EMERGING INFECTIOUS DISEASES EIDs

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EMERGING INFECTIOUS DISEASES (EIDs) A term
introduced by microbiologist and Nobel Prize
winner Joshua Lederberg Diseases of infectious
origin whose incidence in humans has increased
within the past two decades or threatens to
increase in the near future. (CDC)
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Emerging Reemerging Infectious Diseases gt35 new
and emerging infectious diseases and
antibiotic-resistant pathogens have become
evident in the last 2 decades alone. National
Center for Infectious Diseases, Centers for
Disease Control. Addressing Emerging Infectious
Disease Threats. http//www.cdc.gov/ncidod/publica
tions/eid plan/home.htm.
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Emerging Reemerging Infectious
Diseases Bacterial Anthrax1993,
Caribbean Bartonella henselae (Cat scratch
disease/bacillary angiomatosis)1990s, United
States Chlamydia pneumoniae (pneumonia)1990s,
United States (discovered 1983) Cholera1991,
Latin America Diphtheria1993, former Soviet
Union Ehrlichia chaffeensis, human monocytic
ehrlichiosis (HME)United States Ehrlichia
phagocytophilia, human granulocytic ehrlichia
(HGE)United States
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Emerging Reemerging Infectious
Diseases Bacterial Escherichia coli
O15719821997, United States 1996,
Japan Gonorrhea (drug resistant)1995, United
States Helicobacter pylori (ulcers/cancer)Worldwi
de (discovered 1983) Leptospirosis1995,
Nicaragua Lyme disease (Borrelia
burgdorferi)1990s, United States Meningococcal
meningitis (serogroup A)19951997, West Africa
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Emerging Reemerging Infectious
Diseases Bacterial Pertussis1994, United
Kingdom/Netherlands 1996, United
States Plague1994, India Salmonella typhimurium
DT104 (drug resistant)1995, United
States Staphylococcus aureus (drug
resistant)1997, United States/Japan Toxic
strepUnited States Trench fever (Bartonella
quintana)1990s, United States Tuberculosis
(highly transmissible)1995, United States Vibrio
cholerae 01391992, southern Asia
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Emerging Reemerging Infectious
Diseases Viral Bolivian hemorrhagic fever1994,
Latin America Bovine spongiform
encephalopathy1986, United Kingdom Creutzfeldt-Ja
kob disease (new variant V-CJD)/mad cow
disease199596, United Kingdom/France Dengue
fever199497, Africa/Asia/Latin America/United
States Ebola virus1994, Gabon 1995, Zaire
1996, United States (monkey)
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Emerging Reemerging Infectious
Diseases Viral Hantavirus1993, United States
1997, Argentina HIV subtype O1994,
Africa Influenza A/Beijing/32/92, A/Wuhan/359/95,
H5N11993, United States 1995, China 1997,
Hong Kong Japanese encephalitis1995,
Australia Lassa fever1992, Nigeria Measles1997,
Brazil Monkey pox1997, Congo Morbillivirus1994,
Australia
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Emerging Reemerging Infectious
Diseases Viral Onyong-nyong fever1996,
Uganda Polio1996, Albania Rift Valley
fever1993, Sudan SARS ---2003 Hongkong,Canada,Sin
gapore,Taiwan,China Venezuelan equine
encephalitis199565, Venezuela/Colombia West
Nile fever1996, Romania, 1999 USA Yellow
fever1993, Kenya 1995, Peru
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Emerging Reemerging Infectious
Diseases Parasitic African trypanosomiasis1997,
Sudan Ancyclostoma caninum (eosinophilic
enteritis)1990s, Australia Cryptosporidiosis1993
/, United States Cyclosporiasis19951997, United
States/Canada Malaria19951997,
Africa/Asia/Latin America/United
States Metorchis1996, Canada MicrosporidiosisWor
ldwide
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Emerging Reemerging Infectious
Diseases Fungal Coccidioidomycosis1993, United
States Penicillium marneffi--- Southeast Asia
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75 Waterloo Road, Tsim Sha Tsui, Kowloon, Hong
Kong
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• Feb 21, 2003 Hong Kong
• Dr. Liu Jianlun (Patient A),an ill physician
  from Guangdong Province, travelled to Hong Kong
  to visit family and stayed on the ninth floor of
  the Metropole Hotel (Room911) on February 21. He
  was admitted to the Kwong Wah Hospital on
  February 22 and died the next day.

