Achoo on You! What to Do?

Is it contagious?Well, it’s snot!

Jim Gauthier, MLT, CICSenior Clinical Advisor, Infection Prevention

• Jim is employed by Diversey. His expenses to attend this meeting (travel, accommodation, and salary) are paid by this company. Diversey has had no input into this presentation from a commercial interest.

Disclaimer

Objectives

• Have some fun• Review Acute Respiratory Infections• Try to make Infection Control (in general) more real, less

theory• Answer your concerns• Have fun

Acute Respiratory Illness

• “Any new onset acute respiratory infection that could potentially be spread by the droplet route (either upper or lower respiratory tract), which presents with symptoms of a new or worsening cough or shortness of breath and often fever (also known as febrile respiratory illness, or FRI)”

PIDAC 2013

Jim’s History Lesson

• RPAP: CCDR 1999;25S4– Contact (direct/indirect)– Droplet (cough, sneeze, suctioning, bronchoscopy)– Airborne (<5um)

Droplet

– “It appears logical to use a mask when within 1 metre of a coughing patient”

– “However, use of masks and gowns for patients with respiratory illnesses was found not to reduce infection rates in HCWs or patients), probably because of acquisition on hands and eye inoculation”

SARS-CoV 2002/3

• Guangdong Province China• Toronto ON• 37 countries affected• 8098 Cases, 774 Deaths (9.6% case fatality rate)• Enveloped virus, spread by droplets

– Could be aerosolized through respiratory procedures

SARS

• Healthcare workers were getting sick (4 died in Toronto)• Numerous issues with availability of masks and eye

protection, respiratory procedures, screening etc.

So, Let’s Get FRI-ed

• 2005 PIDAC Febrile Respiratory Illness– Cough, fever

• Updated 2006, 2008

pH1N1 - 2009

• Oh, ya, that one.– Bit of panic again in infection control world

• Influenza-Like Illness (ILI) Document 2010

Acute Respiratory Infection

• Trying to protect us from the next new virus, or pandemic• Needs to be active, prospective surveillance

• https://www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Annex_B_Prevention_Transmission_ARI_2013.pdf

MERS-CoV 2012

• Middle East Respiratory Syndrome Coronavirus– Globally: August 2018, 2229 laboratory-confirmed cases,

including 791 associated deaths (case-fatality rate: 35.5 percent)– 83% of cases reported from Saudi Arabia (~1844 cases,

including 716 related deaths with a case-fatality rate of 38.8 percent).

ProMED August 8, 2018 MERS-COV (25): RISK ASSESSMENT, WHO

WHO – August 8, 2018

– …all health care facilities establish and implement clear triage policies for rapid screening and assessment of potential MERS-CoV cases and all cases with acute respiratory symptoms.

– …health care workers apply standard precautions consistently with all patients, regardless of their diagnosis, in all work practices all of the time.

– Droplet precautions should be added to the standard precautions when providing care to any patient with symptoms of acute respiratory infection.

http://www.who.int/csr/disease/coronavirus_infections/risk-assessment-august-2018.pdf?ua=1#

PHAC

• Contact Droplet• Mask, gown• Aerosol Generating Medical Procedures (AGMP)

– Intubation and related procedures (e.g., manual ventilation, open endotracheal suctioning); cardiopulmonary resuscitation; bronchoscopy; sputum induction; nebulized therapy; non-invasive positive pressure ventilation (continuous or bi-level positive airway pressure).

https://www.canada.ca/en/public-health/services/publications/diseases-conditions/infection-prevention-control-guidance-middle-east-respiratory-syndrome-coronavirus-mers-cov-acute-care-settings.html#a2-1

• The degree of attention to precautions is directly proportional to the mystique or fear of the organism

– MRSA - SARS– Pandemic H1N1 - CPE– MERS-CoV - Ebola

Jim’s Theorem of Isolation

test

SARS

Ebola

• The mystique of the organism is inversely proportional to the amount of information staff retain about Routine Practices!

Jim’s Addendum

http://diseasedetectives.wikia.com/wiki/Chain of Transmission

Mucky Mucous

• One millilitre of saliva can have 100,000,000 bacteria and viruses in it!

• Wanna share?

Is That The Only Issue?

• Each finger can have 1,000,000 bacteria

• Many are found under the nails and in the cuticle

Wait, There’s More!

• Feces has over 1,000,000,000,000 bacteria per gram (dry weight)

• Think of one microgram: still one million bacteria– Can’t see it– Can’t smell it– Don’t wanna taste it!

Where Is He Heading With This?

• Always be thinking– This should not be hard!– Everything might be contaminated

• Always be prepared• Keep the term “Risk Assessment” in mind

– Let’s practice!

Masks On!!

What Did We Learn?

