Outbreak Investigation Phicna Lect 2014

Outbreak: Tell-Tale Signs,
Investigations, Actions & Solutions
SILVEROSE ANN A. ANDALES-BACOLCOL, M.D.,

FPCP, FPSMID
Internal Medicine and Infectious Diseases
OUTLINE of this LECTURE:
I. Definition of terms
II. How outbreaks are recognized
III. Reasons for investigating outbreaks
IV. Constraints of outbreak investigation
V. Infection Control Measures
VI. Preparing for the Investigation
VII. Steps in conducting an outbreak investigation
in health care facilities
VIII. Case Study
A. What is an outbreak?
An incident in which two or more people who are

thought to have a common exposure experience
a similar illness or proven infection.
The occurrence of more cases of a disease than
expected:
in a givenplace
among a specific group of people orpopulation
in a particular period oftime
B. Epidemic
-
C. Healthcare-associated infections
-
same as outbreak but more widespread or prolonged

are infections that occur in patients or healthcare
workers as a result of healthcare interventions
D. Hospital-acquired infections
-
Infections acquired during hospital stay which were

not incubating at the time of admission
E. Health Care Facilities

Hospital
Private physicians office
Outpatient clinic
Dialysis centers
Ambulatory surgery
Endoscopy units
Long term care facilities
Nursing homes
Rehabilitation centers
Institutions for mentally or physically
handicapped
-
II. How are outbreaks recognized?
A.
B.
C.
D.
E.
By the clinician, infection control

professional, nurse, or medical staff
By the laboratory personnel or
microbiologist
By the patient or patients family
Hospital or healthcare-associated
infection routine surveillance data
Unusual agent, site or host
When to Consider Nosocomial

Transmissionof Infectious Diseases?
A cluster of similar infections occurs on one hospital

unit or among similar patients
A cluster of infections associated with invasive devices
occurs
HCWs and patients develop the same type of infection
A cluster of infections with organisms typically
associated with hospital-acquired infections (MDR or
opportunistic organisms)
Determine Risk Factors for Disease or

Nosocomial Infection
Host risk factors for HAI
Invasive devices
Severity of illness
Underlying diseases (Malignancy, HIV)
New technology (Chemo agents)
Environmental risk factors
Location (ICU vs. Ward)
III. Reasons for investigating outbreaks

A.
B.
C.
D.
E.
Prevent additional cases in the current outbreak

Prevent future outbreaks
Assess prevention interventions
Learn about a new disease
Learn something new about an old disease
F.
G.
New sources
Unusual modes of transmission
Complications of new procedures
Reassure the public

Minimize economic and social disruption
Negative Effects of Outbreaks
Outbreaks cause
Morbidity, mortality
Prolongation of stay
Additional procedures
Increases cost
Bad reputation
IV. Constraints of Outbreak Investigation

A.
B.
C.
D.
Urgency to find source and prevent

cases
Pressure for rapid conclusions
Pressures because of legal and
financial liability
Delays can limit human/ environmental
samples for testing
V. Infection Control Measures
Introduce preventive interventions before

initiating or completing an investigation.
Handwashing in-service sessions

Close a unit to new admissions
Remove a product or device
Carefully weigh the potential benefit of more

drastic measures against the potential harm to
patients currently residing in the facility
All levels of the health care facilitys personnel

must be committed.
Hospital Administration
Infection Control Unit
Chief of the affected service
Head Nurse or Supervisor
Head of Microbiology
Health care professionals (Doctors, nurses)
Consider availability of microbiologic isolates

for antimicrobial sensitivity (or molecular typing)
Inform Microbiology Lab early
Save specimens and isolates
Be alert for additional isolates that may be
part of the outbreak
Identify the following:
Resources (personnel, supplies, laboratory)

Lead investigator
Person responsible for statistical analysis of
the data
VII. STEPS IN CONDUCTING AN OUTBREAK