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Feb. 26, 2003 Viet Nam

• Johnny Cheng,an American-Chinese businessman
  was admitted to the French Hospital in Hanoi with
  a 3-day history of fever and respiratory
  symptoms. He had stayed on the ninth floor of the
  Metropole Hotel in a room across the hall from
  the Guangdong doctor.

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Mar. 4, 2003 Hong Kong A 26 Year old
local man was admitted to Ward 8A of Prince of
Wales Hospital with symptoms of pneumonia. From
15 to 23 February, he had visited an
acquaintance staying on the ninth floor of the
Metropole Hotel. He was treated with albuterol
through nebulizer four times daily for a total of
7 days.
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March 11, 2003 Hong Kong

• an increase in acute pneumonia cases among
  health-care workers (HCWs) at Prince of Wales
  Hospital was reported to the Department of
  Health of Hong Kong .

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11 Mar 2003 Viet Nam French
Hospital in Hanoi was closed after 16 staff
members contracted pneumonia.The focus of
theinvestigation was a 50-year-old American-
chinese businessman who was the first to be
affected. He fell ill shortly after arrival in
Hanoi from Shanghai and Hong Kong.
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Fri, 14 Mar 2003, Singapore

• MOH was notified about six persons including
  two health-care workers (HCWs) who were admitted
  to Tan Tock Seng Hospital (TTSH) for atypical
  pneumonia. All had close contact with three
  persons who had traveled to Hong Kong.

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Fri, March 14 Toronto

• Ontario issued alert about four cases of atypical
  pneumonia in Toronto that have resulted in 2
  deaths.The disease was first recognized in a
  woman who returned from Hong Kong on February 23,
  2003.

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Mar 11Thailand

• A World Health Organization researcher,a 40
  year old male physician, who was among the first
  to investigate the outbreak of SARS in Hanoi
  entered Thailand on 11 Mar 2003 and was
  immediately transferred to Bamrasnaradura
  Hospital with flu symptoms and high fever which
  later developed into pneumonia.

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7pm.,Mar 19 Hat yai

• A meeting was held at the Faculty of Medicine
  ,PSU.

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March 31, 2003 Hat yai, Songkla A 79
year old Chinese man, a Hong Kong resident,
presented at Songklanagarind Hospitals ER. with
history of having fever increasing dyspnea for
5 days. His illness began on Mar.25,2003, just
three days after arriving in Thailand, when he
developed fever, dry cough and was easily
fatique. On Mar.31,his relatives brought him to a
private hospital because his fever got higher and
he was very dyspnic. He was put on a face mask
and advised to come to PSU Hospital.
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PE. Temp. 40o C HR110 BP 120/80
RR40 not orthopnic but tachypnic He
was conscious cooperative Lungs
Fine rales heard, no wheeze Heart
normal sound, no gallop Lab. O2 sat. on room
air 79 Hct.37 WBC 5400, PMN
92Plt105000 Bl. Culture
neg.Sugar114 Cr.2.04 HCO318
Bilirubin0.37 SGOT65 SGPT25 CXR.

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SARS
Severe Acute Respiratory Disease
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Were we successful or lucky in fighting against
SARS?
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SARS --- Taiwan, 2003

• March 14--April 21 SARS was characterized by
  sporadic cases among business travelers
• April 22--May 22 Health-Care--Associated
  TransmissionThe index patient laundry worker
• with diabetes mellitus spent off-duty time
  socializing in the ER.

