Risk Of Nosocomial Transmission Research Articles

Risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in Hong Kong

SummaryBackgroundCoronavirus disease 2019 (COVID-19) was first reported in Wuhan in December 2019 and has rapidly spread across different cities within and outside China. Hong Kong started to prepare for COVID-19 on 31st December 2019 and infection control measures in public hospitals were tightened to limit nosocomial transmission within healthcare facilities. However, the recommendations on the transmission-based precautions required for COVID-19 in hospital settings vary from droplet and contact precautions, to contact and airborne precautions with placement of patients in airborne infection isolation rooms.AimTo describe an outbreak investigation of a patient with COVID-19 who was nursed in an open cubicle of a general ward before the diagnosis was made.MethodContacts were identified and risk categorized as ‘close’ or ‘casual’ for decisions on quarantine and/or medical surveillance. Respiratory specimens were collected from contacts who developed fever, and/or respiratory symptoms during the surveillance period and were tested for SARS-CoV-2.FindingsA total of 71 staff and 49 patients were identified from contact tracing, seven staff and 10 patients fulfilled the criteria of ‘close contact’. At the end of 28-day surveillance, 76 tests were performed on 52 contacts and all were negative, including all patient close contacts and six of the seven staff close contacts. The remaining contacts were asymptomatic throughout the surveillance period.ConclusionOur findings suggest that SARS-CoV-2 is not spread by an airborne route, and nosocomial transmissions can be prevented through vigilant basic infection control measures, including wearing of surgical masks, hand and environmental hygiene.

Respiratory support for adult patients with COVID-19.

The COVID‐19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non‐invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID‐19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol‐generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non‐rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non‐invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi‐organ failure, or acute respiratory distress syndrome (ARDS).

Coronavirus disease 2019: Implications of emerging infections for transplantation.

The recent identification of an outbreak of 2019- novel Coronavirus is currently evolving, and the impact on transplantation is unknown. However, it is imperative that we anticipate the potential impact on the transplant community in order to avert severe consequences of this infection on both the transplant community and contacts of transplant patients.

Transmission dynamics and control of multidrug-resistant Klebsiella pneumoniae in neonates in a developing country.

Multidrug-resistant Klebsiella pneumoniae is an increasing cause of infant mortality in developing countries. We aimed to develop a quantitative understanding of the drivers of this epidemic by estimating the effects of antibiotics on nosocomial transmission risk, comparing competing hypotheses about mechanisms of spread, and quantifying the impact of potential interventions. Using a sequence of dynamic models, we analysed data from a one-year prospective carriage study in a Cambodian neonatal intensive care unit with hyperendemic third-generation cephalosporin-resistant K. pneumoniae. All widely-used antibiotics except imipenem were associated with an increased daily acquisition risk, with an odds ratio for the most common combination (ampicillin + gentamicin) of 1.96 (95% CrI 1.18, 3.36). Models incorporating genomic data found that colonisation pressure was associated with a higher transmission risk, indicated sequence type heterogeneity in transmissibility, and showed that within-ward transmission was insufficient to maintain endemicity. Simulations indicated that increasing the nurse-patient ratio could be an effective intervention.

Nosocomial Transmission of Emerging Viruses via Aerosol-Generating Medical Procedures.

Recent nosocomial transmission events of emerging and re-emerging viruses, including Ebola virus, Middle East respiratory syndrome coronavirus, Nipah virus, and Crimean–Congo hemorrhagic fever orthonairovirus, have highlighted the risk of nosocomial transmission of emerging viruses in health-care settings. In particular, concerns and precautions have increased regarding the use of aerosol-generating medical procedures when treating patients with such viral infections. In spite of increasing associations between aerosol-generating medical procedures and the nosocomial transmission of viruses, we still have a poor understanding of the risks of specific procedures and viruses. In order to identify which aerosol-generating medical procedures and emerging viruses pose a high risk to health-care workers, we explore the mechanisms of aerosol-generating medical procedures, as well as the transmission pathways and characteristics of highly pathogenic viruses associated with nosocomial transmission. We then propose how research, both in clinical and experimental settings, could advance current infection control guidelines.