INVESTIGATION
Step 1: Learn about the topic

Step 2: Establish the Existence of an Outbreak
Step 3: Verify the Diagnosis
Step 4: Define and Identify Cases
Step 5: Describe and orient the data in terms of
time, place, and person
Step 6: Develop Hypotheses
Step 7: Evaluate Hypotheses
Step 8: Refine Hypotheses and Draw Conclusions
Step 9: Implement Control and Prevention
Measures
Step 10: Communicate Findings
Research about the disease

through
Infectious Diseases practitioner
Clinical Epidemiologist
Laboratory personnel
Infection control/ Infectious
Diseases textbooks
Medical Journals
Step 2: Establish the Existence of an

Outbreak
IS THIS AN OUTBREAK?
More cases than expected in a given place

over a given time.
Determine the expected number of cases
for the area in the given time frame.
Compare the current number of cases with
the number from the previous weeks,
months or years
Hospital surveillance records

Hospital discharge records or census
Morbidity and mortality records

Outbreak
IS THIS A PSEUDO-OUTBREAK?
Clusters of positive cultures in patients

without evidence of disease (colonization)
A perceived increase in infections because
surveillance was not previously being
conducted or because surveillance
definitions, intensity or methods have
changed

Outbreak
What could cause an artificial increase (pseudooutbreaks)?

Alterations in surveillance system:
personnel
definition
case finding method
procedure in reporting
Increased awareness
New Laboratory procedure
New
New
New
New
New diagnostic tests, laboratory equipment

New technician
New susceptible population
New ward, increase in size of population
Ensure that the disease has been properly

diagnosed.
Be certain that the increase in diagnosed cases
is not the result of a mistake in the laboratory.
Confirm the diagnosis:
Clinical syndrome (signs & symptoms)
Epidemiologic risk (person, place, time)
Laboratory & diagnostic tests
Establish a case definition
Inclusion criteria:
A. Clinical criteria (symptoms, signs & onset)
B. Epidemiologic criteria (person, place, time)
C. Laboratory criteria (culture results & dates)
Case Classification:
A. Suspect/Possible- fewer of the typical clinical features
B. Probable- has the typical clinical features of the disease
without laboratory confirmation
C. Confirmed- has the typical clinical features of the
disease and laboratory confirmation
Exclusion Criteria(for suspect and probable)
Identify and count cases
Passive surveillance
Interview staff, patients

Review patients records, log books, employee health
records
Review lab records
Infection surveillance data
Send out letters describing the situation and ask for
reports
Active surveillance
Do telephone surveys or visit the facilities to collect

information
Collect Case Data

Identifying information
Demographic information
Clinical information
Risk factor information
Underlying diseases
Invasive procedures
Surgical risk factors
Laboratory test results
Complete Line Listing

A table consisting of important variables such as
identification number, age, sex, signs& symptoms, lab
test results.
New cases are added to a line listing as they are
identified.
Cas
e#
Initia
ls
MC
Date
of
repo
rt
2/13
Date
of
ons
et
2/4
Diagnos
is
HAP
Ag
e
67
S
e
x
M
symptom
s
Cough,
fever
P.
E.
cr
ac
kl
es
La
bs
CX
R,
Step 5: Describe and Orient the Data in

Terms of Time, Place, and Person
Descriptive Epidemiology
Provide a comprehensive
description of an outbreak by
showing its trend over time, its
geographic extent (place), and
the populations (people)
affected by the disease.
Time: Epidemic Curve
Epidemic curve
A graph of the number of cases by their date
of onset
Gives a simple visual display of the outbreaks
magnitude and time trend.
Y axis= # of cases
X axis= date of onset/time
Epidemic Curve
Epidemic Curve
Place: Spot Map
4 3 1 3
Technic
0
7 8
al
Blue Unit
(vacant)
1 1 1 3 3
5 2 412 03 8 3 25 3 2 3 3
0 6 6 2
7
6
2
3
5
Red Unit
7
7 6
6
1
1
9
1
5
3
4
2
0
Green
3 Unit
1 3
2 93 3 7
2
33 12
2 2
3
4
8
2
1
Soci
al
2 1 2
8Kitc8 7
3
1 3 2
hen
2
4 4 5 40
1 Laund2
2
ry 3
9
1
1
6
8 3
2
Admi6
3
1 n 2
5
1
Ground floor
1 1
3
3 3
7 1
Brown
Unit
2
5
1
9 2
4
2
9 1
1 8
7
1
2
Servic
es1
2
5 2
3
Clini
3 4
1
cs
0
6
1 2
Busines
Classe
s
2
s
Office 1
2nd floor
9
1
4
Person
Determine what populations are at risk for the

