Including Infection Prevention Research Articles

Lessons Learnt from Epidemiological Investigation of Lassa Fever Outbreak in a Southwest State of Nigeria December 2015 to April 2016.

Introduction: An outbreak of Lassa Fever (LF) reported and confirmed in Ondo state, Southwest Nigeria in January 2016 was investigated. This paper provides the epidemiology of the LF and lessons learnt from the investigation of the outbreak.Methods: The incidence management system (IMS) model was used for the outbreak coordination. Cases and deaths were identified through the routine surveillance system using standard definitions for suspected and confirmed cases and deaths respectively. Blood specimens collected from suspect cases were sent for confirmation at a WHO accredited laboratory. Active case search was intensified, and identified contacts of confirmed cases were followed up for the maximum incubation period of the disease. Other public health responses included infection prevention and control, communication and advocacy as well as case management. Data collected were analysed using SPSS 20, by time, place and persons and important lessons drawn were discussed. Results: We identified 90 suspected LF cases of which 19 were confirmed by the laboratory. More than half (52.6%) of the confirmed cases were females with majority (73.7%) in the age group ≥ 15 years. The Case Fatality Rate (CFR) of 63.2% among the laboratory-confirmed positive cases where 9 of 19 cases died, was significantly higher compared to the laboratory confirmed negative cases where 6 of the 65 cases died ( CFR; 8.5%) p ≤ 0.05. Two hundred and eighty-seven contacts of the confirmed cases were identified, out of which 267(93.0%) completed the follow-up without developing any symptoms and 2 (0.7%) developed symptoms consistent with LF and were confirmed by the laboratory. More than half of the contacts were females (64.5%) with most of them (89.2%) in the age group ≥ 25 years. Discussion: One key lesson learnt from the investigation was that the confirmed cases were mainly primary cases; hence the needs to focus on measures of breaking the chain of transmission in the animal-man interphase during Lassa fever epidemic preparedness and response. In addition, the high case fatality rate despite early reporting and investigation suggested the need for a review of the case management policy and structure in the State. Key Words: Lassa fever, Outbreak Response, Incident Management System, Nigeria

Assesing sensitivity and specificity of rapid diagnostic test : the importance and challenges of Influenza surveillance in Indonesia

Background: The rapid detection of influenza viruses from clinical samples is important for establishing public health and clinical decisions, including infection prevention and control measures. The SD Bioline rapid influenza test (Standard Diagnostics, Inc., Suwon, Korea) is a point-of-care (POC) diagnostic test which based on influenza-specific monoclonal antibodies. The purpose of this study is to assess the performance of this assay against the reference diagnostic standards of RT-PCR for Influenza diagnosis in Surveillance activity.Methods: 4,262 nasal and throat swab specimens were collected from influenza-like illness (ILI) patients from sentinel hospital and health-care sites across 10 provinces in Indonesia. Specimens were tested with the SD Bioline rapid influenza test in sentinels and rRT-PCR test was conducted in referral laboratory in Jakarta. Data analysis was performed by comparing the results of rapid test conducted in the POC settting and the results of rRT-PCR test.Results: Testing of throat and nasal swabs from children and adults indicated the specificity of The SD Bioline rapid influenza test to be 97% for influenza A and B, respectively, in 4262 specimens. However, the overall sensitivity of the SD Bioline rapid influenza test for these samples was low at 25%.Conclusions: Overall, the results indicated that the SD Bioline rapid influenza test has a high specificity but low sensitivity for detection influenza from throat and nasal swabs therefore it will be a challenge of laboratory testing on site.Keywords: Influenza, rapid diagnostic test, surveillance