• Always be prepared• If there is a risk, protect yourself

Background

• Many respiratory viruses initiate infection in the nasal cavity or infect the nasal cavity to cause ‘colds’ without infecting the lung (Foxman 2015)

• Some viruses prefer the cooler temperature of the nasal mucosa

The Following Charts

• https://www.canada.ca/en/public-health/services/surveillance/respiratory-virus-detections-canada/2017-2018/respiratory-virus-detections-isolations-week-33-ending-august-18-2018.html

Week 1 = January

January

Influenza

• Need I say more?• Contact and Droplet• Enveloped virus (Easy to kill)• Influenza A&B• Vaccination

Effect of Disinfectants on MicroorganismsOrganism Bucket Examples

Bacterial Spores Spore Bacillus anthracis, Clostridium difficile

Mycobacteria Bacteria M. tuberculosis

Small non-enveloped virus Virus Polio, Norovirus

Fungi and fungal spores Fungus Aspergillus, Penicillium

Gram negative bacteria Bacteria E. coli, Klebsiella including CRE, Pseudomonas, Acinetobacter

Large Virus (non-enveloped) Virus Adenovirus, Rotavirus

Gram positive bacteria Bacteria Staphylococcus including MRSAEnterococcus including VRE

Virus (enveloped) Virus Influenza, HIV, HBV, HCV^Resistant* Sensitive

R^

S*

Rhinovirus

• Small, Non-Enveloped (Not Easy to kill)• Causes ~60-80% of common colds symptoms between

August and November• Can cause rhinitis, pharyngitis, cough, fever, otitis media,

sinusitis, acute disease or exacerbation of chronic pulmonary diseases

• Treatment: Symptomatic• Prevention: Hygiene, disinfection

Respiratory Syncytial Virus

• Enveloped Virus• Causes 64 million infections and 160,000 deaths annually,

winter/early spring• Causes rhinitis, pharyngitis, cough, bronchiolitis,

pneumonia, complications in patients with immunodeficiency or underlying conditions like CF, chronic heart disease

Respiratory Syncytial Virus

• Prevention: Vaccines in development• More likely to cause epidemic outbreaks• Treatment: Immunoglobulin, ribavirin

Parainfluenza Virus

• Enveloped virus• PIV 1 – Epidemics in fall, PIV 3 – Epidemics in early

spring, PIV 2 – Epidemics mainly in autumn• Causes rhinitis, pharyngitis, cough, hoarseness, fever,

croup, bronchiolitis, pneumonia• Treatment: Symptomatic• Prevention: Hygiene, disinfection, no effective vaccines

available

Adenovirus

• Large, non-enveloped virus (easier to kill than small non-enveloped)

• Causes 5% URTI in children, institutional infections. Up to 10% pneumonia in children, mainly late winter to early summer

• Contact and droplet, fecal-oral spread also

Adenovirus

• Causes upper respiratory tract infections, rhinitis, conjunctivitis, tonsillitis (gastroenteritis)

• Treatment: Symptomatic, cidofovir in immunosuppressed patients

• Prevention: Hygiene

Effect of Disinfectants on MicroorganismsOrganism Bucket Examples

Bacterial Spores Spore Bacillus anthracis, Clostridium difficile

Mycobacteria Bacteria M. tuberculosis

Small non-enveloped virus Virus Polio, Norovirus, Hep A

Fungi and fungal spores Fungus Aspergillus, Penicillium

Gram negative bacteria Bacteria E. coli, Klebsiella including CRE, Pseudomonas, Acinetobacter

Large Virus (non-enveloped) Virus Adenovirus, Rotavirus

Gram positive bacteria Bacteria Staphylococcus including MRSAEnterococcus including VRE

Virus (enveloped) Virus Influenza, HIV, HBV, HCV^Resistant* Sensitive

R^

S*

Metapneumovirus

• Enveloped virus• Third leading cause of ARTI in humans, seasonal

distribution in temperate regions (late winter, spring)• Causes cough, wheezing, coryza, fever, diarrhea,

vomiting, bronchiolitis, pneumonia, complications in patients with immunodeficiency or underlying conditions such as asthma, COPD

Metapneumovirus

• Treatment: Symptomatic, ribavirin• Prevention: Hygiene

Coronavirus

• Enveloped virus• Up to 25% of common cold cases• Causes rhinitis, pharyngitis, cough, otitis media• Treatment: Symptomatic• Prevention: Hygiene

Enterovirus D68

• Small, non-enveloped virus• Causes mild to severe respiratory symptoms (cold-like to

pneumonia)• Contact and Droplet• Harder on children with asthma, or a history of wheezing

Enterovirus D68

• In 2014, 2600 specimens examined: 1/3 tested positive for EV-D68, 1/3 other enterovirus or rhinovirus

