public health outbreaks, responses: focus --cough...

for for MUSCMUSC

Public HealthPublic Health

InterInter--disciplinary disciplinary

CourseCourse

Feb. 2011Feb. 2011

Public Health Outbreaks, Public Health Outbreaks, Responses: focusResponses: focus

Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant/ Epidemiologist, SC DHECInfectious Disease Consultant/ Epidemiologist, SC DHEC

CoCo--Chair, SC Pandemic Influenza Ethics Chair, SC Pandemic Influenza Ethics

MUSCMUSC

Public HealthPublic Health

disciplinary disciplinary

CourseCourse

Feb. 2011Feb. 2011

Public Health Outbreaks, Public Health Outbreaks, Responses: focusResponses: focus-- Cough CootiesCough Cooties

R. Ball, MD MPH FACP

Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant/ Epidemiologist, SC DHECInfectious Disease Consultant/ Epidemiologist, SC DHEC

Chair, SC Pandemic Influenza Ethics Chair, SC Pandemic Influenza Ethics TaskforceTaskforce

1. Confirm the Diagnosis/ What is the true Dx?

2. Organize data: time, place, person = line listing,

with demographics & risk factors

3. Make an epi-curve, look for more cases

4. Ask relevant Qs of Pts, generate an hypothesis

5. Develop a (broad) case definition

6. Collect (additional) samples (not

7. Define controls (? case-

8. Refine hypothesis, data, studies… etc…

Cluster/ Outbreak InvestigationCluster/ Outbreak Investigation


Confirm the Diagnosis/ What is the true Dx?

Organize data: time, place, person = line listing,

with demographics & risk factors

curve, look for more cases

Ask relevant Qs of Pts, generate an hypothesis

Develop a (broad) case definition

Collect (additional) samples (not nec. to test all)

-control study)

Refine hypothesis, data, studies… etc…

Cluster/ Outbreak InvestigationCluster/ Outbreak Investigation

TERMINOLOGY: “EXPOSURE” …TERMINOLOGY: “EXPOSURE” …

“EXPOSUREEXPOSURE” = a behavioral event/ incident

(ie, needlestick, mucous membrane splash)

“INFECTIONINFECTION” = a biologic/ immunologic event

(ie, growth of organism, antibody response

“DISEASEDISEASE” = a clinical event

(ie, symptoms and/or signs of the infection)


TERMINOLOGY: “EXPOSURE” …TERMINOLOGY: “EXPOSURE” …

= a behavioral event/ incident

, needlestick, mucous membrane splash)

= a biologic/ immunologic event

, growth of organism, antibody response

= seroconversion)

= a clinical event

, symptoms and/or signs of the infection)

Cluster v. Outbreak v. Epidemic ?Cluster v. Outbreak v. Epidemic ?

“CLUSTERCLUSTER” ~ an increase in cases above

baseline, at one point in time, usually focal

“OUTBREAK” ~ an ongoing cluster (+ time),

usually with growing # of cases among contacts

“EPIDEMIC” ~ an ongoing outbreak, with #s of

cases far exceeding baseline, over a longer span

of time, and beyond the immediate contactsR. Ball, MD MPH FACP

Cluster v. Outbreak v. Epidemic ?Cluster v. Outbreak v. Epidemic ?

~ an increase in cases above

baseline, at one point in time, usually focal

~ an ongoing cluster (+ time),

usually with growing # of cases among contacts

~ an ongoing outbreak, with #s of

cases far exceeding baseline, over a longer span

of time, and beyond the immediate contacts

School nurse vs. pediatricianSchool nurse vs. pediatrician

�� A school nurse calls DHEC A school nurse calls DHEC some children have severe cough some children have severe cough illness, but the pediatricians allow illness, but the pediatricians allow the children to return the children to return

What would you What would you

�� DHEC: DHEC: make Dx, notificationmake Dx, notificationtracing, tracing, PEP the contacts, PEP the contacts, indigent Ptindigent Pt. ? private . ? private provider roles. provider roles. What about HIPAA, etc?What about HIPAA, etc?


School nurse vs. pediatricianSchool nurse vs. pediatrician

A school nurse calls DHEC A school nurse calls DHEC Epi:Epi:some children have severe cough some children have severe cough illness, but the pediatricians allow illness, but the pediatricians allow the children to return the children to return to to class.class.

What would you What would you do?do?

make Dx, notificationmake Dx, notification, contact , contact PEP the contacts, PEP the contacts, even Tx if even Tx if . ? private . ? private & public health & public health

What about HIPAA, etc?What about HIPAA, etc?

Q: What’s the most pQ: What’s the most pcommunicable infectious disease?communicable infectious disease?

�In the viral kingdom ?�In the bacterial kingdom ?

Inf.Dis.: CommunicabilityInf.Dis.: Communicability

�� A: A: ViralViral: measles > : measles > several several herpesvirusesherpesviruses�� A: A: BacterialBacterial: pertussis > ?staph.: pertussis > ?staph.

