Emerging Issues in Infection Control: The …...Emerging Issues in Infection Control: The Continuum...
Transcript of Emerging Issues in Infection Control: The …...Emerging Issues in Infection Control: The Continuum...
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Emerging Issues in Infection Control:The Continuum From the Hospital to
Global Health
Jay C. Butler, MDDeputy Director for
Infectious Diseases
Alaska Infection Control ConferenceAnchorage, AK
October 7, 2019
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• Healthcare-associated pathogens
• Data on infection control practices and tools
• Non-traditional settings for infection control
• Issues in the community• Global health concerns
So, What’s New?
Hospital
Other facilities
Community
Global
Realms of Infection Control
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Candida auris• 2009: isolated from ear canal of patient in
Japan• Bloodstream and intra-abdominal infections• Leading cause of candidemia in some
hospitals:• South Africa• India• Kenya• Spain
• Unlike other Candida species:• Colonizes healthcare environment• Transmitted through facility networks• Highly drug resistant
Vallabhaneni S, et al. Ann Intern Med 2019;171(6):432-433
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Candida auris Drug Resistance
Azoles90%
Polyenes40%
Echinocandins2%
• 33% resistant >1 class• 3 pan-resistant strains
in 2019• Resistance emerged
during treatment• No transmission
documented• Resistance maintained
after treatment stopped
Vallabhaneni S, et al. Ann Intern Med 2019;171(6):432-433
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C. Auris Affects the Sickest of the Sick
• Tracheostomy• Long-term mechanical ventilation• PEG tube• Colonization with other multidrug resistant organisms• Recent exposure to broad-spectrum antibiotics and antifungals• Multiple healthcare facilities and stays
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States Reporting Candida auris, as of July 31, 2019
• >720 clinical isolates• >2,000 clinical or
screening isolates• 11 cases linked to
healthcare abroad
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Outbreak of C. auris Neuro ICU Oxford Hospital, London, Feb 2015-Aug 2017
• Predictors of infection/ colonization:
• Reusable axillary temperature probes (OR 6.8, 95% CI 3.0-15.6)
• Fluconazole exposure (OR 10.3, 95% CI 1.6-65.2)
• Infection rates fell after probe use discontinued
Eyre DW, et al. N Engl J Med 2018;379(14):1322-1331
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Outbreak of C. auris Neuro ICU Oxford Hospital, London, Feb 2015-Aug 2017
Eyre DW, et al. N Engl J Med 2018;379(14):1322-1331
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New York Times, April 6, 2019
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Odds of Lab-Confirmed Influenza Among Healthcare Providers: N95 vs Medical Mask
Radonovich LJ, et al. JAMA 2019;322(9):824-833
• Cluster randomized pragmatic trial• 4 years during 12-week peak influenza season• 137 outpatient study sites• 7 US medical centers
• Staff at centers randomized• N-95• Medical mask
• N=2862 HCPs• 5180 HCP-seasons
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Odds of Lab-Confirmed Influenza Among Healthcare Providers: N95 vs Medical Mask
Intention to Treat Cohort
Per-protocol Cohort
Adjusted*
Adjusted*
Unadjusted
Unadjusted
* Adjusted for: age, gender, race, number of household members aged <5 years, categorical occupation risk level, influenza vaccination status, etc
Odds Ratio (95% CI) for Influenza with N-95
Radonovich LJ, et al. JAMA 2019;322(9):824-833
Lab-confirmed influenza: • N-95: 207; 8.2% of HCP seasons• Medical mask: 7.2% of HCP seasons
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Risk of Invasive Streptococcal Infection Among PEH, Anchorage, 2002-2015
Mosites E, et al. Emerg Infect Dis 2019;25(10):1903-1910
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Widespread Hepatitis A Outbreaks, March 2017-Sept 27, 2019
• 26,276 cases• 15,819 hospitalizations• 268 deaths• Risk factors
• Homelessness• Drug use• Recent incarceration• MSM• Chronic liver disease
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Measles, US, October 2018-October 2019
Patel M, et al. MMWR Early Release Oct 4,2019
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0.6 0.60.7
0.8 0.80.7
0.8 0.8 0.8
1.1
0
1
2
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
HP2020 Goal: <1%
Very few US toddlers receive no vaccines at all, but this group is increasing
*Source: National Immunization Survey, MMWR October 12, 2018, 19-35 months at time of survey
Percentage of 0 Dose children
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For more information please contact the Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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As of Oct 4, 2019: 3,087 confirmed cases/114 probable, 2,137 deaths
Ebola outbreak in conflict zone Infected HCWs and nosocomial spread once again important (6% of cases) Currently, <60% of cases appropriately isolated
Renewed efforts at community engagement Trust building extremely challenging
Systematic evaluation of multiple new therapeutics Vaccines are available Global preparedness improved
Ebola, DRC, 2018-19
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Risk of Transmission of Ebola
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Utilization of Ebola Vaccine: Ring Vaccination
Ebola Case
Contact Case
Contact Contact
August 2019: • Tertiary contacts• Pregnancy women, after 1st trimester
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Ebola Treatment, 2019Investigational Agents:• ZMapp:
• combination of three humanized monoclonal antibodies• evaluated in the PREVAIL II trial in West Africa• trend in benefit but missed the primary endpoints due to the declining
number of cases. • Remdesivir (GS-5734): antiviral drug• REGN-EB3 (Regeneron):
• combination of three, fully human, monoclonal antibodies• efficacy equivalent to ZMapp in non-human primates
• mAb114: • single human monoclonal antibody• protects NHPs with 1 dose given 5d after challenge
• Favipiravir: broad-spectrum polymerase inhibitor
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Improved Domestic Preparedness: Ebola Treatment Centers
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Lessons Learned from Ebola:Human Factors Engineering
• Doffing of PPE• Study of healthcare worker removing PPE artificially contaminated:
• Fluorescent lotion• Bacteriophage MS2
Tomas M, et al. JAMA Intern Med 2015;175(12):1904-1910
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Lessons Learned from Ebola:Human Factors Engineering
Drews FA, et al. Clin Infect Dis 2019;69(S3):S199-S205
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Thinking Holistically to Protect Patients
Protecting Across the Patient Care Spectrum
• Faster diagnostic tools
• Sepsis
• Implement current recommendations
• Innovation
• Antibiotic Stewardship
Appropriate Treatment Early DetectionPrevent Infections
• Emerging Resistant Bacteria• Inter-facility Transmission
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CDC Strategic Priorities
End epidemics
Eliminate diseases
Secure global health and ensure domestic
preparedness
CDC is Science-based, Data-driven, Service-oriented
InfluenzaAntibiotic resistance
Opioid misuseDiabetes
HIV/AIDSHepatitis C
Vaccine-preventable diseases
Pandemic contagionsVector-borne diseases
Terrorism preparedness
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