Improving water, sanitation and hygiene in health-care facilities, Liberia

ProblemThe lack of proper water and sanitation infrastructures and poor hygiene practices in health-care facilities reduces facilities’ preparedness and response to disease outbreaks and decreases the communities’ trust in the health services provided.ApproachTo improve water and sanitation infrastructures and hygiene practices, the Liberian health ministry held multistakeholder meetings to develop a national water, sanitation and hygiene and environmental health package. A national train-the-trainer course was held for county environmental health technicians, which included infection prevention and control focal persons; the focal persons acted as change agents.Local settingIn Liberia, only 45% of 701 surveyed health-care facilities had an improved water source in 2015, and only 27% of these health-care facilities had proper disposal for infectious waste.Relevant changesLocal ownership, through engagement of local health workers, was introduced to ensure development and refinement of the package. In-county collaborations between health-care facilities, along with multisectoral collaboration, informed national level direction, which led to increased focus on water and sanitation infrastructures and uptake of hygiene practices to improve the overall quality of service delivery.Lessons learntNational level leadership was important to identify a vision and create an enabling environment for changing the perception of water, sanitation and hygiene in health-care provision. The involvement of health workers was central to address basic infrastructure and hygiene practices in health-care facilities and they also worked as stimulators for sustainable change. Further, developing a long-term implementation plan for national level initiatives is important to ensure sustainability.

Intra-Facility Acquisition of Methicillin-Resistant Staphylococcus aureus (MRSA) in Southern Wisconsin Skilled Nursing Facilities

BackgroundStudies have shown that skilled nursing facilities (SNFs) are reservoirs for methicillin-resistant Staphylococcus aureus (MRSA). The extent to which resident-to-resident transmission accounts for the high burden of MRSA in these facilities remains poorly understood. The objective of this study was to estimate the frequency of intra-facility MRSA acquisition in a sample of SNFs participating in a longitduinal study in Wisconsin.MethodsMRSA colonization among a cohort of 449 subjects residing in six SNFs in Southern Wisconsin was measured using serial, multi-anatomical surveillance culturing. Phenotypic acquisitions events (i.e., MRSA [-] to MRSA[+]) were identified and further characterized both temporally (calendar date) and genetically (pulse-field gel electrophoresis). An intra-facility acquisition event was defined as incident recovery of an MRSA isolate that was genetically identical to at least one other strain previously recovered in a study facility. A Marascuilo procedure for comparing multiple proportions was employed to determine whether the proportion of intra-facility MRSA acquisitions differed across study facilities. Linear regression was employed to assess if certain facility-level characteristics were associated with rates of intra-facility MRSA acquisition.Results129 acquisition events were identified that met our criteria, of which 74 were determined to be intra-facility (57.4%) [95% CI: 45.5–67.6%]. Statistically significant differences were found between the intra-facility acquisition proportion of multiple SNFs. A facility’s baseline MRSA prevalence was significantly associated with its intra-facility MRSA acquisition rate (R2 = 0.784, P-value = 0.012).ConclusionIntra-facility acquisition represents a large proportion of the burden of MRSA observed in SNFs. The rate of intra-facility acquisition is variable between facilities but may, in part, be explained by the prevalent burden of MRSA in the facility (i.e., MRSA colonization pressure to characteristics of the facility). Whether other facility characteristics, including infection prevention practices are contributing to these transmission dynamics requires further study.Disclosures All authors: No reported disclosures.

Early prevention of trauma-related infection/sepsis.

Trauma still represents one of the major causes of death worldwide. Despite the reduction of post-traumatic sepsis over the past two decades, the mortality of septic trauma inpatients is still high (19.5–23 %). Early prevention of sepsis development can aid in the subsequent treatment of patients and help improve their outcomes. To date, the prevention of trauma-related infection/sepsis has mainly included infection prevention (e.g., surgical management, prophylactic antibiotics, tetanus vaccination, immunomodulatory interventions) and organ dysfunction prevention (e.g., pharmaceuticals, temporary intravascular shunts, lung-protective strategies, enteral immunonutrition, acupuncture). Overall, more efficient ways should be developed to prevent trauma-related infection/sepsis.