�� Q: Are there any more Q: Are there any more �� A: yesA: yes-- CoxsiellaCoxsiella burnettiburnetti


Q: What’s the most pQ: What’s the most p--p contagious/ p contagious/ communicable infectious disease?communicable infectious disease?

kingdom ?

Inf.Dis.: CommunicabilityInf.Dis.: Communicability

: measles > : measles > varicellavaricella > > herpesvirusesherpesviruses > > flu > othersflu > others

: pertussis > ?staph.: pertussis > ?staph.

Q: Are there any more Q: Are there any more transmissabletransmissable organisms?organisms?burnettiburnetti (Q fever)(Q fever)-- 1 organism1 organism

Pertussis Dx, Tx, & PEPPertussis Dx, Tx, & PEP

�� Suspect if paroxysmal or prolonged Suspect if paroxysmal or prolonged cough illness (seldom see whoop), cough illness (seldom see whoop), especially if especially if >>1 other family/ friend ill1 other family/ friend ill

�� Dx: NP swab for PCRDx: NP swab for PCR�� Tx: azithromycinTx: azithromycin�� PEP: azithromycinPEP: azithromycin�� DHEC assists in PEPDHEC assists in PEP


Pertussis Dx, Tx, & PEPPertussis Dx, Tx, & PEP

Suspect if paroxysmal or prolonged Suspect if paroxysmal or prolonged cough illness (seldom see whoop), cough illness (seldom see whoop),

1 other family/ friend ill1 other family/ friend ill

Dx: NP swab for PCRDx: NP swab for PCR

PEP: azithromycinPEP: azithromycinDHEC assists in PEPDHEC assists in PEP

Pertussis: Clinical & Epi FeaturesPertussis: Clinical & Epi FeaturesIncubation Period: 6-21 days, average 7

Symptoms: Catarrhal Stage (URI)

Stage with cough, usu. lasting 6

Transmission: large respiratory droplets ~6’ radius

(sneezing, coughing, kissing, sharing…)/1

Communicability: high (attack rates up to 80% of

nonimmune household contacts)

CONTAGIOUS BACTERIAL INFECTION KNOWN

Complications: pneumonia, encephalopathy, rib

seizures, apneic episodes, death (often < 1yo)R. Ball, MD MPH FACP

Pertussis: Clinical & Epi FeaturesPertussis: Clinical & Epi Features21 days, average 7-10 d.

Catarrhal Stage (URI)→ Paroxysmal

Stage with cough, usu. lasting 6-10 weeks

: large respiratory droplets ~6’ radius

(sneezing, coughing, kissing, sharing…)/1 hr.in room

high (attack rates up to 80% of

household contacts)- MOST

CONTAGIOUS BACTERIAL INFECTION KNOWN

pneumonia, encephalopathy, rib Fx,

episodes, death (often < 1yo)

Stages of Classic PertussisStages of Classic Pertussis

Day 0 7 14 21 28 35 56 63

Incubation Period

7-10 days

(range 5-21 days)

Catarrhal stageCatarrhal stage

2-7 days

(range 7-14 days)Exposure

Paroxysmal cough stageParoxysmal cough stage

~56 days (PCR still +, cultures neg.)~56 days (PCR still +, cultures neg.)(range: min.1, avg. 6(range: min.1, avg. 6

Duration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to Others~21 days without approp.antibiotics~ 5 days once approp. antibiotics started

Date of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onsetDate of Sx onset: : : : : : : : “pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”


Stages of Classic PertussisStages of Classic Pertussis

Day 0 7 14 21 28 35 56 63 70

Paroxysmal cough stageParoxysmal cough stage

~56 days (PCR still +, cultures neg.)~56 days (PCR still +, cultures neg.)(range: min.1, avg. 6(range: min.1, avg. 6--10, max.16 weeks)10, max.16 weeks)

Recovery (“100 day cough”)Recovery (“100 day cough”)

Toxin damage to

tracheobronchial tree

Modified from slide viaS. Jankelevich MD

Duration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to OthersDuration of Infectivity to Others~21 days without approp.antibiotics~ 5 days once approp. antibiotics started

“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”“pick a date, any date!”

A Family Member is the Source of Pertussis in

75% of cases

Nearly 50% of the Time, Infants are Infected by Their Parents

Adult-to-infant transmission has been well

Bisgard, K. et al. Ped Infect Dis J.

