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Update on infectious diseases in Update on infectious diseases in Long Term Care Facility Long Term Care Facility –– TB, MRSA, TB, MRSA,

VRSA, VRSA, LegionellaLegionella

Dr Vivien CHUANGCenter for Health Protection

Common Infectious Diseases in LTCFs(Top 4)

MRSA, VRSA

ESBLCatheter-related UTIUrinary Tract

CAMRSAScabies, Norwegian scabiesSkin & Soft Tissues

NorovirusFood poisoning: bacteria, toxinsSalmonella

GE

TB, Legionella,Metapneumovirus

Flu A&B, RSV, AdenovirusRespiratory Tract (URI &LRI)

Emerging / Remerging Diseases

Common Outbreak Examples Type of Infections

Tuberculosis inLong Term Care Facilities

Global Prevalence The Lancet 2006 367:938

• How common is TB infections in our locality?

• How about the mortality rate?

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Prevalence of Tuberculosis Infection and Active Tuberculosis in Old Age Homes in Hong Kong

��� ����� � � � � ��� � "! # # $&% ' (*) + , , (.- + , ( #General population / 75 years old (2003): 424 per 100,000 population

What is the prevalence of TB in LTCF in our locality?

No Evidence of Transmission of TB in the old age homesJ Am Geriatr Soc 2006,54:1334-1340

Is there any evidence of intra facility transmission of TB in the LTCF?

Are all patients diagnosed with TB infection infectious to others?

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Low Infectious Risk

OR

Extrapulmonary TB, such as skin infection, meningitis etc

Smear Negative pulmonary TB

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Open pulmonary TB:sputum smear + for AFB

Pharyngeal TB

Route of Transmission• Droplet nuclei (1-5 um)• Created by cough,

talking and singing• Airborne for prolonged

period• Incubation: variable, at

least 2 weeks• Extrapulmonary rare,

except larynx and during autopsy and tissue irrigation

Risk of transmission depends on:

1. The infectiousness of the TB patient

2. The environmental characteristic

3. The characteristic of the contact exposure

Characteristics of contact exposure: High Risk Procedures

• Bronchoscopy• Endotracheal intubation• Suctioning• Sputum induction • Aerosol treatment that induce coughing• Open abscess irrigation• autopsy

Tuberculosis in Long Term Care Facilities

• Persons with confirmed or suspected infectious TB may NOT require isolation precaution, providing the following conditions are met:

1. Chemotherapy is begun promptly at the time of confirmation or suspicious of diagnosis

2. Current and recent contacts are evaluated and given appropriate therapy

3. No new contacts within 2 weeks after start of anti-TB drugs

Infection control and epidemiology 2000;21:611-615

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Tuberculosis in Long Term Care Facilities

Respiratory isolation required:1. Not fulfill the conditions2. Laryngeal TB3. Suspected or known history of non-

compliance 4. MDRTB / XDRTB

• Refer to hospitals

Infection control and epidemiology 2000;21:611-615

TB: Infection Control Measures:

• Administrative control to reduce exposure

• Environmental control to control spread and concentration of droplet nuclei

• Personal respiratory protection

What is MDRTB?MDRTB stands for Multiple drugs resistant TB

Defined as resistance to at least isonizid and rifampinWhy is it important?MDRTB requires the use of second line drugs that are less

effective, more toxic, and costlier than first line drugs.

What is the prevalence of MDRTB?

WHO/IUATLD Global Project on Drug-Resistance Surveillance•MDRTB about 1% (median) (range 1-14%) in 64 countries / geographicalsites surveyed•Hot spot: Estonia, Latvia, the Oblasts of Ivanovo, Tomsk in Russia, and the provinces of Henan and Zhejiang Provinces in China

what is XDR-TB? XDR-TB stands for Extensively drug-resistant TB

• A strain of MTB resistant to isoniazid and rifampin (which defines MDRTB) in addition to any fluoroquinolones and at least one of the three following injectabledrugs: capreomycin, kanamycin, and amikacin (MMWR Nov 3 2006)

XDR-TB• 53 patients with XDR TB were diagnosed in South

Africa in early 2005

• All but one died of XDRTB, with a median survival periods of only 16 days from the time the first sputum specimen was collected

• Genotyping reveals most of the isolates belonged to the KwaZulu-Natal family of TB strains which has been recognized in the province for a decade

How common is XDRTB?

• Population-based data

15South Korea(2004)

19Latvia (2000-2002)

4USA(1993-2004)

% = XDR/MDRTB

Country

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Do we need to isolate a resident with MRSA in LTCF?

• Do NOT refusing admission to RCHE• Should be informed if the resident is a MRSA

carrier after discharged from hospitals• Do not need isolation• Do socialize, visit friends, see older people

and babies, go to hairdressers, work as normal

• Keep confidentiality for colonized and infected MRSA residents

Infection control guidelines for community settings. Health Protection Agency Feb 2007

Imply general hygiene • Keep the environment clean and dust free• No special disinfectants are needed, use the

usual detergent• Wash crockery and cutlery as normal• No precautions needed with newspaper,

books, posts pets• Change bedding frequently, use hottest wash

possible and don’t shake the bed linen

Infection control guidelines for community settings. Health Protection Agency Feb 2007

What are the high risk groups who we have to pay special precaution

in LTCF?