Development and Evaluation of an Infection Prevention Self-care Application for Cancer Patients with Chemotherapy

Purpose: The aim of this study is to develop and evaluate an infection prevention self-care application for cancer patients who have been discharged from hospital after receiving chemotherapy. Methods: The app was developed through five stages: analysis, design, development, implementation and evaluation. The app’s contents included infection prevention education, checking daily self-management, checking daily inquiry and information about the app. Cancer patients undergoing chemotherapy were asked to use the app and then a nonequivalent control group non-synchronized design was conducted to analyze the effect of the app on infection prevention self-care knowledge, self-care performance, infection occurrence and temperature. Twenty-two patients in the experimental group and twenty-four patients in the control group participated in this study. Results: The self-care knowledge score (t=6.74, p<.001) and self-care performance score (t=13.44, p<.001) were statistically higher in the experimental group compared with the control group respectively. The infection occurrence was not different between the experimental and control groups. But temperature in the control group was statistically higher than in the experimental group (t=-2.39, p=.021). Conclusion: The infection prevention self-care application for cancer patients receiving chemotherapy was an effective intervention to decrease infections during home care.

Neonatal admissions, quality of care and outcome: 4 years of inpatient audit data from The Gambia's teaching hospital

Background:National facility-based neonatal mortality audits are an important source of data to identify areas for improvement of service delivery and outcome of care.Objectives:To examine admissions to the neonatal unit, Edward Francis Small Teaching Hospital, Banjul, The Gambia and make recommendations for programme action to reduce mortality through improvements in the quality of care, particularly with respect to suspected neonatal infections.Methods:Case notes were reviewed for all neonates admitted to the neonatal unit during a 5-year period (1 January 2009 to 31 December 2013) to assess outcome and quality of care. Data for 2009 were subsequently excluded because of the low proportion of records retrieved.Results:Of the 4944 admissions between 1 January 2010 and 31 December 2013, 1734 infants (35%) died, with 57% of all deaths occurring within the first 48 hours of admission. There were 1267 early neonatal deaths (deaths occurring during the first 7 days of life), 67% of which occurred during the first 48 hours of life. Independent predictors of neonatal death in the multivariable analysis were; maternal lack of antenatal care, non-teaching hospital delivery, admission weight < 1500g, abnormal blood glucose concentration ( < 2.6 mmol/L or >6.9 mmol/L) and hypothermia (axillary temperature < 36.5˚C). Forty-eight per cent of newborns had point-of-admission hypothermia. Possible severe bacterial infection (pSBI) accounted for 44% (2166/4944) of admissions, prematurity/low birthweight for 27% (1340/4944) and intrapartum-related conditions for 20%. Only 5% (104/2166) of pSBI cases had at least one supportive investigation; 41 had a chest radiograph, 26 had a blood culture and 43 had a lumbar puncture. Although 94% of the newborns received intravenous antibiotics, 55% of those who did lacked clinical evidence of pSBI and had no diagnostic work-up.Conclusion:Priority areas for action include infection prevention and improved diagnosis and management. There is also scope to reduce hypothermia with feasible interventions particularly targeting preterm infants. Improved patient records and audit data with linked action and accountability are interventions which could prevent such deaths of newborns in The Gambia and other developing countries.

Reducing CLABSIs Through Team Empowerment: A 67% Reduction

As a 250-bed regional pediatric medical center in New Orleans, Louisiana boasts a 36-bed Neonatal Intensive Care Unit (NICU) that experienced continual central line associated bloodstream infections (CLABSI) since January 2014. These infections were not associated with acuity, location within the unit, or a lack of adherence to basic infection control principles. By June 2014, it was determined that a more active approach was needed. In June 2014, a multidisciplinary team formed, including Infection Prevention, Quality Assessment and the NICU team to quickly and effectively tackle the infection rate. The team rapidly implemented strategic initiatives to include insertion and maintenance bundles, checklists, a dressing change team, a “buddy system” for tubing changes, use of sterile linens, chlorhexidine gluconate (CHG) bathing, daily assessment of device need with indication documented, a “kick the bucket” campaign, a “days since last CLABSI” poster, and root-cause-analyses from the Infection Preventionist (IP) for every infection. Using Excel, device days and infections were compared to before implementation (January to June 2014) and after (July to December 2014) to determine statistical significance of the strategies implemented. The adherence to the bundles, CHG bathing, and dressing changes was audited, with case reviews by the IP on any suspect or confirmed CLABSIs. The infections in NICU from January to June 2014 was compared to July – December 2014, with no statistical difference in device days. Process audits and case reviews showed excellent adherence to the initiatives, with staff feedback revealed a feeling of empowerment and in-control of preventing CLABSIs. By implementing bundle approaches and best practices to central line insertion and maintenance, the NICU experienced a 67% reduction in CLABSIs. This achievement has paved the way for the team to adopt these strategies house-wide.