2004; 23:985-989. R. Ball, MD MPH FACP7

A Family Member is the Source of Pertussis in

75% of cases

Nearly 50% of the Time, Infants are Infected by Their Parents

infant transmission has been well-documented for decades

Source:Mom or Dad

in 47% of cases

n PCR: Polymerase chain reaction – rapid, very sensitive and specific, high predictive value

n Culture: Isolation of Bordetella Pertussis

– preferred test, but fastidious growth of organism make it very difficult to isolate, slower turnPCR and DFA, confounded by prior antibiotic use

Pertussis Testing (DHEC Districts)Pertussis Testing (DHEC Districts)

nDFA: Direct fluorescent antibody (ceased 8/8/03)

– rapid & cheap, but low sensitivity and variable specificity, with low positive predictive value


PCR: Polymerase chain reaction rapid, very sensitive and specific, high predictive value

Bordetella Pertussis

preferred test, but fastidious growth of organism make it very difficult to isolate, slower turn-around than PCR and DFA, confounded by prior antibiotic use

Pertussis Testing (DHEC Districts)Pertussis Testing (DHEC Districts)

DFA: Direct fluorescent antibody (ceased 8/8/03)

rapid & cheap, but low sensitivity and variable specificity, with low positive predictive value

simple Dacron NP swabs

Pertussis Tx & PEP:Pertussis Tx & PEP:

• Azithromycin: Z-pack (

& convenient, cost ~ $70, has least side effects

• Erythromycin: cheaper, but QID dosing x 14

days, side effects →→→→ suboptimal compliance

• Clarithromycin: BID OK, but more expensive

• Others: TMP/ SMX (but NOT

Isolate case 1Isolate case 1ststR. Ball, MD MPH FACP

Pertussis Tx & PEP:Pertussis Tx & PEP:>> 3 antibiotics3 antibiotics

pack (5 days) most available

& convenient, cost ~ $70, has least side effects

Erythromycin: cheaper, but QID dosing x 14

suboptimal compliance

Clarithromycin: BID OK, but more expensive

Others: TMP/ SMX (but NOT ß-lactams like amoxicillin!)

5 days of Rx !5 days of Rx !

10.20.1010.20.10

CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10


CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10CDC MMWR 10.29.10

PERTUSSIS WEBCAST DR. CHERRY 10.6.10


PERTUSSIS WEBCAST DR. CHERRY 10.6.10

Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10


Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10Pertussis: JAMA 8.25.10

http://www.llr.state.sc.us/pol/medical/


http://www.llr.state.sc.us/pol/medical/

PEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SC

* and Epi-Treatment of STDs, including Expedited Partner Therapy

*


PEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SCPEP of cootie contacts: new standard of care in SC

Treatment of STDs, including Expedited Partner Therapy

Respiratory Illnesses in a FacilityRespiratory Illnesses in a Facility

�� A hospital ICP calls A hospital ICP calls Several admissions for fever, cough, Several admissions for fever, cough,

and pneumonia from a facility. and pneumonia from a facility. Limited testing nonLimited testing nonSome response to antibiotics, but…Some response to antibiotics, but…

�� DHEC: DHEC: make a Dx, notificationmake a Dx, notificationcontact tracing, contact tracing, PEP the contacts, PEP the contacts, Tx if indigent PtTx if indigent Pt. ? Roles . ? Roles public health public health providers.providers.


Respiratory Illnesses in a FacilityRespiratory Illnesses in a Facility

A hospital ICP calls A hospital ICP calls DHEC DHEC Epi:Epi:Several admissions for fever, cough, Several admissions for fever, cough,

and pneumonia from a facility. and pneumonia from a facility. Limited testing nonLimited testing non--contributory. contributory. Some response to antibiotics, but…Some response to antibiotics, but…

make a Dx, notificationmake a Dx, notification, , PEP the contacts, PEP the contacts, even even . ? Roles . ? Roles of private & of private &

providers.providers.

InfluenzaInfluenza-- Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned

� Learn from history of pandemics� Providers MUST keep up constantly with medical

information explosion (articles etc = TNTC)� Descriptive, Epi (US,state,local), & Clinical Mx/ Tx guidance� You can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]

�Vaccines: seasonal/pandemic: +/�Testing: types/methods, +/�Antiviral Tx & PEP: meds, guidance, supplies OK…� Guidelines freq. “updated”, ~confusing (eg: N95s)�Communication: w/ peers, patients, public = poor

Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned

history of pandemics (or else repeat…)Providers MUST keep up constantly with medical information explosion (articles etc = TNTC)Descriptive, Epi (US,state,local), & Clinical Mx/ Tx guidanceYou can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]

: seasonal/pandemic: +/- guidance, supplies: types/methods, +/- guidance, supplies OKTx & PEP: meds, guidance, supplies OK…freq. “updated”, ~confusing (eg: N95s)

: w/ peers, patients, public = poorR. Ball, MD MPH FACP

Pandemic nH1N1: Transmissibility Pandemic nH1N1: Transmissibility

(Attack Rate) vs. Morbidity/Mortality(Attack Rate) vs. Morbidity/Mortality

Transmissibility

(Attack Rate)

Qs: what are the determinants of these Qs: what are the determinants of these influenza virus characteristics,influenza virus characteristics,

and do they apply to all/ most viruses ?and do they apply to all/ most viruses ?R. Ball, MD MPH FACP

Pandemic nH1N1: Transmissibility Pandemic nH1N1: Transmissibility

(Attack Rate) vs. Morbidity/Mortality(Attack Rate) vs. Morbidity/Mortality

Severity/ Virulence

(Morbidity/ Mortality)

Qs: what are the determinants of these Qs: what are the determinants of these influenza virus characteristics,influenza virus characteristics,

and do they apply to all/ most viruses ?and do they apply to all/ most viruses ?

