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2015 BEST
OUTBREAK
Epidemic Keratoconjunctivitis
(EKC) in an Ophthalmology
Practice
Roberto Henry, MPH
Public Health Associate
Kanawha-Charleston Health Department
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BACKGROUND:
Conjunctivitis (Pink Eye)
• Common eye condition that causes inflammation of the conjunctiva.
• Symptoms:
• Pink or red eyes, swelling of conjunctiva, tearing, discharge, itching, irritation, burning, foreign body sensation, crusting of eyelids/lashes, respiratory symptoms, photophobia
• Transmission:
• Contact with eyes by hands or objects that are contaminated
• Caused by:
• Bacteria, Viruses, Allergens
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BACTERIAL
CONJUNCTIVITIS
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_
tools/pinkeye_slideshow/PRinc_rm_photo_of_crust_on_eyelid.jpg
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ALLERGIC
CONJUNCTIVITIS
http://allergyadvice.com/wp-content/uploads/2013/08/Allergic-Conjunctivitis.jpg
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VIRAL
CONJUNCTIVITIS
http://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v4/0070/008af
.jpg
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Epidemic
Keratoconjunctivitis (EKC
http://i.dailymail.co.uk/i/pix/2014/02/11/article-2556771-1B63673700000578-
989_634x420.jpg
https://c1.staticflickr.com/9/8460/8045731614_d12a218e40.jp
g
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INITIAL CALL:
September 4th
, 2015
• KCHD was notified of outbreak by DIDE on 9/4/2015.
• An ophthalmologist reported to DIDE that their practice
initially diagnosed 1 patient with EKC on 8/14/15.
• As of 9/4/2015, 12 additional patients were diagnosed with
EKC.
• As of the date of notification, only 1 of the 13 patients had
been lab confirmed.
• The index case is believed to have contracted the virus
after visiting an ophthalmologist while travelling abroad.
Her symptoms began upon return to the U.S., where she
was seen by the ophthalmologist on 8/11/15 and
diagnosed with EKC on 8/14/15.
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INITIAL RESPONSE
KCHD’S ACTIONS
• Took initial report from DIDE
• Conducted research on EKC
• Made contact with physician
• Discussed guidelines and made recommendations
• Requested a line list
KCHD’S RECOMMENDATIONS
• Enforce hand hygiene
• Increase
environmental
cleaning
• Designate an isolated
room for patients with
EKC or suspected
EKC
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INVESTIGATION OBJECTIVES
Control the outbreak
Prevent additional
cases
Reduce severity &
risk to others
Respond to concerns
from providers &
public
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METHODS:
Outbreak Case Definition
Probable case:
• Acute, non-bacterial eye disease characterized by conjunctival inflammation and lacrimation, as well as at least two of the following:
• foreign body sensation, palpebral edema, pain, and photophobia.
Confirmed case:
• Meets above criteria AND one of the following: 1. Corneal epithelial infiltrates/erosions
2. Adenovirus laboratory confirmation
Suspected healthcare-associated infection (HAI) cases:
• Probable or confirmed cases that were seen at the healthcare site under investigation within 14 days of developing symptoms of EKC.
Suspected community-acquired cases:
• Probable or confirmed cases that were seen at the healthcare site under investigation >14 days prior to symptom onset, or were not connected to the site, or were contacts of other known cases prior to visiting the site.
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FOLLICLES &
INFILTRATES
http://pediatriccare.solutions.aap.org/data/Books/1017/chp215_F014.jpeg
http://www.aao.org/image.axd?id=d630f388-ac82-4acb-b25e-
d13ddf5fcfe7&t=635596183507070000
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METHODS:
Data Collection
• Two site visits made to meet with office staff
• Reviewed charts
• Made a detailed line list
• Requested that they begin testing EKC patients
• Disseminated a HAN Alert to area urgent cares, hospitals
and eye doctors
• Some community cases were reported
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METHODS:
Infection Control Assessment
• First site visit conducted by KCHD’s Division of Epidemiology on 9/10/15:
• Team did a run through of the office with the technicians to evaluate their current cleaning practices.
• Also met with office manager to conduct chart review.
• Second site visit conducted by KCHD, EIS Officer, Hospital IP, and Clinical Virologist on 9/15/15:
• Conducted a more thorough assessment of IC procedures, while offering recommendations on how to improve procedures.
• Took environmental specimens for testing.
• Provided formal, written IC recommendations to the practice along with a review of their current practices.
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METHODS:
Environmental Cleaning Methods
• Increase cleaning with antiviral wipes effective against Adenoviruses.
• Clean every surface between patients.
• Make sure cleaning supplies are available and easily accessible in every room.
• Wear gloves and change gloves between patients.
• Exclude symptomatic employees for 14 days.
• Date multiuse vials, throw away 28 days after opening.
• Enforce proper hand hygiene.
• Use separate dedicated rooms and ensure intensified cleaning procedures are carried out for all patients symptomatic for infection.
• Have a written infection control protocol; review it regularly with all clinic staff to ensure standardized implementation.
