Case of CJD Disease in New Hampshire

Bill Rutala

by Bill Rutala, Ph.D.

In September 2013, health officials confirmed that a patient who underwent neurosurgery at a New Hampshire hospital earlier in the year had Creutzfeldt-Jacob disease.  The death, and suspicions that the patient may have had the devastating brain ailment, prompted authorities in two states to warn that as many as 13 patients may have been exposed to surgical equipment used during the patient's surgery, thus to the same disease. The now-deceased patient had undergone neurosurgery at a New Hampshire hospital and the patient was later suspected of having sporadic Creutzfeldt-Jakob disease, a rare, rapidly progressing and always-fatal degenerative brain disease. But by the time this diagnosis was suspected, equipment used in the patient's surgery had been used several other operations. This raised the possibility that the equipment might have been contaminated -- especially since normal sterilization procedures are not enough to get rid of the disease proteins, known as prions, tied to Creutzfeldt-Jakob disease -- thus potentially exposing the other patients to infection (Botelho, CNN, September 2013).  This exposure scenario could happen in any hospital and this is why we must remain vigilant and implement practices that minimize its occurrence in our hospitals.

           Creutzfeldt-Jakob disease (CJD) is a degenerative neurologic disorder of humans with an incidence in the United States of approximately 1 case per million population per year. CJD is caused by a proteinaceous infectious agent, or prion.  Prion diseases elicit no immune response, result in a noninflammatory pathologic process confined to the central nervous system, have an incubation period of years, and usually are fatal within 1 year after diagnosis. 

Epidemiology and Management of Noroviruses in Healthcare Facilities

David J. Weber

by David J. Weber, MD, MPH

Acute gastroenteritis is one the most common illnesses, affecting both adults and children.  Infection is the most common cause of acute gastroenteritis.  Pathogens include viruses (e.g., norovirus, rotavirus), bacteria (Campylobacteria, Salmonella, Shigella, E. coli, Clostridium difficile), and protozoans (e.g., Giardia, ameba).  Among viruses the most causes of infection are human caliciviruses (including noroviruses and sapoviruses), enteric adenoviruses, rotaviruses, and astroviruses.  However, the caliciviruses, principally noroviruses, are the most common cause of acute gastroenteritis in both adults and older children with an estimated 23 million illnesses in the United States each year. 

Noroviruses contain a single-strained RNA genome.  As with other RNA viruses there is substantial genetic diversity among these viruses.  Noroviruses are subdivided into five genotypes based on sequence homology.  Genogroups GI, GII and GIV include human pathogens and multiple genotypes are recognized within each group. 

Noroviruses cause an average of 20 million total illnesses, 1.8 million physician visits, 400,000 ED visits, ~60,000 hospitalizations, and ~700 deaths per year.  Young children (i.e., <5 years of age) and older adults (>65 years of age) are at greatest risk for hospitalization and death.  Although illness occurs throughout the year, there is a pronounced winter peak (hence the name “winter vomiting disease”).

Novoviruses are readily transmitted person-to-person (via the fecal oral route) and spread through airborne droplets, food, water, fomites, and contaminated surfaces.  As few as 18 viruses are infectious and viral shedding can occur at levels as high as ~8.0x10¹⁰ viruses/gm of stool.  Although the major route of transmission is fecal-oral, there are also observations from outbreaks that suggest that on occasion airborne transmission can occur, most likely when virus is aerosolized during vigorous emesis.  Immunity to norovirus is relatively short lived and persons can become repeatedly infected. 

Hospital Surveillance Summaries for Clinical and Public Health Staff

By Lauren DiBiase, MS, Public Health Epidemiologist, UNC Health Care

During influenza season, UNC Hospitals distributes a comprehensive influenza and other respiratory virus surveillance summary to relevant clinical and public health staff on a weekly basis.  This summary of surveillance data allows staff to find out when influenza activity is occurring, to track the seasonal trends of influenza-related illness, to determine what specific influenza viruses (i.e., H1N1, H3N2, B) are circulating and to ascertain what other respiratory viruses are prevalent. The first figure in the report displays the weekly count of positive lab-confirmed influenza cases, distinguishing between influenza type A and influenza type B, as well as the weekly count of total influenza tests ordered at UNC McLendon Laboratories.

   

Example of Figure 1.

A table summarizes the number of cumulative positive results by virus type identified at both UNC McLendon Laboratories and the NC State Laboratory of Public Health.  

Example of Table 1. 