Global Air TravelGlobal Air Travel--

Thanks to Mike Schmidt, PhD R. Ball, MD MPH FACP

-- 1 day, mid1 day, mid--20092009

Thanks to Mike Schmidt, PhD- MUSC for this graph

Pandemic mortality curves: 1918, othersPandemic mortality curves: 1918, othersTaubenberger. EID 1Taubenberger. EID 1--0606


Pandemic mortality curves: 1918, othersPandemic mortality curves: 1918, others

“Cytokine Storm”“Cytokine Storm”

10%

90%

Graph F: U.S. Percentage of Seasonal Flu Deaths Among People on Average

Seasonal Influenza DeathsSeasonal Influenza Deaths


Graph F: U.S. Percentage of Seasonal Flu Deaths Among People ≥65 Years Old Each Year on Average

0-64 Yrs ≥65 Yrs

Seasonal Influenza DeathsSeasonal Influenza Deaths

2009 H1N1 Deaths

1,230

8,980

CDC Estimates of 2009 H1N1 Deaths by Age Group in the United States (n=11,690)

(April 2009 –January 16, 2010)


2009 H1N1 Deaths

1,480

CDC Estimates of 2009 H1N1 Deaths by Age Group in the States (n=11,690)

January 16, 2010)

0-17 Yrs

18-64 Yrs

≥65 Yrs

InfluenzaInfluenza-- Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned

�Learn from history of pandemics� Providers MUST keep up constantly with medical

information explosion (articles etc = TNTC)� Descriptive, Epi (US,state,local� You can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]

�Vaccines: seasonal/pandemic: +/�Testing: types/methods, +/�Antiviral Tx & PEP: meds, guidance, supplies OK…� Guidelines freq. “updated”, ~confusing (�Communication: w/ peers, patients, public = poor


Seasonal, Pandemic, Seasonal, Pandemic, H1N1: some Lessons LearnedH1N1: some Lessons Learned

history of pandemics (or else repeat…)Providers MUST keep up constantly with medical information explosion (articles etc = TNTC)

US,state,local), & Clinical Mx/ Tx guidanceYou can’t be too aggressive re: testing, Tx, PEP [CAP=FLU UPO]

: seasonal/pandemic: +/- guidance, supplies: types/methods, +/- guidance, supplies OKTx & PEP: meds, guidance, supplies OK…freq. “updated”, ~confusing (eg: N95s)

: w/ peers, patients, public = poorR. Ball, MD MPH FACP

• AA (H3N2)/ (H3N2)/ Perth/16/2009

• A A (H1N1)/(H1N1)/ California/2009

• BB / Brisbane/60/08 (same as last year)

Myths/misconceptions we must combat:Myths/misconceptions we must combat:“Flu shots give me the flu.” (rare S.E. are “Flu shots give me the flu.” (rare S.E. are natural immune reaction: Tx= E&R, NSAIDs)natural immune reaction: Tx= E&R, NSAIDs)“The flu shots are dangerous/ untested…”“The flu shots are dangerous/ untested…”“I’m not in a ‘risk group’ & won’t get it”“I’m not in a ‘risk group’ & won’t get it”

etc…etc…

Inactivated Trivalent Influenza Vaccine (ITIV):

3 Components for 2010


Perth/16/2009-like

California/2009-like [“swine”]

/ Brisbane/60/08 (same as last year)

Myths/misconceptions we must combat:Myths/misconceptions we must combat:“Flu shots give me the flu.” (rare S.E. are “Flu shots give me the flu.” (rare S.E. are natural immune reaction: Tx= E&R, NSAIDs)natural immune reaction: Tx= E&R, NSAIDs)“The flu shots are dangerous/ untested…”“The flu shots are dangerous/ untested…”“I’m not in a ‘risk group’ & won’t get it”“I’m not in a ‘risk group’ & won’t get it”

Inactivated Trivalent Influenza Vaccine (ITIV):

3 Components for 2010-2011, selected 2.10


CDC 8.13.10

Influenza vaccination:Influenza vaccination:2 main reasons to get vaccinated2 main reasons to get vaccinated� Greatly ↓ chance (by 3/4) of influenza (& transmitting

� Even if a person gets vaccinated and still catches influenza, vaccination will greatly ↓ the chance of (eg, hospitalization, pneumonia, & death)

R. Ball, MD MPH FACPR. Ball, MD, MPH

Influenza vaccination:Influenza vaccination:2 main reasons to get vaccinated2 main reasons to get vaccinated

chance (by 3/4) of catching transmitting to others)

Even if a person gets vaccinated and still catches influenza, vaccination will

the chance of complications(eg, hospitalization, pneumonia, & death)

Good reasons why people benefitGood reasons why people benefit

from influenza vaccination: summaryfrom influenza vaccination: summary1. Efficacy studies suggest the vaccine will prevent about

75% of influenza infections.