Outbreak Column 16: Cognitive errors in outbreak decision making.

During outbreaks, decisions must be made without all the required information. People, including infection prevention and control teams (IPCTs), who have to make decisions during uncertainty use heuristics to fill the missing data gaps. Heuristics are mental model short cuts that by-and-large enable us to make good decisions quickly. However, these heuristics contain biases and effects that at times lead to cognitive (thinking) errors. These cognitive errors are not made to deliberately misrepresent any given situation; we are subject to heuristic biases when we are trying to perform optimally. The science of decision making is large; there are over 100 different biases recognised and described. Outbreak Column 16 discusses and relates these heuristics and biases to decision making during outbreak prevention, preparedness and management. Insights as to how we might recognise and avoid them are offered.

Impact of a Hygiene Intervention on Virus Transmission in a Long-term Care Facility

ISSUE: Unexpected bed bug infestations in patients are concerning in ambulatory care centers, as hospital and long-term care facility outbreaks have been described. Although there has been resurgence nationally, strategies for bed bug management in outpatient environments have not been well-defined. Bed bugs are of particular concern at our comprehensive cancer center, as many patients reside in on-campus housing and are seen in multiple locations throughout the center. PROJECT: In December 2011, a team which included Infection Prevention, Environmental Services, Social Work, Materials Management, Nursing and a Pest-Control Service, convened to develop an ectoparasite management policy for our outpatient oncology center. A flexible policy design was utilized to account for a variety of exposure scenarios. The policy’s main goals were timely case identification, proper isolation and containment procedures, and management of follow-up visits for patients with confirmed bed bugs. During policy implementation in June 2012 staff education was provided. Post-implementation, bed bug events were tracked, cases underwent review, and policies modified as needed. RESULTS: From June 2012 to October 2013, 8 bed bug events were reported. A total of 4/8 (50%) were confirmed patient infestations, including 3/4 (75%) identified during the patient’s clinic appointment; activating isolation, cleaning and inspection components of our policy. In each instance, a pesticide company inspected and found no evidence of spread within patient care areas and no transmission events were documented. Staff reported challenges in care coordination, especially for patients with multiple follow-up appointments. Tailored personal feedback reinforced policies in healthcare workers, and Environmental Service staff required additional training on linen management and cleaning procedures. LESSON LEARNED: While identification of bed bugs at our outpatient cancer center was infrequent, the impact on patient care was significant. Development of an organized centerwide policy enabled us to manage proven and possible bed bug events. Our policy was improved through simple learning tools, including quick reference guides and patient education sheets. Quality reviews and debriefing after events helped to disseminate best-practices, identified educational gaps, enhanced staff engagement and ultimately improved policy implementation.

Clostridium Difficile Infection Prevention Initiative: A Community Hospital's Multidisciplinary Approach Using Targeted Evidence-Based Interventions

Clostridium difficile (CDI) was consistently the most frequent healthcare associated infection (HAI), at our small, acute care community hospital, contributing to increased length of stay, increased medical costs, and affecting patient outcomes. With a goal to reduce CDI, using targeted, evidence based CDI prevention and reduction strategies, a CDI team was assembled with staff from all levels, to drive improvement. The team included Infection Prevention (IP), Pharmacy, Nursing, Environmental Services, Laboratory, Administration, Medical Staff and Performance Improvement.