High Risk Groups in LTCF: Wound and Indwelling Devices

damaged skin, such as eczema, chronic wounds, insertion sites ofinvasive devices

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Special precautions for Wound and Indwelling Devices

• Wear gloves and aprons for handling wounds, catheters and wound drains

• Ideally not share a room if either room-mates has open wound or catheters

Hand Hygiene

70-80% alcoholic hand rub

To minimize the spread of VRSA, the CDC recommended

1. Standard Precaution Plus Contact Precaution2. placing the patient in a private room, 3. wearing gloves and gowns during contact, and 4. washing hands thoroughly after examination.

What should I do if a family member or close friend has VISA or VRSA?

persons having close physical contact with infected patient while they are outside of the healthcare setting should:

(1) keep their hands clean by washing thoroughly with soap and water

(1) avoid contact with other people’s wounds or material contaminated from wounds

(3) If you visit a friend or family member who is infected with VISA or VRSA while they are hospitalized, follow the hospital’s recommended precautions

Legionella Disease in Long Term Care Facilities

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LD – Human Cases (DH Notifiable Diseases registry)

• Year No. of cases of infection No. of deaths2004 3 02005 11 12006 16 32007* 2 1

*As at April 23, 2007

• Year No. of water samples No. of water samples > the acceptable level bacterial content

2001 74 12002 4,587 4262003 2,966 3102004 1,130 1012005 1,300 54Total 10,057 892

LD- Cooling tower water samples• It has been reported that, among some 3 000 water samples

taken from cooling tower systems of buildings and tested by the Hong Kong Productivity Council's laboratory since 2004, nearly 30% were found to have Legionella pneumophila (any counts)

• It is recommended in the technical guidelines of the Occupational Safety and Health Administration of the U.S. Department of Labor, that cooling towers have to be cleansed and disinfected when the concentration of Legionellapneumophila exceed 1,000/ml and the EMSD considered that only water samples with Legionella pneumophila concentration exceeding 1,000/ml should be regarded as exceeding the acceptable level

http://www.info.gov.hk/gia/general/200705/02/P200705020185.htm

Legionella Outbreaks in LTCF

17 daysyes11Gorwitz, US, 2003

? Legionella infection is endemic in many LTCF but is unrecognized and unreported

Additional cases and clusters of up to five cases have been reported in nine additional nursing homes to public health agencies in Pennsylvania, Maryland, Massachusetts, Oregon, and Ontario during 1999 to 2003

1 weeksNo2Maesaki, Japan, 1992

10 weeksyes11Nechwatal, Germany, 1993

5 weeksyes29Loeb, Canada, 1999

Duration of study

Portal water

Pts w/ LD, n

Author

Prospective studies for Legionellain LTCF

-yesUA, CUL3Sarro, US, 2003

2 yearsyesSER, UA, CUL

6Stout, US, 2000

10 monthsyesSER13Brennen, US,1987

Duration of study

Portal water

Diagnostic test

Pts w/ LD, n

Author

Nebulizers used for Humidification Use of nebulizer and humidifier in community setting

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• According to Communicable Disease Watch, Sterile water is preferred to be used to fill and rinse the reservoirs of bubbling humidifiers and nebulizers after such items have been cleaned and disinfected1. However, if sterile water is not immediately available, an alternative is to refill the nebulizer bottle / humidifier tank with freshly boiled water aseptically after cooling down in the original kettle. Do not use secondary container for the storage of the boiled water.

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Avian Flu Vaccine Development & Progress

April 17, 2007 H5N1 Influenza Vaccine

• Targeted vaccinees: 18 -64 years of age who could be at increased risk of exposure to the H5N1 influenza virus contained in the vaccine.

• Route of Administration: Two IM injections

• Schedule: one month apart.

• Side effects: pain at the injection site, headache, muscle pain & general ill feeling

• Efficacy: two-dose regimen developed antibodies at a level that is expected to reduce the risk of getting influenza, have the potential to helpreduce disease severity and Influenza related hospitalizations and deaths.

Safety and effectiveness in other age groups are being collected andwill be available to FDA in the near future.

H5N1 Influenza Vaccine - Supply

• The vaccine will be manufactured at sanofi pasteur's Swiftwater, Pa., facility and will not sell the vaccine commercially.

• Instead, the vaccine has been purchased by the federal government for inclusion within the National Stockpile for distribution by public health officials if needed.

• With the support of FDA, the U.S. National Institutes of Health and other government agencies, sanofi pasteur and other manufacturers are working to develop a next generation of influenza vaccines for enhanced immune responses at lower doses, using technologies intended to boost the immune response. Meanwhile, the approval and availability of this vaccine will enhance national readiness and the nation's ability to protect those at increased risk of exposure.