2. Those who are protected will not transmit to others (e.g.,

family, co-workers, patients).

3. For the 25% of vaccinees who may get the flu, the

chances of complications, hospitalization or death are

much less. (Efficacy preventing hospitalization


Good reasons why people benefitGood reasons why people benefit

from influenza vaccination: summaryfrom influenza vaccination: summaryEfficacy studies suggest the vaccine will prevent about

75% of influenza infections.

Those who are protected will not transmit to others (e.g.,

workers, patients).

For the 25% of vaccinees who may get the flu, the

chances of complications, hospitalization or death are

much less. (Efficacy preventing hospitalization > 90%)

Influenza Vaccine: Priority GroupsInfluenza Vaccine: Priority Groups

& 2005& 2005--08 Vaccination Coverage Rates08 Vaccination Coverage Rates

SHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USHCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !

How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?

CDC. MMWR July 24, 2009 / Vol. 58 ER


Influenza Vaccine: Priority GroupsInfluenza Vaccine: Priority Groups

08 Vaccination Coverage Rates08 Vaccination Coverage Rates

SHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USSHAME ON USHCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !HCWs avg from 33% to 44% !

How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?How to increase HCW compliance with influenza vaccination ?

Influenza nonInfluenza non--HCWs: Adverse EffectsHCWs: Adverse Effects

� HCWs w/ flu are contagious ~1 day prior to Sx, 5+ days after, & still try to work with Sx!

�→ Increased employee illness & absenteeism: (50% more sick days shortages, medical errors)

�→ Increased #s Pt cases/outbreaks in facilities

�→ Increased facility’s & HCW health care costs

--Vaccination in Vaccination in HCWs: Adverse EffectsHCWs: Adverse Effects

HCWs w/ flu are contagious ~1 day prior to Sx, 5+ days after, & still try to work with Sx!

Increased employee illness & absenteeism: (50% more sick days →coworker illnesses & shortages, medical errors)

Increased #s Pt cases/outbreaks in facilities

Increased facility’s & HCW health care costsR. Ball, MD MPH

Mandatory Influenza Mandatory Influenza Vaccination for HCWs?Vaccination for HCWs?

Some hospital systems now mandate HCW influenza Some hospital systems now mandate HCW influenza

vaccination as a condition of employment.vaccination as a condition of employment.

(eg, UNC, Johns Hopkins, Duke, others, & growing)

eg, in SC: Georgetown Hosp.System

SCHA: 18 hosp. report 24-99.8% (

R. Ball, MD MPH

Mandatory Influenza Mandatory Influenza Vaccination for HCWs?Vaccination for HCWs?

Some hospital systems now mandate HCW influenza Some hospital systems now mandate HCW influenza

vaccination as a condition of employment.vaccination as a condition of employment.

(eg, UNC, Johns Hopkins, Duke, others, & growing)

eg, in SC: Georgetown Hosp.System→→→→99.8% compliance

99.8% (55%) HCW H1N1 vax.rates

HCW Pushback counterHCW Pushback counter

• As an absolute condition of employment, we (your

employer) have the right to inject into your arm a PPD

test- which offers you no immune protection at all, is

simply a test of LTBI/ TB ,and can inflame your arm.

You do NOT have a right to refuse if you want this job.

• As a absolute condition of employment, you must take a

3-shot HBV vaccination series which offers high (but

not perfect) protection and consent to a blood test.

IF you refuse, you MUST sign a R. Ball, MD MPH

HCW Pushback counterHCW Pushback counter--strategiesstrategies

As an absolute condition of employment, we (your

employer) have the right to inject into your arm a PPD

which offers you no immune protection at all, is

simply a test of LTBI/ TB ,and can inflame your arm.

You do NOT have a right to refuse if you want this job.

As a absolute condition of employment, you must take a

shot HBV vaccination series which offers high (but

not perfect) protection and consent to a blood test.

you refuse, you MUST sign a declination form…


October 2010

SCHA- DHEC article by Drs. Eric Brenner & R. Muhammed 11.10


DHEC article by Drs. Eric Brenner & R. Muhammed 11.10

nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009

Wise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timelimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resources


nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009nH1N1 vaccine allocation guidance: fall of 2009

Wise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of timeWise use of time--------limited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resourceslimited resources

Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 R. Ball, MD MPH FACP

July 2008July 2008July 2008July 2008

Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 Progressive timeline October 2009 →→→→ 2010201020102010 →→→→ 2011201120112011

For 2010-2011:- everyone > 6 mos.- no priority groups- ~distribution = rationing

Flu: Rapid Tests, PCR & CulturesFlu: Rapid Tests, PCR & Cultures

•• Rapid tests occas. false (+) or false (Rapid tests occas. false (+) or false (

• Some (+) rapid tests do not differentiate

between seasonal influenza A & B.