Multidrug-Resistant Gram-Negative Bloodstream Infections among Residents of Long-Term Care Facilities

Prevalence of multidrug-resistant (MDR) gram-negative (GN) bacteria is increasing globally and is complicated by patient movement between acute and long-term care facilities (LTCFs). In Asia, the contribution of LTCFs as a source of MDR GN infections is poorly described. We aimed to define the association between residence in LTCFs and MDR GN bloodstream infections (BSIs). Secondary analysis of data from an observational cohort. Two tertiary referral hospitals in Singapore, including the 1,400-bed Tan Tock Seng Hospital and the 1,600-bed Singapore General Hospital. Adult patients with healthcare-onset (HCO) or hospital-onset (HO) GN BSI. Patients were identified from hospital databases using standard definitions. Risk factors for both MDR GN HCO and HO BSI were analyzed using a multivariable logistic regression model. A total of 675 episodes of GN BSI occurred over a 31-month period. Residence in a LTCF was an independent risk factor for developing MDR GN BSI (odds ratio [OR], 5.1 [95% confidence interval (CI), 2.2-11.9]; P < .01) when antibiotics were not used within the preceding 30 days. This risk persisted beyond the first 48 hours of hospitalization (OR, 3.4 [95% CI, 1.3-9.0]; P = .01). Previous culture growing an MDR organism (OR, 1.8 [95% CI, 1.3-2.7]; P < .01), previous antibiotic use (OR, 1.8 [95% CI, 1.2-2.6]; P < .01), and intensive care unit stay (OR, 2.2 [95% CI, 1.2-3.9]; P = .01), increased the risk of MDR GN BSI. Residence in a LTCF is an independent risk factor for MDR GN BSI. Attempts to contain MDR GN bacteria in large Asian cities, where the proportion of the population that is elderly is projected to increase, should include infection prevention strategies that engage LTCFs.

P334: Catalysing local production of alcohol based handrub in african hospitals: the power of south-north-south partnership

The 58th WHO African Regional Committee in 2008 called for action in 12 patient safety action areas, including infection prevention and control (IPC). Hand hygiene through use of alcohol based handrub (ABHR) is a clear mechanism to translate a regional mandate into local action. However, ABHR availability is a key challenge in African hospitals.

O032: Patient safety improvement in 14 african hospitals through partnerships: learning, doing and catalysing change

The 58th WHO African Regional Committee in 2008 called for action in 12 patient safety action areas, including infection prevention and control (IPC). Hospital-to hospital partnerships is a mechanism utilized by the WHO African Partnerships for Patient Safety to respond to this call, linking policy to local action in 14 African and 3 European countries.

Key informant interview on antimicrobial resistance (AMR) in some countries in the western pacific region

BackgroundThe World Health Organization (WHO) selected antimicrobial resistance (AMR) as the theme for World Health Day 2011. The slogan was “Combat Drug Resistance – No action today, no cure tomorrow” A six-point policy package was launched as a core product for World Health Day. It aimed to stimulate extensive and coherent action to overcome the many challenges presented by antimicrobial resistance.MethodsAs a preparation for World Health Day, interviews were conducted with a series of key informants, mainly senior government staff, to assess their awareness of the topic and the interventions proposed in the policy package. Since the key informant interview methodology was used with a small number of interviewees, it may be difficult to demonstrate the validity of the findings.ResultsKey informants from twelve out of fifteen countries responded, which included Fiji (n = 5), Kiribati (n = 1), Lao PDR (n = 2), Malaysia (n = 6), Micronesia (n = 3), Mongolia (n = 5), the Philippines (n = 5), Vietnam (n = 6), Vanuatu (n = 1), Solomon Islands (n = 3), Cambodia (n = 5) and Brunei (n = 1). There was a total of forty-three respondents (n = 43). AMR was widely recognized as a problem. Lack of a coherent, comprehensive and national plan or strategy was noted. Surveillance was often seen as weak and fragmented even where presented. Laboratory capacity was felt to be insufficient across all countries interviewed. The majority of respondents stressed the need for national and local plans to combat AMR including reliable estimates of the financial cost of combating and managing AMR, the need for legislation to control inappropriate use of antimicrobials in food animals and more serious efforts to promote Standard Treatment Guidelines (STGs) and Rational Prescription. Also, importance was highlighted of the need to include infection prevention and control (IPC) as a part of accreditation and registration of health institutions and programs to promote IPC to the general population.ConclusionA coalition of interested parties at the local, national and international levels need to generate and sustain the political will to organize a more comprehensive, sustainable, and coherent approach to AMR.

