new information becomes available.

Keep yourself updated!



www.ritm.gov.ph


Patient care Safety of HCW


Definitions

“Emerging" infectious diseases

Infectious diseases whose incidence in humans has increased in the past 2 decades or threatens to

increase in the near future which respect no national boundaries

http://wwwnc.cdc.gov/eid/page/background-goals


Definitions

Re-emerging Infectious Diseases

Old infections re-emerging as a result of antimicrobial resistance in known agents or breakdowns in public

health measures/ infrastructures, e.g. diphtheria, pertussis, measles, Chikungunya


European Centre for Disease Prevention and Control. Communicable disease threats report, Week 21, 17-23 May 2015. Accessed on 23 May 2015 from http://www.ecdc.europa.eu/en/publications/Publications/ communicable-disease-threats-report-23-may-2015.pdf

MERS-CoV Case Count as of 23 May 2015

• Total no. of confirmed cases: 1,152

• Total no. of deaths: 471 deaths

• Crude case fatality rate: 40.9%


Where did MERS-CoV come from?

• MERS CoV found in camels from Egypt, Qatar, and Saudi Arabia

• Camels from Jordan, Oman, Qatar, Saudi Arabia and the UAE (even from Egypt, Kenya, Nigeria and other African araes) have shown high rates of antibodies against MERS-CoV

Evidence for Camel-to-Human Transmission of MERS Coronavirus. New England Journal of Medicine, 2014. 371(14): p. 1359-1360.Alagaili, A.N., et al., Middle East respiratory syndrome coronavirus infection in dromedary camels in Saudi Arabia. mBio, 2014. 5(2): p. e00884-14.


Where did MERS-CoV come from?

• Many similar coronaviruses have been isolated in bats

• In MERS case, an identical MERS-CoV strain have been isolated from a bat captured near the patient’s house

Taphozousperforatus


How did it transfer from camels to humans?

• Still not clear.

• Droplet contact?

– high viral loads in nasal swab samples from camels

– Fecal samples

– conjunctival swabs




• A recent study published by Azhar EI et al. reported the isolation of the virus in an air sample collected in a camel barn involved in a possible camel-to-human outbreak, warranting further investigations for the possible airborne transmission of MERS-CoV




Camel urine:

A traditional medicine

Camel milk:

suggests a potential food-borne transmission of the virus by

consuming raw milk, a traditional behaviour in Arabic culture

Evidence for Camel-to-Human Transmission of MERS Coronavirus. New England Journal of Medicine, 2014. 371(14): p. 1359-1360.

How infectious is MERS?



Reproduction Number



MERS: Reproduction number

MERS R0 = 0.60 to 0.69

suggests that MERS-CoV does not yet have pandemic potential

No ongoing spreading of MERS-CoV in the community

Romulus Breban, Julien Riou, Arnaud Fontanet: Interhuman transmissibility of Middle East respiratory syndrome coronavirus: estimation of pandemic risk. The Lancet, 05 July 2013


MERS: Transmission

• human-to-human transmission occurs via, close contact

– caring for or living with an infected person

– healthcare workers taking care of MERS patients

• All reported cases have been linked to countries in and near the Arabian Peninsula.



MERS-CoV

• It is not always possible to identify patients with MERS-CoV early because some have mild or unusual symptoms

– It is important that health-care workers apply standard precautions consistently with all patients regardless of their diagnosis in all work practices all the time



MERS-CoV

• Droplet precautions should be added to the standard precautions when providing care to all patients with symptoms of acute respiratory infection

• Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection

• Airborne precautions should be applied when performing aerosol generating procedures


Personal Protective Equipment (PPE)

• Goggles or face shield

• N95 mask (or P100)

• Gown

• Gloves

• Shoecover

• Additional: cap

Spot Quiz

What is the is the single most important action to stop

spreading infection and disease?

A. Wearing a mask

B. Taking daily Vitamin C

C. Handwashing

D. Taking antibiotics


General Guidelines in the Preparation and Management of EIDs

1. Operationalize your response.2. Designate a team in charge of EIDs.3. Designate areas in your institution for:

– Screening and triage– Isolation of suspect cases

4. Apply standard precautions for all patients.5. Understand the basics of transmission-based

precautions.6. Decide on the extent of your patient

involvement and prepare accordingly.