A Methodology for Determining Which Diseases Warrant Care in a High-Level Containment Care Unit.

Although the concept of high-level containment care (HLCC or ‘biocontainment’), dates back to 1969, the 2014–2016 outbreak of Ebola virus disease (EVD) brought with it a renewed emphasis on the use of specialized HLCC units in the care of patients with EVD. Employment of these units in the United States and Western Europe resulted in a significant decrease in mortality compared to traditional management in field settings. Moreover, this employment appeared to significantly lessen the risk of nosocomial transmission of disease; no secondary cases occurred among healthcare workers in these units. While many now accept the wisdom of utilizing HLCC units and principles in the management of EVD (and, presumably, of other transmissible and highly hazardous viral hemorrhagic fevers, such as those caused by Marburg and Lassa viruses), no consensus exists regarding additional diseases that might warrant HLCC. We propose here a construct designed to make such determinations for existing and newly discovered diseases. The construct examines infectivity (as measured by the infectious dose needed to infect 50% of a given population (ID50)), communicability (as measured by the reproductive number (R0)), and hazard (as measured by morbidity and mortality). Diseases fulfilling all three criteria (i.e., those that are highly infectious, communicable, and highly hazardous) are considered candidates for HLCC management if they also meet a fourth criterion, namely that they lack effective and available licensed countermeasures.

Severe acute respiratory syndrome and other emerging severe respiratory viral infections.

Severe acute respiratory syndrome and other emerging severe respiratory viral infections.

Critical care considerations and pandemic preparedness

Critical care units are a vital component of pandemic preparedness. In a severe pandemic of a respiratory viral illness, it is likely that critical care resources will be stretched tremendously. Even for non-respiratory illnesses such as encephalitis or one of the hemorrhagic fever syndromes, there will be a significant demand for mechanical ventilation, hemodynamic monitoring and all the other elements of a modern critical care unit. While critical care is costly and resource intensive, it can result in dramatic “cures” which have enormous intangible benefits for healthcare worker morale. In addition, there is no doubt that safe and effective critical care can improve outcomes, encourage sick individuals to seek medical attention early and mitigate the devastating consequences of a severe pandemic. At the same time, it is important to realise that in a setting with vulnerable patients who may be immunocompromised, a high intensity of medical device use and stretched staff, there are significant risks of nosocomial transmission of either the pandemic pathogen or other infectious agents. It is thus vital that basic infection control practices are not compromised in critical care units even in the face of a pandemic. Ultimately, good planning that incorporates training, education and resource allocation prioritization will be important to ensure that all healthcare systems are prepared for the pandemics that we might face in the near future.

Willingness to care for blood-borne virus-infected patients in Thailand.

Although stigma and discrimination by nurses against patients infected with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) have been reported, potential determinants of nurses' willingness to care for these patients have not been well studied in Thailand. To identify factors associated with Thai nurses' willingness to care for patients infected with HIV or HCV. Multivariable logistic regression analysis of data from a questionnaire completed by nurses at a large hospital in Bangkok, Thailand. Of 626 nurses, 546 (87%) nurses participated. Eleven per cent (59) and 6% (34) had previously experienced HIV- or HCV-infected blood contamination incidents, respectively. Forty-four per cent (240) and 38% (208) reported unwillingness to care for HIV- or HCV-infected patients, respectively. Willingness to care was less common [adjusted odds ratios 0.51 (0.34-0.74) for HIV and 0.62 (0.42-0.89) for HCV] in nurses aged ≥ 40 years and in those who feared HCV [0.63 (0.37-0.99)], but not HIV [0.84 (0.5-1.26)] transmission. Nurses who had confidence in protecting themselves against infection with HIV [1.84 (1.52-2.04)] and HCV [1.87 (1.45-2.18)], and accepting attitudes towards HIV-infected co-workers [1.39 (1.08-1.66)] but not HCV-infected co-workers [1.16 (0.83-1.5)], were more willing to care for HIV- and HCV-infected patients. Around 4 in 10 Thai nurses in our sample were unwilling to care for HIV- or HCV-infected patients. Minimizing the risk of nosocomial transmission and improving the public perception of infected individuals may help improve nurses' willingness to care for such patients, in Thailand or elsewhere.