	# Cumulative Positive Results
Virus Type	UNC McLendon Laboratories	NC State Laboratory of Public Health
A (not typed)	595	0
A/H1	2	0
A(H1N1) Pandemic	17	12
A/H3	127	315
A/H3N2v	0	0
B	172	90
Total	913	417

The report’s second figure shows the weekly number of positive labs for other respiratory viruses, including rhinovirus, RSV, parainfluenza, adenovirus, coronavirus and human metapneumovirus. 

Example of Figure 2.

  

The final figure utilizes data collected via NC DETECT, the statewide syndromic surveillance system, to display the percentage of ED visits at UNC Hospitals due to CDC influenza-like illness, defined as patients with fever (temperature ≥38˚C) and cough or sore throat.  This figure includes data from the previous influenza season as a comparison.  

Example of Figure 3.

The surveillance summary also includes the cumulative number of any influenza-associated deaths at UNC Hospitals and some brief details about the patients who died – age group, type of influenza virus and whether or not they were a direct admission or transferred to UNC Hospitals.

 

This influenza season, we will be adding information to the report on the number of patients who were hospitalized at the time of influenza testing vs. those who were in the outpatient setting, to provide a sense of the severity of the circulating strains of influenza.

Is that a Single-Dose or Multi-Dose Vial? Imagine it was you!

by Marilee Johnson, MBA, MT (ASCP), Campaign Coordinator, NC One & Only Campaign, NC Division of Public Health

The information is clearly written on the label: Single-dose or multi-dose.  However, surveys have found that 6% percent of US clinicians admit to using single-dose vials for more than one patient.¹ In a recent assessment of infection prevention practices in ambulatory surgical centers, 28% percent of centers were found to reuse single-dose vials for more than one patient.² When you, as a healthcare worker, reuse a vial intended for only one patient, a person’s life and well-being are at stake.

It’s also important to remember that the preservatives in multi-dose vials have no effect on viruses and do not protect against contamination when healthcare personnel fail to follow safe injection practices. For this reason, even vials labeled as “multi-dose” should be dedicated to a single patient whenever possible.  If multi-dose vials must be used for more than one patient, they should never be kept or accessed in the immediate patient treatment area.³

Since 2001, at least 50 outbreaks involving unsafe injection practices have been reported to CDC, with 90% of these occurring in outpatient facilities.⁴ Misuse of multi-dose vials – including accessing a medication vial with a syringe that has already been used to administer medication to a patient – is one of the leading culprits.

If you do not believe that someone in your facility could harm your patients by misusing a multi-dose vial, I challenge you to read on.

In 2007, Johnny Robertson of Red Springs, NC, elected to have a preventative health care checkup. After all, he was turning 50 years old and it was time to have some preventative health screening.  His primary care provider recommended a few procedures, including a colonoscopy and a cardiac perfusion study.   Johnny followed this advice, scheduled the procedures and found the results were all good.  All was well and Johnny continued to donate blood regularly, as he had done for years. However,  when he donated blood this time (in 2007), he received an official letter from the Red Cross stating that he was infected with hepatitis C. Johnny was shocked because he did not have any known risk factors associated with hepatitis C.  He kept digging to see how he could have possibly gotten this awful disease.

North Carolina Healthcare-Associated Infections Prevention Program 2013 Activities to Help Detect and Prevent the Spread of CRE

Carbapenem-resistant Enterobacteriaceae

by Connie Jones, RN, CIC and Megan Sanza, MPH

Carbapenem-resistant Enterobacteriaceae (CRE) has been deemed an urgent public health hazard by the CDC. (Sources: Antibiotic Resistance Threats in the United States, 2013: http://www.cdc.gov/drugresistance/threat-report2013/pdf/ar-threats-2013-508.pdf and the 2012 CRE Toolkit – Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE): http://www.cdc.gov/hai/organisms/cre/cre-toolkit/background.html )  With that in mind, the HAI Advisory Group recently formed two Task Forces to concentrate on the prevention and detection of CRE.  Some pertinent information regarding CRE infection is provided below followed by details for ongoing and planned activities to assess and reduce current prevalence in affected healthcare settings. 

Background:

CRE are a group of bacteria found in the gut.  They can cause a variety of diseases including pneumonia, UTIs, and serious bloodstream or wound infections.   CRE are resistant to commonly used antibiotics and occasionally to all available antibiotics, which makes them a serious threat to public health. 

Who is at risk?  

Patients who require devices like ventilators, urinary catheters, or intravenous catheters, and patients who are taking long courses of certain antibiotics are most at risk. CRE have been found among patients in both acute and long term care settings. 

