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Thursday, March 27, 2014

Ebola - the stuff my dreams are made of!!

Next week marks my 11th year in the infection prevention world, however my interest in outbreak investigation started well before that.  I would say it all began as early as 1985 after watching the science fiction - horror film Warning Sign where there was an outbreak of a virulent bacteria in a secret military laboratory operating under the guise of a pesticide manufacturer.  Secret labs always run into bad luck do they not?  Ten years later, came Outbreak and the American medical disaster film with its Ebola-like virus called Motaba.  I was hooked.  It seems fitting that in 2003, almost 10 years after Outbreak debuted, I started in the industry during the first wave of SARS and now as I head into my 11th year, the virus that really got me interested in infection prevention is hitting the news.

In February, an outbreak of Ebola in Guinea began.  As of last week, there were at least 80 infections and 59 deaths. Hitting closer to home, there was speculation that a man who had taken ill in Saskatchewan after a recent trip to western Africa may have contracted Ebola on his travels. He has since been cleared, but it certainly sends a message that like SARS in 2003, worldwide travel has the potential to bring pathogens - often deadly ones - to geographical areas they are not native to.  

Ebola hemorrhagic fever with its often fatal outcome is by far one of the scariest  known human pathogens due to its fatality rate of approximately 83%.  Discovered in Zaire (now the Democratic Republic of the Congo) in 1976 there have now been 5 species of Ebolaviruses identified, with 4 of the 5 virus species causing illness to humans. Unfortunately, the reservoir host for Ebolaviruses has yet to be found.  Researchers believe the virus is zoonotic in nature and bats are the most likely culprit.

From a virology perspective, Ebola is an enveloped virus that can be transmitted via direct contact with blood or secretions of an infected person, and exposure to fomites that have been contaminated with infected secretions.  Symptoms may appear anywhere from 2 to 21 days after exposure to Ebolavirus, though 8-10 days is most common.  Symptoms characterizing Ebola are unspecific in the first few days of the infection, making the virus even more dangerous.  Infection is marked by initial signs of fever, fatigue, exhaustion, muscle aches, and dizziness. As the disease progresses bleeding under the skin, in internal organs, and from the eyes, ears, and mouth are seen. Patients with severe progressions of the disease express symptoms of shock, delirium, coma, seizures, and nervous system malfunction.

As highlighted by past outbreaks, Ebola can spread easily through household contacts (families and friends) because of close contact with infectious secretions while caring for the ill.  Likewise within healthcare settings the virus can spread rapidly, particularly if hospital staff are not wearing the appropriate PPE (masks, gowns and gloves). Cleaning and disinfection of fomites and medical equipment is an important part of minimizing transmission.

I have to chuckle, because as I write this blog, I am sitting in a plane on a trip back from Des Moines, Iowa via Chicago. The fact that worldwide travel (okay, North American for me) can be accomplished in a matter of days really hits home!  We just truly never know when an infected person, or contaminated food or object may be on its way to spread disease to unsuspecting populations!   Since my introduction to the idea of outbreaks almost 30 years ago, my interest has never waned.  I'm curious to learn what the next 10 years has in store!

Bugging Off!



Friday, March 21, 2014

What's your definition of Sterilization?

At times, nothing can be more polarizing than the discussion of how to reprocess semi-critical and critical devices.  I've experienced this first hand as a member of the Reprocessing Subcommittee for the CSA Z314.8-14 standard.  A room full of experts with differing opinions on the concept of A0 is something to behold (not quite as good as a fight between siblings mind you), but passion abounds around A0
This brings me to this week's  blog and can devices be chemically sterilized?   In keeping with the Talk Clean To Me blog, my focus will be on liquid chemical disinfectants that are registered by Health Canada or by the US FDA for use in reprocessing of semi-critical or critical devices. First, I apologize, definitions by their nature are boring...generally I just hyperlink to avoid making everyone read them but for the purpose of this discussion I need to set the stage:

"A Sterilant is a substance, or mixture of substances, capable of destroying or irreversibly inactivating all forms of microbial life present on inanimate objects, including all forms of vegetative bacteria, bacterial spores, fungi, fungal spores, and viruses, present on inanimate objects.  These are also referred to as chemical sterilants or chemosterilants, and include substances which at the time of use are liquids, gases or vapours."