1. Operationalize your response.2. Decide on the extent of your patient

involvement and prepare accordingly.3. Designate a team in charge of EIDs.4. Designate areas in your institution for:



precautions.

• Align with national preparedness plan.• Determine response based on current situation.oNo reported case locally, one reported cases, all

referral hospital full, overflow of cases in the community

• Determine how the regular hospital operations will be affected by admitting EID cases.







precautions.

• Assess your capacity as a hospital in terms of:o Manpower and skillso Space, equipment, facilityo Hospital operationo Need of the communityo Availability and proximity of other institutions

who will admit EIDs







precautions.

• Formulate and train your ICC• Attend trainings• Seek the help of experts (IDS, ICN Nurses, PHICS)







precautions.


Screening and Triage

Screening

To quickly identify people with a travel history to affected countries

Triage

To determine if these persons have significant contact and if they have symptoms

Goal

To promptly isolate suspects if symptomatic or provide home advice as necessary



Screening and Triage

A stepwise process of screening based on travel history followed by triage is more manageable in most

institutions than a combined screening and triage process.



Isolation/Holding Area

• This is the area where patients wait while

transfer to the referral hospital is being

coordinated.

• Provide surgical masks to the patients and as

much as possible minimize contact with them

unless deemed necessary



Isolation/Holding Area

• The holding area should be:

– Near triage area for quick transfer

– Distant from other crowded areas1

– Well ventilated / adequate ventilation and room

air exchange (negative pressure or

independent air-conditioning unit and exhaust

or open windows)1,2

– Own sink and toilet facilities2

– Have adequate sunlight1

– Known to everyone in the facility11Clinical Management of Patients with Viral Haemorrhagic Fever: A pocket Guide for the Front-line Health Worker

13 April 2014. . World Health Organization 20142Interim Clinical Guidelines on Severe Acute Respiratory Syndrome (SARS) for Health Facilities in the Philippines

Department of Health. Technical Working Group on SARS Clinical Guidelines, July 25, 2003

What if we don’t have a negative pressure room?

• Properly labeled and identified, easily recognizable by visitors and hospital personnel

• Good ventilation• Entering HCWs should wear appropriate PPE

by AD Roman presented during the 21st PHICS Annual Convention, 27-28


Air Changes

Room conditions ACH

Completely open window + open door 29.3–93.2

Completely open window + closed door 15.1–31.4

Half-open window + closed door 10.5–24

Closed window + open door 8.8

World Health Organization, Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. 2007.


Air Changes

Exhaust

fan is:

The door connecting the

room to the corridor is:

The door and windows

connecting room to the

balcony and outside air is:

ACH

OFF Closed Closed 0.71

OFF Closed Open 14.0

OFF Open Open 8.8–18.5

ON Closed Closed 12.6

ON Closed Open 14.6

ON Open Open 29.2

World Health Organization, Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. 2007.

Caveat: Air exhaust should not be directed in an area with high human traffic.







precautions.

Airborne precautions for...

by AD Roman presented during the 21st PHICS Annual Convention, 27-28

CHECKLIST FOR THE ACUTE MANAGEMENT AND/OR TRANSPORT OF SUSPECTED OR

CONFIRMED CASES OF MERS

ACTIVITY DONENOT

APPLICABLE

1. Screen and triage patients to identify suspects by inquiring about history

of travel to affected countries or contact with confirmed or probable

case and the presence of compatible symptoms

2. Institute standard precaution and the necessary transmission-based

precaution (contact, airborne, respiratory)

3. Isolate suspected patients in a room with adequate ventilation (negative

pressure room if available)

4. Ensure isolation room has the following:

Toilet or commode

Hand hygiene facility

Waste bin

Puncture-resistant sharps container

Telephone or other method of communication in the isolation room to

enable patients, family members or visitors and healthcare workers to

communicate with one another




ACTIVITY DONENOT

APPLICABLE

5. Dedicate non-critical patient-care equipment (e.g.

stethoscope, thermometer, blood pressure cuff and

sphygmomanometer) to the patient, if possible.

6. Post appropriate signage (discretely) alerting healthcare

personnel to isolation status, PPE required, proper hygiene, and

handling/management of infected patients and contaminated

supplies.