disease by characterizing by person.
Age, gender
Health status:
Increased susceptibility
Risk factors
Underlying disease
Exposures
Procedures
Drug, IV line
Formulate a hypothesis to explain why and how the

outbreak occurred based on results of preliminary
investigation.
Hypothesis should address the source of the agent,
the mode of transmission, and the exposures that
caused the disease.
Clues from clinical syndrome

Clues from etiologic agent
Clues from case interviews (have in common?)
Clues from existing knowledge base
Comparison of the hypotheses with the

established facts.
Analytic Epidemiology
Cohort studies
Case-control studies
Compare groups of people who have been exposed to

suspected risk factors with groups who have not been
exposed.
Compare people with disease (case patients) with a
group of people without the disease (controls)
Statistical Methods
Lab and Environmental Studies
Step 8: Refine Hypotheses and Draw

Conclusions
When an outbreak occurs, you

should consider what questions
remain unanswered about the
disease.
Draw conclusions from descriptive
or analytic studies
Causal inferences
Step 9: Implement and EvaluateControl

and Prevention Measures
Should be implemented early

Control strategies:
Reduce contact between susceptibles and potential
infectives
Reduce probability source is infective
Reduce infectiousness of infectious source
By treatment
Reduce susceptibility of susceptible hosts
By treatment/prophylaxis or vaccination
Interrupt transmission
Physical/Chemical methods
Environmental/Engineering methods
Prevention at Source of Infection
Human source:
Isolation or treatment of the

human source
Length of time the patient is
infectious after treatment
must be known
Prevention of Transmission
Contact and indirect contact:
Airborne or Droplet:
Wearing mask with sufficient filtering

ability.
Simple surgical mask sufficient for large
droplet (as long as the mask is dry)
Masks with HEPA type filters for droplet
nuclei
Food and water borne:
Prevent contact, wear gloves if contact

isnecessary, handwashing
Avoid suspected food and water
Prevention: Protection of At Risk Person
Protection of susceptible
individuals
Immunization (passive or
active, if time permits)
Chemoprophylaxis
1. Communicate preliminary assessments

and recommendations (letter, memo)
Communicate any changes necessitated by the

outbreak analysis to the appropriate
departments
2. Prepare interim/final report
Issue a concluding report to the hospital or

healthcare facility committees
VIII. CASE STUDY
An ICC nurse receives a report from the NICU of an

increased number of cases of sepsis 2 toBurkholderia
cepaciabloodstream infection among newborns who
were delivered via normal spontaneous delivery from
January1-31, 2013.
For the month of January 2013, 16 out of 59 newborn
babies were treated for sepsis. For the 16 patients,
blood cultures were taken during the first few hours of
life (ranging from 6 hours to 24 hours). All blood
cultures were positive forBurkholderia cepacia.
OUTBREAK INVESTIGATION:CASE
STUDY
Step 1: Learn
about the topic
The ICC nurse looks upBurkholderia cepaciain

her desk copy of Bergys Manual of Systematic
Bacteriology and Infectious Diseases textbook
by Mandell. She found out thatBurkholderia
cepaciais a gram negative bacillus commonly
found in soil and moist environments and
capable of surviving and growing in nutrientpoor water. It is an important opportunistic
pathogen in hospitalized and
immunocompromised patients.
STUDY
Step 2: Establish
the existence of an
outbreak
The NICU averages about 2 % infections per