As one would expect, there are approved test methods that a company must use in order to obtain a claim for high level disinfection and chemical sterilization. In Canada, a company can use either a Quantitative Carrier Test (ASTM E2111-12) which provides proof of a 10-6 or greater log reduction against Bacillus subtilis and Clostridium sporogenes the US FDA approved AOAC 966.04 Suture Loop / Penicylinder method in which the spore concentration must be 10-6 or greater and 0 of the 60 carriers can be positive for spore growth In general, by definition used in Canada and the US, chemical sterilization equals a sporicidal reduction of 6 Logs (10-6).

 What does this mean from an application perspective?  Well, liquid chemical disinfectants are generally used for reprocessing of heat sensitive devices.  Certainly, for non-heat sensitive devices, the gold standard is the use of steam or thermal sterilization where the process can be monitored to verify that the correct time and temperature has been reached in conjunction with the use of biological indicators to verify sterility should be used.  However, there are times when access to such devices is impossible and alternative methods for reprocessing needs to be considered and do have a role to play in reprocessing of semi-critical and critical devices. 

Why? First, they are effective (they achieve the required 6 Log reduction against bacterial spores).  Second, they are approved for sale and use as a sterilant in both Canada and the US and third, they are approved for use by North American Infection Prevention and Control Guidelines.   

When should they be considered?  As noted above, the primary use is for reprocessing of heat-sensitive devices.  However, another consideration is use by healthcare workers (HCWs), healthcare or other facilities who do not have access to mechanical sterilizers and perhaps most importantly, consideration for use should be given by those who do not have the appropriate training and ability to develop a preventative maintenance program to ensure sterility is achieved.  I realize this seems counterintuitive, however, simply having and using a steam sterilizer does not ensure sterility is achieved.  Many smaller clinics or homecare nurses do not the support of an acute care facility and access to a Medical Device Reprocessing Department.  Case in point, a few years ago, I met a group of nurses who had pooled together funds to jointly buy a steam sterilizer.  They were so excited!  When I spoke to them, they had had their sterilizer in place for about 6 months.  They did not have a process in place to trace their reprocessing batches, and had just learned that while they were doing biological tests, they were not conducted correctly and that the machine they purchased was not intended to sterilize wrapped instrument sets!  The long and the short was that all clients they saw over that time period were put at risk.  

There are some cases where I think we need to look not only at the risk of transmitting disease and what level of disinfection or sterilization is needed, but also to look at the user and their capabilities.  There are times when perhaps the use of a chemically sterilized instrument is safer than a false sense of security of a device that has "gone through a sterilization cycle".

What do you think?

Bugging Off!


Friday, March 14, 2014

Bugs, NOT Robbers Close Police Station!

Admittedly, I can be cheeky and without a doubt have a rather odd sense of humour - just ask those involved in what I refer to as "social experiments"!  Apparently, to some substituting decaf coffee in the morning is not shall we say a laughing matter?!    Similarly, the topics of the Talk Clean To Me blog do not often leave much wiggle room for humour, after all HAIs cause infections and can lead to death and that's no laughing matter.  

However, there are times when an infection caused by a bug can be downright comical.  Case in point is an article I came across over the weekend "Legionnaires' bacteria shuts down Dartmouth PD".   I'm not downplaying Legionella and its ability to cause outbreaks.  However, Legionnaires’ disease is not a common disease, and the risk of getting it is generally quite low in part due to the fact that it cannot spread from one person to another.  In fact, if 100 people are exposed to Legionella, fewer than 5 of them will get Legionnaire’s disease.   From a risk perspective, people are at greater risk of developing the disease if over 40 years of age (crap..), if they smoke, if they are alcoholics, if they have chronic lung disease (does asthma count?),  kidney disease, diabetes or have weakened immune systems.

So, let's go back to Dartmouth's Police Station.  A single officer got sick sometime in February.  Tests showed that the officer had Legionnaires' disease.  In determining where the infection was picked up from the station was checked and low and behold Legionella was found in the department's hot water system.  As a result out of "an abundance of caution," officials decided to close down the building as they want to make sure everyone is safe because the employees deserve a safe work environment.

Let's do a quick review of the situation.  A total of 82 employees, including 67 police officers work out of the police station.   For simplicity sake, I am going to assume all 82 employees are police officers and apply the statistics I found on age distribution of police officers.  This would give us 6.7 people under 24 yrs of age, 56 between 25 and 44, 19 between 45 and 65 and 0.2 of a person who is older than 65.  Ignoring health conditions of the officers (we do not need to get into stereotyping) and simply focus on age based on the risk for acquiring Legionaries disease only those 40 years and up should be concerned.  I'm going to assume of the 56.1 people in the 25 to 44 age range, that a third or 16.8 people are above 40.  So, that would give us a total of 36.03 people that could be at risk for acquiring Legionnaire's disease, but don't forget that for every 100 people less than 5 will be affected.   So, I think we could be safe to say that their 1 illness is about what they can or could expect!