• Not definitely linked to acute flaccid paralysis• Prevention: Hygiene

Enterovirus A71

• Outbreak in Denver CO.• 41 cases• More common in Southeast Asia• Symptoms include: a loss of balance, unsteady walking,

unusual jerking motions — especially while sleeping —and fever

https://www.denverpost.com/2018/10/09/colorado-children-enterovirus-outbreak/

Acute Flaccid Myelitis

• Sudden onset of flaccid limb weakness• Confirmatory : MRI showing spinal cord lesion largely

restricted to gray matter and spanning one or more vertebral segments

• Supportive: cerebrospinal fluid (CSF) with pleocytosis (white blood cell count >5 cells/mm3)

https://www.cdc.gov/acute-flaccid-myelitis/hcp/case-definition.html

Hand, Foot and Mouth Disease

• Enterovirus: Usually Coxsackievirus A16 (Small, non-envl.)• HFMD is highly contagious • Contact and droplet, fecal-oral spread also• Preventive measures include avoiding direct contact with

infected individuals (including keeping infected children home from school), proper cleaning of shared utensils, disinfecting contaminated surfaces, and proper hand hygiene.

• https://www.youtube.com/watch?v=DVJNWefmHjE

• Multi Plex• ePlex

Viral Panels

• Influenza A, A (H1N1), B, C; parainfluenza viruses 1, 2, 3 and 4; coronaviruses NL63, 229E, OC43 and HKU1 ; human metapneumoviruses A/B ; rhinovirus ; respiratory syncytial viruses A, B ; adenovirus; enterovirus ; parechovirus; bocavirus; Pneumocystis jirovecii; Mycoplasma pneumoniae; Chlamydia pneumoniae; Strept. pneumoniae; H. influenzae type B; Staph. aureus; Moraxella catarrhalis; Bordetella spp.; Kleb. pneumoniae; Legionella pneumophila / longbeachae; Salmonella species including internal control

Viral Panels

Masks• Public Health Agency of Canada (PHAC)

– Procedure mask or surgical mask

• PIDAC– For all Droplet precaution

• Procedure masks with eye protection

• Consensus Conference– No consensus other than we need more studies!

Masks

• MOHLTC – N95 for pandemic influenza– When it gets here– Fit testing issues– Reality issues of wearing mask for 12 hour shifts– Stay tuned…

Masks - NS

• …all LTCF are expected to have a respiratory protection program as per the Occupational Health and Safety Act.

• …as a minimum, enough core staff need to have current respirator fit-testing to be able to provide continuous care for residents in the event of a case or outbreak of an infectious disease requiring airborne precautions.

Infection Prevention and Control: Guidelines for Long-Term Care Facilities June 2015 Infection Prevention and Control Nova Scotia (IPCNS), Department of Health and Wellness

What is the Risk

• Tired of pandemic influenza planning?• Tired of avian flu horror stories?• Tired of cruise ship outbreaks?

ME TOO! BUT….

• Don’t wanna puke• Don’t wanna shake• Don’t wanna cook• Don’t wanna sweat• Don’t wanna drool• Don’t wanna do the two step• Don’t wanna DIE!

Horizontal vs Vertical Infection Control

Wenzel 2010

Jim’s Routine Practices

2 thoughts to live by in 20 simple words! 1. If they are leaking, protect yourself and limit their movement2. If it is dirty or you used it – clean it.

Leaking

• Uncontrolled nasal secretions• Productive cough, not contained• Wounds with increased drainage• Diarrhea not contained by brief

Limits

• Need to stay in room / go home• Need to stay on resident care unit• May need to go to another facility• Increase hand hygiene

Acronyms

• MRSA– Must Really Scrub Alot

• VRE– Very Risky Environment

• CDAD– Can’t Do Anything, Dude!

• ESBL– Everything Stinks, Better Leave?

• Forget about them!

Routine Practices

• Your practices should never change based on a diagnosis

Or an acronym!!

ESBL CDI HbsAgCOPDSTOP THE

MADNESS!!

Droplet Precautions

• Fancy way of warning other staff that mask is indicated

• Can be stopped once symptoms are stable, or new diagnosis is entertained

• Restrict patient movement

Airborne Precautions

• Deep down, the only one we really need!• Mask issue to be resolved• Tuberculosis is NOT a dead disease!

– Especially in our elderly– But soon?

In Summary

• Be prepared• More masks need to be used• Try to see the lighter side of things!

Questions, Comments

• Stories• Soapboxes

References

• Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Annex B – Best Practices for Prevention of Transmission of Acute Respiratory Infection. Annexed to: Routine Practices and Additional Precautions in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013.

• Public Health Agency of Canada “Public Health Online”. http://www.phac-aspc.gc.ca/sub-ins/news-nouv-eng.php

• Infection Prevention and Control: Guidelines for Long-Term Care Facilities June 2015 Infection Prevention and Control Nova Scotia (IPCNS), Department of Health and Wellness

• Wenzel RP et al. Infection control: the case for horizontal rather than vertical interventional programs. Int J Infect Dis 2010;14S4:S3-S5