• (+) rapid tests, and (-) tests (in the presence

of clinical ILI Sx, or meeting the “evolving”

case definition) should be accompanied by

2nd swab for Culture with PCR (DHEC).Culture with PCR (DHEC).

• Specimen technique is important (NP,

throat, and/or bronchial washings) !

• Doubtful if current rapid tests can detect H5

(N1) or new “swine” flu H1 (April 2009)

• HCW MUST WEAR PPE !R. Ball, MD MPH

Flu: Rapid Tests, PCR & CulturesFlu: Rapid Tests, PCR & Cultures

Rapid tests occas. false (+) or false (Rapid tests occas. false (+) or false (--).).

Some (+) rapid tests do not differentiate

) tests (in the presence

of clinical ILI Sx, or meeting the “evolving”

case definition) should be accompanied by

Culture with PCR (DHEC).Culture with PCR (DHEC).

Specimen technique is important (NP,

Doubtful if current rapid tests can detect H5

(N1) or new “swine” flu H1 (April 2009)

HCW MUST WEAR PPE !

Seasonal: NP better yieldSeasonal: NP better yieldSeasonal: NP better yieldSeasonal: NP better yieldH5N1 Flu: throat or bronch.H5N1 Flu: throat or bronch.H5N1 Flu: throat or bronch.H5N1 Flu: throat or bronch.H1N1: Either site is OK.H1N1: Either site is OK.H1N1: Either site is OK.H1N1: Either site is OK.

R. Ball, MD MPH FACPSlide courtesy: R. Wenzel MD

Zanamivir “Relenza” & Oseltamivir “Tamiflu”Zanamivir “Relenza” & Oseltamivir “Tamiflu”treat & prevent most Influenza A & B infectionstreat & prevent most Influenza A & B infections(& cover most strains of A(& cover most strains of A

Influenza Antivirals:Influenza Antivirals:For Treatment AND PreventionFor Treatment AND Prevention

MMWR July 31, 2009 / Vol. 58 RR8 R. Ball, MD MPH FACP

Zanamivir “Relenza” & Oseltamivir “Tamiflu”Zanamivir “Relenza” & Oseltamivir “Tamiflu”treat & prevent most Influenza A & B infectionstreat & prevent most Influenza A & B infections(& cover most strains of A(& cover most strains of A--H1N1 “swine flu”H1N1 “swine flu”

Influenza Antivirals:Influenza Antivirals:For Treatment AND PreventionFor Treatment AND Prevention

deJong et al.NEJM 12-22-05

Influenza Antivirals: Tx EffectsInfluenza Antivirals: Tx Effects

• Children with influenza: 53% less likely to develop pneumonia,

• Adults ill with influenza: 71% less likely to die.

if given oseltamivir early (~ 1

∴∴∴∴∴∴∴∴ Tx with Tx with “TIMELY TAMIFLU”*“TIMELY TAMIFLU”*

*Source: ICAAC abstracts*Source: ICAAC abstracts

“…treat patients ASAP…” (duration 5 days) CDC

7.09

Influenza Antivirals: Tx EffectsInfluenza Antivirals: Tx Effects

Children with influenza: 53% less likely to develop pneumonia,

Adults ill with influenza: 71% less likely

if given oseltamivir early (~ 1st 2+ days)

“TIMELY TAMIFLU”*“TIMELY TAMIFLU”*

R. Ball, MD MPH*Source: ICAAC abstracts*Source: ICAAC abstracts-- 9/29/069/29/06

“…treat patients ASAP…” (duration 5 days) CDC


Slide courtesy: F. Hayden MD Feb.2010

SC Pandemic Influenza Ethics

Taskforce: New Guidelines

Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant & Epidemiologist, SC DHEC

Phil Schneider, PhD, Emeritus Professor of BioethicsPhil Schneider, PhD, Emeritus Professor of BioethicsCoastal Carolina University

CoCo--Chairs, SC Pan Flu Ethics TaskforceChairs, SC Pan Flu Ethics Taskforce

with thanks to Covia Stanley, MD M.Div., Tom Fabian, MD MPH, Covia Stanley, MD M.Div., Tom Fabian, MD MPH, Pan Flu Consultant, SC DHEC, Pan Flu Consultant, SC DHEC, and

New Standards of Care for

Medical Professionals re: Pan Fluspring 2010

SC Pandemic Influenza Ethics

Taskforce: New Guidelines

Robert Ball, MD MPH FACPRobert Ball, MD MPH FACPInfectious Disease Consultant & Epidemiologist, SC DHEC