7. Encourage respiratory hygiene (i.e. Provide and advise patient to wear a regular facemask whenever possible, use of tissues when coughing or sneezing followed by hand hygiene)

8. Limit visitation.

9. Wear the appropriate PPE (N95 mask, face shield or goggles,

gown, shoe cover, cap if preferred) for healthcare workers who

will be involved in the care of the patient identified.by AD Roman presented during the 21st PHICS

Annual Convention, 27-28 May 2015



ACTIVITY DONENOT

APPLICABLE

10. Assign healthcare workers who have been adequately trained to

attend to the index patients. Entry of healthcare workers should be

limited only to those essential for patient care and support.

11. Keep track and monitor healthcare workers who took care of

suspect cases.

12. Environmental cleaning and decontamination of patient care area,

supplies and equipment based on standard hospital procedures.

13. Management of waste, laundry and linen based on standard hospital

procedures.

14. Perform screening and triage of contacts. Provide necessary advice.

15. Inform the Infection control office and other designated hospital

personnel/administrator.

16. Inform the DOH, NEC or your respective Epidemiology and

Surveillance Units.

17. Hand hygiene as frequently as recommended.by AD Roman presented during the 21st PHICS Annual Convention, 27-28 May 2015



FOR HOSPITALS WHO WILL ADMIT AND MANAGE

PATIENTS

1. Manage patients based on the Management Guidelines for the

Treatment of Severe Acute Respiratory Illness associated with

MERS-CoV.

2. Develop contingency plans for staffing, logistics, procurement,

security, and treatment. This includes sick leave policies and work

restrictions (for personnel who will have unprotected exposure).

3. Ensure adequate supply of PPEs are available at any time.

4. Coordinate with RITM regarding collection, preparation, and

transport of specimens and releasing of result.

5. Collection of samples wearing appropriate PPE and practicing

the necessary transmission-based precautions.




FOR HOSPITALS WHO WILL ADMIT AND

MANAGE PATIENTS

6. Perform aerosol generating procedures with extreme

caution, preferably inside a negative pressure room.

7. Adequate preparation and coordination when

transporting patient between units within the hospital.

8. Maintain constant communication and coordination

with the Department of Health/NEC

9. Proper risk communication




FOR HOSPITALS WHO WILL TRANSFER PATIENTS

1. Coordinate with DOH, NEC or your respective Epidemiology and

Surveillance Units regarding transfer.

2. Inform receiving unit of plans for transfer to allow ample time for

preparation.

3. Perform aerosol generating procedures only when necessary.

4. Develop staffing plan, sick leave policies and work restrictions

(for personnel who will have unprotected exposure).

5. Conduct a detailed inventory of available supply of PPE. Replace

used stocks to ensure availability.

6. Call the receiving institution prior to actual transport of patient

7. Decontamination of transport vehicle based on standard hospital

procedures.



Transport

• Use portable devices (e.g. portable x-ray, ultrasound) as much as possible.

• Decontaminate infected surfaces afterwards.

• Transport and move patients only when necessary.

• Ask patients to wear surgical masks (if they can tolerate) when going out of the isolation room to contain secretions.


Transport

• Ensure that health-care workers who are transporting patients wear appropriate PPE and perform hand hygiene afterwards.

• Prior to transport and arrival, notify the receiving unit of the patient's diagnosis and precautions that will be required.


Transport: Ebola


Contact numbers

• NEC 711-1001/711-1002

• RITM Hotline 664-6568 (24 hrs)

• RITM Surveillance Unit 994-1887 (24 hrs)

EIDs are here and they are here to stay.

Efficient screening and triage is important:To prevent entry and spread in the country

For prompt isolation and management

In the management of EIDs, balance between patient care & healthcare worker

safety should be achieved

Summary


Infection control strategies play a major role in the control of EIDs. This will depend on

transmission-based precautions and application of standard precautions on all patients.

Institution should be ready to handle specific issues that may arise in the course of

management in EIDs via a multidisciplinary approach.

Do not be caught off guard.

Summary


ありがとう (JP) Thank you (En)Arigatou


ABCs in EIDs: Preparing for Emerging Infectious Diseases

Health & Medicine

Transcript of ABCs in EIDs: Preparing for Emerging Infectious Diseases