Risk of Rotavirus Nosocomial Spread After Inpatient Pentavalent Rotavirus Vaccination.

Infants born prematurely or with underlying conditions are at increased risk of severe rotavirus disease and associated complications. Given the theoretical risk of nosocomial transmission of vaccine-type rotavirus, rotavirus vaccination is recommended for infants at or after discharge from neonatal care settings. Because the first dose should be administered by 104 days of age, some infants may be age-ineligible for vaccination if delayed until discharge. This prospective cohort included infants admitted to an urban academic medical center between birth and 104 days who received care in intensive care settings. Pentavalent human-bovine reassortant rotavirus vaccine (RV5) was used, per routine clinical care. Stool specimens were collected weekly (February 2013-April 2014) and analyzed for rotavirus strains using real-time reverse transcription-polymerase chain reaction. Demographic and vaccine data were collected. RV5 safety was not assessed. Of 385 study infants, 127 were age-eligible for routine vaccinations during hospitalization. At discharge, 32.7% were up-to-date for rotavirus vaccination, compared with 82.7% for other vaccinations. Of rotavirus-unvaccinated infants, 42.6% were discharged at age >104 days and thus vaccination-ineligible. Of 1192 stool specimens collected, rotavirus was detected in 13 (1.1%): 1 wild-type strain from an unvaccinated infant; 12 vaccine-type strains from 9 RV5-vaccinated infants. No vaccine-type rotavirus cases were observed among unvaccinated infants (incidence rate: 0.0 [95% confidence interval: 0.0-1.5] cases per 1000 patient days at risk). These data suggest that delaying rotavirus vaccination until discharge from the hospital could lead to missed vaccination opportunities and may be unnecessary in institutions using RV5 with comparable infection control standards.

Impact of Electronic Hand Hygiene Monitoring on Hospital-Acquired Clostridium difficile Infection Rates

BackgroundLower rates of hand hygiene adherence are linked to increased risk of nosocomial transmission of infectious pathogens, thereby increasing morbidity and mortality. Assessing true adherence is difficult using direct observation due to the low number of observations collected, heterogeneous observer training and bias, and the Hawthorne effect. We assessed whether radio frequency identification (RFID) hand hygiene monitoring resulted in changes to our hospital-onset Clostridium difficile (HO-CDI) rates. We also assessed whether electronically measured hand hygiene improved by the end of the intervention period.MethodsThe RFID system was installed in Apr 2016 in 2 medical/surgical units, a progressive care unit, and an intensive-care unit (study group). Registered nurses, certified nursing assistants, and selected physicians wore RFID badges to track hand hygiene adherence. Adherence is defined as washing with soap or alcohol-based hand rub within 1 minute before or after entering or exiting a patient’s room. A second set of rooms (1 ICU, 1 short-stay unit, and 5 medical/surgical units) without the system served as the control group. HO-CDI rates were tracked monthly for each group using NHSN definitions. HO-CDI trends were compared for 15 months before and 12 months after installation of the system using interrupted time series analysis. Average electronic hand hygiene adherence for the first two months and last two months of the intervention period was compared using the Wilcoxon rank-sum test. Other interventions aimed at reducing HO-CDI were consistently applied to both the study and control groups.ResultsOne hundred and eighty-six HO-CDI occurred: 73 in the study group and 113 in the control group. In the study group, the trend in HO-CDI rates changed from increasing in the pre-intervention to decreasing in the post-intervention (P = 0.02) (Figure 1). HO-CDI rates in the control group demonstrated no change in trend (P = 0.69) (Figure 2). In the study group, electronically tracked hand hygiene adherence increased from a mean of 46% in Apr-May 2016, to 77% in Feb-Mar 2017 (P < 0.0001).ConclusionElectronic RFID hand hygiene systems can have a tangible effect on hospital-acquired infection rates. This result strengthens the argument for using these systems to improve patient safety.Disclosures All authors: No reported disclosures.

Infection prevention and control practice for Crimean-Congo hemorrhagic fever-A multi-center cross-sectional survey in Eurasia.