month. The rate of infection appeared to begin to
rise around August.
Decembers BSI rate was 3% and Januarys rate
was 27%.
There was no past record of BSI caused
byBurkholderia cepacia.However, there were
past records of BSI caused by other
organisms(Pseudomonas aeruginosa and
Staphylococcus aureus)
STUDY
Step 3: Verify the

diagnosis
The ICC nurse reviewed the charts and culture

results of the 16 patients who developed BSI.
She visited 5 of the patients with a positive
culture forB. cepaciawho were still admitted.
She asked the medical and nursing staff from
NICU and DR if there were any new personnel,
new practices, equipment or solutions used.
STUDY
Step 4: Define and

Identify Cases
The initial case definition is,Any newborn baby

developing a BSI following normal spontaneous
delivery performed in the past 6 months.
The ICC nurse called the micro lab and asked for
2 reports:
one screening for Blood cultures from the NICU
and another screening for any
positiveBurkholderia cepaciacultures from the
NICU from August 2012 to present.
STUDY
Step 5: Describe
and Orient the
Data in terms of
time, place, and
person
All charts were reviewed using a data collection

form developed by the ICC. Seven additional
BSIs were identified related to January 2013
deliveries.Burkholderia cepaciacaused five of
the infections.
Place
A total of 59 babies were delivered in the month

of January. 35 babies were delivered via NSD
while 24 were via CS. All 16 babies with BSI
were delivered via NSD in Delivery Room # 3.
NSDs are performed in DR # 3 and 4.
Cesarean Deliveries are performed in DR # 1
and 2
Person
Obstetrician Xis associated with 9/16 deliveries of

newborns who developedBurkholderia cepaciaBSI.
She has been practicing for 10 years in the hospital.
Nurse A, a DR nurse assisted the deliveries of 16/16
knownBurkholderia cepaciaBSI cases. Records
showed that she was newly hired and started on
January 1, 2013
Nurse B, a NICU nurse performed newborn care to
8/16 babies who developedB. cepaciaBSI. She has
been employed for 5 years.
STUDY
Step 6: Develop a
Hypothesis
It was decided to narrow down the case

definition to:
A BSI that is culture positive forBurkholderia
cepaciain a newborn patient who was delivered
via NSD in the month of January 2013.
The tentative hypothesis is that patients are
being exposed toBurkholderia cepaciain the
Delivery Room or NICU.
STUDY
Step 7: Test the

Hypothesis
The ICC nurse notes that Obstetrician X was

involved in 9/16 cases,
Nurse B was involved in 8/16 cases, and Nurse A
was involved in all 16/16 cases.
She decides to determine if their presence
during these deliveries is significant.
STUDY
ICC nurse reviewed perinatal and intra-operative
Step 7: Test The
care by interviewing obstetricians, OB and Pedia
and other D.R. and NICU personnel and by
Hypotheses residents,
observing a NSD procedure performed by Obstetrician
X in D.R. # 3 where both Nurse A & Nurse B were

assisting.
Nurse A prepared the patient in labor prior to NSD.

Aseptic technique was performed. Cotton cherries presoaked in betadine solution was used for cleaning the
perineal area. The umbilical cord was clamped using
sterile clamps and was cut by a disposable sterile
blade.
STUDY
B assisted the Pediatrician in performing
Step 7: Test Nurse
newborn care. Aseptic technique was performed while
the baby. Sterile suction tubing was used for
Hypotheses handling
suctioning of airways. The newborn was bathed using
pre-boiled water. Cord care was done using 70%

isopropyl alcohol.
STUDY
Step 7: Test
Hypotheses
Environmental cultures were done to determine

the source of the outbreak.
A culture of the ff. were done:
Cotton cherries pre-soaked in Betadine solution
in DR #3
Betadine solution stored in big bottles at DR #3
Kelly pads in DR# 3
Pre-boiled water used for bathing newborns
Bath tub used during bathing of newborns
STUDY
Step 7: Test
Hypotheses
Result of cultures:
Cultures of cotton cherries pre-soaked in
Betadine solution in DR #3 grewBurkholderia
cepacia.
STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
Newborn babies who were delivered via NSD in