Phil Schneider, PhD, Emeritus Professor of BioethicsPhil Schneider, PhD, Emeritus Professor of BioethicsCoastal Carolina University

Chairs, SC Pan Flu Ethics TaskforceChairs, SC Pan Flu Ethics Taskforce

Covia Stanley, MD M.Div., Tom Fabian, MD MPH, Covia Stanley, MD M.Div., Tom Fabian, MD MPH, and Rick Foster, MD, VRick Foster, MD, V--P, SCHAP, SCHA

R. Ball, MD MPH

New Standards of Care for

Medical Professionals re: Pan Fluspring 2010

CURRENT MODEL OF MEDICINE:

Sickest Patients get first claim on

medical resources.

PANDEMIC MODEL OF MEDICINE:

Patients with best chance of recovery get

first claim on medical resources.

South Carolina Prepares for Pandemic Influenza:South Carolina Prepares for Pandemic Influenza:

An Ethical PerspectiveAn Ethical PerspectiveSouth Carolina Pandemic Influenza Ethics Task ForceSouth Carolina Pandemic Influenza Ethics Task Force


CURRENT MODEL OF MEDICINE:

Sickest Patients get first claim on

PANDEMIC MODEL OF MEDICINE:

Patients with best chance of recovery get

first claim on medical resources.

South Carolina Prepares for Pandemic Influenza:South Carolina Prepares for Pandemic Influenza:

An Ethical PerspectiveAn Ethical PerspectiveSouth Carolina Pandemic Influenza Ethics Task ForceSouth Carolina Pandemic Influenza Ethics Task Force

What events prompt ‘altered’ standards of care?What events prompt ‘altered’ standards of care?


New EnglandJournal of Medicine358:1

What events prompt ‘altered’ standards of care?What events prompt ‘altered’ standards of care?


Of the manygood articles…

SC Pandemic Influenza Ethics Task ForceSC Pandemic Influenza Ethics Task ForceStandards of Care paper & Summit 2009Standards of Care paper & Summit 2009

Clinical Practices

Public Health Practices

Public Risk Communication

Ethics Workgroup: Co-Coordinators

Legal Workgroup: Co-Coordinators

SC Pandemic Influenza Ethics Task Force

Co-Chairs (DHEC & non-DHEC)

Steering Committee

SC Pandemic Influenza Coordinating Council

South Carolina Prepares for Pandemic Influenza:

An Ethical Perspective

many thanks to:Tom Fabian,Max Learner,Phyllis Beasleyet al.


SC Pandemic Influenza Ethics Task ForceSC Pandemic Influenza Ethics Task ForceStandards of Care paper & Summit 2009Standards of Care paper & Summit 2009

Clinical Practices Workgroup: Co-Coordinators

Public Health Practices Workgroup: Co-Coordinators

Public Risk Communication Workgroup: Co-Coordinators

Workgroup: Co-Coordinators

Workgroup: Co-Coordinators

SC Pandemic Influenza Ethics Task Force

Co-Chairs (DHEC & non-DHEC)

Steering Committee

SC Pandemic Influenza Coordinating Council

*

South Carolina Prepares for Pandemic Influenza:

An Ethical Perspective

These Clinical Practice and Public Health Practice Guidelinesbecome SC’s Standard of Care in Pandemic Influenza mainlyby consensus via adoption by many/ most major health careorganizations, providers, DHEC, etc (ie, new laws unnecessary)


These Clinical Practice and Public Health Practice Guidelinesbecome SC’s Standard of Care in Pandemic Influenza mainlyby consensus via adoption by many/ most major health careorganizations, providers, DHEC, etc (ie, new laws unnecessary)

Pan Flu rationing scenario 1Pan Flu rationing scenario 1

An elderly lady with Pan Flu is admitted with An elderly lady with Pan Flu is admitted with ARDS and other complications and put on the last ARDS and other complications and put on the last ventilator in the ICU. Additional patients, some ventilator in the ICU. Additional patients, some less severely ill & younger w/ more of a chance less severely ill & younger w/ more of a chance of survival come to the ED also needing ventilator of survival come to the ED also needing ventilator support. Their physicians appeal to the lady’s support. Their physicians appeal to the lady’s

physician/ the hospital triage team to remove her physician/ the hospital triage team to remove her from the ventilator into palliative care so that from the ventilator into palliative care so that one of their patients can have a better chance.one of their patients can have a better chance.

What does each participant do, and why?What does each participant do, and why?

Pan Flu rationing scenario 1Pan Flu rationing scenario 1

An elderly lady with Pan Flu is admitted with An elderly lady with Pan Flu is admitted with ARDS and other complications and put on the last ARDS and other complications and put on the last ventilator in the ICU. Additional patients, some ventilator in the ICU. Additional patients, some less severely ill & younger w/ more of a chance less severely ill & younger w/ more of a chance of survival come to the ED also needing ventilator of survival come to the ED also needing ventilator support. Their physicians appeal to the lady’s support. Their physicians appeal to the lady’s

physician/ the hospital triage team to remove her physician/ the hospital triage team to remove her from the ventilator into palliative care so that from the ventilator into palliative care so that one of their patients can have a better chance.one of their patients can have a better chance.