BackgroundCrimean Congo Hemorrhagic Fever (CCHF) is a life threatening acute viral infection that presents significant risk of nosocomial transmission to healthcare workers.AimEvaluation of CCHF infection prevention and control (IP&C) practices in healthcare facilities that routinely manage CCHF cases in Eurasia.MethodsA cross-sectional CCHF IP&C survey was designed and distributed to CCHF centers in 10 endemic Eurasian countries in 2016.ResultsTwenty-three responses were received from centers in Turkey, Pakistan, Russia, Georgia, Kosovo, Bulgaria, Oman, Iran, India and Kazakhstan. All units had dedicated isolation rooms for CCHF, with cohorting of confirmed cases in 15/23 centers and cohorting of suspect and confirmed cases in 9/23 centers. There was adequate personal protective equipment (PPE) in 22/23 facilities, with 21/23 facilities reporting routine use of PPE for CCHF patients. Adequate staffing levels to provide care reported in 14/23 locations. All centers reported having a high risk CCHFV nosocomial exposure in last five years, with 5 centers reporting more than 5 exposures. Education was provided annually in most centers (13/23), with additional training requested in PPE use (11/23), PPE donning/doffing (12/23), environmental disinfection (12/23) and waste management (14/23).ConclusionsStaff and patient safety must be improved and healthcare associated CCHF exposure and transmission eliminated. Improvements are recommended in isolation capacity in healthcare facilities, use of PPE and maintenance of adequate staffing levels. We recommend further audit of IP&C practice at individual units in endemic areas, as part of national quality assurance programs.

A study on factors influencing use of standard precautions in the emergency department at BPKIHS, Dharan

Background: This study investigated knowledge of and practices towards standard precautions, among all health care workers working in the emergency department in BPKIHS. Objective: To find out the factors influencing use of standard precautions in the emergency department, BPKIHS Dharan.Methods: This was a prospective observational study conducted in the emergency department. Data was collected in three ways: by direct observation of work practice, a questionnaire about knowledge, attitude and skills and through focus group discussions.Results: Regarding standard precaution, majority (54.2%) had partial knowledge. Only 4.2% know the component of it. In practice 69.52% among doctors group washed hand even though once in four observations; 96% used soap. 43.80% used gloves in doctors group in four observation; sisters used gloves the entire times. 74% washed hand after gloves removal (178). 35.23% didn’t recapped needles before disposal from those who used it among doctors group. Recapping is complete in sisters’ group. 60.95%. Sisters had complete proper disposal practice.Conclusion: Knowledge and practice of SP has direct impact in health of patient and HCW. High level of occupational exposure to blood highlights the urgent need for intervention to enhance occupational safety to prevent unnecessary nosocomial transmission of BBD. Strategies for promoting injection safety are necessary if the risk of nosocomial transmission of BBV via unsafe injection practice is to be minimized. Health Renaissance 2015;13 (3): 54-64

Exposure of Health Care Workers to Crimean-Congo Hemorrhagic Fever in Senegal: An Investigation of Two Imported Cases

Introduction: Crimean Congo hemorrhagic fever (CCHF) is a potentially fatal arbovirus with a high risk for nosocomial transmission. The goals of this study were to describe two cases of imported CCHF in Senegal and to evaluate health care worker exposure during the hospitalization of these two cases. Methodology: Exposed health care workers were identified, administered a questionnaire, and kept were under clinical surveillance for 9 days. The level of risk associated with exposure was determined using the French National Institute of Health Surveillance (InVS) classification system. Results: Two cases of CCHF transferred to Senegal from Mauritania, were admitted to the Infectious Diseases Service at Fann Teaching Hospital. The first case was admitted with diffuse hemorrhage and coma; the second case was admitted with febrile gastroenteritis. Both cases were fatal. The length of hospitalization was 06 hours and 07 days respectively. A total of 60 health care workers were exposed, including 11 doctors, 13 medical students, 14 nurses, 11 support staff, 09 nursing students, and 2 administrative staff. The majority of health care workers had a high-risk exposure (n=43, 65.2%). Moderate-risk exposure occurred among 21.2% (n=14) and low-risk exposure occurred among 13.6% (n=9). The high- risk was particularly prevalent among physicians (91,7%), support staff (91.7%) and nurses (66.7%). None of the contacts had clinical signs of CCHF during the monitoring period and none received prophylaxis with ribavirin. There were no known cases of nosocomial transmission. Conclusion: Despite high-risk exposure among the majority of health workers, no secondary cases were identified. Important strategies were identified to decrease the risk of nosocomial transmission for future cases of viral hemorrhagic fever in our hospital.

Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from five Ebola Holding Units in Western Area, Sierra Leone.

A central pillar in the response to the 2014 Ebola virus disease (EVD) epidemic in Sierra Leone was the role of Ebola Holding Units (EHUs). These units isolated patients meeting a suspect case definition, tested them for EVD, initiated appropriate early treatment and discharged negative patients to onward inpatient care or home. Positive patients were referred to Ebola Treatment Centres. We aimed to estimate the risk of nosocomial transmission within these EHUs. We followed up a cohort of 543 patients discharged with a negative EVD test from five EHUs in the Western Area, Sierra Leone, and examined all line-listed subsequent EVD tests from any facility in the Western Area to see whether the patient was retested within 30 days, matching by name, age and address. We defined possible readmissions as having the same name and age but uncertain address, and confirmed readmissions where name, age and address matched. We found a positive readmission rate of 3.3% (18 cases), which included 1.5% confirmed readmissions (8 cases) and 1.8% possible readmissions (10 cases). This is lower than rates previously reported. We cannot ascertain whether EVD was acquired within the EHUs or from re-exposure in the community. No demographic or clinical variables were identified as risk factors for positive readmission, likely due to our small sample size. These findings support the EHU model as a safe method for isolation of suspect EVD patients and their role in limiting the spread of EVD.

Transmissibility of Clostridium difficile Without Contact Isolation: Results From a Prospective Observational Study With 451 Patients.

Contact precautions are recommended by health authorities in Europe and the United States for patients with Clostridium difficile infection (CDI). Recently, the significance of nosocomial transmission has been challenged by screening on admission studies and whole-genome sequencing, providing evidence for an endogenous source of C. difficile. We discontinued contact precautions for patients with CDI, except for patients infected with hypervirulent ribotypes or with stool incontinence, to determine the rate of transmission. From January 2004 to December 2013, contacts of each index case with CDI were screened for toxigenic C. difficile by culturing rectal swabs. Transmission was defined as possible if toxigenic C. difficile was detected in contacts, as probable if the identical polymerase chain reaction ribotype was identified in index–contact pairs, and as confirmed if next-generation sequencing (NGS) revealed clonality of strains. Four hundred fifty-one contacts were exposed to 279 index patients nursed in 2-to 4-bed rooms. Toxigenic C. difficile was detected in 6.0% (27/451) after a median contact time of 5 days. Identical ribotypes were identified in 6 index–contact pairs, accounting for probable transmission in 1.3% (6/451). NGS was performed for 4 of 6 pairs with identical strains, and confirmed transmission in 2 contact patients. The rate of transmission of toxigenic, predominantly nonhypervirulent C. difficile, was low and no outbreaks were recorded over a 10-year period after discontinuing contact precautions for patients with CDI who were not severely incontinent and who used dedicated toilets. As contact precautions may lead to lower levels of care, their implementation needs to be balanced against the risk of nosocomial transmission.

Clostridium difficile-associated clinical burden from lack of diagnostic testing in a Chinese tertiary hospital

Despite Clostridium difficile infection (CDI) being a common cause of diarrhoea in hospitals worldwide, diagnostic testing or management guidelines are not available in most hospitals in China. In this prospective two-year study, the incidence of CDI among 276 patients with watery diarrhoea was 23.1%. Lack of diagnostic testing for CDI was associated with improper management in 26.4% of patients, risk of nosocomial transmission from lack of isolation precautions, and risk of community transmission from discharging symptomatic toxigenic C.difficile carriers. Updating practice guidelines in line with the current evidence and implementing diagnostic testing for CDI are recommended in hospitals in China.

Highlighting the need for more infection control practitioners in low- and middle-income countries.