January 2013 developed Bloodstream infection
due to exposure toBurkholderia cepaciain
Delivery Room # 3.
The technique used by Nurse A in preparing
patients in labor by using cotton cherries presoaked in contaminated Betadine solution for
cleaning the perineal area caused the exposure
of newborn babies toB. cepaciaduring delivery.
STUDY
Step 9:
Implementing
Control and
Prevention
Measures
The ICC nurse recommends a change in

procedure in preparing patients in labor
prior to NSD.
Cherries pre-soaked in betadine
solution used for prep were not allowed
in the DR. Sterile cotton cherries
packed for single use and Betadine
solution stored in small sterile
containers were recommended.
Aseptic technique during delivery and
newborn care was reinforced.
Nurse A was required to attend insevice ICC seminar.
STUDY
Step 10:
Communicate
Findings
All staff was informed of findings and the

procedure change.
A written summary of findings was distributed to
appropriate staff.
STEPS IN CONDUCTING AN OUTBREAK

INVESTIGATION

Step 2: Establish the Existence of an Outbreak
Step 5: Describe and orient the data in terms of
time, place, and person
Step 8: Refine Hypotheses and Draw Conclusions
Step 9: Implement Control and Prevention
Measures
OUTBREAK INVESTIGATION WORKSHOP
1.
2.
3.
4.
MECHANICS:
THE LINK NURSES SHALL BE DIVIDED INTO 4
SMALL GROUPS.
EACH GROUP SHALL BE GIVEN A CASE
SCENARIO.
THE MEMBERS OF THE GROUP SHALL
ANALYZE THE SCENARIO USING THE 10 STEPS
OF OUTBREAK INVESTIGATION.
ONE REPRESENTATIVE FROM THE GROUP
WILL PRESENT THEIR ANALYSIS AND
RECOMMENDATIONS AT THE END OF THE
GROUP SESSIONS.
VIII. CASE STUDY
On March 2014, the ICU Link Nurse was the charge

nurse on duty. Upon updating the cultures of patients,
the link nurse has noticed that 4 out of 10 patients in
the ICU have growth of Klebsiella Pneumoniae
Carbapenemase (+) in their cultures.
The Link Nurse immediately notified the Infection
Prevention and Control Office. The surveillance
coordinator together with the Link Nurse conducted an
on-the-spot audit of Infection Prevention and Control
Practices of all healthcare workers at the ICU and
reviewed the interactions that occurred with the
patients.
STUDY
Step 1: Learn
about the
topic
The link nurse reads aboutKlebsiella pneumoniae

carbapenemasefrom
the Infectious Diseases textbook by Mandell. She
found out thatKlebsiella pneumoniae
carbapenemaseis a gram negative bacteria which
develop resistance to most antibiotics including
cabapenems. It is a common cause of nosocomial
infections such as UTI, pneumonia, and meningitis. It
is an important opportunistic pathogen in hospitalized
and immunocompromised patients.
STUDY
Step 2:
Establish the
existence of an
outbreak
The rate of infection due to KPC at the ICU

appeared to begin to rise around March
2014.
The KPC HAI rates for the past 6 months
were reviewed.
There were no HAIs 2 to KPC last October,
November, January and February 2014.
There was a past record of HAI 2 to KPC last
December (2 cases of UTI).
STUDY
Step 3: Verify
the
diagnosis
The ICU link nurse reviewed the charts and

culture results of the 4 patients who
developed HAI 2 to KPC.
She correlated the culture results with the
clinical findings of the patients.
Patient A.N.- VAP 2 to KPC