Ref.MMWR 2003,52,461-466
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EID 200410777-781
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During early control of SARS in Taiwan, the
small number of imported cases was adequately
contained in these isolation rooms. After the
rapid increase of cases, affected hospitals
quickly exceeded their capacity to accommodate
all patients in such isolation rooms.
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EID 20041025-31
Through June 2003, a total of 2,521 patients with
probable cases of SARS were hospitalized in
Beijing. The outbreak peaked during the 3rd and
4th weeks in April, when hospitalizations for
probable SARS exceeded 100 cases for several
days,
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SARS occurred in healthcare workers in gt70
hospitals throughout Beijing, and clusters of gt20
probable SARS cases among healthcare workers
occurred in four Beijing hospitals.
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Schools were closed, travel was restricted, the
community was educated about seeking care at
designated sites, and temperatures were monitored
at frequent check points. By June 19, 2003, a
total of 30,172 people who had had close contact
with probable or suspected SARS case-patients had
been quarantined.
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SARSLessons from other countries
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Crit Care Med 200533S53-S60
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SARS and Critical Care Lessons Learned the
most important of which is preparedness. We were
not prepared for SARS, nor did we have a
systemwide critical care communication strategy
in place.....
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it would be ideal to have a war room
established with someone reporting to leadership
daily about activities in each area highlighted
here (i.e., communication, resources, infection
control, education, research, system planning,
and staff morale).
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EID 200410771-776
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Management Steps Planning Organizing Directing
Control
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Management Steps Planning
Task
Force Committee Organizing Directing
EID Committee Control
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• Steps
• Literatures Review.
• Setting up Objectives.
• Construct the Methods. (Process)
• Organizing
• Operation
• Monitoring Evaluation.
• Research Development.

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• Planning
• Literatures Review.
• CDC recommendations. (http//www.cdc.gov/mmwr/)
  
• Texts
• Journals - EID, Promed mail etc.

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• Planning
• Literatures Review.
• Prestored - data.
• Evidence-based.
• Conceptualize the data.

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Planning 2. Setting- up objectives.
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????????????

• Which Diseases?
• Minimize Mortalities
• Minimize Morbidities
• Prevent Spread
• Patients to Staffs
• Patients to Patients
• Patients to Community

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• EID Alert When??
• Clustering of cases with the following syndromes
• Pneumonia
• Encephalitis
• Papulopustular rash
• Hemorrhagic fever
• Descending paralysis

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Planning 3.Construct the Methods. (Process)
Patients Patients
Patients HCW.
Detection
Surveillance Treatment
Guidelines Prevention
Education

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Treatment Control 1.Articles -
Disinfections Sterilizations 2.Transmission
Personal Respiratory Protection
Aseptic Hygienic
Techniques (Hand Washing)
- Isolation Techniques 3.Patients
Treatments
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Examples of Guidelines
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Criteria for an ICU admission At NYGH, patients
who had an oxygen saturation lt92 and needed any
amount of supplemental oxygen had their vital
signs with oxygen saturation monitored every 2
hours instead of every 4. If patients required
more than 4 L/min of oxygen, the monitoring
increased to every hour. Once patients required
gt6 L/min of oxygen, they were transferred to the
ICU.
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Exit the patients room What to do? the first
pair of gloves was removed, followed by the hair
net, the face shield, and the second pair of
gloves next, hands were washed with quick-drying
antiseptic solution, and the gown was carefully
removed then the hands were washed again before
the staff member left the room. In the hallway,
hands were washed, goggles removed and disposed
of, hands washed again, respirators removed,
hands washed, and finally, a new N95 respirator
was donned.
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Education Develop a system for intensive training
in the use of personal protective equipment and
infection-control procedures.
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Education Team
a case-control study of 72 hospital workers
with SARS and 144 matched controls showed that
the likelihood of SARS infection was strongly
associated with having lt2 hours of infection
control training, and not understanding infection
control procedures.
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Management Steps Planning Organizing Directing
Control
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Organizing
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EID Control Comittee

• Multidisciplinary membership
• Evidences-based
• Prestored data

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EID Comittee

• Key persons
• Hospital Director - authoritive power
• Hospital Epidemiologist
• Infection Control Nurses (ICN)
• Infectious Diseases Physician
• Director of Nursing

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EID Control Comittee

• Budget
• Equipments eg. Masks, Respirators, Gowns etc.
• Back-up facilities eg. Labs., Engineering etc.