Background: Many low- and middle-income countries struggle to implement, monitor and evaluate the efficacy of infection control (IC) measures within health care facilities. This hampers their ability to prevent nosocomial infections, identify emerging pathogens and rapidly alert officials to possible outbreaks. The lack of dedicated and trained IC practitioners (ICPs) is a serious deficit in the health care workforce, and is worsened by the lack of institutions that offer IC training. Discussion: While no single individual can entirely eliminate the risk of nosocomial transmission, there is literature to support the value of designated IC persons. Recommendations from the World Health Organization in 2008 and 2009 describe the need for this specialized cadre of workers, but many countries lack the national regulations to authorize, train and manage such professionals at the national or local level. This article provides an overview of how ICPs are trained and credentialed in several countries, and discusses approaches countries can use to train ICPs. Conclusion: Trained ICPs can help prevent future outbreaks and control nosocomial transmission of diseases in health care facilities. For this to occur, supportive national policies, availability of training institutions and local administrative support will be required.

Seroprotection to vaccine‐preventable diseases among workers at a Victorian tertiary hospital

ObjectiveTo determine seroprotection for the vaccine‐preventable diseases (VPDs) measles, mumps, rubella, varicella and hepatitis B among new employees seen at a Victorian tertiary hospital staff clinic. MethodsEmployees who presented to the staff clinic for immunisation assessment between 1 January 2012 and 31 December 2013 were included. Demographic data, self‐reported disease history and previous vaccination status were reviewed retrospectively to determine impact on serological results. ResultsA total of 1,901 new employees were included, 83% of whom were at risk of direct contact with blood or body substances. Overall, the proportion of workers seropositive to measles was 88%, mumps 90%, rubella 78%, varicella 93% and hepatitis B 80%. Staff born before 1966 were more likely to have positive measles or mumps serology but negative rubella or hepatitis B serology (p<0.05 for each). Staff who self‐reported measles (99% vs. 93%, p=0.03) or varicella infection (98% vs. 92%, p<0.001) were more likely to be seropositive, but those reporting previous vaccination to measles, mumps or rubella were no more likely to be seropositive. Conclusions and implicationsThis study demonstrated levels of seropositivity of 78–93% for the five VPDs. Despite recognised limitations of serological testing, 10–20% of new employees to a healthcare institution lacking seroprotection represents a potentially unacceptable risk of nosocomial transmission of these VPDs. Our findings support ongoing serological testing of new healthcare staff at risk of direct contact with blood or body substances.

Infection Control for Drug-Resistant Tuberculosis: Early Diagnosis and Treatment Is the Key.

Multidrug-resistant (MDR) tuberculosis, "Ebola with wings," is a significant threat to tuberculosis control efforts. Previous prevailing views that resistance was mainly acquired through poor treatment led to decades of focus on drug-sensitive rather than drug-resistant (DR) tuberculosis, driven by the World Health Organization's directly observed therapy, short course strategy. The paradigm has shifted toward recognition that most DR tuberculosis is transmitted and that there is a need for increased efforts to control DR tuberculosis. Yet most people with DR tuberculosis are untested and untreated, driving transmission in the community and in health systems in high-burden settings. The risk of nosocomial transmission is high for patients and staff alike. Lowering transmission risk for MDR tuberculosis requires a combination approach centered on rapid identification of active tuberculosis disease and tuberculosis drug resistance, followed by rapid initiation of appropriate treatment and adherence support, complemented by universal tuberculosis infection control measures in healthcare facilities. It also requires a second paradigm shift, from the classic infection control hierarchy to a novel, decentralized approach across the continuum from early diagnosis and treatment to community awareness and support. A massive scale-up of rapid diagnosis and treatment is necessary to control the MDR tuberculosis epidemic. This will not be possible without intense efforts toward the implementation of decentralized, ambulatory models of care. Increasing political will and resources need to be accompanied by a paradigm shift. Instead of focusing on diagnosed cases, recognition that transmission is driven largely by undiagnosed, untreated cases, both in the community and in healthcare settings, is necessary. This article discusses this comprehensive approach, strategies available, and associated challenges.