Patient B.L- VAP 2 to KPC
Patient N.D.- CAUTI 2 to KPC
Patient S.R.- Infected Decubitus
ulcer 2 to KPC
STUDY
Step 4: Define
and Identify
Cases
The initial case definition is,Any ICU

patient developing a HAI secondary to KPC
in the month of March 2014.
The ICU link nurse called the micro lab and
asked for a report:
A report screening for any positive culture
ofKlebsiella pneumoniae
carbapenemasefrom the ICU from March 1
to 31, 2014.
STUDY
Step 4: Define
and Identify
Cases
Na
me
Line List:
Isolate Sourc Room Date

e
#
collecte
d
Date
admitt
ed at
ICU
Date
transferr
ed to
floor
A.N. (+)
KPC
ETA
ICU 2
3/12/14
3/10/14 3/15/14
B.L. (+)
KPC
ETA
ICU 2
3/8/14
3/4/14
3/10/14
N.D. (+)
KPC
Urine
ICU 5
3/5/14
3/2/14
3/15/14
S.R. (+)
KPC
Woun
d
ICU 9
3/8/14
3/5/14
3/11/14
STUDY
Step 5:
Describe and
Orient the Data
in terms of
time, place,
and person
All ICU charts were reviewed using a data

collection form developed by the IPCO.
Place
ICU 2 = 2 CASES (Patients B.L. & A.N.)

ICU 5 = 1 CASE (Patient N.D.)
ICU 9 = 1 CASE (Patient S.R.)
Person
RISK FACTORS FOR KPC HAI:

Patient A.N. was intubated since 3/08/2014. He is under the care
of Dr. B. He was cared by NurseLoveon 3/8/2014.
Patient B.L. was intubated since 3/4/2014. He is under the care
of Dr. A. He was cared by NurseCompetenceon 3/8/2014.
Patient N.D. has a foley catheter since 3/4/2014. He is under the
care of Dr. A. He was cared by NurseCompassionon 3/5/2014.
Patient S.R. has a 2 x 2 bedsore observed since 3/5/2014. He is
under the care of Dr. C. He was cared by NurseCompetenceon
3/8/2014. He was also handled by NurseCompassionon
3/5/2014.
STUDY
Step 6: Develop
a Hypothesis
The tentative hypothesis is thatKlebsiella

pneumoniae carbapenemaseinfection is
being transmitted from an index case to
other patients in the ICU probably because
of a break in infection control practices.
STUDY
Step 7: Test
the
Hypothesis
The ICU link nurse notes that Nurse

Compassion was involved in 2/4 cases and
in the first case of KPC (patient N.D.)
Nurse Competence was involved in 2/4
cases, and Nurse Love was involved in 1/4
cases.
Dr. A was involved in 2/4 cases (B.L. and
N.D.)
She decides to determine if their presence
are significant by conducting an audit of
their practices.
STUDY
Step 7:
Test
Hypothese
s
Audit of Healthcare Worker Practices:

Nurse Competence has a hand hygiene
compliance of 15%.
Nurse Compassion has a hand hygiene

compliance of 50%, but he uses the same gloves
for draining the urinary bag.
Dr. B and A both have a hand hygiene

compliance of 30%.
On 3/10/2014, Patient A.N. was immediately

admitted to the ICU-2 post-OR due to severe
hemodynamic instability. The room has just been
vacated by Patient B.L.
STUDY
Step 7: Test
Hypotheses
Environmental cultures at the ICU were

done to determine the source of the
outbreak.
A culture of the ff. were done:
Bedrails at ICU Beds 2,5,9
Gloves used by Nurse Compassion for
draining urine of patient N.D.
STUDY
Step 7: Test
Hypotheses
Result of cultures:
Bedrails at ICU Beds 2 & 5 were positive for
KPC
Gloves used by Nurse Compassion for
draining urine of patient N.D. was positive
for KPC
STUDY
Step 8: Refine
Hypotheses and
Draw
Conclusions
Patient N.D. with CAUTI 2 to KPC is the