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NUMBER OF CASES BY SYMPTOM
ONSET DATE
0
1
2
3
4
5
6
7
7/2
8/2
015
7/3
0/2
015
8/1
/20
15
8/3
/20
15
8/5
/20
15
8/7
/20
15
8/9
/20
15
8/1
1/2
015
8/1
3/2
015
8/1
5/2
015
8/1
7/2
015
8/1
9/2
015
8/2
1/2
015
8/2
3/2
015
8/2
5/2
015
8/2
7/2
015
8/2
9/2
015
8/3
1/2
015
9/2
/20
15
9/4
/20
15
9/6
/20
15
9/8
/20
15
9/1
0/2
015
9/1
2/2
015
9/1
4/2
015
9/1
6/2
015
9/1
8/2
015
9/2
0/2
015
9/2
2/2
015
9/2
4/2
015
9/2
6/2
015
9/2
8/2
015
9/3
0/2
015
10
/2/2
015
10
/4/2
015
10
/6/2
015
10
/8/2
015
10
/10
/201
510
/12
/201
510
/14
/201
510
/16
/201
510
/18
/201
510
/20
/201
510
/22
/201
510
/24
/201
510
/26
/201
510
/28
/201
510
/30
/201
511
/1/2
015
11
/3/2
015
11
/5/2
015
11
/7/2
015
11
/9/2
015
11
/11
/201
511
/13
/201
5
Nu
mb
er
of
Pro
bab
le o
r C
on
firm
ed
Cases
Symptom Onset Date
UnlinkedCases
HAI Cases
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RESULTS
• 51 cases of EKC were reported during the outbreak
period, 8/14/15-11/13/15.
• 39 of these cases came from the particular
ophthalmologist’s practice.
• 15 lab tested
• 14 tested positive for adenovirus
• 10 of 12 submitted for further testing tested positive
for adenovirus-8
• 44 clinical diagnosis only
• 12 were reported from other providers and were not linked
to the ophthalmology practice or their EKC patients.
• 2 lab confirmed
• 10 clinical diagnosis only
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RESULTS:
Site Visit
POSITIVES
• Understanding of
EKC
• Willing to make
changes
• Germicidal wipes
were available in
all areas
NEGATIVES
• No written IP/C policy
• No written cleaning procedures
• Gloves not available in every room
• Germicidal wipes used were ineffective
• Were only cleaning touched surfaces once a day and exam rooms once a week
• Multiuse vials were not dated
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RESULTS:
Laboratory Testing
PATIENTS
• 17 of 51 cases
were tested by
Multiplex-PCR
• 16 + for adenovirus
• 12 sent to NY State
DOH’s Wadsworth
Lab for additional
next gen testing and
serotyping
• 10 + for
adenovirus-8
ENVIRONMENTAL
• 7 environmental samples
• Tonometer- Room 3
• Exam Chair- Room 4
• Cyclo- Room 2
• Ocular- Room 1
• Chin Rest- Room 4
• Tonometer- Room 4
• Topicide
• 3 tested positive
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DISCUSSION
• From 9/4/15 to 11/13/15, the ophthalmologist’s practice
reported 39 case of EKC, and an additional 12 cases were
reported from other providers. Serotyping of 21 specimens
(human & environmental) confirmed that the EKC cases from
the ophthalmologist’s practice were in fact related.
• A combination of delayed notification of the outbreak, poor
infection prevention practices at this medical practice, and the
easy communicability of this virus allowed for this outbreak to
reach the levels that it did.
• However, great support from our Health Officer, State Partners,
and Hospital Partners allowed us to quickly and effectively get
this under control.
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LIMITATIONS
• The practice notified DIDE about the outbreak after 13 patients
had been diagnosed and the outbreak had been going on for
over 1 week.
• After the HAN alert was sent out, KCHD began to receive
reports for all types of conjunctivitis, not just cases that met the
case definition.
• No one on the outbreak team had experience with EKC, and
there was very little information out there on EKC. We had to
do a lot of research quickly in order to develop guidelines and
recommendations.
• Poor environmental cleaning practices.
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RECOMMENDATIONS
• Every clinical practice should have a comprehensive infection
control plan understood by all members of the staff, regardless
of pathogen.
• During an outbreak, a room should be designated only for
symptomatic patients.
• It is a good practice to note what room a patient was seen in
on their chart, even when there is no outbreak occurring.
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REFERENCES
• http://www.cdc.gov/conjunctivitis/index.html
• Pihos, AM. Epidemic keratoconjunctivitis: A review of current
concepts in management. Journal of Optometry 2013; 6:69-74.
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ACKNOWLEDGMENTS
KCHD Staff
• Janet Briscoe, Lindsey Mason, Christy Reed & Dr. Michael
Brumage
DIDE Staff
• Dr. Joel Massey, Dr. Dee Bixler, Dr. Sherif Ibrahim
Hospital Partners
• Linda Minnich, Deana Samms
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QUESTIONS?
Thank You!
Roberto Henry, MPH
Public Health Associate
Kanawha-Charleston Health Department
108 Lee Street East
Charleston, WV 25301
(304) 348-1088