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

• 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

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

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

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

States Reporting Candida auris, as of July 31, 2019

• >720 clinical isolates• >2,000 clinical or

screening isolates• 11 cases linked to

healthcare abroad

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

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

New York Times, April 6, 2019

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

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

Risk of Invasive Streptococcal Infection Among PEH, Anchorage, 2002-2015

Mosites E, et al. Emerg Infect Dis 2019;25(10):1903-1910

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

Measles, US, October 2018-October 2019

Patel M, et al. MMWR Early Release Oct 4,2019

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

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.

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

Risk of Transmission of Ebola

Utilization of Ebola Vaccine: Ring Vaccination

Ebola Case

Contact Case

Contact Contact

August 2019: • Tertiary contacts• Pregnancy women, after 1st trimester

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

Improved Domestic Preparedness: Ebola Treatment Centers

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

Lessons Learned from Ebola:Human Factors Engineering

Drews FA, et al. Clin Infect Dis 2019;69(S3):S199-S205

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

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