Certainly, this highlights there is an obvious need for a preventative maintenance program for the police station's water supply, but does anyone else find the fact that this hit the news comical?  A police station shuts down out of caution to protect their staff when a single officer became ill with a bug that DOES NOT transmit from person to person when almost 100,000 people die each year from HAIs and a further 1.7 Million people are infected?

People get infected every day in hospitals due to HAIs.  People die every day in hospitals due to HAIs.  Why then are senior hospital officials not shutting their doors to ensure patients and staff are kept safe?  Do healthcare workers not deserve a safe work environment?  Do patients not deserve safe healthcare? If a police department is willing to do everything they can to remediate the problem before we go back in, why can healthcare not do the same?

Bugging Off!



Friday, March 7, 2014

Measles - just when we thought they were "wiped" away!

You may be thinking that vaccinations and disinfection really do not have much in common.  If you'll pardon my pun, vaccinations and disinfection both "wipe" germs away and both directly work toward the prevention of outbreaks.   Why then, with a disease such as Measles which most would say we've conquered are we seeing increased reporting of outbreaks?  What impact does this have on society not only in terms of illness and deaths, but the economic burden to our healthcare infrastructure? 

Yesterday, Ottawa Public Health announced their first lab-confirmed case of measles since 2011 and the European Centre for Disease Control (ECDC) confirmed there has been a measles outbreak onboard a cruise ship that had travelled between Spain and Italy.   If you didn't already know, measles is considered one of the MOST contagious infectious diseases.  In fact it is one of the leading causes of death among young children even though there is a safe and cost effective vaccine available.  Prior to widespread vaccination in the 1980's measles caused 2.6 million deaths each year (based on my age, I could have been one of the unlucky children...).  To give an idea of the significance of measles from a cost perspective,  Massachusetts reported that in 2011 there were 107 confirmed cases in their state which cost local and state officials between $2.7 million and $5.3 million!

Measles has a long incubation period - anywhere from 7 - 18 days.  A person is considered infectious from about 4 days before the rash starts to 4 days after the rash appears.  The virus itself is transmitted by airborne droplets or direct contact with nasal or throat secretions, but can also spread through contact with surfaces or fomites that have been contaminated with nasal and throat secretions.    No wonder it's so contagious!  You have 4 days to walk around infecting people before you know you're sick, a perfect storm not just onboard cruise ships, but any public setting!

As we know, there is no singular step, process or intervention that can stop the spread of germs.   PREVENTION is our best line of defense.  The use of vaccinations certainly play a very important role in preventing outbreaks. Hand Hygiene as we know plays probably the single most important role in preventing transmission of germs not just in healthcare settings, but all community settings.  Cleaning and Disinfection as we have mentioned in numerous blogs plays an important part in not just the prevention of transmission, but intervention of outbreaks that do occur.

When talking about infection prevention programs, cost is often a road block to implementation.    In the US, a cost-benefit analysis showed that every dollar invested in a vaccine dose saves $2 to $27 in health costs which equates to cost savings of millions upon millions of dollars.  We also know that every day, about 1 in every 20 hospitalized patients will get an infection caused by receiving medical care which relates to an overall direct cost of HAIs in hospitals ranging from US$28 billion to 45 billion.

When it comes to hand hygiene, studies have shown a linear relationship exists between hand hygiene compliance and HAI rates. For each 1% increase in hand hygiene compliance, there is a 0.6% decline in the prevalence rate of Methicillin-Resistant Staphylococcus Aureus (MRSA). Increasing hand hygiene compliance can save hospitals big money by avoiding HAI related costs and freeing up beds. As an example, a hospital that improves its compliance rate from 40% to 80% could experience a 24% decline in infections.  A hospital with a history of 50 HAIs per year means they can prevent 12 HAIs and if we assume an average cost of $43,000 per infection, the hospital would save $516,000 per year in HAI related costs.

Similarly, there are studies to support that improved Environmental Hygiene programs can directly impact HAIs.   The contribution to reducing HAIs varies, but from work I have reviewed a 20% reduction from improved cleaning and disinfection programs is reasonable.  This would mean a prevention of 10 HAIs (remember the hospital has 50/yr) - a savings of $430,000 per year!

The savings add up!  What would our healthcare system look like if we had 100% vaccination rates, 100% hand hygiene compliance and environmental hygiene programs that have sufficient staff and allow sufficient time to cleaning and disinfect......NIRVANA!

Bugging Off!