How is it spread?

CRE bacteria are spread by person-to-person transmission, primarily in healthcare settings, through contact with those infected or colonized. Due to the movement of patients throughout the healthcare system, if CRE are a problem in one facility, then typically they are a problem in other facilities in the region as well.

How is it controlled?

Treatment is difficult, and not possible in some cases.  As a result, prevention and control measures are critical.  Standard practices such as hand washing, contact precautions, and communication of CRE status with transferring/receiving facilities can help prevent the spread of disease.

Falls not associated with UTIs in elderly nursing home residents

Theresa Rowe, Virginia Towle, Peter H. Van Ness, Manisha Juthani-Mehta.   Lack of association between falls and bacteruria plus pyuria in older nursing home residents.  Journal of American Geriatrics Society 2013, 62(4); 653.

by Kirk Huslage, RN, BSN, MSPH, CIC

Falls are common occurrences among nursing home residents, with an estimated 36% of residents having at least 1 fall event in the past 6 months.  While falls are certainly caused by multiple factors, they are frequently attributed to the presence of a urinary tract infection (UTI), and often result in potentially inappropriate  treatment with antibiotics for a presumed UTI.  A group from the Department of Internal Medicine at Yale University School of Medicine recently undertook a prospective cohort study of 551 nursing home residents in the New Haven, CT community to determine if there is a correlation between falls and the presence of UTI [defined as bacteruria ( >100, 000 colony-forming units/ml bacteria) plus pyuria (>10 WBC/high-powered field in UA)].  The longitudinal association between falls and bacteruria plus pyuria was examined.

In the analysis, the researchers found that of the 45 fall episodes, nine (20%) were associated with bacteruria plus pyuria .  For comparison, of the 352 episodes without falls, 137 (38.9%) were also associated with bacteruria plus pyuria.  Using a multivariable regression model, the researchers did not find a statistically significant correlation between falls and bacteruria plus pyuria.  This suggests that UTI is unlikely to be associated with falls and a majority of individuals in this cohort for whom UTI was suspected due to falls would not have benefited from antibiotics.

Editors Comments:  This study is important because antibiotic resistance among nursing home residents is increasing and is heavily associated with antibiotic overuse and misuse.   Indeed, antibiotics are the most frequently prescribed medications in nursing homes, with approximately 70% of residents receiving at least one course of antibiotics annually.

Many long-term care residents are colonized with bacteria, and it is challenging to separate colonization from true infection in this population.   Several studies have shown that 30-50% of elderly long-term care residents can have positive urine culture even without any symptoms of a urinary tract infection, resulting in many of these patients being placed inappropriately on antibiotic therapy.

Please see the CDC FAQ on Antibiotic Use in Nursing Homes for more information on the problem and what can be done at your facility to improve antibiotic utilization and stewardship.

References:
1.  T Rowe, V Towle, et al. Lack of positive association between falls and bacteruria plus pyuria in older nursing home resdient. J Am Geriatr Soc 2013 2013;64(4):653.

2.  Loeb M et al. Antibiotic use in Ontario faciltiies that provide chronic care.  J Gen Intern Med 2001;16:376-383.

New NC law requires education about pertussis

by Kirk Huslage, RN, BSN, MSPH, CIC

A new law requiring pertussis disease education in hospitals, passed by the general assembly and signed by Gov. McCrory in June, 2013, became effective October 1, 2013.  This new law requires that all licensed hospitals in North Carolina provide free, medically accurate educational information about pertussis disease and the availability of tetanus-diphtheria and pertussis (Tdap) vaccine to parents of newborns delivered in the hospital. This information must be provided during the post-partum period (defined as from admission for delivery through the first few hours after childbirth) and prior to the mother’s discharge. At a minimum, the educational information provided must cover the most current CDC ACIP recommendations regarding the use of Tdap vaccine to reduce the burden of pertussis in infants. This law does not require hospitals to provide or pay for any vaccination against pertussis disease.

The CDC has excellent resources regarding Pertussis and pregnancy:

http://www.cdc.gov/Features/Pertussis

http://www.cdc.gov/vaccines/vpd-vac/pertussis/tdap-pregnancy-hcp.htm

http://www.cdc.gov/vaccines/adults/rec-vac/pregnant/whooping-cough/get-vaccinated.html

There is also information available via the March of Dimes Sounds of Pertussis Campaign:  http://www.soundsofpertussis.com

and the American College of Obstetricians and Gynecologist:   

http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice /Update_on_Immunization_and_Pregnancy_Tetanus_Diphtheria_and_Pertussis_Vaccination

Hand Hygiene before non-sterile gloving: a waste of time?