What does each participant do, and why?What does each participant do, and why?R. Ball, MD MPH

SOFA Scoring: a scientificallySOFA Scoring: a scientifically

method of predicting mortalitymethod of predicting mortality


SOFA Scoring: a scientificallySOFA Scoring: a scientifically--validated validated

method of predicting mortalitymethod of predicting mortality

JAMA. 2001;286:1754-1758

Critical Care Triage Tool


Critical Care Triage Tool

1.20.09


1.20.09

SC laws addressing health SC laws addressing health provider limited liability, 2008provider limited liability, 2008

� Emergency Health Powers Act � “Any HCP appointed by [DHEC]… civil damages as a result of medical care or Tx… unless the damages result from Tx… under circumstances demonstrating a reckless disregard for the consequences…”

� Medical Malpractice Act� “Volunteer {non-compensated} health care provider… not liable for any civil damage for any act or omission resulting from the rendering of the (medical) services unless… act or omission was the result of…gross negligence or willful misconduct. The agreement to provide voluntary noncompensated service must be made before…”


Emergency Health Powers Act 44-4-570, (C)(1)“Any HCP appointed by [DHEC]… MUST not be held liable for any

civil damages as a result of medical care or Tx… unless the damages result from Tx… under circumstances demonstrating a reckless disregard for the consequences…” (not automatic/ billing OK)

Medical Malpractice Act 38-79-30compensated} health care provider… not liable

for any civil damage for any act or omission resulting from the rendering of the (medical) services unless… act or omission was the result of…gross negligence or willful misconduct. The agreement to provide voluntary noncompensated service must be made before…”

R. Ball, MD MPH


� Medical Practice Act 40� “The Board may publish advisory opinions and position statements relating to practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of practice.”

� Nurse Practice Act 40-33� “The Board may publish advisory opinions and position statements relating to nursing practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of nursing

practice.”


40-47-10, (I)(1)“The Board may publish advisory opinions and position statements

relating to practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of practice.”

33-10, (I)(1)“The Board may publish advisory opinions and position statements

relating to nursing practice procedures or policies authorized or acquiesced to by any agency, facility, institution, or other organization that employs persons authorized to practice under this chapter to comply with acceptable standards of nursing

R. Ball, MD MPH


SCHASCHASCHASCHA

GI illnessesGI illnesses--? contaminated food? contaminated food

10 Question: HOW did the food become contaminated, and with what bug?

A: During the months of April-May, in the upper hills of Guatemala,

the local village populations experience “Mal de Mayo”

(diarrheal illness of May), caused predominantly by Cyclospora.

Most village people use outhouses which runoff directly into

the local streams (or use the streams directly).

Many raspberry farmers, in order to harvest the raspberries at their

“juiciest” in April-May, usually drench the plants x 3 days with

pumped directly from the local stream, often contaminated with Cyclospora.

Raspberries are then picked & packed directly (not rinsed) into clamshells

and quickly shipped (refrigerated) directly to the USA (R. Ball, MD MPH FACPR. Ball, MD, MPH

? contaminated food? contaminated food

food become contaminated, and with what bug?

May, in the upper hills of Guatemala,

the local village populations experience “Mal de Mayo”

(diarrheal illness of May), caused predominantly by Cyclospora.

Most village people use outhouses which runoff directly into

the local streams (or use the streams directly).

Many raspberry farmers, in order to harvest the raspberries at their

May, usually drench the plants x 3 days with waterwater, often

pumped directly from the local stream, often contaminated with Cyclospora.

Raspberries are then picked & packed directly (not rinsed) into clamshells

and quickly shipped (refrigerated) directly to the USA (ie, Miami)…


1st US report

NEJM. Vol. 336: 1548NEJM. Vol. 336: 1548


NEJM. Vol. 336: 1548NEJM. Vol. 336: 1548--56, 556, 5--2929--9797

“Those who carry on great public schemes

must be proof against the most fatiguing delays,

the most mortifying disappointments,

the most shocking insults,

and what is worst of all,

the presumptuous judgments

of the ignorant.

- Edmund Burke (1729

The mind can absorb only

as much as the fanny can endure.

Thank you for your interest. Questions?


Those who carry on great public schemes

must be proof against the most fatiguing delays,

the most mortifying disappointments,

the most shocking insults,

and what is worst of all,

the presumptuous judgments

of the ignorant.”

Edmund Burke (1729 - 1797)

The mind can absorb only

as much as the fanny can endure.

Thank you for your interest. Questions?

public health outbreaks, responses: focus --cough...

Documents