Kim Roberts, Quality Improvement Advisor

Surveillance, Epidemiology, Reporting, and Emergency Preparedness

Module 7

October 2016

What is covered in this module:

2

  WHAT: Identifying and managing disease outbreaks; public health threats; and preparing for emergencies and disasters

  WHY: These activities help protect health and appropriately respond to outbreaks and extreme events

  WHO: Diseases in long-term care facilities can have public health consequences. Long-term care facilities have a key role in their community’s ability to prepare, respond, and recover from disasters.

  HOW: Several key references, tools and resources are provided

Surveillance

3

  Purpose of surveillance •  Identify outbreaks and prevent the spread of disease

  Types of surveillance •  Active

•  Actively contacting people or organizations for information about diseases •  More expensive and time-consuming, but get complete information

•  Passive

•  CDC and State Department of Health rely on long-term care facilities to report

•  This method can result in under-reporting of diseases •  Syndromic

•  Based on certain symptoms occurring in a population

•  Example: “flu-like illness” (fever and sore throat / cough)

Common Surveillance Targets

4

  Flu-like illness, Rash-like illness, drug-resistant organisms   Sexually transmitted diseases (STDs)   Contaminated medical equipment, devices, or medication   Foodborne illness •  Listeria, E. coli, Salmonella, Hepatitis A, Vibrio, Shigella

  Bioterrorism •  “Germ warfare” (bacteria, viruses, toxins)

•  Intentionally trying to infect people to cause harm •  Could be through contaminated food, water, air, surfaces, medication, insects,

person-to-person contact

•  Look for unusual pattern of illness, unusual # of people getting sick •  Symptoms of bioterrorism might not seem unusual at first:

•  fever, rash, stomach ache, diarrhea, headache, cough, sore throat, etc.

What is an Outbreak?

5

  A disease outbreak is when there are more cases of disease than normal in a particular area •  For rare diseases, 1 or 2 cases could be an outbreak •  To determine whether an outbreak is happening, you have to know how many

cases would normally be present

  How do outbreaks spread? •  Common source (everybody who got sick was exposed to the same source)

•  Examples: water supply, air, foodborne illness

•  Propagated (the disease spreads from person to person) •  Examples: influenza, Norovirus, C. difficile, E. coli, Salmonella, scabies, RSV

  An endemic disease is common to a particular area or group of people   An epidemic is when diseases spread to a larger group of people than usual   A pandemic is when a disease spreads throughout the world

Outbreaks in U.S. History

6

Pandemic Influenza (Flu) http://www.healthline.com/health/worst-disease-outbreaks-history

  Smallpox   Yellow Fever

  Cholera   Scarlet Fever (Group A Strep infection)

  “Typhoid Mary” (1906-1907) New York

  Diphtheria (1921-1925)   Polio

  HIV/AIDS (1980s-present)   Measles

  Cryptosporidium from contaminated water (1993)

  Whooping cough, Pertussis (2010, 2014)   Foodborne - many

Pandemic flu impact on the U.S.

7

Pandemic Influenza (Flu) http://www.flu.gov/pandemic/history/ https://www.ncbi.nlm.nih.gov/pubmed/21342903

  An estimated 30–50 million people died from influenza, called the Spanish flu during the 1918-1919 pandemic

•  675,000 Americans died   Pandemic flu (1957-1958)

•  70,000 deaths in the U.S.

  Pandemic flu (1967-1968), called the Hong Kong flu •  33,000 deaths in the U.S.

  Pandemic flu (2009), called H1N1 Swine flu •  From April 12, 2009 – April 10, 2010 in the U.S.

•  Approximately 60.8 million cases of influenza in the U.S.