Rock, C, Harris, AD, Reich, NG, Johnson, JK, Thom, KA.  Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? - A randomized controlled trial.  Am J Infect Control 2013; 41(11); 994-996.  

by Kirk Huslage, RN, BSN, MSPH, CIC

Hand hygiene is recognized as a basic measure for the prevention of HAIs, but there have been limited studies about the importance of hand hygiene prior to donning non-sterile gloves.   A group of researchers from the University of Maryland School of Medicine conducted a prospective, randomized controlled trial of healthcare personnel entering Contact Isolation rooms in 7 ICUs in an academic medical center. 

Two hundred thrity Healthcare personnel were randomized into two groups, hand hygiene prior to donning gloves (n=115)  and direct gloving without hand hygiene(n=115).   Workers for whom hand hygiene was observed prior randomization or they had already participated.  For both groups, hand imprint cultures were taken prior to any intervention, and were  repeated following donning of non-sterile gloves for both groups.  Both groups were also timed to see how long it took to don gloves.

The researchers found no statistical difference in the average colony forming units (CFU) counts of gloved hands between the hand hygiene  prior to gloving and direct gloving groups (6.9 vs 8.1 CFU, p=0.52).  Pathogenic organisms were rarely identified (1 MRSA isolate in hand hygiene prior to gloving group and 2 MSSA isolates in the direct gloving group), with most other organisms constituting expected transient flora including CONS, micococcus, diphtheroids adn bacillus.    They also found that the average time needed per episode for the hand hygiene and direct gloving groups were 53.3 seconds and 21.8 seconds (p <0.01), respectively.

Curriculum update: 10A NCAC 41A .0206 INFECTION PREVENTION – HEALTH CARE SETTINGS

by Amy Powell, MPH 
On October 1, 2013, State Epidemiologist Megan Davies issued a memo reminding all North Carolina healthcare providers of state requirements for infection prevention in healthcare settings and providing resources for meeting these requirements.

In North Carolina, every healthcare organization that performs invasive procedures (including injections) is required to designate a credentialed staff person to implement an infection control program.  The infection control curriculum developed by SPICE will prepare designated healthcare providers to implement North Carolina’s rule, 10A NCAC 41A .0206 INFECTION PREVENTION – HEALTH CARE SETTINGS.  The seven training modules (listed below) for outpatient, dental and home health/hospice settings, are designed to make an impact on infection control.

Module A: North Carolina Laws Concerning Infection Prevention

Module B: Complying with the OSHA Bloodborne Pathogen Rule

Module C: Epidemiology and Risk of Infections

Module D: Outbreaks and Safe Injection Practices

Module E: Principles and Practices of Asepsis, Hand Hygiene, and Environmental Issues in Disease Transmission

Module F: Principles of Disinfection and Sterilization

Module G: Application of Cleaning, Disinfection and Sterilization Principles

The NC Statewide Program for Infection Control and Epidemiology has updated the curriculum: Infection Control in Outpatient Settings. The course is offered on-line, as well as in classroom and webinar formats. The update has a fresh look and feel, and efficiently relays information with fewer slides.  In addition, the order of presentation is changed slightly, and all slides are accompanied by notes. NCNA has approved 6.25 CEs for participants completing the on-line outpatient course which is hosted on SPICEducation.unc.edu. Click here for other course formats.

Infection control curricula are also offered for dental, and home health/hospice settings. Click here.  Updates for the Dental and Home Health/Hospice Courses are planned for 2014.

DPH Welcomes New Team Members

Megan Sanza and Marilee Johnson

The NC Department of Public Health, Communicable Disease branch welcomes two new team members, Marilee Johnson and Megan Sanza. Marilee has been the Campaign Coordinator for North Carolina’s One & Only Campaign since July of 2013. She works with partners around the state to provide training and education to healthcare providers and the public about safe injection practices. Marilee was previously a public health epidemiologist at WakeMed Health & Hospitals. Marilee has a BS in Medical Technology from UNC-Chapel Hill and an MBA from Meredith College. Megan joined the team in October as a Public Health Epidemiologist for the HAI program. Megan came to us from Washington, DC where she obtained her MPH from The George Washington University. She has been working in the public health field on epidemiological studies for the past 7 years while completing her degree, acquiring a great deal of data management, analysis, and program evaluation experience. Welcome Megan and Marilee!