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Crisis Management Strategies
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System Thinking and Lobby Team Important issues
that were considered by this group included the
following whether to create SARS
hospitals BoothCM,Stewart TE. Severe acute
respiratory syndrome and critical care
medicineThe Toronto experience. Crit Care Med
200533S53-S60
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EID 20041025-31
Through June 2003, a total of 2,521 patients with
probable cases of SARS were hospitalized in
Beijing. The outbreak peaked during the 3rd and
4th weeks in April, when hospitalizations for
probable SARS exceeded 100 cases for several
days,
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.
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Local shortages of isolation rooms, intensive
care facilities, and hospital beds were
addressed by dispatching specially equipped
ambulances to transfer SARS patients to
designated facilities. An anticipated shortage of
hospital beds for care and isolation of SARS
patients prompted authorities to construct a new
1,000-bed hospital in 8 days.
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we would have in place a mechanism whereby we
could limit unnecessary flow of patients into
ICUs (such as canceling elective surgeries) and
preserve the care of emergent patients (such as
trauma, cardiac, neurosurgery, and
transplant)...... Such a response appears to
require a regionalized approach or systemwide
thinking to the delivery of critical care.
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Do we need ward with negative- pressure rooms?
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• No. of Staffs needed
• Calculate the maximum number of beds available
  for conversion to negative-pressure rooms on the
  wards, in the ICU, and the emergency department.
  The resulting figure will indicate the number of
  staffs. Such staff must be preparedfor training
  and able to commit their services for a minimum
  of 3 to 4 weeks

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Patient Physician Ratio The patient-to-physician
ratio was 510 SARS patients per physician.
(including emergency department physicians,
general internists, family physicians, surgeons,
and anesthesiologists) One infectious disease
consultant was assigned to each SARS ward, and
one also covered the SARS ICU for a ratio of 20to
30 SARS patients per infectious disease
consultant.
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Patient Nurse Ratio At the beginning of the
outbreak, the ratio was approximately 45
patients per nurse, a potentially dangerous ratio
that could lead to transmission. During SARS II,
the ratio was 11 if the patient was on oxygen
requiring hourly monitoring and 21 for more
stable patients. In the ICU, the ratio was two
nurses per patient,
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Security Traffic Control ? SARS
Police Security ensured that unauthorized persons
did not enter the hospital a security staff
member, with a nurse, escorted SARS patients on
transports between departments, logging the date,
time, and persons involved in the transfer.
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Psychological Team At NYGH, we put together a
SARS psychological team (including social
workers, psychiatric crisis nurses,
psychiatrists, and infectious disease
specialists) that developed a plan to manage the
psychological impact on patients and staff..
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Public Health Team a mobile public health
outbreak management team. swift contact tracing
and the quarantine of persons identified as
having had unprotected exposure to a SARS
patient
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Research Team Research is imperative during
such an outbreak, particularly for a new disease
The ethics board was prompt in attending to
required approvals, often a lengthy process.
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Do we have to prepare for an EID outbreak?
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Pathogenic microbes can be resilient, dangerous
foes. Although it is impossible to predict their
individual emergence in time and place, we can be
confident that new microbial diseases will
emerge. Institute of Medicine, Emerging
Infections Microbial Threats to Health, 1992
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EID 200410777-781
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Early Detection triage screening. For this, a
questionnaire was administered to entrants to
identify SARS symptoms and exposures. Screening
was accompanied by a temperature check, mandatory
hand hygiene by the patient, and often by
providing a surgical mask before admission to the
hospital.
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Fever Clinics Fever clinics were established
for triage of patients who might have SARS to
separate them from other persons being evaluated
in emergency rooms or outpatient clinics.
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Staff and patients were grouped into cohorts,
and a space of gtl m was allocated between
patients to make direct contact and droplet
transmission less likely. Dedicated entrances and
exits and clearly marked patient pathways were
provided to segregate patients under evaluation.
Provisions were made to ensure adequate
ventilation and air exhaust to reduce the risk
for droplet or airborne transmission.
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EID 200410771-776 Tent assessment clinic was
constructed within 1 week. It contained eight
negative-pressure isolation rooms built with pipe
framing andplastic walls and ceilings. Areas for
clerical work, registration, and changing
personal protective equipment were also created.
Other components included an area for case
review, a lead-lined x-ray room, and an x-ray
viewing room.
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Emergency Department and SARS Assessment
Clinic North York Grneral Hospital, Toronto
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Emergency Department and SARS Assessment
Clinic North York Grneral Hospital, Toronto
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EID 200410777-781
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EID 200410777-781
Officials either constructed or retrofitted
existing facilities to create SARS evaluation
centers (i.e.,Fever Clinics) ...in both Toronto
andTaiwan, no transmission was reported in these
facilities.
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EID 200410210-216
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