•  274,304 hospitalizations •  12,469 deaths

8

Pandemic Influenza (1918-1919 Spanish flu) http://www.flu.gov/pandemic/history/

Outbreaks in Nursing Homes

9

Disease Outbreaks in Nursing Homes http://cid.oxfordjournals.org/content/36/7/870.full.pdf http://www.pharmacytimes.com/publications/issue/2012/january2012/outbreaks-in-the-nursing-home-responding-responsibly

  Respiratory (lung) infections •  Influenza, RSV, Legionella •  Rhinovirus, Tuberculosis (TB), Pertussis

  Skin / soft tissue infections •  MRSA

  Gastrointestinal (nausea/vomiting/diarrhea) •  Norovirus

•  Clostridium difficile (“C. diff”)

•  Salmonella

  Parasite infestations •  Scabies, bed bugs, fleas

•  Head lice, body lice, “kissing bugs”

Outbreak – A True Story

10

Nursing Home Pro website http://www.nursinghomepro.com/1070/an-infection-control-case-study-that-may-make-you-sick/

  Outbreak experience shared by a Nursing Home administrator •  Staff asked him what he could to about “the roach problem” •  Got pest control to treat for cockroaches in Dietary department

•  Several residents started getting sick with Salmonella •  Check food prep techniques and kitchen hygiene

•  Looked for possible food sources

•  Asked the staff if they had any pet reptiles •  Tested the tube-feeding formula

•  The connection = ROACHES •  Each resident had a water pitcher in his/her room

•  New pitchers were stored in a closet, some not washed before use

•  The roaches had crawled on the pitchers and contaminated them

Reportable Diseases & Conditions

11

 Kentucky •  Kentucky Department for Public Health

•  “Reportable Disease Desk Reference” is currently being updated •  http://chfs.ky.gov/NR/rdonlyres/4CEAA588-E5CB-4FEC-

B163-8E61A24A62D8/0/KYEPID200A.pdf

 Mississippi •  Mississippi State Department of Health (MSDH)

•  List of Reportable Diseases and Conditions •  http://msdh.ms.gov/msdhsite/_static/resources/877.pdf

National Notifiable Diseases

12

https://wwwn.cdc.gov/nndss/

Emergency Preparedness

13

 CMS rule posted in September 2016 •  Requirements for health care providers participating in Medicare and

Medicaid: •  Emergency plan based on a risk assessment •  Policies and procedures based on the emergency plan and risk

assessment •  Coordinate with federal, state, tribal, regional, and local emergency

preparedness systems. Develop and maintain a communication plan. •  Training and testing program. Conduct drills and exercises to test your

plan. •  Install and maintain emergency and standby power systems

Core EP Rule Elements

14

 Risk Assessment and Emergency Planning •  Identify likely hazards in the area •  Care-related emergencies •  Assess the chance of equipment or power failures •  Consider the impact of an interruption in communications (including

cyber attacks) •  What if you lost all/part of your facility •  What if you lost of all/part of your supplies •  Review and update the plan at least annually

Emergency Support Functions (ESF)

15

  Emergency Support Functions group capabilities into an organizational structure to provide support, resources, program implementation, and services that are most likely needed to save lives, protect property and the environment, restore essential services and critical infrastructure, and help victims and communities return to normal following domestic incidents.

  Long-term care facilities pay a role in helping to prevent, detect, and respond to emerging outbreaks and public health threats

•  ESF 8

15 Emergency Support Functions

16

List of the Emergency Support Functions http://www.phe.gov/preparedness/support/esf8/Pages/default.aspx

•  ESF 1 – Transportation •  ESF 2 – Communications •  ESF 3 – Public Works and Engineering •  ESF 4 – Firefighting •  ESF 5 – Emergency Management •  ESF 6 – Mass Care, Housing, and Human Services •  ESF 7 – Resources Support •  ESF 8 – Public Health and Medical Services •  ESF 9 – Urban Search and Rescue •  ESF 10 – Oil and Hazardous Materials Response •  ESF 11 – Agriculture and Natural Resources •  ESF 12 – Energy •  ESF 13 – Public Safety and Security •  ESF 14 – Long-term Community Recovery and Mitigation •  ESF 15 – External Affairs