Barriers and bridges to infection prevention and control: results of a qualitative case study of a Netherlands' surgical unit

ObjectivesThe objectives of the study are to observe the overall work environment including infection prevention and control (IP&C) practices on the target surgical unit; to analyse the policies and procedures...

Transmission of 2009 Pandemic Influenza A (H1N1) Virus among Healthcare Personnel—Southern California, 2009

In April 2009, 2009 pandemic influenza A (H1N1) (hereafter, pH1N1) virus was identified in California, which caused widespread illness throughout the United States. We evaluated pH1N1 transmission among exposed healthcare personnel (HCP) and assessed the use and effectiveness of personal protective equipment (PPE) early in the outbreak. Cohort study. Two hospitals and 1 outpatient clinic in Southern California during March 28-April 24, 2009. Sixty-three HCP exposed to 6 of the first 8 cases of laboratory-confirmed pH1N1 in the United States. Baseline and follow-up questionnaires were used to collect demographic, epidemiologic, and clinical data. Paired serum samples were obtained to test for pH1N1-specific antibodies by microneutralization and hemagglutination-inhibition assays. Serology results were compared with HCP work setting, role, and self-reported PPE use. Possible healthcare-associated pH1N1 transmission was identified in 9 (14%) of 63 exposed HCP; 6 (67%) of 9 seropositive HCP had asymptomatic infection. The highest attack rates occurred among outpatient HCP (6/19 [32%]) and among allied health staff (eg, technicians; 8/33 [24%]). Use of mask or N95 respirator was associated with remaining seronegative (P = .047). Adherence to PPE recommendations for preventing transmission of influenza virus and other respiratory pathogens was inadequate, particularly in outpatient settings. pH1N1 transmission likely occurred in healthcare settings early in the pandemic associated with inadequate PPE use. Organizational support for a comprehensive approach to infectious hazards, including infection prevention training for inpatient- and outpatient-based HCP, is essential to improve HCP and patient safety.

Infection preventionists' experience during the first months of the 2009 novel H1N1 influenza A pandemic

BackgroundA novel strain of influenza A (H1N1) was identified in April 2009 and developed into a pandemic by June 2009. This rapid and unexpected event had enormous implications for infection preventionists (IP) internationally. Lessons learned from this event should guide future pandemic planning efforts.MethodsFocus groups were conducted at the Association for Professionals in Infection Control and Epidemiology, Inc, (APIC) 2009 conference to evaluate IPs' experience with the novel H1N1 influenza pandemic and assess their perceived needs related to novel H1N1 topics and products required for future education and reference materials.ResultsForty IPs (37 from the United States and 3 international) participated in the focus groups. Needed reference materials identified by attendees included infection prevention guidance for nonacute care settings; occupational health polices; and brief, multilanguage patient/family educational materials. Educational topics on which IPs need to be trained include isolation precautions/personal protective equipment recommendations for novel H1N1 patients, coordination between hospitals and community response agencies, and surge management. The rapidly changing and conflicting recommendations related to patient management made responding to this event challenging. IPs require synthesized infection prevention guidelines developed in a concise, real-time format.ConclusionIPs must continue to partner with public health and other response agencies to address gaps in pandemic planning.

Prophylaxe der Sepsis – Infektionsprävention, Hygienerichtlinien und Akutmanagement

In spite of improved diagnostic and therapeutic strategies, the incidence and mortality rates of sepsis and septic shock are still high and associated with rising cost for the health care systems. Many instructions for the management of sepsis and septic shock have been issued. These treatment guidelines focus on early diagnosis and effective treatment with initial fluid resuscitation and antibiotic selection. Another important approach is the prevention of sepsis. This includes infection prevention by continual surveillance and re-education. A multi-professional team approach is required to to develop and implement strategies to prevent infection of the critically ill patient. Rational use of antibiotic agents and a rigorous hygiene management are indispensable. However, the impact of various preventive strategies, e. g. administration of corticosteroids as well as of insulin and statins remains unclear.

The Promise of Plasma: Medical Applications Include Healing and Infection Prevention

The Promise of Plasma: Medical Applications Include Healing and Infection Prevention