index case (infected March 5, 2014).
Nurse Compassion transmitted KPC from
the urine of Patient N.D. to the wound of
Patient S.R. on March 5, 2014 because
she does not change gloves when
draining the urine bag.
Patient B.L developed VAP 2 to KPC on
March 8, 2014 which was transmitted
from Patient S.R. through the
contaminated hands of Nurse
Competence (HHC of 15%).
STUDY
Step 8: Refine
Hypotheses and
Draw
Conclusions
The wound of Patient S.R. was infected

with KPC on March 8, 2014 which was
transmitted from patient B.L. through the
contaminated hands of Nurse
Competence (15% Hand hygiene
compliance).
Patient A.N. developed VAP 2 to KPC on
March 12, 2014 because of inadequate
environmental cleaning of ICU 2 which
was just vacated by Patient B.L. with VAP
2 to KPC.
STUDY
Step 9:
Implementing
Control and
Prevention
Measures
The ICU link nurse recommends the

following:
Implement contact precautions for all

patients with KPC HAI and Droplet
Precautions for all patients with VAP 2
to KPC.
Gloves used for draining urine should
be disposed immediately after single
use.
Routine environmental cleaning of all
ICU cubicles should be done.
Nurse Competence and Nurse
Compassion were required to attend insevice Infection Control seminar.
STUDY
Step 10:
Communicate
Findings
All staff was informed of findings and the

recommendations.
A written summary of findings was distributed
to appropriate staff.
Thank you for your attention!
References:
http://www.cdc.nationalcenter for chronic disease

prevention and health promotion.Outbreak Investigation
http://www.idready.org. Aragon, T., W. Enanoria, A
Reingold.Conducting an outbreak investigation in 7
steps. Center for Infectious Disease Preparedness, UC
Berkeley School of Public Health.
Outbreak investigation-Case Study by University of
Michigan Hospitals and Health Centers, Infection
Control & Epidemiology 2002.

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Outbreak: Tell-Tale Signs,

Investigations, Actions & Solutions

SILVEROSE ANN A. ANDALES-BACOLCOL, M.D.,

OUTLINE of this LECTURE:

An incident in which two or more people who are

same as outbreak but more widespread or prolonged

Infections acquired during hospital stay which were

E. Health Care Facilities

II. How are outbreaks recognized?

By the clinician, infection control

When to Consider Nosocomial

A cluster of similar infections occurs on one hospital

Determine Risk Factors for Disease or

Host risk factors for HAI

Environmental risk factors

Location (ICU vs. Ward)

III. Reasons for investigating outbreaks

Prevent additional cases in the current outbreak

Reassure the public

Negative Effects of Outbreaks

IV. Constraints of Outbreak Investigation

Urgency to find source and prevent

V. Infection Control Measures

Introduce preventive interventions before

Handwashing in-service sessions

Carefully weigh the potential benefit of more

VI. Preparing for the Investigation

All levels of the health care facilitys personnel

VI. Preparing for the Investigation

Consider availability of microbiologic isolates

VI. Preparing for the Investigation

Identify the following:

Resources (personnel, supplies, laboratory)

VII. STEPS IN CONDUCTING AN OUTBREAK

Step 1: Learn about the topic

Step 1: Learn about the topic

Research about the disease

Step 2: Establish the Existence of an

More cases than expected in a given place

Hospital surveillance records

Step 2: Establish the Existence of an

Clusters of positive cultures in patients

Step 2: Establish the Existence of an

What could cause an artificial increase (pseudooutbreaks)?

New diagnostic tests, laboratory equipment

New susceptible population

New ward, increase in size of population

Step 3: Verify the Diagnosis

Ensure that the disease has been properly

Step 4: Define and Identify Cases

Establish a case definition

Step 4: Define and Identify Cases

Identify and count cases

Interview staff, patients

Do telephone surveys or visit the facilities to collect

Step 4: Define and Identify Cases

Collect Case Data

Laboratory test results

Step 4: Define and Identify Cases

Complete Line Listing

Step 5: Describe and Orient the Data in

Time: Epidemic Curve

Place: Spot Map

Determine what populations are at risk for the