Role of-epidemiology-for-clinical-services nirmal-kandel
-
Upload
nirmal-kandel -
Category
Health & Medicine
-
view
53 -
download
0
Transcript of Role of-epidemiology-for-clinical-services nirmal-kandel
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 1 |
3rd Epidemiology National Scientific Meeting
Role of Epidemiology in
Clinical Services
Dr Nirmal Kandel , MBBS, MA (Anthropology), MPH, EMBA
Public Health Specialist
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 2 |
Outlines
Application of Epidemiology in real life in clinical settings – an example
Personal Experience
Application of Epidemiology
– When
– How
– Where
– Why
– What next
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 3 |
Background
In 2011, KPC came to one of the nation’s flagship research hospitals, the
Clinical Center at the National Institutes of Health in Bethesda, Maryland,
known as the NIH.
Klebsiella pneumoniae carbapenemase (KPC)
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 4 |
43 Lung
Transplant
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 5 |
Patient Zero
A 43-year-old woman with complications from a lung transplant is transferred from a
New York City hospital with a highly resistant superbug known as KPC – June 13,
2011
The NIH is one of the most prestigious research hospitals in the country, but it has
never had a case of KPC before.
Immediately went on high alert, implemented IPC measures.
– The woman went into strict isolation:
– Everyone entering her room donned a protective gown and gloves and rigorously washed their
hands.
– Her medical equipment got special decontamination.
– All other patients in the ICU had their throats and groins tested regularly to see if the bug was
spreading.
The patient was later discharged – July 15, 2011
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 6 |
43 Lung
Transplant
34 Tumor
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 7 |
Second Infection
Several weeks later,
a 34-year-old man hospitalized with a tumor tests positive for KPC.
The two patients have no known link:
They spent no time in the ICU together, and
they had different caregivers and equipment.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 8 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
29
Lymphoma 71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
19
Immuno-
deficiency
29
Aplastic
Anemia
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 9 |
Outbreak
Over the next few months, several more patients test positive for KPC.
As the NIH attempts to deal with the outbreak, no combination of
antibiotics seems to be able to stop it.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 10 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
37 Sickle
Cell
Anemia
29
Lymphoma 71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
34
Aplastic
Anemia
19
Immuno-
deficiency
29
Aplastic
Anemia
60
bronchiec
tasis
59
Immuno-
deficiency
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 11 |
Beyond ICU
The hospital creates a separate ICU for KPC patients.
The old ICU is cleaned out and disinfected by robots before patients are
moved back in.
But somehow, it spreads beyond the ICU.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 12 |
The Victims
Doctors try several combinations of antibiotics
even an experimental drug still in development.
Nothing works.
And some patients die.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 13 |
Underlying Conditions
Five other patients die, but the hospital believes their deaths are due to
their underlying health problems, not the KPC infection.
Ultimately, 11 infected patients die.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 14 |
Hospital Measures
New ICU was constructed for KPC infection
To stop the bug, entire sinks have been disassembled and vents cleaned with
bleach.
The hospital has tested and retested patients and health professionals looking for
carriers of the superbug (using rectal swabs too).
Test after test never found the bug on hospital workers' hands. Tainted objects like
the ventilator couldn't be ruled out
It went on an aggressive campaign to demand more stringent hand washing.
NIH adopted more complex and expensive decontamination, using robot-like
machines to spray germ-killing hydrogen peroxide into the tiniest of crevices in all
affected rooms and equipment.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 15 |
Looking for a link
Throughout the outbreak, the hospital used epidemiological and genetic
analysis to help understand the transmission sequence.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 16 |
Looking for a link
They compared samples from each patient, along with information such
as whether patients overlapped in the same ward, to track the most
plausible transmission sequence:
– Black lines mean the infected patient was in the same ward, which likely
provided an opportunity for the KPC to spread to the next patient.
– Red lines indicate the two patients had no overlap, but genetic analysis makes
clear the bacteria in the two patients were closely related and likely spread in a
more complicated path.
– Dotted black lines mean the patients shared a ward, but there’s at least one
other way they might have been infected.
– Dotted red line mean the patients didn’t overlap in a ward, but there’s more
than one way they might have been infected.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 17 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
37 Sickle
Cell
Anemia
29
Lymphoma 71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
34
Aplastic
Anemia
19
Immuno-
deficiency
29
Aplastic
Anemia
60
bronchiec
tasis
59
Immuno-
deficiency
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 18 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
37 Sickle
Cell
Anemia
29
Lymphoma 71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
34
Aplastic
Anemia
19
Immuno-
deficiency
29
Aplastic
Anemia
60
bronchiec
tasis
Young Man
ID
59
Immuno-
deficiency
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 19 |
Last Case
Then, a year after the outbreak, a young man arrives at NIH due to
complications from a bone marrow transplant. He becomes infected
with KPC and dies.
Finally, the outbreak – contained – December 2012
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 20 |
Links
27 years old female (transplant) had been in the ICU at the same time
as the New York woman and really was the next infected, silently
carrying the bug longer before becoming sick.
that was enough time for 34 year old man’s (tumor) infection to spread
to 27 year old female, who just got sick faster.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 21 |
Personal Experience
Was Medical Officer for Surgery - noticed post surgical wound infection
Observed and triangulate all the causes of wound infection with those
cases
Simple experimental study carried out
– All the cases of my unit is asked to shave a 2 hours before surgery
– Controls – other unit who were practicing exiting mechanism (shaving a day
before
– After one month – there was significant decrease of wound infection in our unit
than others
– we didn’t do any statistical analysis and I just presented and hospital adopted
since then to apply pre-operative shaving before 2 hours of surgery
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 22 |
Application of Epidemiology
– When
• any abnormal events, aberration from normal phenomena
– How
• Abreast with disease endemicity in your area,
• basic with epidemiology techniques
– Where
• OPDs, IPDs, ICUs, Post Ops
– Why
• The first contact of patient or any suspected case is Physician/Clinicians
– What to do
• If you find any abnormalities then inform authorities accordingly
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 23 |
References and Acknowledgement
1. Evan S. Snitkin, Adrian M. Zelazny, Pamela J. Thomas, Frida Stock, David K.
Henderson, Tara N. Palmore, Julia A. Segre. Tracking a Hospital Outbreak of
Carbapenem-Resistant Klebsiella pneumoniae with Whole-Genome Sequencing .
Sci Transl Med. 2012 August 22; 4(148): 148ra116.
doi:10.1126/scitranslmed.3004129
2. Authors of this article and the investigation team and all people directly or
indirectly related to control of this outbreak investigation.
Disclaimer: This reference and its content is only used for teaching purpose.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist 24 |
Thank You