All-Hazards Approach

17

FY 2017 Budget – U.S. Department of Health & Human Services http://www.hhs.gov/about/budget/fy2017/budget-in-brief/index.html

 Infectious diseases •  Outbreaks and epidemics

 Natural disasters •  Earthquake, tornado, flood, wildfire, hurricane, ice storm, blizzard

 Accidental •  chemical, biological, radiological, and nuclear threats

•  Industrial accidents, transportation accidents

 Intentional •  chemical, biological, radiological, and nuclear threats

“Effective public health emergency response depends on maintaining and constantly improving the preparedness capabilities of public health departments and healthcare facilities at a state and local level.”

Kentucky Department for Public Health

18

Kentucky Public Health Preparedness website http://chfs.ky.gov/dph/epi/preparedness/

Lead agency for Emergency Support Function #8-Public Health and Medical Services (ESF 8)

Emergency Preparedness in KY

19

http://kyem.ky.gov/programs/Documents/Kentucky%20ESF%20-%2008%20Public%20Health%20and%20Medical%20Services%20Oct%202013.pdf

Emergency Preparedness in MS

20

http://msdh.ms.gov/msdhsite/_static/resources/4778.pdf

Resources to Help with Preparedness

21

CMS Requirements page on TRACIE website https://asprtracie.hhs.gov/cmsrule

Incident Command System (ICS)

22

 A standardized approach to the command, control, and coordination of emergency response providing a common hierarchy within which responders from multiple agencies can be effective

Basic ICS Training

23

FEMA online training courses

 IS-100.HCB •  Introduction to the Incident Command System (ICS 100) for Healthcare/

Hospitals •  https://training.fema.gov/is/courseoverview.aspx?code=IS-100.HCb

 IS-200.HCa •  Applying ICS to Healthcare Organizations

•  https://training.fema.gov/is/courseoverview.aspx?code=IS-200.HCa

 IS-700.A •  National Incident Management System (NIMS) An Introduction

•  https://training.fema.gov/is/courseoverview.aspx?code=IS-700.a

Center for Domestic Preparedness

24

Center for Domestic Preparedness (Anniston, Alabama) https://cdp.dhs.gov/find-training/healthcare

Center for Rad/Nuc Training

25

Center for Radiological Nuclear Training (Mercury, Nevada) http://www.ctosnnsa.org/index.htm

Checklist

26

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Provider.pdf

Emergency Preparedness checklist for health care facility planning (6 pages)

Planning Guide

27

Planning Guide http://www.cdc.gov/phpr/healthcare/planning2.htm

Long-Term, Home Health, and Hospice Care Planning Guide for Public Health Emergencies (Published by the CDC)

Guide

28

http://www.dlp.vermont.gov/forms/emergency-preparedness-planning

Emergency Preparedness Planning for Nursing Homes and Residential Care Settings (Sample guide from Vermont)

Tools and Resources   Hand Hygiene in Healthcare Settings

https://www.cdc.gov/handhygiene/

  Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

  Using personal protective equipment the right way

http://professionals.site.apic.org/10-ways-to-protect-patients/using-ppe-the-right-way/

  National Notifiable Diseases Surveillance System (NNDSS)

https://wwwn.cdc.gov/nndss/

  CMS Emergency Preparedness Requirements for Healthcare

https://www.gpo.gov/fdsys/pkg/FR-2016-09-16/pdf/2016-21404.pdf

  Kentucky’s Emergency Support Function (ESF) 8 – Annex

http://kyem.ky.gov/programs/Documents/Kentucky%20ESF%20-%2008%20Public%20Health%20and%20Medical%20Services%20Oct%202013.pdf

  Mississippi State Department of Health – Emergency Preparedness Overview

http://msdh.ms.gov/msdhsite/_static/resources/4778.pdf

29